While teaching the Community Health Module, to midwives in Haiti, I came to appreciate the value of observation,  conversations and a walk about the area.  As part of the WHO curriculum, the students were asked to go on such a walk and find people to interview.  This method of learning about maternal health was compelling and life changing.

Road in the Marshal Islands 

I had started my midwifery career because I observed young children with fetal alcohol syndrome.  I noticed a problem in the community where I was working and could see that it took route in early pregnancy as well as in how women perceived themselves.  Within the context of Head Start, I saw maternal health as an integral part of the community.  But once I was a midwife I focused on clinical measurements with far less of a focus on the community.  Healthcare in the United States was rarely embedded in a specific community, reflective of its unique strengths and challenges.  Mothers were islands within a large healthcare system, disconnected from culture and community.

When I arrived in the Marshal Islands, I knew I would be meeting with the midwives and mothers. I quietly began this informal and enjoyable way of doing a maternal health assessment.  I do this now, without even thinking, everywhere I go.  Doing this, in Portland, led me to begin to see the Portland Harbor and it fossil fuel hub and their relationship to maternal health.  I began to see the world in relationship to how it cared for and protected mothers and babies.

The premise of these walks is that the well-being of mothers and babies, is directly connected to the resources available to them from the time of their own birth.

Children in the Marshal Islands at a morning assembly.  All children in the Marshal Islands receive a free k-12 education.

One of the first things I am interested in is the state of education in a community.  If all children and particularly girls are able to receive a free k-12 education with access to higher education, they are far more likely to avoid a child marriage, plan when they give birth and access health care.  They are more likely able to prevent abuse of themselves and their children and to be able to contribute to the community.  In the Marshal islands, all children receive a free k-8 education.  In high school, they go to regional boarding schools and have an opportunity for college.  Requiring uniforms, certain shoes and ribbons, may serve as a barrier to education.  Here uniforms are not a barrier to education.

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Here we see a coconut charcoal burner, a common source of fuel in the Marshal Islands.

Another thing I look at is the fuel that people use to cook their food.  How far they had to walk to get fuel and the impact that fuel has on their well- being, including air pollution.  In my community, we are often dependent on fossil fuels such as gas and oil and coal to cook our food.  This method of cooking our food, heating our homes and transportation has a desperate impact on our own health as well as the people in other places in the world.  Climate change and pollution impacts a small island like this, while they create a sustainable method of producing charcoal from cocoanut husks. In many countries, the few trees available in a community are cut for charcoal so that families can send their children to school or pay for healthcare.

Water capture system installed but the government. In the marshal islands, most drinking water must be captured
from rainfall.  Draught is one of the most serious problems facing a country with almost no fresh water sources.

Collecting water is one of the greatest challenges many women face around the world.  Young girls and women may walk hours a day to collect water from a pump.  Rain catchment, in the Marshal Islands, saves women hours of work each day and assures them a clean source of water.  This system prevents contamination of a water source by human or animal waste.  Because it is covered, it can not provide a breeding place for mosquitoes.  It is easy to see that water catchment, makes a significant impact on women's health.  

A community health station in the Marshal Islands.  Each atol has a community health clinic with a trained nurse who provides preventative and day to day care.  The nurse can communicate with the health department in the capitol and order medical transport, as needed.  This model provides the community basic healthcare, immunizations and first-aide.  This basic level of free community care assures the people on this island the security of health care.

How and where women and children receive healthcare, is critical to any community assessment.  Is the care easy to assess? Is it close by and are the clinics well supplied with necessary medications and supplies?  Can women access prenatal care, family planning and a safe birth?   Although the island had no skilled birth attendants, it had a certain level of health security.  All women could choose to fly to the capitol for their birth.

Access to food is a critical need of any community.  The people of the Marshal Islands, lived
for thousands of years in a culture of sustainability.  They gathered shell fish and fished and ate local coconuts and breadfruit.  World War II and the subsequent years, have destroyed much of their food security.  It is now estimated that 90 percent of their food is imported.  Locally grown and gathered food has been replaced by white rice, processed meat and sugar.  With this comes, higher levels of diabetes and high blood pressure.  There is evidence of stunting in children and a decreased life expectancy.  A culture's ability to produce their own food is critical to their well-being.

