Whither Equity in Health: The State of the Poor in Latin America
By Dr. Paul Farmer, co-founder of Partners in Health
 It is a humid afternoon, and huge drops of warm rain are starting to fall outside the door of this clinic in rural Haiti. A young woman is watching as her 10-year-old son, Dominique, clutches miserably at his abdomen; he is staring at the roof, not saying anything. A Haitian colleague says to me, "His temp is 104; it's been up for over a week; his belly pain began three days ago. I'm getting the films and labs now." He pauses, looks darkly at the mother: "It's late." I say nothing, but look at the woman as I reach for the boy's abdomen, praying that it's not yet rigid. (It is not.) Though she is no doubt younger than I, she appears weathered, for Haiti has been no kinder to her than to her son. She looks at me, sighs, and wordlessly makes a weary gesture. I know it well: "What can I do?" she asks with her hands. "It's beyond my control."
And so it is. Her boy probably has typhoid fever, and the severe abdominal pain is ominous: one of the worst  complications of typhoid is intestinal perforation, which usually leads to peritonitis and death in rural Haiti. Typhoid, a classic public-health problem, is caused when drinking water is polluted by human feces. Not her fault. Ours perhaps, I think immediately. We-Partners In Health, a Harvard-affiliated public charity-could have worked harder on water-protection efforts, even though another, more conventional voice in my head reminds me that Dominique and his mother live well outside of our "catchment area," the region in which we work closely with community-health workers. And only by redefining the whole of public health as a private concern, one to be handled by do-gooder organizations like our own, could this be seen as our responsibility. Increasingly, such a redefinition-the "privatization" of health-has come to hold sway in Latin America. Assessing public health in this region is a treacherous exercise, and not just because the countries and their populations are so varied and complex. It is treacherous to comment on public health in Latin America because of the ideological minefields one has to traverse in order to do so.
As public health has become a larger enterprise, it has defined a turf of its own; as nation-states have come into being in Latin America, they have defined national public-health agendas. The health of the poor is now deemed less important than what is often termed "cost-effectiveness." Doctors and health care workers for Latin America's poor must now show that their work is both effective and inexpensive, regardless of what health problems they are tackling.
In fact, the largest financiers of public health in Latin America include the international financial institutions, such as the World Bank and, less directly, the International Monetary Fund. In some regards, this makes sense, given the undeniable association between economics and health. But there is a dark side to the new accounting: Such sources of funding for public health put us in the unfortunate position of relying on market forces alone to solve social problems. In the pursuit of cost-effective health care, the destitute sick are often left out altogether.
Some health care trends in Latin America have been favorable: vaccination and other interventions have lowered infant mortality; polio has been  eradicated from Latin America. Some countries, such as Chile and Cuba, have health indices similar to those registered in North America. But in most of Latin America, we have seen a shrinking commitment to public subvention of health care and a push for privatization that have led to a widening gap in access to quality health care. This is happening even as technology gives us increasingly cheap and effective therapies. And that, in my view, is the central irony of public health in Latin America: National statistics continue to suggest improvement, even here in Haiti. But the poor, as Dominique's experience illustrates, are still doing poorly.
It has been my great privilege to spend most of my adult life working as a doctor in Latin America, including many working visits to Peru and Mexico. But the country I know best, although it is sandwiched between two indisputably Latin countries, is one often forgotten in Latin American studies. When I first went to Haiti in 1983, I remember writing "West Indies" at the end of my Port-au-Prince return address. I stopped doing this after reading a multi-volume history of the U.S. military occupation of Haiti (1915-1934). The author, Roger Gaillard, had affixed his address to the inside of each volume. After Port-au-Prince, Haiti, he added "Amérique Latine."
 It was a polemic note, perhaps, but Gaillard had a point. Haiti is, in many ways, the most "Latin American" of all countries-not because it is "Latin" in having romance-based Creole for its national language, and not because it is historically Catholic, but because it has endured a history the outlines of which are familiar throughout South and Central America. When we look back at mid-century writings about the region, we find political scientists describing Latin America as poor, rural and agrarian; as having high indices of social inequality; as marked by colonialism. A trip to a poor village in Chiapas or highland Guatemala reminds one of Haiti far more than might a trip to the French overseas départements of Guadeloupe and Martinique. Political violence, among other afflictions of poverty, is endemic here. The history of Haiti's poverty-how it was generated and sustained-is important, though often forgotten. If you are interested in public health, which you necessarily are if you are sitting in a clinic in rural Haiti, you cannot forget poverty's impact on the Haitian people.
This year, 45,000 patients will come to the ambulatory clinic-as many as will come to the emergency room of Boston's Brigham and Women's Hospital,  where I also have the good fortune to work. The difference, of course, is that the Brigham has a huge medical and nursing staff, excellent laboratories and diagnostic services, operating rooms and so forth. And apart from the fact that we don't have such amenities here in Haiti, the patients are sicker. They come to us with illnesses such as tuberculosis, hypertension, malaria, dysentery, complications of HIV infection, all typically in a more advanced state than we'd see at the Brigham. The children are malnourished, and many of them will have severe protein-calorie malnutrition as well as an infection. Some will have typhoid, measles, tetanus or diphtheria (although these patients will be, like Dominique, from outside of our catchment area). Some will have surgical emergencies: abscesses, infections in the chest cavity, fractures, gunshot and machete wounds.
Haiti is often compared, unfavorably, to the Dominican Republic. Neither country has much to boast about in terms of public health. The country sited on the other two-thirds of the island has poor health indices, though nowhere near as bad as those here in Haiti. But what about Haiti's second-closest neighbor, Cuba?
