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José translates instructions about how to take anti-nausea medications after chemotherapy into Dominga’s native language, Kaqchikel.

Cancer rates are rapidly rising in Latin American countries, according to a recent report published in the Lancet [1]. Low- and middle-income countries of Latin America have a lower overall prevalence of cancer, but higher cancer death rates, than developed nations. This disparity can be largely explained by several common themes in cancer care provision throughout Latin America: late diagnoses, poor access to treatment, and limited availability of efficacious therapies.

Guatemala faces many of the challenges that beset Latin American countries in cancer care. Geographic, economic, and linguistic barriers conspire to restrict access to cancer therapy for a large portion of the population. Guatemala’s National Cancer Hospital [Instituto de Cancerología, INCAN], the nation’s only institution that provides cancer care to the public sector, is located in the capital, Guatemala City. Patients living in other areas of the country—particularly rural areas—must travel anywhere from several hours to several days to reach the hospital. Although INCAN receives some funding from the Guatemalan Ministry of Health to offset the costs of patients’ initial laboratory exams and diagnostic procedures, patients must pay for the majority of their treatment costs, which are all too often prohibitively expense. While the majority of Guatemala’s population is indigenous and 23 indigenous languages are spoken in the country [2], all services at INCAN are delivered in Spanish. On top of these issues, the hospital itself suffers from an enormous backlog of 1200+ patients on the waiting list for radiotherapy services. These problems are intimately linked to poor follow-up care and patient retention rates. According to the director of the hospital, Dr. Walter Guerra, 33% of patients who receive a cancer diagnosis at INCAN never begin treatment; 33% of patients start, but do not finish, therapy; and only 33% of patients complete the recommended course of therapy. These statistics are worse for indigenous patients with cancer, 50% of whom never begin treatment after initial diagnosis.

In the midst of these challenges, the non-governmental sector has come to represent an important source of health care for many Guatemalans [2-4]. In Guatemala alone, there are an estimated 10,000 to 15,000 non-governmental organizations [NGOs], many of which are involved in health care provision to varying degrees [2]. Other Latin American countries, such as Bolivia, El Salvador, and Mexico, have experienced similar explosions in the NGO sector in recent years, in light of global economic policies encouraging the privatization of social services [5-7].

Private sector health organizations could play a crucial role in increasing the number of patients who make it all the way through treatment. Take the case of Dominga Puac*, a 60-year-old woman who was diagnosed with cervical cancer three years ago. Dominga is a monolingual speaker of the Mayan language Kaqchikel. She lives in a small adobe house in a rural hamlet of the highland town of San Juan Comalapa, and supports herself through subsistence agriculture, farming a small plot of land adjacent to her home. In 2010, Dominga began to experience vaginal hemorrhage. After seeking care at the local government health center in San Juan Comalapa, Dominga was referred to INCAN.

Public transportation from Dominga’s village to San Juan Comalapa is only available once a week, and as such, Dominga planned well in advance the four-hour journey to the capital. When she arrived at INCAN for an initial consultation, she barely understood what the Spanish-speaking doctors there told her. She completed required initial laboratory exams, whose costs were already beyond her means, only to receive a staggering estimate of treatment costs for several thousand quetzales—more money than she sees in one year. Lacking the ability to pay for the services, she did not return to INCAN for her first chemotherapy appointment.

Over the next year, the hemorrhage worsened. Dominga grew increasingly concerned and desperate. With the help of relatives and village officials, Dominga reached out to Maya Health Alliance, a non-governmental organization (NGO) that sponsors a nutrition and primary health care program in a nearby village. After initial evaluation by a physician, Dominga was enrolled in the NGO’s Complex Care Program, which attends to rural patients with specialized health care needs ranging from pediatric heart surgeries to dialysis to cancer care. Through this program, Maya Health Alliance currently funds treatment for about 75 patients who require treatments in tertiary care centers in Guatemala City. Sometimes, the costs of treatment are covered in conjunction with other NGOs or charities, and local Guatemalan institutions collaborate with Maya Health Alliance by offering services at- or marginally above-cost.

