Dixon describes how midwives are in both an in group and outgroup relationship with the state, engaged in a process of “push and pull,” where they strategically engaging when it will help the persistence of their practice and care for women. This idea really resonated with me within my own work with midwives in Ecuador, in a collective called Amupakin. There are many ways in which the midwives at Amupakin selectively engage with the state, receiving the official state-sponsored certificates that allow them to practice midwifery, yet do not want to work in the hospital itself because of the racist treatment that persists. They choose how to engage with the state on their own terms, which costs them patients and funding. In her discussion of infrastructural violence, Dixon mentions the “año rural” in particular, where doctors fresh out of medical school go and practice medicine in rural areas of the country for a year before they can get their medical licenses. This, she quotes the CASA founder, is another example of infrastructural violence and racism, because the doctors are inexperienced and unequipped and literally end up experimenting on these populations, as they get their medical footing. I wonder, though, how this system could be better reformed? I do see that it solves a number of other issues, bringing care to places where the other option is no care at all, and I’ve met a number of people who did an año rural in Ecuador actually stay in the communities they were sent to and settle down. Do the obvious harms outweigh the good? How might training be reformed in order to address the harms? I could imagine a better cultural training for doctors before they go, but this still would not change the overarching dynamic and racial breakdown.
In chapter 3, Dixon calls out how global health as an institution focuses on maternal mortality, which can distract from other serious morbidities. This totally resonated with me. For a grant proposal I just turned in, my advisor suggested that I tie the arguments to the maternal mortality rate, so that it would get the attention of the reviewers. I really liked Dixon’s discussion of how this can be distracting and limiting from other problems. It also makes midwives tools of the state in a new way, which can be helpful if the midwives choose to participate, again engaging in a push-pull relationship. But it limits what they can do and forces them to practice within the confines and under the gaze of western medicine. I wonder, will this emphasis on mortality be net helpful or harmful to the practice of midwifery?