As per Dr. William Muller, Children's Memorial Hospital, Chicago, IL:
1. The average of two standards of care is not a third standard of care.
2. Vaccines are not a religion.
3. Always ask: where and how?
4. Antibiotics are not anti-pyretics.
5. Never pull out the big guns without an exit strategy.
Tuesday, October 20, 2009
Saturday, October 3, 2009
A terrible commerce: Bourdieu, capital accumulation, and growth failure among indigenous children in rural Guatemala
Presented September 2009 at Society for Medical Anthropology annual conference, Yale University.
This paper was one of 5 in a panel organized by Bridget Hanna and me: "Global Health and Social Theory: Practice, Pedagogy and Unintended Consequences
...
Since I began collaborating in community health interventions in Guatemala in 2007, I have felt so utterly demoralized at times that I think I’ve hit rock bottom. Struggling against the baleful synergies between disease and structural violence, as a medical student and wannabe anthropologist among the indigenous, rural poor in the Kaqchikel highlands, I have been faced with the abominable tasks of explaining and making sense of the unnecessary suffering and irredeemable deaths of patients, friends, and colleagues. If, as Paul Farmer writes, engagement with the indigent sick makes for a “vital practice,” shaping my imagined life-work in exciting ways, it has been in learning to write ethnography and think with social theory that I have found some solace. Even if we failed to identify any pragmatic contribution to be made by social theory to the clinical practice of social medicine, for me, at least, the practices of reading and writing—hobbies or not--have become central to my sense of who I am. Experiences, memories and vignettes about people and places compel me to go back to the communities I have grown to care about, but compulsions like this can be ignored until they become cold. It is in the application of social theory, implicit but nonetheless palpable in the vignette I will present shortly, that I have found new spaces to imagine solutions and renewed the desire to make meaning, permitting to keep going as often as I can.
This paper was one of 5 in a panel organized by Bridget Hanna and me: "Global Health and Social Theory: Practice, Pedagogy and Unintended Consequences
...
Since I began collaborating in community health interventions in Guatemala in 2007, I have felt so utterly demoralized at times that I think I’ve hit rock bottom. Struggling against the baleful synergies between disease and structural violence, as a medical student and wannabe anthropologist among the indigenous, rural poor in the Kaqchikel highlands, I have been faced with the abominable tasks of explaining and making sense of the unnecessary suffering and irredeemable deaths of patients, friends, and colleagues. If, as Paul Farmer writes, engagement with the indigent sick makes for a “vital practice,” shaping my imagined life-work in exciting ways, it has been in learning to write ethnography and think with social theory that I have found some solace. Even if we failed to identify any pragmatic contribution to be made by social theory to the clinical practice of social medicine, for me, at least, the practices of reading and writing—hobbies or not--have become central to my sense of who I am. Experiences, memories and vignettes about people and places compel me to go back to the communities I have grown to care about, but compulsions like this can be ignored until they become cold. It is in the application of social theory, implicit but nonetheless palpable in the vignette I will present shortly, that I have found new spaces to imagine solutions and renewed the desire to make meaning, permitting to keep going as often as I can.
I have found Pierre Bourdieu’s (1990) typology of capital to be very productive for making meaning and explanations, and for acting in my lifeworlds, and in the following vignette I have attempted to highlight the transactions and forceful deployments of social capital (that is, the force of relationships), cultural capital (that is, the force of privileged epistemology and habitus), and economic capital. In the case of child malnutrition in Guatemala—as in many other cases—I think we must consider bodily and biological capital in the flows that comprise this abhorrent commerce. Bourdieu’s typology of capital can be augmented by more economistic and biological
considerations, and global health practice can become more sophisticated and effective by deploying Bourdieu’s analytic method. The consequences of child malnutrition are pervasive and debilitating. An analysis of epidemiologic studies suggested a significant association between child malnutrition and mortality that could not be attributed merely to confounding by socioeconomic factors or intercurrent illness; extensive reviews of published empirical data subsequently concluded that malnutrition is indeed an underlying cause of childhood mortality from diarrhea, acute respiratory illness, and malaria. (Pelletier, 1994; Rice, 2000; Caulfield, et al, 2006; WHO, 1995) Poor infant and childhood nutrition in the first two years of life is associated with impaired neurodevelopmental attainment, manifested as poor school performance, fewer years of schooling and, ultimately, deficits in productivity and inequalities in health in adulthood. (Lissauer, 2001; Caulfield, et al, 2006) By paying attention to the transactions—and to the quality and quantity of capital we bring as clinical or ethnographic practitioners—I think we begin to have a methodology for devising social strategies in solidarity
with the sick and poor.
…
There is an abandoned stable on a defunct German plantation in the central coffee-growing piedmont of Guatemala, where, this past Tuesday, two “health promoters,” arrived from their nearby communities, also former coffee plantations, and began setting up to weigh the children who are being raised there. The “health promoters,” Vicente and Dominga, are trained as nurses
and are able to provide some basic but quite competent primary care during these visits. They have some medicines—amebicides, antibiotics, anti-helminthics, even equine-dose ivermectin—a rare commodity where onchocerciasis is endemic and human-dose formulations of ivermectin are strictly rationed. Therapeutic decisions for the children who present with acute cases, or just as often, acute exacerbations, of diarrhea, are made on the basis of very crude symptom-based algorithms. Despite Vicente’s eagerness to have me teach them to do stool microscopy for ova and parasites, the only microscopes that were donated to us were unrepairably broken.