Addressing economic barriers to care, however, is only one component of Maya Health Alliance’s Complex Care Program. Fulltime staff member José Cali works to address the cultural and logistical barriers to care, which would otherwise represent formidable obstacles for patients from rural and indigenous areas of Guatemala. José, who is bilingual in Kaqchikel and Spanish, takes care of the nitty-gritty details of scheduling consultations, transportation, and language interpretation.

Staff member José Cali begins his day at INCAN by reviewing the cases of the six patients whose care he will be managing for the day.

The philosophy of patient accompaniment has long been recognized by health organizations, such as Partners in Health and the American Cancer Society, as a crucial step towards breaking down barriers to care for impoverished and underserved patients. In the realm of cancer care, a handful of other NGOs in Guatemala with similar programming to that of Maya Health Alliance can attest to this fact. Even when NGOs do not fund patients’ therapy or provide only partial funding, the logistical support in transportation, communication, and follow-up visits that they offer can spell the difference between a patient abandoning and finishing cancer treatment. By accompanying patients through care, non-governmental organizations could play an important role in reducing cancer disparities and deaths in Guatemala and, more broadly, Latin America.

–
References
[1] Lancet Oncology. 2013. Abstract. 14:391-436.
[2] Rohloff, P, Kraemer Díaz, A, and Dasgupta, S. 2011. “Beyond development”: A critical appraisal of the emergence of small health care non governmental organizations in rural Guatemala. Human Organization 70(4):427-437.
[3] Maupin, JN. 2009. “Fruit of the Accords”: Health Care Reform and Civil Participation in Highland Guatemala. Social Science and Medicine 68(8):1456-63.
[4] Cardelle, AJ. 2003. Health Care Reform in Central America: NGO-Government Collaboration in Guatemala and El Salvador. Miami, FL: North-South Center Press.
[5] Gill, L. 2000. Teetering on the Rim: Global Restructuring, Daily Life, and the Armed Retreat of the Bolivian State. New York: Columbia University Press.
[6] Smith-Nonini, S. 2010. Healing the Body Politic: El Salvador’s Popular Struggle for Health Rights from Civil War to Neoliberal Peace. New Brunswick, New Jersey: Rutgers University Press.
[7] Schneider, SD. 2010 Mexican Community Health and the Politics of Health Reform. Albuquerque, NM: University of New Mexico Press.

–

*Pseudonym.
Dominga and José gave permission for their photos to be used in this post.

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The Daily Impact: Villagers in Niger Take Stand Against FGM

Background: Equity in access to health care among people living with HIV (PLHA) has not been extensively studied in Peru despite the fact there is significant social diversity within this group. We aimed to assess the extent to which health care provision to PLHA, including ARVT, was equitable and, if appropriate, identify factors associated with lower access. Methods: We conducted a survey among adult PLHA in four cities in Peru, recruited through respondent-driven sampling (RDS), to collect information on socio-demographic characteristics, social network size, household welfare, economic activity, use of HIV-related services including ARV treatment, and health-related out-of-pocket expenses. Results: Between September 2008 and January 2009, 863 individuals from PLHA organizations in four cities of Peru were enrolled. Median age was 35 (IQR = 29–41), and mostly male (62%)

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But where do we begin?  She was five years old, one of two children of a desperately poor family from a district to the north of ours.  A little over a week ago, she had started swelling.  Not being close to anything much by means of medical care, her parents kept her at home until she developed worsening fevers and breathing difficulties.  Their hands forced, they made the several-hours-long trek south to our hospital, which by now had developed a regional reputation for its services.  So, the system starts there: no health worker to identify her symptoms, no transportation to get her here quickly.

By the time she arrived, in the late evening, she was breathing heavily and quite sick, though not in extremis.  She received appropriate antibiotics.  She continued to worsen however (antibiotics only start to work within about 24-48 hours).  When I met her that morning, on rounds, she had vomited and likely aspirated, was in respiratory distress, and her level of consciousness was depressed.  I was pessimistic about her prognosis; she needed an ICU which was over 14 hours away, a trip she would never survive.   Another systems issue: lack of any sort of regional capacity for intensive care.

