Whither Equity in Health?
The State of the Poor in Latin America [continued...]


By Paul Farmer, MD MPH *

page 5

Some years ago I turned, with fascination and a bit of dread, to comparing these two neighbors. 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). 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- all are common in Haiti and almost unknown in Cuba. I could rattle off any number of indices leading to the same contrasts. 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. Why, then, do Cubans leave Cuba? One of the reasons is probably that poor people are not satisfied to die like rich people, they want to live like them, too. This is for me a philosophical question rather than a medical one; I have not interviewed poor people who die of the same diseases that end affluent lives in their eighth decade. The people who crowd our waiting rooms here in Haiti do not have such expectations; they do not have such life expectancies.

I recently went to visit the new Escuela de Medicina de las Americas, with which Cuba proposes to serve the hemisphere by training a new generation of doctors. Say what you will about propagandistic intent, transforming- in less than a year- a naval base into an international medical school is the ultimate in swords-into-plowshares. The facility was attractive and clean. There were few supplies, of course, and not much in the way of textbooks. But the student body came from all over Latin America. And they looked quite different from the students I had met in the capital cities of the region. Several of the students from Bolivia, Mexico, and even Colombia had the look of indigenous people, the ones you could imagine seeing scorned for their appearance or their accent in the streets of La Paz or San Cristobal de las Casas. 

I was there to beg for medical school spots for rural Haitians, of course, and the Cubans were more than interested. My tour guide was none other than Dr. José Miyar, a Secretary of State and one of the leading figures in the development of Cuba's health sector after the revolution. We spoke about Haiti and other countries with similar health indices. "Maternal mortality?" commented the white-haired doctor, looking pained. "Not merely a tragedy in itself, but the cause of a long chain of tragedies for the other children who survive. For then comes malnutrition, diarrhea, and, often enough, death for these children."

Maternal mortality brings me back from pleasant memories; I am not visiting Cuba this morning, but opening office hours in Haiti, the place I call home. 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. We've had offers from U.S. physicians, but need fluent Creole speakers. The operating room is closed for a while, as we await the arrival of a full-time surgeon. She is Cuban.

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? Audiences in the United States, I have found, are not pleased to hear such analyses. But if they are revealing and startling, surely there is some point in discussing them? I know that I'm not so much interested in the ideological underpinnings of the various approaches to public health as I am in the results, as manifest in morbidity and mortality rates. 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 privilege 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 manifest in my waiting room here in Haiti: their lives will be short, desperate and unfree.


Just ask the Cuban doctors now working here. There are probably more Cuban physicians in rural Haiti than there are Haitian doctors (remember: the Haitian M.D.s are in Port-au-Prince, Florida, New York, Montreal, et cetera). What do the Cubans do when they encounter patients so poor that they cannot fill prescriptions, buy intravenous solutions, or feed their children? The Cubans are well trained, clearly, and skilled at making the most of scanty resources. But all the training in the world cannot substitute for a healthcare system. They, too, will have to start from scratch-and learn to beg for supplies, as we all do down here- if they wish to serve the Haitian poor.

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% 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.

Watching the health of the poor is the best way to assess public health in Latin America, but these days there is more enthusiasm for "environmental report cards" than for this once-respected marker. Indeed, the rain forests and their non-human fauna seem to occasion more comment than the premature deaths of the hemisphere's poor. The poor in most poor countries are living in the worst of the industrial world's off-scourings, surrounded by bad air, bad water, bad soil, and working, when they can find jobs, under dangerous conditions; but it is a rare First World environmentalist who recognizes them as deserving to be "saved" no less than the forests, the whales and the tree frogs.

Back to our waiting room. 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 for them 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 or our descendants will have a lot of explaining to do when history sits to consider our case.

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*Paul Farmer, MD, PhD,  is a medical anthropologist whose work draws primarily on active clinical practice: he divides his clinical time between the Brigham and Women's Hospital (Division of Infectious Disease) and a small charity hospital in rural Haiti.  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.  The Program in Infectious Disease and Social Change, which Farmer runs along with his colleagues in the Department of Social Medicine, has pioneered novel, community-based treatment strategies for sexually transmitted infections (including HIV), drug-resistant typhoid, and tuberculosis in resource-poor settings.

Bibliography and Other books on the website of Partners in Health