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Who Lives and Who Dies?

Paul Farmer
Trauma Center at Public Chicago Hospital Treats Severely Injured

This article originally appeared in the London RevWhat 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?

The people I lived with in the hills of central Haiti had a concise way of putting it: These were “stupid deaths.”
Our grandiose 1987 mission statement—most of us were still students—even promised to serve as “an antidote to despair.” Much of the despair we’d seen was generated by the “OOPS approach” to sickness. “Out Of Pocket Spending,” a leading cause of destitution in countries rich, poor, and in-between, was largely responsible for the stupid deaths we witnessed, since the care people paid for was expensive and mostly bad. PIH committed itself to the fight for health care as a human right. Such a right was in principle guaranteed by governments, even if they were unable, alone, to provide both health care and protection from destitution caused by a lack of health insurance. That meant PIH would try to help public health authorities to do their jobs, an aspiration dismissed as silly or worse by most other NGOs. We knew little about (and had nothing against) private health insurance, but we’d seen what it meant to be poor and sick or injured. The vast majority of Haitians had no insurance, public or private; they paid for their poor-quality health care, and inadequate education, with their own scarce cash.

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.

Unlike my Haitian co-workers, in 1988 I escaped a stupid death. Outside my friend’s house in Cambridge, I ran to catch a bus. A car in the first lane slowed and waved me across Huron Avenue. I turned back to my friend and, referring to my paper, said: “You’re not paying attention.” A car in the second lane hit me, knocking me in front of the bus, which swerved just in time. I tried to get up and out of the way of the traffic, but failed: My left leg was broken. But lying in the road, I was already grateful for two things: that the bus I’d missed had missed me, and that I would soon be in a proper hospital. The doors to the House of Yes would swing open. But there was more than a touch of the OOPS plan evident here, too, and a dysfunction I could see even before I reached the emergency room. “We’re taking you to Sancta Maria Hospital,” one of the ambulance crew said. I’d never heard of Sancta Maria; the ambulance service, a private and for-profit concern, must have had some sort of contract with it. I asked instead to be taken to the Mount Auburn, a Harvard teaching hospital less than half a mile away. From the Mount Auburn I was transferred, again by ambulance, to the emergency room of Massachusetts General Hospital, which I’d just left after a long clinical rotation. My orthopedic surgeon would be Dr. Boland, the surgeon for the local professional football team.

The first dose of morphine (a cheap drug, but one largely unavailable in Haiti as in much of the poor world) made me voluble and almost cheerful. If Dr. Boland could patch up the New England Patriots and return them to the field, surely he could put me to rights; I’d be back in Haiti in no time. In the second ambulance with me was another friend, an emergency physician from Colombia. We talked about Pinochet—it was the day of the plebiscite in Chile that denied him another eight years in power—whose many sins had included the dismantling of the country’s public health care safety net.

The emergency room of MGH was, in those days, chaotic, poorly laid-out, and slow, as the Colombian doctor complained to the nurse. My morphine-induced euphoria began to give way: The pain returned and my leg looked less amenable to repair. Nausea, whether from the morphine or from too little of it, was taking over. It was some time before the orthopedic resident showed up. Knowing I was a medical student, she spoke telegraphically: “Your knee is destroyed. You will go to the OR as his first case.” She was referring to Dr. Boland. “Anesthesiology will come and see you tonight; not sure when; they’re busy too.” In those days, doctors-in-training and students, rather than phlebotomists, drew blood at night, with varying success (this at one of the best resourced hospitals in the world, and one of the oldest in the United States). The resident stuck a needle in the crook of my arm and popped a glass tube into the plastic sleeve on the bevelled surface of the other end of the needle. Instead of dark, homogenous venous blood, a raspberry-and-cream swirl of blood and fat came out of my arm. Fat in the bloodstream after an injury like mine signaled the possibility of a fat embolus, a rare but potentially fatal complication of long-bone fractures. “I will have the anesthesia resident come right away,” she said, more gently. “Just in case.”

I gave myself up to illness. The next dose of morphine, long overdue, made me vomit, and by morning I was happy to be wheeled to Dr. Boland’s operating room. It was more than a month before I returned to Haiti, in a wheelchair, and three months before I walked without a crutch or a cane. But I knew, even as I saw—for the first time as a patient—the imperfections of our medical system, that I’d been given excellent surgical and nursing care. After five years between Harvard and Haiti, I knew I was lucky to receive it.

What did my failure to look before crossing the road cost? It’s smarter to think of price, rather than cost, in the crazy and profoundly ideological arena of health care financing. All told, the price of my care was about twice my widowed mother’s annual salary as a grocery store cashier. How was it paid, given that in 1988 she, like all but one of her six children, was a student? By the private health insurance provided to students at Harvard. It covered most of the bills, though I was hounded for more than two years by the ambulance service that had taken me to two of Harvard’s teaching hospitals in one night. For some reason my student insurance didn’t cover that expense, or perhaps I made a mistake filling out the stacks of forms that piled up along with the “co-pays” for medication, crutches, renting a wheelchair, and physical therapy—all obtained from different companies rather than from the hospital.

Published: MARCH 15 2015. By Paul Farmer

Copyright © 2014 The Slate Group LLC.

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