 From the outside, there are striking similarities: less than 100 miles apart, the two islands have identical climates and topography. And like Haiti, Cuba has known major economic disruption in the past decade. But there the similarities end. Haiti has the highest maternal mortality in the hemisphere; Cuba's is among the lowest. Haiti has the highest infant mortality rate in the hemisphere; Cuba, the lowest (in fact, infant mortality in Mission Hill, mere yards from the front door of the Brigham and Women's Hospital, is said to compare unfavorably to Cuba's). The leading killers of young adults in Haiti are tuberculosis and HIV; Cuba has the lowest prevalence of HIV in the hemisphere, and remarkably little tuberculosis. Typhoid, measles, diphtheria, dysentery, dengue, parasitic infestations-I could go on and on-these all are common in Haiti and almost unknown in Cuba. There's a saying in Cuba: "We live like the poor, but we die like the rich." In Haiti, as in Chiapas and the slums of Lima, poor people live and die like poor people. They die of preventable or treatable infections; they die of violence.
There is a long line in front of the women's health clinic. We're hoping to recruit a new obstetrician-gynecologist. We're also in need of a pediatrician, one fluent in Creole. The operating room is closed for awhile, as we await the arrival of a full-time surgeon.
Outside, I hear the midwives chattering. When they talk to me, they speak of their own ailments. "How can I walk to deliver babies when my leg hurts so much?" queries one. Another adds, "We are hungry and do not have gloves or aprons." Definitely back in Haiti.
At the close of June 2000, the World Health Organization released an assessment of the health systems of all member states. The evaluation took into account several indicators, including quality of health services; overall level of health; health disparities; and the nature of health-system financing. Of 191 countries surveyed, the United States spent the highest portion of its gross domestic product on health, but ranked only 37th in terms of overall performance. Tiny Cuba, spending a smaller portion of its small GDP, was ranked at roughly the same level as the United States, and was one of the four highest-ranked countries in Latin America. As for "fairest mechanism of health system financing," Cuba was the number one nation in Latin America; in this category, the United States did not even figure in the top 50.
What conclusions can be drawn from these comparisons? I'm not so much interested in the ideological underpinnings of the various approaches to public health as I am in the results. Let the editorialists rant about socialism or its opposites; doctors and public-health practitioners have to be "outcome-oriented." Of course, the major debate in social policy is about what outcomes should be perceived as "of interest." For economists, such matters as GNP and external debt are the preferred indices (although these are, in my view, ideologically freighted subjects in and of themselves). For education experts, it's literacy rates.
The human rights community, interestingly, almost always narrows its focus to privileged rights of expression and representation and to exclude social and economic rights - an omission that should trouble physicians, who need supplies of tangible goods, the very tools of their trade, before they can go to work. Unless the Latin American poor are accorded some right to health care, water, food and education, their rights will be violated in precisely the ways manifested in my waiting room here in Haiti: their lives will be short, desperate and un-free.
And so I return, as always, to the health of the poor as the most telling social-policy outcome. Even as national economies and stock markets boom, the health of the Latin American poor remains abysmal by both absolute and relative criteria. This is true in Chile, Brazil, Mexico, Peru-and of course, Haiti. It's a quick enough trip from the glittering towers of Mexico's zona rosa to the squalid villages of Chiapas. In Lima, excellent highways lead past glass bank and insurance skyscrapers to the miserable invasiones of the city's northern reaches, where, as noted, rates of tuberculosis run as high as anywhere in Latin America.
The shiny towers and dismal health statistics are of course related, since the privatization of health care occurs at the same time, and as part of the same policy environment, as do massive transfers of public wealth to private coffers. This year, Peru will pay about 20 percent of its GNP to finance its foreign debt. Most of it will go to even taller towers in wealthy cities like New York. Even well-off Chile, with three times the per-capita income of Cuba, has been forced to acknowledge a growing equity gap in health outcomes.
What is to be done if we want to take stock of the health of Latin America's poor-and act purposefully? Of course, we need resources, and to be quite honest, resources should not be the problem. In this time of record profits for many industries and dazzling individual fortunes, is it unthinkable that we should spread the wealth? I just came across an interview with the chairman of Intel, a certain Andy Grove. He grew up in Hungary, he notes, during the Stalinist era. "Profits are the lifeblood of enterprise," he remarks. "Don't let anyone tell you different."
Unlikely that anyone would try, these days. Certainly not a physician sitting in a clinic in rural Haiti. But surely there is some way to redirect some part of the profit stream to take care of the destitute sick, right now. Otherwise, doctors will stand by, as helpless as Dominique's dispirited mother, watching resources flow-along the gradient established by our policies, our choices, and our blind spots-to become ever more narrowly concentrated in the hands of a few. If the health of the poor is the yardstick by which our public-health efforts in Latin America are judged, we will have a lot of explaining to do when history sits to consider our case.
This article is adapted from Paul Farmer's "Whither Equity in Health: The State of the Poor in Latin America." Read the full version at
www.pih.org.
Paul Farmer, MD, PhD, is a medical anthropologist whose work draws primarily on active clinical practice. Through Partners In Health, the public charity he helped to found, his work has focused on the prevention and treatment of diseases disproportionately afflicting the poor. He divides his clinical time between the Brigham and Women's Hospital in Boston and Partners In Health hospitals and clinics in Haiti, Rwanda and elsewhere in Africa.
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The High Price of "Cost-effective" Health Care
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