Catholic Church in the Marshal Islands

The role of religion in any community is an important part of a community's health.  Does true freedom religion exist?  Do religious leaders abuse their power and exploit the resources of the community?   Religion appears to be important in the Marshal Islands but I did not observe the abuses that we see both in my country and Haiti.  There was no evidence of a class based religious system.  I was never in a community in Haiti, where I did not observe some sort of abuse by priests which impacted women and children and almost universally remained unchallenged by NGO's.  In my country, fundamental branches of  many religions, negatively impact health outcomes of women in our country and around the world.   Women appeared to be able to use church spaces for community education and gatherings in this community.

Harms and Risks 

The Marshal Islands face many risks including climate change, over fishing by other countries and drought.  Because of the compact it has with the United States, they estimate that 1/3 of the country has left for the United States.  Residents of the Marshal islands do not need a Visa to enter the United States.  The outer islands are losing their populations and thus their culture.  Many people move to the crowded urban center on Majuro or to the US military base for work.  Rising seas, the loss of traditional foods and the on-going military relationship with world powers, puts the people of the Marshal Islands at risk. Despite a good education and healthcare system, the risks are still high.  Once in Hawaii and the mainland United States they face discrimination, cultural barriers and exploitation.   

The impact of dropping atom bombs on these small islands, can not be underestimated.  The United States works to avoid responsibility for the harm done to this island nation.  

Birth and Women's Health

I'll share my visit with the midwives in the next post.

Mejemkwaad, Managua and the Monsters all over the world who steal newborns

Around the world, people must grasp the concept of a corona- virus.  They are asked to prevent the spread of an invisible germ that can be passed from person to person, as they pursue everyday activities.

 At first we are told that it will spread if we cough or sneeze on someone and now are told it can spread just from talking.  We are asked to stay six feet from each other and to wear masks.  Six foot x's are placed on the grocery store floors.  We are asked to stay home and wash our hands with soap over and over again.

Those of us who can, listen to scientific explanations of the structure of the virus and how it spreads.  We come to see that only soap and water can destroy the virus on our hands.  The concept of a bar of soap a mystery to the younger generation who search frantically for fragrant, foaming soap in bottles.


These invisible foes, have existed for thousands of years in many forms.  Long before we knew about germs, epidemics were called plagues and were blamed on mysterious enemies and human flaws.  A mold led to the Salem Witch Trials.  Stories of vampires emerged from misunderstood European diseases.  Diseases were blamed on a lack of religious fervor, on nationality and gender.  Yesterday a very old friend, posts three maps on Facebook that illustrate that the carom-virus is related to immigration and being a democratic.  We look someone to blame, beyond the actual virus and its ability to spread and survive.  When I was a child I was told ice cream and public swimming pools caused polio.  There are Old Testament verses that beg God to deliver pestilence and disease on a person's enemy.

My drawing of a mythical monster that seeks to harm the newborn.  In my interpretation the "baby" is the earth and all it offered us.  The monster is all the forces that make the world unhealthy for newborns everywhere.  The wings are air, water and soil pollution.  The claws represent the greed that robs children of good health.  

People used human attributes of cunning and greed, to explain newborn and maternal death.  While most likely true that the deaths were caused by broad forms of cunning and greed, they were of a human sort that most often denied them an education, health education and the right to choose their own future.  Epidemics often were brought by colonial powers to far away parts of the world, without the immune system to defend them.

In Haiti, a well educated translator told me that there is a bad spirit that kills babies and mothers, after birth.  We have just done a home visit.  He seems skeptical that all our advice will be of use because if the spirit comes and takes the breath from the baby, there is nothing that can stop this.  I reason. There are a few things that could cause an otherwise healthy newborn to die.  I review the things that we test for; the silent germs and genetic disorders that could cause a newborn to die.  I review the need for exclusive breastfeeding, proper cord care and hygiene.  The need for some filtered sunlight and skin to skin contact.  Ah, he says.  This is all true but the spirit may still come in the window at night and draw the baby's breath out and cause death.  This spirit may be sent by your enemy's or someone who is quite jealous of you.

