Who Lives and Who Dies?
Monday, March 16, 2015
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 toward 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 health care system is available. And who recovers, if recovery is possible, depends on the way emergency care and hospitals are financed.
In the 30 years since I began my medical training in Boston, 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 health care 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 “health care 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 subsidized U.S. 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?
One afternoon in October 1988, I was leaving a friend’s house in Cambridge, Massachusetts, in a self-important rush. As a medical student also getting a degree in anthropology, I was headed back to Haiti, then experiencing a great political upheaval. My friend was one of the founders of Partners In Health, which we believed, even then, might make a difference in rural Haiti and beyond. But that’s not the reason I was in a rush: I was eager to correct the proofs of an academic paper (my first) before boarding an early flight to Port-au-Prince, where electricity and postal services were uncertain. The paper was on the political economy of health and illness in Haiti. I was also distracted (distressed, really) because three of the Haitian founders of PIH, all in their 20s, had recently died stupid deaths. The first of puerperal sepsis shortly after childbirth; the second of cerebral malaria in a psychiatrist’s waiting room after being misdiagnosed as psychotic; the third of typhoid fever, a rare infection where there is modern sanitation; it had eaten through his small intestine and he died as he was being rolled into one of the operating rooms of Haiti’s large, dysfunctional university hospital. My three co-workers, seriously ill, found themselves at the door of the House of No, even as they were working to dismantle it.
- Health Care