But let’s turn now to the systems that are more in our control.  Firstly, we had to deduce what she was suffering from and the resources we had.  Though definitive diagnoses are rarely possible out here, let me suspend belief for a moment and describe what I think led to her demise.  Our laboratory investigations showed hypoalbuminemia, or low protein in her blood.  This is due to either malnutrition (Kwashiokor), protein losing enteropathy from an intestinal worm infection, or nephrotic syndrome.  The latter, though epidemiologically less likely given the prevalence of both malnutrition and intestinal infections, is plausible since she otherwise didn’t appear malnourished and the parents did not give a history of diarrhea.  In any case, all three are associated with overwhelming infection.  In any case, we have treatments for all three of the leading possibilities.  For Kwashiokor, we run a government program for the treatment of severe malnutrition; we have anti-helminthic medicine for worms; and we have steroids for nephrotic syndrome.   We also have laboratory capacity to measure electrolytes, and intravenous fluids and medicines to correct imbalances.  We have oxygen concentrators to help improve oxygenation when patients, such as she, develop respiratory complications.  We have a team of doctors, nurses, midwives, health assistants, administrators to deliver these interventions.

That was where we started.  What broke down was a systematic approach to her care.  We ordered electrolytes, including a blood sugar, on rounds at 8:30am.  We all acknowledged she was incredibly sick but there isn’t a rigorous system in place to continue to monitor her.  I went to outpatient department with one of our health assistants.  The child’s mother, distraught and crying, somehow had the strength to get through the outpatient crowd and present to us about some chronic gynecologic issues that she had been having.  It’s a matter of survival; even as her daughter was dying, this would be the only opportunity she would have to access care.  She ultimately had both pelvic inflammatory disease and pelvic organ prolapse.  When we came back to the emergency department during a break in the outpatient department, the girl was obtunded and seizing, though nobody seemed to have notice.  We checked her sugar and electrolytes from a hand-held i-Stat device.  Her sugar was undetectable.  She had been in hypoglycemic seizure for an unknown amount of time.  She was also in worsening renal failure and her potassium had increased.  She was still somehow breathing but with low oxygen, a fact that was exceedingly difficult to assess rigorously because we as of yet do not have a pediatric pulse oximeter (one of those items that littered with literally years’ worth of discussions and intermittently successful attempts).  I called our staff physician, and we administered the usual interventions to treat hypoglycemia, seizures, hyperkalemia.  She was already receiving our maximum amount of oxygen we could give her—we can’t do higher-level interventions like non-invasive or positive pressure ventilation or intubation.     These are just some of the systems-issues; there are always so many that lead to that tragedy of errors of stupid deaths in resource-denied health systems like ours.  We will be conducting a morbidity and mortality review on this case, during which we will dissect via a root cause analysis we have developed some of more of these issues [2].

And so, engulfed by flies in our emergency department, the little girl died.  A crowd was gathered outside, watching the mother pound her bare hand against our non-reinforced concrete walls of this government-owned, Nyaya health-run hospital, walls constructed 30 years before.  Walls that housed little more than dust and graffiti and rodents until we came four years ago. Walls that now, on a daily basis, witness both the possibility and utter failure of rural health systems.   Walls that represent some of the best healthcare this region has ever seen, and yet were constructed in such a way that would crumble at even the slightest quake of the earth.

I’m proud of our team.  There is a reason why 350 patients come to the outpatient department on many days.  We do our best to provide dignified and effective care within the knowledge and resources that we have.  Folks here are dedicated and work tremendously hard.   And many patients really do get the right care at the right time and get better.  Our staff physician on duty beautifully counseled the parents throughout the process and managed the crowd.  Our doctor calmly and compassionately talked with the father, who literally seconds after his daughter had died, started to ask for medicines for a chronic leg ulcer he had.  The father was gently told he would get the medicine; he then burst into tears.  Everyone recovered quickly to get back to the dozens of patients still waiting to be seen, lab tests to be assessed, x-rays to be reviewed, procedures to be performed, medicines to be dispensed.   We just lack some of the basic tools and systems to practice our craft—medicine—well.   From community triage and referral to advanced hospital management, we have such a long way to go.