The almost universal baby stealing monster who exists the world around.  The monster who explains the unimaginable  grief of losing a perfectly healthy newborn.




In light of this, cultures developed rituals and customs to protect the newborn; a piece of red string, a knife by their head when they sleep, amulets and prayers.   Beautiful traditions accompanied by deep fears that are hard to shake.  Fears that sometimes keep parents from having healthy babies.

I try to think.  How many babies, I delivered, would have died quietly in their sleep without newborn screening or testing cord blood for incompatibilities.  Not a lot, but babies in low resource communities, do not have access to these screenings and so some babies, will surely mysteriously die.  Some will die because someone told the midwives to cover the cord or to not give the baby the first milk.  Some will die from post colonial birth practices.  Some will die from the many issues of environmental exploitation.

Monsters.

In the Marshal Islands, the unbearable loss of a newborn was blamed on the monster, Mejnwaad.  This female monster steals newborn babies and eats them!  These unexplainable deaths must have a villain and someone to blame.  In the Philippines, its Mannanggal, a winged monster who comes and devours newborns.

Today, in many communities around the world the monster that threatens the newborn, lives in the form of those who would pollute the world; its air, its water and its soil. It lives in the greedy claws of those who de-forest; destroying indigenous cultures, contributing to climate change and destroying food sources.  The monster dwells in the industries, built along our rivers and streams that are jammed with pollution and chemicals.  It wraps its tendrils around affordable housing and healthy food sources.  The world is polluted with radiation from nuclear bomb testing and chemical waste.  The terrible monster delivers its blow in premature births, a lack of equitable, not for profit healthcare.  The monster who sucks the life out of our newborns flies amongst us, only now we don't know how to name it.  There is no story to scare young children.  There are no rituals or amulets.  The monster has no name.  It flies without boundaries throughout the world - as a virus, as a war, as a baby in a refugee camp.

Watch out.  This baby eating monster is at all of our windows.  The ancients understood this and were beware.

Monster

                                      by Kathy Jetnil-Kijiner

                                  A spoken voice poem 

Sometimes I wonder if Marshallese women are the chosen one

I wonder if someone selected us from a stack. Drew us out slow, methodical and then issued the order.

Give birth to a nightmare.

Show the world what happens when the sun explodes inside you.

How many stories of nuclear war are hidden in our bodies?

574- the number of miscarriages and stillbirths after the bombs. Before the bombs- 52.

Bella told the UN she could no longer have children. They say their friends give birth to ugly things.

Derek gave birth to something resembling the eggs of a sea turtle 

and Flora gave birth to something resembling intestines.

She told this to a committee of men who washed their hands of this sin-

These women who gave birth to unholy things -

created from exploding spit and ugly things.

And how these women buried their nightmares. Beneath a coconut tree. Pretended it never happened.

Sinister.  Hideous. Monster.  More jellyfish than child. 

And yet.  They could see the chest inhale. Exhale.  Could it be human?

 Kathy is a poet and climate activist in the Marshal Islands.  I don't think anyone could better describe the impact of atomic bomb testing on mothers and babies in the Marshal Islands and the impact of their continued use.  I struggle to write this blog in the midst of the pandemic that faces the world.  But I know the virus, like these babies, is the earth crying; the earth asking us to pay attention,  be kinder, gentler and more generous.

   Everything we put in the air, the soil and the water ends up in a developing fetus.  In my country, we pollute the growing babies with air, water and soil pollution.  We run gas and oil pipelines through vulnerable communities.  The harm done to the developing child, is not always as apparent as what happened in this poem.  Babies are born premature or with severe learning disabilities.  Removed and displaced over and over again, their parents struggle to provide stable and secure lives.  The poverty that inevitably results from environmental degradation, is quickly followed by discrimination, shunning and class based isolation.   

I leave this poem with you, my sometime reader, with a sad heart.  Isn't it enough to watch emergency hospitals constructed in New York City's Central Park?  Isn't it enough o be sheltering in place?  And so, I would reflect that it is all connected.  This poem, these stories of mothers after atomic bomb testing and this virus that is embedded in our communities.  

