Tuesday, December 6, 2011
Development in Guatemala: history, political economy, ethnography
The abstract is available here. The paper as a whole is worth reading if you have access, if I do say so myself.
Wednesday, October 12, 2011
Do not be afraid...
...to really want what you desire.
I pledge to really want: pneumococcal conjugate vaccine for the indigenous and poor in rural Guatemala.
Description of the problem:
In rural Guatemala, Maya children are theoretically at increased risk of invasive infection with encapsulated organisms, not only for socioeconomic reasons, but also via possible genetic or hereditary mechanisms. This theoretical risk is based on data from populations served by US Indian Health Service (primarily Apache, Alaskan native and Navajo nation) and Canadian Inuit and First Nations populations.
Evidence for multiple etiologies for this elevated risk has been presented (increased nasal carriage, inadequate vaccine coverage, dysfunctional maternal-to-infant transmission of passive immunity to encapsulated organisms, increased host and community susceptibility, i.e. genetic polymorphisms that decrease immunogenic response to encapsulated pathogens and/or vaccine components vs. underlying malnutrition vs. poor living conditions and crowding vs. inaccessibility of healthcare services), and the importance of timely and universal immunization against lethal encapsulated organisms of among indigenous populations in North America is well established, and some have even advocated "enhanced" vaccines and vaccination schedules for this at-risk population. (See: Lancet 1996;347(9000):517-20; Pediatrics 1999,104(3 Pt 1):564-7; Lancet 1996 Feb 24;347(9000):517-20; Am J Dis Child 1986, 140(9):943-6.)
Unfortunately, because of limited health services in rural areas of Guatemala and the long-standing marginalization of Maya communities, little to no research has been done on the elevated risk that encapsulated organisms may pose to indigenous Guatemalans. The single epidemiologic research study from Guatemala (Pubmed search terms, July 8, 2010: ("Haemophilus influenzae"[Mesh] OR "Streptococcus pneumoniae"[Mesh]) AND ("Guatemala"[Mesh] OR "Indians, Central American"[Mesh])) is based on cases presenting to large biomedical centers in Guatemala City--centers that are accessible to few impoverished, rural Maya communities; these studies, thus, suffer from distortions due to selection and severity biases (Int J Infect Dis. 2008 May;12(3):289-97). Moreover, besides one study on shifting antimicrobial sensitivity of nasopharyngeal S. pneumo isolates in Guatemalan children (Int J Infect Dis 2008, 12(3):289-97), and another on passive immunity via breastfeeding (Adv Exp Med Biol 1991;310:1-15), the only published study on prevention of invasive infection with encapsulated organisms in Guatemalan children is based on 103 Guatemala-to-US adoptees from Guatemalan orphanages and foster homes between 1988-2004 (Pediatrics 2005; 115(6):e710-7).
The latter data showed that 46% of the 103 adoptees had any (i.e., adequate and inadequate) documented vaccination against Hib, and only 26% of the 103 adoptees had adequate, documented vaccination against Hib. That is, about one-quarter of this cohort of Guatemalan children met the recommended standards for immunoprophylaxis against Hib. Of course, this data also suffers from selection bias, as protection and healthcare in orphanages and foster homes, most of which will be in larger urban centers, may be quite dissimilar from the experience of the general population of rural Maya children. This cohort of children should not be taken as a representative sample of pediatric preventative care in Guatemala, as they were being actively optimized, from legal, biomedical and moral standpoints, for adoption by concerned and sympathetic families in the US. Moreover, while the sample size (n = 103) lends an added measure of biostatistical robustness to the analysis, the cohort was accumulated over the course of sixteen tumultuous years in recent Guatemalan history. Even from a limited biomedical perspective, this cohort is neither homogeneous, spanning the years when Hib vaccination would have been introduced in Guatemala (late 1980's to early 1990's), nor representative, polysaccharide pneumococcal vaccination having been introduced briefly in the mid-2000's (indeed, no mention is made of pneumococcal vaccination status in this paper). More broadly, in sociological and historical terms, the years between 1988-2004--to say nothing of the years since--saw huge upheavals in the organization of the Guatemalan government and health systems (e.g., the transition to democracy in the 1990's, and the neoliberalization of rural healthcare in the 2000's).