The flies, they eat at your soul.  It’s not the bites on the skin.  It’s not that they are even close to the biggest problems we face as a healthcare team.  It’s not even the frustrating fact that we’ve tried many different interventions and they continue to come back with a vengeance.  It’s the sense that those flies are winning, that the forces of un-dignity and useless suffering are stronger than our own desires for dignity, justice, health.  It’s the deep feeling of loss, that they survive and flourish even while yet another child has fallen.  It’s the knowledge that we have the means to beat those flies—well-resourced health systems, that “resource-poor” is a lame term describing more our collective impotence than any intrinsic reality.  It’s the realization that its our collective moral failing that those systems remain an incomplete, imperfect, and fly-ridden work-in-progress.

1.              Farmer, P., Pathologies of Power: Health, Human Rights, and the New War on the Poor. 2003, Berkeley: University of California Press.

2.              Schwarz, D., et al., Implementing a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement. BMJ Quality and Safety, 2011.

Cross referenced from: http://www.nyayahealth.org/blog/walls-and-flies

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Here, I sit down with Maupin to discuss in greater detail his view of the history of primary health care initiatives and CHW program in Guatemala and Latin American. Our discussion covers a broad range of topics, including the historical factors which led to the emergence of the model, as well as the effects of first civil wars and revolutions and then neoliberal health care reform.

Tell me a bit more about your background.

Well I went to Tulane University initially for pre-med as an undergraduate – before realizing that medicine wasn’t for me! My interest in Guatemala and healthcare – and in Tulane specifically – was that my grandfather Carroll Behrhorst once taught there. He went to Guatemala in the late 1950′s as a Lutheran medical missionary. However in the 1960′s he separated from the Lutheran Church and opened a clinic in the department of Chimaltenango, which then developed into a very well known clinic, the Behrhorst Clinic. Subsequently, I went to SUNY Albany, where I did my PhD dissertation looking at community participation in health care programs. The dissertation focused primarily on community participation after the [end of the civil war] in Guatemala. Now, I’m looking at a historical perspective of primary health care initiatives in Guatemala, using the Behrhorst Clinic as an ethnographic case study to examine these issues from the 1960s to 1970s, where there was really a boom in primary health care initiative — in terms of a push for integrative development, and the number of CHWs and NGOs involved. Then I look at violence during the civil war, which decimated the clinic and the health promoter program, and which was also very formative in changing the idea of what a health promoter was. Finally, going through the 1990s, I look at the end of violence and the neoliberal health reform that went with it.

Can you elaborate a bit more on the history of the Behrhorst Clinic? Because the founding of the Behrhorst Clinic is really a foundational moment in global health.

The clinic was innovative and unique, but it was also part of this growing movement in Latin America for primary health care initiatives and ideas about comprehensive health and development programs. There’s always a bit of debate whether the Behrhorst Clinic was really the first health promoter program What was going on in Guatemala was also going on with [other community health worker programs] in Mexico and other programs throughout Central America. These movements coalesced in the 1960s and 1970s and were influential in developing the primary health care model.

The Behrhorst Clinic started out as a curative clinic. My grandfather first opened up a small clinic in Chimaltenango, he had a lot of patients coming in every day with basically the same illnesses. He would provide medicine, people would get better, and then they would come back in a month with the same issues. There was then a big turning point in his philosophy; rather than just focusing on curative medicine inside a clinic, he felt there needed to be more interventions in rural communities where people were living, focusing on they exposures and conditions that were producing bad health. So the Behrhorst Clinic started a pilot program, where they sent a group of 3 Kaqchikel Maya women who were working as nurses in the clinic to a [rural community]. They started doing community surveys, finding very high rates of tuberculosis and very poor dietary quality. That was the start of the CHW program. They recruited a couple of community members to start coming to the clinic to receive basic biomedical training so that they could diagnose common illness and provide medication. After that trial period, in the mid 1960s, they started a much larger health promoter program, recruiting participants throughout the department to come to the clinic and get a year of training in the clinic before returning to their communities.

It really does seem that health promoter programs started first in Latin America and then spread around the world? Or is that an unfair characterization? What was it about the 1960s in Latin America that allowed this model to emerge?

I think the model of what we think about as a CHW definitely has its roots in Latin America. There are other examples however from around the world that are similar; for example the “barefoot doctor” in China was going on at about the same time. In Guatemala in particular in the 1960s you had a lot of activism. There was a growing campesino movement as well as the Catholic Action movement. These factors coalesced around ideas about health and community participation to produce something that was unique.