At dusk, we sing to our neighbors.  We bang on pots and bans.  We say, "We are still here."  We say, "We will survive this."   And I might offer, that our survival in ways I wish I could document with science, our connected to the survival of the Marshal Islands and Haiti and the people of New York City.  

That when we sing, that when we pray, that when we shout- it is for all the world's people.

Nuclear Bomb Testing and It's Impact on Birth Outcomes in the Marshal Islands

The impact of nuclear testing on the newborns of Marshal Islands


During World War II, the United States drove the Japanese out of the Marshal Islands in order to set up airfare bases for future military battles in the Pacific Theatre.  The islands were heavily bombed in 1934-1944.  Following this, the Marshall Islands were put under the care of the United States.  One of the first things, the United Sates decided to do was to use the islands to test nuclear bombs.

They began testing in 1946, dropping 23 nuclear bombs and conducting 67 tests.

Through religious messaging, they convinced the residents of Bakini Atol to leave their island so the United States could conduct nuclear testing.  They were told they could return after the tests.

However, the bombs were 1,000 times more powerful than Hiroshima and Nagasaki in Japan.  It created a four mile firewall with heavy winds and thunder. The radiation covered the surrounding islands and people for years to come, impacting pregnant women and their newborns.

Babies were born with many birth defects.   The United States never fully acknowledged the harm done to the people of the Marshal Islands.

Atom Bomb testing in the Marshal islands.  It was the same as dropping the Hiroshima Bomb every day for 12 years.  It took many years for the United States to agree to testing and that the islands were not safe to live on.  Perhaps it is the US policy that if you don't test, an illness does not exist and therefore no actions needed.

 It is painfully hard to reconcile the cruelty of this atomic testing.  And yet, we must.  It is part of our history and every day in history contains within its arms, the birth of the next generation.  As Henry Kissinger said, "Who gives a damn?"

Coral and The Marshal Islands

In the Marshal; Islands, I walk on the skeletons of corals from the minute I wake up till the time I go to bed.  They are everywhere.  Small, rock like corals of every size, shape and shade of white.  Crunch, crunch, crunch.  They are so ordinary, so common and yet here in Portland I will never walk on coral all day.

So, I have asked you"who gives a damn" and to trust me that this will all one day relate to mothers, babies and midwives.

The Marshal Islands are coral islands.  They are made of millions of years of coral deposits; of coral being born, growing, setting out into the sea and landing on a coral skeleton that has created a nesting place for the future generations.

I come to understand that these islands are very flat and very small.  You can at times see both the lagoon and sea at the same time.  They are dependent on the coral growing to maintain their islands.  If the seas rise, with climate change, and the coral dies, the future of these mothers and children is at risk.  If the coral dies, the coral fish and crabs cannot not survive so you can see, in any place, understanding the life cycle of critical species is vital to the health of the humans who share that habitat.

Coral polyps have babies every year.  Their eggs and sperms are released in mass out into the perfect, clear waters of the Pacific.  Each fertilized egg becomes a baby coral called a planula. Once it comes a planula it must find a home. Covered with tiny hairs, this baby coral swims along until it finds a perfect place in a shallow, healthy lagoon that is sunny but not too hot.  Once our baby coral, finds a place to attach, it grows twelve little tentacles for catching food.  They build a hard white skeleton and make other polyps that are all connected.   Life for this baby is rich with other sea animals and the friendly algae that lives inside their skin.  It takes thousands of years to build a coral reef or a coral island.   Year after year, the cycle of baby planula and new polyps and hiding places for sea life and safety for the people of the Marshal Islands.

The coral reefs and the very fabric of Marshalese Culture is dependent on us caring about coral.   The people of the Pacific Islands have thrived, on these islands for thousands of years, without destroying their coral reefs.  In these posts I will tell this story but wanted to start with the building block of their culture- coral.