In short, there is insufficient data on the risk of and rates of vaccination against invasive pneumococcal and H. influenzae, type B disease in Guatemalan children, particularly in rural areas where majority Maya communities may have both a higher incidence and severity of infection due to encapsulated organisms. According to official sources, national coverage with 3 doses of Hib is 92%, thanks in large part to a combined Hep B/Hib/DTaP (i.e. Pediarix) that was introduced in 2005. No similar data is available, however, for pneumococcal vaccination. Children do not routinely receive this vaccine, even though many government-issue vaccination cards actually include a blank space for PCV7 (and, on some newer cards, even PCV13). The Guatemalan Association of Infectious Diseases, the Guatemalan Pediatric Association and the Guatemalan Internal Medicine Association justify the absence of PCV7 in governmental community outreach programs in rural areas by citing WHO guidelines that "countries should consider implementing pneumococcal vaccination, especially countries with under-5 mortality > 50/1000 live births"--the official national rate in Guatemala being 35/1000, which hides the same regional and ethnic disparities that I have alluded to above--"and countries with total under-5 deaths >50,000"--the official national rate being 15,000. This line of argumentation assumes that we cannot truly want what is only humane to desire: it assumes that it is impossible to make morally and statistically significant improvements on the rate of infant and child mortality.
My task, then, is to have the courage to really want a world where indigenous Guatemalan children are protected against unnecessary death due to invasive pneumococcal disease. In pragmatic terms, it will be necessary to mount direct assaults on intellectual property rights by establishing strategic alliances that re-establish and protect the domain of the biomedical commons.
---
Citations:
Clin Infect Dis 2000, 31(1):34-41; Clin Infect Dis 2010, 50(9):1238-46; Pediatr Infect Dis 2009, 28(8):711-6; Clin Infect Dis 2008, 47(4):476-84; J Infect Dis 2007 Oct 15;196(8):1211-20; J Infect Dis 2007 Jul 1;196(1):104-14; JAMA 2007, 297(16):1784-92; Clin Infect Dis 2007, 44(9):1173-9; Vaccine 2007, 25(19):3816-26; Am J Epidemiol 2004,160(3):270-8; Lancet 2003,362(9381):355-61; J Infect Dis 2003 Jul 1;188(1):81-9; Pediatrics 1999,104(3 Pt 1):564-7; J Infect Dis 1994, 170(2):461-4; J Infect Dis 1994,170(2):368-76; J Infect Dis 1994, 170(2):368-76; Arch Intern Med 1992, 152(8):1641-5; J Infect Dis 1974,130(1):67-9; Am Rev Respir Dis 1974;109(5):577-8.
I pledge to really want: pneumococcal conjugate vaccine for the indigenous and poor in rural Guatemala.
Description of the problem:
In rural Guatemala, Maya children are theoretically at increased risk of invasive infection with encapsulated organisms, not only for socioeconomic reasons, but also via possible genetic or hereditary mechanisms. This theoretical risk is based on data from populations served by US Indian Health Service (primarily Apache, Alaskan native and Navajo nation) and Canadian Inuit and First Nations populations.
Evidence for multiple etiologies for this elevated risk has been presented (increased nasal carriage, inadequate vaccine coverage, dysfunctional maternal-to-infant transmission of passive immunity to encapsulated organisms, increased host and community susceptibility, i.e. genetic polymorphisms that decrease immunogenic response to encapsulated pathogens and/or vaccine components vs. underlying malnutrition vs. poor living conditions and crowding vs. inaccessibility of healthcare services), and the importance of timely and universal immunization against lethal encapsulated organisms of among indigenous populations in North America is well established, and some have even advocated "enhanced" vaccines and vaccination schedules for this at-risk population. (See: Lancet 1996;347(9000):517-20; Pediatrics 1999,104(3 Pt 1):564-7; Lancet 1996 Feb 24;347(9000):517-20; Am J Dis Child 1986, 140(9):943-6.)
Unfortunately, because of limited health services in rural areas of Guatemala and the long-standing marginalization of Maya communities, little to no research has been done on the elevated risk that encapsulated organisms may pose to indigenous Guatemalans. The single epidemiologic research study from Guatemala (Pubmed search terms, July 8, 2010: ("Haemophilus influenzae"[Mesh] OR "Streptococcus pneumoniae"[Mesh]) AND ("Guatemala"[Mesh] OR "Indians, Central American"[Mesh])) is based on cases presenting to large biomedical centers in Guatemala City--centers that are accessible to few impoverished, rural Maya communities; these studies, thus, suffer from distortions due to selection and severity biases (Int J Infect Dis. 2008 May;12(3):289-97). Moreover, besides one study on shifting antimicrobial sensitivity of nasopharyngeal S. pneumo isolates in Guatemalan children (Int J Infect Dis 2008, 12(3):289-97), and another on passive immunity via breastfeeding (Adv Exp Med Biol 1991;310:1-15), the only published study on prevention of invasive infection with encapsulated organisms in Guatemalan children is based on 103 Guatemala-to-US adoptees from Guatemalan orphanages and foster homes between 1988-2004 (Pediatrics 2005; 115(6):e710-7).