How did these first programs get off the ground?

Funding initially was a big issue. For the Behrhorst Clinic, a private donor, World Neighbors, played a big part in financing. The Catholic Action movement was also influential, especially in the selection of the first health promoters. One misconception of CHWs that I always have a problem with is the idea that they were democratically elected and representative of their communities. But for the most part, it is hard to find programs where [that actually occurred]. In the 1960s when programs first started most of the individuals who became CHWs were nominated either by Peace Corp workers or through existing connections with the Catholic Church, where they worked as catechists as part of Catholic Action. So there was a selection of people who were already active outside of their own communities. So there was some reinforcing of power structures that already existed.

How does the history of CHW programs, in Guatemala for example, go from this initial boom in the 1960s and 1970s to where we are today?

The [civil war in Guatemala] was fundamental in transforming CHWs and health and development programs in the region, and it shaped expectations about what a CHW is. The Guatemalan government started its own program of CHWs in the 1970s, but there is very little information about it to this day. There was a point where the Behrhorst Clinic was hired to train government CHWs, but there was a lot of tension, in terms of ideas about the quality of training and responsibilities. By the late 1970s and early 1980s with the increasing scale of the violence, a significant number of CHWs were identified as being subversives just because of their acts of community organizing and health education. There were a lot of accusations of CHWs providing health care to the guerrilla…but that was really a very small portion of CHWs. The majority of CHWs were somewhat caught in the middle. So the role of CHWs during the violence is very complicated. But one pattern that came out of the time of violence, is that many CHWs were killed or disappeared or fled their communities. And those who did stay in their communities restricted their practices away from this integrative development, and they really just focused on curative medicine. So by the mid 1980s, that was largely the role and function of CHWs. And so I think that legacy continues today in rural communities in terms of what people see as a CHW position.

What happens after the war, especially as privatization and neoliberal health care reform takes off?

I think that now CHWs in the current neoliberal adjustment are being picked up on again because they have this symbolic and ideological tie to notions of democracy, stakeholding, citizen participation, which was something that was very big with primary health care in the 1970s. There are some people in the mid to late 1990s who feared that neoliberal economic reforms would essential destroy the position of the CHW, mostly because of arguments from cost effectiveness. But I think the reality is the opposite. They are cost effective, although mostly because they are now given less training than they should be, so training costs are reduced. They sort of maintain this symbolic relationship between rural communities and the government. In Guatemala at least, there is this idea that after the war, that CHWs are a means for the government to go to rural communities and try to cooperate with them and have this process of democratization.

Is this just rhetoric?

I think so. In the interviews that I’ve conducted with CHWs, I have had not had any who talk about these larger themes. Within rural communities I don’t think that people associate the [CHW model] with these larger ideas.

Now let’s turn specifically to the Guatemalan government’s efforts to outsource Ministry of Health (MOH) functions to NGOs through the SIAS program. This program has been viewed as an important model for how to conduct health care reform in the new millennium.

Under SIAS, many CHWs have been contracted, but their role has become incredibly circumscribed. The role of the CHW in the primary healthcare model as it was introduced in the 1970s was largely based on the idea that they would also serve as points of referral to higher levels of care. However a big difference was that back then CHWs [were also allowed] to provide basic curative services themselves. I think this is a world-wide pattern, that CHWs are now very restricted in what they are allowed to provide, especially in terms of medicine. In Guatemala, the SIAS system is incredibly restricted; CHWs are basically allowed only to provide only aspirin and oral rehydration therapy. So they are authorized to provide less than things that people can get for themselves.

Another element of SIAS is attempting to set up a better referral network, but I don’t know how effective that referral system is. If people who are ill do not recognize that they need to go to a higher level of care, I’m not sure how much CHWs and their referral advice actually impacts peoples’ decisions to seek higher levels of care. With the SIAS program this is sort of a numbers game. If you have a CHW who is responsible for 20 households, then you have a major proliferation of CHWs, which serves as the basis for the claim that the government are expanding rural access to healthcare very quickly even though access really hasn’t changed.

