Kasensero, Part II

A few weeks have passed since I traveled to Kasensero and I have a few more thoughts I’d like to share. There is a level of indignation I failed to express in the previous blog post which has been smoldering, waiting to catch fire. Also, I've posted some pictures of Kasensero on Facebook - just click on the link to view them.

Yesterday I finished reading a book entitled Mountains Beyond Mountains, by Tracy Kidder. It’s a biography of Dr. Paul Farmer, a Harvard physician famous for his tireless work in the central plateau of Haiti – the poorest country in the Western hemisphere – to improve health care there. Farmer advocates a “preferential option for the poor” that is backed by his belief in liberation theology. Liberation theology was developed by priests in Latin America who preached that “the oppression of the poor was ‘institutionalized sin’” and as Christians we are fundamentally called to do something about it. For Farmer, this translates into a duty to serve the poor of the world, to work toward rectifying the stark inequality humanity has created between the rich and the poor. Kidder writes:

How could a just God permit great misery? The Haitian peasants answered with a proverb: “Bondye konn bay, men li pa konn separe,” in literal translation, “God gives but doesn’t share.” This meant, as Farmer would later explain it, “God gives us humans everything we need to flourish, but he’s not the one who’s supposed to divvy up the loot. That charge was laid upon us.” Liberation theologians had a similar answer: “You want to see where Christ crucified abides today? Go to where the poor are suffering and fighting back, and that’s where He is.” Liberation theology, with its emphasis on the horrors of poverty and redressing them in the here and how, its emphasis on service and remediation, seemed to fit the circumstances in Haiti. (p79)

Fundamental to this argument is the global (mal)distribution of resources, particularly those allocated for health care. Farmer is frequently criticized in his work for not adhering to standards of ‘cost-effectiveness,’ ‘sustainability,’ and ‘appropriate technologies’ for health development work in resource-limited settings in developing countries. Again, Kidder writes:

“Resources are always limited.” In international health, this saying had great force. It lay behind most cost-effectiveness analyses. It often meant, “Be realistic.” But it was usually uttered…without any recognition of how, in a given place, resources had come to be limited, as if God had imposed poverty on places like Haiti. Strictly speaking, all resources everywhere were limited, Farmer would say in his speeches. Then he’d add, “But they’re less limited now than ever before in human history.” That is, medicine now had the tools for stopping many plagues, and no one could say there wasn’t enough money in the world to pay for them.

What it ultimately comes down to is how much human life is valued. Farmer would argue that “cost-effectiveness” frequently translates into the lives of the poor being less valuable than the lives of the rich – those who can afford quality health care, or who live in a country where it is provided for them. In essence, he medically treats his Haitian patients in the way he himself would want to be treated as a patient.

Now, coming back to Uganda. Kasensero, in many ways, might as well be central Haiti. Its people are impoverished, socially and economically isolated by a nearly impassable road, in addition to a dying fishing industry. This road is such a huge source of frustration that the head of the Kasensero fisherman’s association was recently caught on the local news with his hands around the neck of the head of the district, who has been offering empty promises to pave the road for years. The HIV/AIDS epidemic there is like a magnifying glass held up in the sun: it distorts and enlarges the underlying inequity and, if left long enough, will cause it to burst into flames. Scores of children are being orphaned, not to mention contracting HIV, and social support networks are stretched to the point of collapse.

What makes me most angry is that the world outside of Kasensero knows about it, yet little has been done. Epidemiologic studies have shown that HIV probably originated in what is now the Democratic Republic of Congo and migrated east. Uganda was one of the first places that was hit, and it was hit hard. Over 20 years ago, the first case of HIV/AIDS was reported out of Kasensero. The Rakai District, in which Kasensero lies, has been a source of a prolific number of research projects and landmark published papers on the HIV epidemic. Yet there seems to be little to concretely show for it in Kasensero. After 20 years of knowing about a burgeoning epidemic, there is only a tiny clinic staffed by nurses, with no permanently stationed physicians. Supposedly someone comes every two weeks to distribute antiretroviral drugs. But these drugs, if not carefully managed and monitored, can have deadly side effects. I have no idea what HIV+ patients do if they have problems with their treatments regimens, or develop an opportunistic infection. It would take them 3 hours at least to travel to the nearest hospital, assuming they can find and afford transport, and that it doesn’t get stuck on the road on the way. They also have to be able to afford the cost of hospitalization.

HIV is only one of Kasensero’s health problems. The day I left, a concerned set of parents approached me to look at their 1 ½ year old child. She looked like she was about 9 months old and couldn’t hold her head up well. They told me she couldn’t walk and was not yet saying any words. In sum, she was grossly underdeveloped for her age and had some signs of mild flaccid paralysis that had been present for some time, according ot the parents. Upon further questioning, the mother had delivered at home and the child had not received any vaccinations at all. In fact, I was the first medical professional who had ever seen the child. There were many things that it could have been, some preventable, some not. The child could have had a polio infection or cerebral palsy, possibly due to injury during pregnancy or birth. She also could have had a genetic muscular dystrophy. My first internal reaction was to be irritated with the parents, that they hadn’t taken the child to see a medical professional before then. It seemed to me there was little excuse for not vaccinating children when vaccines are free. Yet after some reflection I began to feel that it is the health care system that has failed these parents, and this child. If there were trained birth attendants at every birth and community health workers to conduct child vaccination campaigns, or do home visits to check on neonates and mothers perhaps things would have turned out differently.

A ‘preferential option for the poor’ does not mean that it is the sole burden of the poor to rectify their own oppression and unequal treatment. Moreover, the poor cannot ‘fight back’ when they are dying of AIDS, malaria and tuberculosis. In answering my call to become a physician, it is my duty to go to the poor, meet them where they’re at, especially in miserable places like Kasensero. Especially there. Farmer says, “It’s through journeys to the sick that we identify needs and problems.”

God never promised it would be easy to fight against oppression or serve the poor. But, for Christians, He very clearly called us to do it. My pastor, Bill, once preached a sermon about a man who decided to physically cut out every reference to serving the poor in the Bible. Once he was done the book barely held together – the tattered pages had gaping holes through the Old and New Testament. This image struck me as incredibly profound. The physical representation of my faith, the word of God, literally does not hold together if you take out the call to serve the poor.

To whom much has been given, much will be required. Luke 12:48