The latter data showed that 46% of the 103 adoptees had any (i.e., adequate and inadequate) documented vaccination against Hib, and only 26% of the 103 adoptees had adequate, documented vaccination against Hib. That is, about one-quarter of this cohort of Guatemalan children met the recommended standards for immunoprophylaxis against Hib. Of course, this data also suffers from selection bias, as protection and healthcare in orphanages and foster homes, most of which will be in larger urban centers, may be quite dissimilar from the experience of the general population of rural Maya children. This cohort of children should not be taken as a representative sample of pediatric preventative care in Guatemala, as they were being actively optimized, from legal, biomedical and moral standpoints, for adoption by concerned and sympathetic families in the US. Moreover, while the sample size (n = 103) lends an added measure of biostatistical robustness to the analysis, the cohort was accumulated over the course of sixteen tumultuous years in recent Guatemalan history. Even from a limited biomedical perspective, this cohort is neither homogeneous, spanning the years when Hib vaccination would have been introduced in Guatemala (late 1980's to early 1990's), nor representative, polysaccharide pneumococcal vaccination having been introduced briefly in the mid-2000's (indeed, no mention is made of pneumococcal vaccination status in this paper). More broadly, in sociological and historical terms, the years between 1988-2004--to say nothing of the years since--saw huge upheavals in the organization of the Guatemalan government and health systems (e.g., the transition to democracy in the 1990's, and the neoliberalization of rural healthcare in the 2000's).
In short, there is insufficient data on the risk of and rates of vaccination against invasive pneumococcal and H. influenzae, type B disease in Guatemalan children, particularly in rural areas where majority Maya communities may have both a higher incidence and severity of infection due to encapsulated organisms. According to official sources, national coverage with 3 doses of Hib is 92%, thanks in large part to a combined Hep B/Hib/DTaP (i.e. Pediarix) that was introduced in 2005. No similar data is available, however, for pneumococcal vaccination. Children do not routinely receive this vaccine, even though many government-issue vaccination cards actually include a blank space for PCV7 (and, on some newer cards, even PCV13). The Guatemalan Association of Infectious Diseases, the Guatemalan Pediatric Association and the Guatemalan Internal Medicine Association justify the absence of PCV7 in governmental community outreach programs in rural areas by citing WHO guidelines that "countries should consider implementing pneumococcal vaccination, especially countries with under-5 mortality > 50/1000 live births"--the official national rate in Guatemala being 35/1000, which hides the same regional and ethnic disparities that I have alluded to above--"and countries with total under-5 deaths >50,000"--the official national rate being 15,000. This line of argumentation assumes that we cannot truly want what is only humane to desire: it assumes that it is impossible to make morally and statistically significant improvements on the rate of infant and child mortality.
My task, then, is to have the courage to really want a world where indigenous Guatemalan children are protected against unnecessary death due to invasive pneumococcal disease. In pragmatic terms, it will be necessary to mount direct assaults on intellectual property rights by establishing strategic alliances that re-establish and protect the domain of the biomedical commons.
---
Citations:
Clin Infect Dis 2000, 31(1):34-41; Clin Infect Dis 2010, 50(9):1238-46; Pediatr Infect Dis 2009, 28(8):711-6; Clin Infect Dis 2008, 47(4):476-84; J Infect Dis 2007 Oct 15;196(8):1211-20; J Infect Dis 2007 Jul 1;196(1):104-14; JAMA 2007, 297(16):1784-92; Clin Infect Dis 2007, 44(9):1173-9; Vaccine 2007, 25(19):3816-26; Am J Epidemiol 2004,160(3):270-8; Lancet 2003,362(9381):355-61; J Infect Dis 2003 Jul 1;188(1):81-9; Pediatrics 1999,104(3 Pt 1):564-7; J Infect Dis 1994, 170(2):461-4; J Infect Dis 1994,170(2):368-76; J Infect Dis 1994, 170(2):368-76; Arch Intern Med 1992, 152(8):1641-5; J Infect Dis 1974,130(1):67-9; Am Rev Respir Dis 1974;109(5):577-8.