Another aspect of the SIAS program that is interesting is the adoption of conditional cash transfer approaches, mostly modeled on successful deployments of these schemes in rural Mexico.

I have mixed feelings about this. On the one hand, conditional cash transfer programs do encourage people to send their children to school, because the director of the school has to sign off on attendance forms which mothers can then turn into to receive incentive payments. Also women in rural communities have to go and have preventative health exams each month with SIAS CHW staff; staff sign off on their forms which allows them to get their monthly stipend. So this is helping some by increasing preventative care and getting children into school. But this also creates a sense of self regulation and self monitoring. Women, for example, may not want to receive certain services, such as pap smears. The CHW team is clear that they don’t have to receive the service, but if they don’t they will not receive their stipend. This forces some women; it may be encouraging preventative care, but it is a lot more regulation on people. If women are not able to attend, there is a sense that “It’s your fault.” If the child is not able to go to school, that is very much blamed on the mother. As the amount of surveillance in rural communities is increasing through this system, it is really targeted at mother. You never really see men coming in. Mothers are the sole focus. Any critiques of lack of improvement fall on the mothers.

What is the future for primary health care initiatives and CHWs programs – not just in Guatemala, but also elsewhere in the world?

My own view is that CHWs can do so much more. This idea of them being just a point of contact for initiating referrals without the training or ability to provide basic medications is a huge limitation. There is a lot of discounting the abilities of CHWs, based on the argument that it is too dangerous to allow them to provide medication or to diagnose illness. However, the evaluations of CHWs in the 1960s and 1970s were quite positive. So in my view, the role of CHWs could be expanded, especially towards providing basic curative services. Instead of being just a point of referral, they could be a source of care. There are some NGOs in Guatemala that still work with this model, but they are very few. As SIAS expands and as more NGOs opt for subcontracting relationships with the Guatemalan MOH, the CHW role will become more and more limited.

And this, in your view, is a loss?

I think so. In some municipalities in Guatemala there are still a lot of CHWs who were trained in the old model, and they are still operating their rural clinics and pharmacies. Many of them are still called “little doctors.” I don’t argue that CHWs should gain the knowledge and skills to be able to provide curative skills and then become totally independent. There needs to be some oversight. However the way CHWs are used in the SIAS program right now is a real waste of the position and doesn’t serve the needs it could.

Do you think NGOs and civil society organizations could use CHWs in more effective way?

At least in the region of Guatemala where I work, the possibility is vanishing. The history of funding for these programs has really limited the ability of NGOs to continue with CHW programs that are independent of the SIAS subcontracting model. A lot of NGOs who were opposed to the SIAS model originally have mostly converted because of the lack of funding from other sources.

Another issue is that many of the NGOs who now subcontract with the Guatemalan MOH have no experience in healthcare. Many are contracted just to serve as administrators. Part of the original deal with the SIAS model was that NGOs would continue to integrate their other more comprehensive services into the SIAS “minimal package” model. However the NGOs I’ve talked to in fact have very little integration of their subcontract responsibilities with their other core activities They mostly just work as administrators for SIAS, they are not really amplifying the basic package.

This is what has happened with the Behrhorst Clinic. They tried to remain independent at first. They were very opposed to SIAS and government contracts, and they tried to provide NGO-based alternatives. However, by the mid 2000s, primarily because of the lack of funding from other sources, they accepted the SIAS contracts. But their work as a comprehensive clinic is completely separate from their rural health work under SIAS. There is not even necessarily a referral system where the CHWs they contract and supervise under SIAS can refer patients to their clinic. So the clinic, which is historically known for its community health work and integrative approach, is now completely separated from their rural health work under a government subcontract.

This sounds tremendously unfortunate. Isn’t the whole point of being an NGO the ability to be innovative, different, focused on advocacy?

I don’t think that participating in SIAS undermines an NGO’s mission statement or philosophy towards social justice, but it also doesn’t expand it at all. NGOs that accept these contracts – the ones that I’m familiar with – they do it because of the financial security that comes along with the government contract. Even if they have a social justice philosophy, that doesn’t affect the way they approach the government contract.

