Lately I’ve been thinking about the narratives we use when we talk about public health. There are plenty of nuanced, complex analyses out there, but more often than not we treat health as a particularly black and white issue. Disease is the bad guy. Scientists and development practitioners are the good ones. We fight pathogens with mosquito nets and medication as our weapons.

Think, for example, of the recent coverage of the ebola outbreak in West Africa. The heroic images of WHO personnel clad in their plastic aprons and gloves. I in no way mean to criticize their efforts; ebola is a horrific disease and there are many brave men and women risking their lives to get the epidemic under control. But it is one more example of the way in which we portray Western medicine as a heroic force in the face of dark and nefarious disease.

But this doesn’t tell the whole story. People don’t get sick because disease is insidious or cruel. While luck has something to do with it, it’s far from everything. People get sick because of poverty. They get sick because of injustice. They get sick because structural inequalities become written in and upon our bodies.

In order to see these powers at work, we need simply ask ourselves, “Why?”

Let me begin with the example of malaria. I worked on malaria education for a couple years in West Africa. More often than not, we treat mosquitoes as the bad guys. If people don’t get bitten by mosquitos, they won’t get malaria. If we provide them with mosquito nets and teach them to avoid standing water and use repellents at night, the problem will be solved.

But we have to dig deeper. Why do people get bitten by mosquitos which carry malaria? We’re inclined to think that it’s because they don’t have nets. Sometimes this is true, and again – I don’t mean to criticize the efforts which have saved many lives over the years. But sometimes it’s more than this. Sometimes people have nets, they just don’t sleep under them. Why not? Because they don’t like the way that the nets obstruct air flow. Because they keep their nets at home and during the planting season they sleep in the fields. Because they don’t know that mosquitos are how you get malaria, so they don’t understand the use of the nets. Even if they do try to use them, they may not understand proper instillation.

How is it that people don’t know that mosquitoes are how you get malaria, and how is it that they don’t know how to use a net? Well, a lot of people are illiterate, so they can’t read the materials distributed by health centers. They may not know and trust the doctors giving out information. Many people have never been to school. They can’t go because of lack of infrastructure, poverty, and priorities of their parents. Those who do go to school often don’t make it past primary school. Primary school is often taught in a European language which isn’t the student’s first language. Creative thinking isn’t a priority in the system – rather rote memorization is valued. Many students I worked with knew that malaria comes from “l’annophelle femelle” (a female of the species of mosquito which does indeed transit malaria) but they didn’t understand that l’annophelle femelle was a mosquito. They didn’t understand the practical implications of their learning.

This is a tiny slice of the whole story, but already we see that the problem isn’t necessarily just a lack of nets. It’s the education system, it’s infrastructure, it’s poverty. This is why people get malaria, not because of mosquitoes.

So if we begin to ask “Why?” when we look at uterine prolapse in Nepal, we find that here, too, the story is rather complicated.

Why is the problem of uterine prolapse in Nepal so great? Lots of factors, the most cited including the fact that not many women give birth at medical facilities, many women return to work shortly after giving birth, and women do particularly grueling physical labor. Also, women don’t seek treatment when the problem is still minor.

Well, why don’t most women give birth at a medical facility? Because the infrastructure is lacking – many women don’t live near clinics. Because of poverty, women can’t afford the fees or the transport. Because of social norms – their families don’t support them going to the hospital. Because of education – they don’t know the advantages to giving birth at a clinic.

Why are so many women so far from clinics? The terrain in Nepal is definitely challenging for expanding infrastructure. Beyond that, hospitals that do exist in remote areas have trouble getting adequate staff, as many Nepali doctors want to go abroad where they can make more money, or to work in Kathmandu or another big city. The government’s budget is limited, as the country faces many challenges. Nepal went through a decade long war during which health infrastructure couldn’t be a priority.

Why do women return to work so soon after giving birth, and why do they do such particularly grueling physical labor? Cultural and social norms – it is expected that women will work hard to support their families. Poverty and economic need. Lack of other options – women are less likely than men to be literate, less likely to own assets, more likely to marry younger. These factors limit a woman’s options beyond agricultural work.

Why are women less likely to be literate, less likely to own assets, and more likely to marry younger? Deep-rooted gender discrimination which is present in society and in institutions.

Why don’t women seek treatment early on for this condition? Many don’t know that prolapse can be treated at all. There is a lot of shame and stigma associated with the condition. Those who want to may not have a clinic which is easily accessible or the money for treatment or transportation.

Why don’t women know that prolapse can be treated? Why is there so much shame and stigma? Lack of education, gender discrimination. Emphasis on a woman’s value being directly related to her ability to produce children (especially sons). Cultural norms.

Again, this is a small snapshot of the story and these are only partial answers. But it begins to highlight how uterine prolapse is more than a health problem. It is a direct result of gender discrimination, of poor infrastructure, of conflict, and of poverty. Uterine prolapse in Nepal is just one more example of the ways in which disease is the legacy of inequality and injustice which becomes imprinted on our bodies – especially on the bodies of the most marginalized members of society.