Sunday, July 24, 2011
Protocolos de los promotores de salud de San Lucas T. - Enfermedades Crónicas
Protocolos – Promotores de Salud del Área Rural de San Lucas Tolimán
Asma
Menores de 8 años:
Etapa 1: Diagnostico nuevo
-Albuterol/salbutamol tomado
Etapa 2: si usa albuterol/salbutamol o tiene síntomas de asma más de dos días a la semana, o si tiene tos nocturna más de dos veces al mes
-Seguir albuterol/salbutamol cuando hay muchos síntomas
-Empezar una medicina de control: montelukast (4mg al día para los niños entre 6 meses y 5 años; 5mg al día para los niños entre 5 años y 14 años, 10mg al día para los mayores de 15 años)
Etapa 3: si a pesar de usar la montelukast, todavía sigue con síntomas o usa albuterol/salbutamol más de dos días a la semana, o si tiene tos nocturna más de dos veces al mes
-seguir albuterol/salbutamol, y montelukast
-medir fiebre, escuchar los pulmones y respiraciones para descartar una neumonía
-si no hay neumonía, es precisa una referencia antes de buscar otros tratamientos
Mayores de 8 años y adultos
Etapa 1: Diagnostico nuevo
-Albuterol/salbutamol tomado
Etapa 2: si usa albuterol/salbutamol o tiene síntomas de asma más de dos días a la semana, o si tiene tos nocturna más de dos veces al mes
-Seguir albuterol/salbutamol cuando hay muchos síntomas
-Empezar una medicina de control: montelukast (5mg al día para los niños entre 5-14 años; 10mg al día para los mayores de 15 años)
Etapa 3: si a pesar de usar la montelukast, todavía sigue con síntomas o usa albuterol/salbutamol más de dos días a la semana, o si tiene tos nocturna más de dos veces al mes
-seguir albuterol/salbutamol, y montelukast
-medir fiebre, escuchar los pulmones y respiraciones para descartar una neumonía
-si no hay neumonía, empezar segunda medicina de control: esteroide inhalado (por ejemplo, beclometasona, mometasona, budesonide)
Para ataques de asma:
-pensar en una referencia para sacar al paciente
-usar esteroide tomado o inyectado
-prednisona 1 mg/kg dos veces al día x 7 días (60mg dosis máxima en un día)
-prednisolona 1mg/kg dos veces al día x 5-7 días (80mg dosis máxima en un día)
-dexametasona 4mg inyectada para niños o 8mg inyectada para adultos x 2 días
-usar albuterol/salbutamol cada 4-6 horas todos los días por 5-7 días
Para cualquier paciente con asma, evaluar por reflujo gástrico y rinitis alérgica:
-para reflujo gástrico, si tiene dolor de la boca del estómago, considerar un tratamiento por H. pylori
-amoxicilina, metronidazole, omeprazole/lansoprazole, peptobismol (2 semanas)
-amoxicilina, claritromicina, omeprazole/lansoprazole (2 semanas)
-metronidazole, tetraciclina, peptobismol, ranitidina/famotidina (2 semanas, después del tratamiento, seguir ranitidina/famotidina por 2 semanas más)
-para reflujo gástrico sin dolor de la boca del estómago, se puede tratar con ranitidina, famotidina, o en casos más graves de reflujo gástrico, omeprazole, lansoprazole
-para rinitis alérgica, se puede tratar con loratidina (5mg para los niños entre 2-5 años, 10mg para los mayores de 6 años)
...
Enfisema
Sospechar enfisema en los adultos ancianos (mayores de 55 años) que se han quedado expuestos a mucho humo durante el transcurso de su vida, o que han fumado puros/cigarros, o que han tenido muchas infecciones respiratorias (neumonías).
Los síntomas de enfisema son lo siguiente:
-tos por más de 3 meses
-tos crónica con flemas
-dificultad de respirar
Los signos de enfisema son lo siguiente:
-chispas y sibilancias en los pulmones
-muy lenta la expiración comparada con la inhalación
-deformidad de los dos lados en forma de un barril
-saturación baja de oxígeno de forma crónica (menos de 94%)
OJO 1: si hay fiebre con los síntomas y signos mencionados, o pérdida de peso, o escupen sangre, se tiene que sospechar la tuberculosis.