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Bangladesh workers ask Americans to make garment factories less deadly

I’m angry that it is so easy for anyone here to fall off the edge, when successfully balancing on that edge means the difference between life and death. One small thing, one small break, bite, or burn that in many other places might put someone out of commission for a day or three, here, might not just be life-threatening but livelihood-threatening for an entire family. Our services may be free, but free care isn’t really “free” when you include the opportunity cost, particularly when patients have to walk 2-5 hours to get to it. For every child brought to the hospital by a parent, there are three or four children left at home to fend for themselves. For every adult carried into the ER, there are two less adults laboring in the fields. For every case referred to another facility because it’s beyond our capacity to treat, hard-earned savings are spent instead of invested.

I’m angry that every day we see tragic cases that should never have happened in the first place. The 10-year old girl who huddled too close to the fire trying to get warm but fell in and burnt 50% of her body, badly enough that she felt no pain while her family said their goodbyes. The middle-aged woman who has severe COPD from countless years of cooking over an enclosed wood stove and now has difficulty standing, much less walking, in a place where mobility means livelihood. The young man with an arm fracture that turned gangrenous because the family couldn’t afford the trip to the larger hospital several hours away and now faces amputation or death. The old man who should have had an aortic valve replaced years ago but now won’t make it to the surgical center in time. The teenage girl with rheumatic heart disease who died waiting for a surgery date; and every case that risks being too late because they have waited 10-15 days before coming in. Not because they don’t want or value treatment, but because the “cost” of doing so is so high.

I’m angry that I’m sometimes put in the position of making difficult choices with lives at stake. Do we spend $1200 to send the critical patient 12 hours to another hospital when there is a good chance she won’t make it? Or do we save that money to spend on 10 patients we know we can treat? I realize clinicians make these choices regularly and it is no less difficult for them, but the reality of deciding how far to go and who to save is one I’d never confronted before, and the simple fact of having to do it at all makes me angry every time I’m forced to.

I’m angry that the local government hospital, which we and our patients rely on for higher level care, isn’t better. That when we send a critical case who urgently needs a blood transfusion, even after our staff drive the 1.5 hours one way—not once, but twice—in order to donate blood, the lack of electricity prevents them from giving it, until finally the patient expires. That the district hospital is the only place to get anti-venom, and they have had only a single dose for months despite repeated promises that more is on the way from the capital. That we have to send mothers in dire need of C-sections 1.5 hours on bumpy, scary roads during a desperate time to a place that may or may not even have a doctor present.

I’m angry that although our care is far better than that, it’s still not good enough for many. I’m angry each time we don’t save a patient, even when no one could have. I’m angry that by the accident of their birth some people don’t get a fair chance at a full life. I’m angry that the moral of the story seems to be: don’t be born poor, and don’t be born in Achham.

It wouldn’t be too hard to let all this anger turn ugly. The truth is that in order to survive here sometimes I have to ignore bloodcurdling screams coming from the clinical space and go back to work on a spreadsheet that seems so useless, and yet without which we couldn’t fund our work. But ultimately it means that I appreciate every healthy day I’ve ever had. It means I’m proud of my colleagues and friends who keep just one more person from falling off that edge. And it means that every day, I know exactly why I’m here.

Andrea Hatch holds an MSc in Anthropology and International Development. She is currently the Director of Operations at Nyaya Health.

The term isomorphic mimicry has been getting a lot of use lately. In biology, it means shapes and structures that are similar in appearance but not function. Based on some quick web searches, the term has been almost entirely coopted by development wonks. For development types, “isomorphic mimicry” is a baroque way of saying that institutions in and of themselves don’t have a meaningful impact on development.

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A brief meditation on isomorphic mimicry

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New York Times Profiles Carter Center’s Leader For Guinea Worm Eradication

Standing atop a disused amphitheater in a disused airforce base, we could see over the surrounding area. On the right, a sea of shacks nuzzled together in hope and desperation. On the left, stretches of cracked concrete with just one shack here, one shack there.The emptying expanse to the left was the story of success. More than three years after the massive earthquake that shattered so much of Port-au-Prince, Haiti, rental subsidies were moving households quickly out of camps to houses in the community. read more

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The View Across Haiti & the Need for Disaster Resilience