Finally, when it seemed that we might be able to obtain a functional microscope from an itinerant parasitologist and physician, our efforts in this respect were convincingly discouraged by those who were concerned that the health promoters’ free stool studies would create
unwelcome competition for local labs, which in turn would undermine their valuable support for Vicente and Dominga’s existing efforts--and the support of these labs and associated clinical facilities has, in fact, been quite valuable. In any case, the aforementioned medicines, as well as stethoscopes, otoscopes and other supplies, are provided by a local Catholic mission. Vicente and
Dominga also receive some support from a pediatrician at Stanford, Paul Wise, who applies and holds pressure as necessary to maintain their stock of medicines, as well as a steady supply of Incaparina, a cornmeal-based therapeutic food. (To me, the irony of providing a cornmeal-based therapeutic food to children whose ancestors were responsible for domesticating maize, is quite grotesque.)
But after a few hours here in “Nueva Providencia”--New Providence--it becomes clear that much more is needed. This slow trickle of pharmaceuticals and calories—which can feel like quite a bit on the backs of those carrying it across the stream and up the hill to the abandoned stable--is overwhelmingly inadequate. The national prevalence of stunting, or deficits in height for age,
among children under-5 y/o in Guatemala is ~40 %, which is already the worst rate in the hemisphere. In this particular community, according to data collected by Vicente and Dominga, it is closer to 70%. Incidentally, the space and time necessary to collect that data were made available to the health promoters through the intervention of Paul Wise. Again, as a pediatrician at Stanford who is engaged in community health interventions and biosocial research, in Guatemala and elsewhere, Paul has access to funding—capital—that can help Vicente and Dominga set aside enough time to collect anthropometric data to guide and evaluate their interventions in the communities they serve.
When presented with Vicente and Dominga’s independently collected data, the functionaries at the local statesponsored healthcare NGO refused to make any changes to their reports to municipal and departmental authorities that rates of malnutrition have stabilized at around 30%--better, that is, than national indicators. One health promoter, Rogelio, who works closely with Vicente and Dominga, expressed his anger at the government functionaries’ rude dismissal of their concerns. “We are not malnourished,” he was told by the administrator, “we are ‘chapines’—Guatemalans—that’s just the way we are.” The government functionary—a man with a relatively comfortable salary and a home in the center of town—could afford to dismiss the concerns of a “muchacho de la finca”—“a boy from the plantation.” A medical and public health student at Stanford, nonetheless, is working with Vicente, Dominga and others to publish their independent data.
In the face of what is now being referred to grandiosely as “the financial crisis,” the state-sponsored NGO announced in November 2008 that due to central government budget cuts, they would discontinue community health and primary care services until further notice. Curiously,
the services to be discontinued did not include growth monitoring nor other data collection activities. Rising unemployment and the 2nd consecutive coffee crop failure exacerbated the effects of the acute-on-chronic crisis for poor families in Nueva Providencia. The water pump in Nueva Providencia broke last year, leaving half the households in the community without any water source, which is to say nothing about its potability. In fact, even before the water pump broke, Vicente and Dominga, again with donated supplies, had conducted their own tests and detected heavy coliform contamination of the water in Nueva Providencia.
…
There are many ways to begin to approach the difficulties of the situation I’ve described. Paul Wise, for example, is concerned about the synergies between unequal pediatric health outcomes and what he calls “failed governance,” for example, the relationship between infant mortality (120 per 1,000 live-births in some communities, three times the national average) and a concomitant neoliberal neglect of public services and burgeoning of an unregulated, uncoordinated and inexpert Third Sector to fill the gaps--which, incidentally, I am a part of, as a medical student who is forced by necessity and scarcity to provide clinical services beyond his level of official training and without basic resources. Vicente, also, can be disarming and
eloquent when he engages with this sort of biosocial analysis. But his more immediate concerns are of a different sort, as expressed in a recent email: “nos miraremos de repente si es posible para unos c.d. regrabables para informes anuales y un cargador de baterías se lo agredece mucho cuidese mucho saludos de Vicente y José Eduardo” [“we’ll see each other by chance if it is possible for some re-writable CD’s for annual reports and a battery charger, you are much thanked, take care, greetings from Vicente and José Eduardo [Vicente’s 3-y/o son]”].
Vicente has learned from experience that it will be a few months, yet, till I graduate from medical school and before he will be able to convince me to bring antibiotics and amebicides when I travel from Chicago or Boston to Guatemala. Until then, besides my continuing accompaniment and support as their “doctorcito, ri tijoxel chin aq’omanel, mo’s, qa-visitante, ntzijon pa qachab’al” [“little doctor,” “the foreigner, our visitor who speaks our language”), what are the most important things he wants from me?
Re-writable CD’s and a battery charger, the latter for his digital camera! He is meticulous in documenting the problems facing their patients, as well as their efforts to alleviate their suffering.
…
This is, of course, one of the recurrent and compelling apologias for an anthropology of suffering as witnessing. I personally do not know if I am entirely convinced by the moral force of such cultural capital, and I certainly do not believe in a mechanistic interaction between economic
capital and social and cultural capital—otherwise, I would be much more successful than I have been in getting my friends and loved ones with means, and grantmakers and foundations, to give cash and in-kind donations.
Ultimately, tracing the movements of capital makes me hopeful because I see points where I can intervene. While anthropology is personally, intellectually and clinically important to me, then, I must admit that very utilitarian stakes are in play for me as I continue this hobby of medical anthropology. Ultimately, medical anthropology’s place at the margins of clinical medicine seems to be the most effective space for clinicians who hope to marshall capital in various forms towards the alleviation of suffering in places like Nueva Providencia.
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