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Unless the poor are accorded some right to health care, water, food, and education, their lives will inevitably be short, desperate and unfree; these are not indicators by which we will want to be judged. Equity; Delivery of Health Care; Privatization. A waiting room in a charity clinic in rural Haiti. It is a humid afternoon, and huge drops of warm rain are starting to fall. A young woman is watching as her ten-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 , 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.

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She looks at me, sighs, and wordlessly makes a weary gesture. I know it well: What can I do? It's beyond my control. And so it is. Well beyond her control. 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.

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Typhoid, a classic public health problem, is caused when drinking water is polluted by human feces. Not her fault. Ours perhaps, I think immediately. 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. Assessing public health in Latin America is a treacherous exercise.

This is not because it is impossible to evaluate the state of the region's health, nor is it because the admittedly enormous variation, both across and within nations, leads to analytic impasse. 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. In the past, such assessments may have been easier, and not because public health was then a more robust undertaking.

Rudolph Virchow has been called the father of social medicine, and it was he who termed doctors the natural attorneys of the poor.

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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, increasingly with the assistance of international experts. The welfare state that we think of as having been progressively built up, from the s to the beginning of its decay in the s, barely got a start in Latin America before debt, the cupidity of local strongmen, and the agenda-setting of First World economic advisers attempted to terminate it as a public responsibility.

The health of the poor is now deemed less important than what is often termed cost-effectiveness, which too often calls for minimizing the drain on national budgets increasingly dedicated to the supposedly higher goals of debt service and privatization. Those struggling to promote the health of the hemisphere's poor are now in the defensive position of having to show that proposed interventions are both effective and inexpensive, regardless of the gravity of the health problem in question.

Some would be surprised to learn that 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, as even a physician can see: such sources of funding for public health place us within a framework developed by economists working within a paradigm in which market forces alone are expected to solve social problems. As efforts are made to determine whether or not an intervention is cost-effective, the destitute sick are often left out altogether.

As time has gone by, certain trends have become palpable within much of Latin America. Some 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 see that a shrinking commitment to public subvention of health care and a push for its privatization have led to a widening gap in access to quality health care.

These trends are registered even as the fruits of science become ever more readily translated into 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 suggests, are doing poorly. They are doing a bit better than in previous decades, but much less better than might be expected, if the fruits of science and technology were used wisely and equitably.

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. I stopped doing this after reading a multi-volume history of the U. The author, Roger Gaillard, had affixed his address to the inside of each volume.

It was a polemic note, perhaps, but Gaillard had a point. 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 once European, now a condition described as being in the sphere of influence of the U. On each of these counts, the most extreme example is Haiti. One of the reasons Haiti has become so Latin American is that it has had more time to do so. Haiti is the oldest republic in Latin America, independent at least in name since Although Latin America has changed enormously since mid-century, there is a part of every Latin American country that has much in common with Haiti.

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 departments of Guadeloupe and Martinique. Political violence, among other afflictions of poverty, is endemic here. Haiti is the sickest of New World republics I am writing this essay in our clinic, between emergencies.

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. The difference, of course, is that the Brigham has a huge medical and nursing staff, excellent laboratories and radiographic services, operating rooms and blood banks, is located in the middle of a region dedicated to advanced medical research, and so forth.

And apart from the fact that we don't have such amenities here in Haiti, the patients are sicker.

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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.

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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. Or they will be pregnant and sick. Few things are more tragic than third-trimester catastrophes: eclampsia, arrested labor, hemorrhage.

As I write these lines, the local midwives are meeting outside. None know how to gauge blood pressure. Many feel overwhelmed. And justifiably so. Maternal mortality is higher in Haiti than anywhere else in Latin America. In one study, conducted a decade ago around the town of Jacmel in southern Haiti, maternal mortality was 1, per , live births.

It's under 20 in Cuba, Jamaica, St. Lucia, and the U. Our clinic's obstetrician-gynecologist long ago left for Florida, where he joined a community of more Haitian physicians than are now present in all of rural Haiti. When I first went to Mexico it was on a visit to the national school of public health, in beautiful Cuernavaca.

This looks nothing like Haiti, I thought. Then I started visiting Chiapas, and had something with which to compare both Haiti and Cuernavaca. Peru was another eye-opener: although significantly less poor than Haiti, the slums of northern Lima recalled the dusty towns of northwest Haiti.

What's more, disruptions in the economies of these countries were felt immediately among the people who were my hosts in each of these settings. As in Haiti, the poor felt the impact of adverse trends before any others; their health suffered, often grievously. Haiti is often compared, and 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, if nowhere near as bad as those here in Haiti.

But what about Haiti's second-closest neighbor? There are some similarities in initial conditions: less than miles apart, the two islands have identical climates and topography. And like Haiti, Cuba has known major economic disruption in the past decade. The impact on Cuba of the breakup of the Soviet Union, which contained its major trading partners, has been much commented upon.

From onward, the Miami papers have been full of predictions of the imminent fall of Castro and the end of communism in Cuba. But in fact Cuba, unlike Haiti or Chiapas or Peru, has not known significant unrest or political violence. The Cuban economy, however, did sustain major blows. This was as severe a contraction as that faced by any Latin American economy.

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