Birth of baby corals 

Birth of an Atol

You may wonder, my friends, how I came to see birth from a geological perspective?  How I came to be curious about the forces that formed the landscape where  midwives and mothers walk.  I came to see that certain geological events such as volcanoes, earthquakes, and glaciers would determine food sources, clean water and the ability to get to a clinic for care.   Mountains, rushing rivers, droughts and the extraction of minerals would play a role in maternal health,  beyond my imagination.  I gained a curiosity about geology and the role it played in a community's health.

In my community, we live with the certain inevitability of earthquakes and volcanoes.  Fossil fuel pipes, trains and tanks line our river.  It is our geological landscape.  The mothers of Haiti lived through earthquakes and must cross mountains and rivers just to get food, water and healthcare.

Our geological story offers opportunities and challenges.  It contains the stories of our ancestors, of lost communities and migrations for the benefit of future generations.   Mothers and fathers for tens of thousands of years, walked and crossed seas for the sake of their unborn children.   Mothers fled geological events and sought safer landscapes.  This included and includes wars fought over minerals buried deep within the ground.



The Marshal Islands are home to one of the world's most remarkable geological stories. This is a story of undersea volcanoes in the Pacific Ocean; volcanoes that erupted millions years ago and then sunk back into the sea.  The rim of the volcanoes remained and corals slowly grew on the sides of the volcano and finally up onto the rims to create beautiful Atols.  The Atols are now lovely circles of blue lagoons surrounded by coral islands and reefs.  The Marshal islands are composed of twenty-nine of such Atols.  The islands are part of Micronesia in the broader geographic region of what we call Oceana.  It is between the Philippines and Hawaii.

It is where I begin the story of mothers, midwives and babies on the Marshal islands.  It has come to be where I like to start all birth stories; with the story of how the earth gave birth to there landscape which then became the place of the stories.   Without this it will be hard to understand what I will come to share with you.

I enjoyed scribbling down this poem, written from the perspective of the volcano that gave birth to the Atol.

Birth Poem of An Under the Sea Volcano in the Pacific Ocean 


I have opened
my heart for you,
brought forth the
burning fires
of my desire.

Broken down the hard layers
of resistance I carry
 in my soul

I have let the gentle rains
fill the hollow bowl of
my waiting womb
with warm, clear water

Where corals climb
into my arms
laying down layer after
layer of nesting places
of earth and sky and sea

I have opened my heart
for you
watched birds and coconuts
and women in flying
boats rest upon my shores

I have opened up my
heart for you.
Islands in the deep
blue sea floating
beyond time.

My children, my home
My hopes and dreams.

The Marshal Islands - "Who gives a damn?"

In 1969, Henry Kissinger, when discussing the future of the Marshal islands, said the following:
"There are only 90,000 people out there.  Who gives a damn?"

And so these Blog Posts are about what it means to "give a damn" and the many forms it can take.
When I think about the Marshal Islands, a country of 50,000 people spread over many islands and 29 Atols, I think of the Dr Seuss Book, Horton Hears a Hoo.  I think of a small island, with children calling out, "We are here."

I think of an unsuspecting, sustainable culture being caught in the middle of world wars, atom bomb testing, international trade and now climate change.  It was and is, in many ways, the world's Sacrifice Zone.

I write this, in the midst of fear about a spreading virus and a presidential election.  My own neighborhoods spill over with people camping on the streets.  We have much to care about within our own country.  So, how do we, with the  Heart of a Midwife, care about this story?   How do we tell the stories of World war II with the people on the ground, watching bombs fall, as the main characters?

What does it mean to create a way of life, of education, of policy that forever gives a damn for everyone.  I hope these few stories fill in the holes we all had in our education about the Pacific Islands and in particular, the Marshal Islands.

One way that we can "give a damn" when there is so much to care about,is to simply bear witness, to take a moment to say in your heart.  "I understand what happened."

And to know that you can never, ever drop bombs, ignore climate change, pollute an ocean without it hurting mothers and children.   The first thing we do, as midwives, in walking into a birth space, is to assure safety, privacy and cleanliness.  When the world, becomes the birth room, we notice the air, the water, the food and the assurance of a fair and safe future.

Beautiful children on the Marshal Islands, play beside the life giving lagoon, so essential to their culture and way of life.