Who Lives and Who Dies

Medical BedsBy Paul Farmer

London Review of Books

What is it like to be a passenger on a bus, or standing in a cheering crowd at the finishing line of a marathon, in the seconds after a bomb goes off, when you know you’re hurt but not where or how badly? What’s it like to be a child who finds a discarded toy and picks up what turns out to be a landmine? What’s it like to be giving birth at home, and see blood pooling between your legs, and look up at the ashen faces of a birth attendant, a midwife, a spouse? What’s it like to feel the earth tremble and see the roof and walls of your home or school fall towards you? More to the point, in terms of survival: what happens next? It depends. Not just on the severity of the injury, but on who and where you are. Death in childbirth, once the leading killer of young women across the world, is now registered almost exclusively among women living in extreme poverty, many of them in rural areas. Trauma is now the leading cause of death for children and young adults in much of the world. Who lives and who dies depends on what sort of healthcare system is available. And who recovers, if recovery is possible, depends on the way emergency care and hospitals are financed.

In the thirty years since I began my medical training in Boston, Massachusetts, I’ve cared for critically ill patients in Harvard’s teaching hospitals, as well as in Haiti, Peru, Rwanda and elsewhere in Africa. Study of healthcare financing was almost wholly absent from the curriculum at Harvard Medical School. But after working in rural Haiti I felt it was a necessary topic. I have seen patients grievously injured, often at the point of death, from a weapon or neglect or a weak health system or carelessness. Some died; those who had rapid access to a well-equipped hospital had a better chance of survival. I convinced myself, at first, that the differences in outcome must have been due to worse injuries, greater impact, more blood loss. But with time and broader experience, I was tempted to record the cause of death as ‘weak health system for poor people’, ‘uninsured’, ‘fell through gaping hole in safety net’ or ‘too poor to survive catastrophic illness’.

The people I lived with in the hills of central Haiti had a concise way of putting it: these were ‘stupid deaths’. It was to prevent such deaths that Partners In Health was founded in the mid-1980s, with the aim of providing care for the ailments, trivial or catastrophic, that afflicted the poorest, who were doing most of the stupid dying. PIH would also recruit and train others, whether as community health workers or nurses or doctors or managers, and generate knowledge about ‘healthcare delivery’: what’s the best way to treat Aids or cancer or drug-resistant tuberculosis in a squatter settlement in rural Haiti or a slum in Peru? How might we introduce trauma care, much of it surgical, where none exists? How might we prevent and treat malnutrition, which complicated most of the illnesses we diagnosed in children, without importing cheap food from subsidised US farms (which would further decrease the paltry incomes of local farmers, the parents of the malnourished)? How would we help the people who lived in these places, and had the most at stake, to get trained and qualified?

Our grandiose 1987 mission statement – most of us were still students – even promised to serve as ‘an antidote to despair’. Much of the despair we’d seen was generated by the ‘OOPS approach’ to sickness. ‘Out Of Pocket Spending’, a leading cause of destitution in countries rich, poor and in-between, was largely responsible for the stupid deaths we witnessed, since the care people paid for was expensive and mostly bad. PIH committed itself to the fight for healthcare as a human right. Such a right was in principle guaranteed by governments, even if they were unable, alone, to provide both healthcare and protection from destitution caused by a lack of health insurance. That meant PIH would try to help public health authorities to do their jobs, an aspiration dismissed as silly or worse by most other NGOs. We knew little about (and had nothing against) private health insurance, but we’d seen what it meant to be poor and sick or injured. The vast majority of Haitians had no insurance, public or private; they paid for their poor-quality healthcare, and inadequate education, with their own scarce cash.

Continue to full article . . .

Picture: Канопус Киля (my photo) [Public domain], via Wikimedia Commons

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