OJO 2: los pacientes con enfisema, por ser mayores de edad, se tienen que hacer exámenes generales porque muchas veces hay otra enfermedad común también, por ejemplo: anemia, diabetes, presión alta, infecciones urinarias, dislipidemia, ataques cardiacos, fallos cardiacos etc.
Para enfisema, los tratamientos principales son:
-esteroide inhalado dos veces al día
-tiotropium inhalado dos veces al día
-formoterol inhalado dos veces al día
-albuterol/salbutamol inhalado cuando hay más síntomas
-omeprazole/lansoprazole a diario, aunque no hay síntomas de reflujos gástricos ni de gastritis (esto baja la incidencia de infecciones respiratorias, según un estudio reciente)
-para los casos muy graves (saturación de oxígenos menos de 89%), se puede buscar oxígeno inhalado para la casa
-evitar el humo (por ejemplo, a traves de un poyo mejorado con chimenea)
-también si fuera posible, ponerles sus vacunas de PPSV23 cada 5 años, y de Influenza viral trivalente cada año
-si al paciente con enfisema se pone el flema muy blanco (color de papel), se puede probar un tratamiento de antibiotico: doxiciclina (200mg por 7 días) o azitromicina (500mg por el primer día, después 250mg por 4 días)
...
Epilepsia
-para todos los casos de epilepsia, se deben de sacar los siguientes estudios en algún momento: resonancia magnética, electroencefalograma, electrolitos, urea, creatinina, bilirubinas, ALT y AST, fosfatasa alcalina, albumina, amonio
-para los niños, se debe evitar el uso de fenitoina y de fenobarbital; en cambio unas medicinas con menos efectos secundarios son carbamazepine y ácido valproico (depakene)
-cualquier mujer con epilepsia que toma una medicina para epilepsia debe tomar su suplemento de ácido fólico y seguir su tratamiento durante el embarazo bajo observación médica. Si una mujer embarazada está tomando fenitoina durante el embarazo, durante los últimos meses, debe recibir inyecciones de vitamina K.
-cualquier mujer con epilepsia que está mamando a un niño debe evitar la fenobarbital y la fenitoina. Es más seguro tomar la carbamazepine, y ácido valproico, pero siempre bajo observación médica.
Dosis de las drogas anti-epilepticas:
Carbamazepine:
Para adultos, empezar 200mg dos veces al día.
Para niños, empezar 10mg/kg dos veces al día.
Antes de empezar carbamazepine, los pacientes deben sacar una hematología completa, bilirubinas, ALT y AST, fosfatasa alcalina, albumina. Si el paciente ha tenido cualquier problema de la sangre o del hígado en el pasado, no debe tomar carbamazepine.
Ácido valproico:
Para adultos y niños, empezar 5mg/kg dos veces al día.
Antes de empezar el ácido valproico, los pacientes deben sacar bilirubinas, ALT y AST, fosfatasa alcalina, albumina, amonio. No usar ácido valproico en los niños menores de 2 años, sin receta médica.
Fenitoina:
Para adultos, empezar 100mg dos veces al día.
Para niños menores de 10 años, empezar 4mg/kg, dos veces al día.
Para niños de 10 a 16 años, empezar 3mg/kg, dos veces al día.
Fenobarbital:
Para adultos, empezar 50mg, tres veces al día.
Para niños, empezar 5-6 mg/kg, una vez al día.
OJO: fenobarbital tiene muchos efectos secundarios, y sólo se debe usar en los casos que no se han podido controlar con otras medicinas. Desde nuestras observaciones, es muy común encontrarnos con pacientes con epilepsia que han tomado fenobarbital durante mucho tiempo, pero esto se da porque fenobarbital es una medicina muy barata, y no es por ser la mejor medicina para convulsiones.
...
Hipertensión (presión alta)
-Más de 140/90 es hipertensión (presión alta).
-Más de 160/100 es hipertensión avanzada.
-Más de 200/120 es una crisis hipertensiva.
-Pero, más de 120/80 es pre-hipertensión.
-En un caso de un embarazo, siempre referir cualquier mujer con presión alta.
-Para diagnosticar la hipertensión, tiene que haber dos veces que la presión sale alta.
-Para pre-hipertensión, se aconseja no echarle sal a la comida, salir a caminar una hora todos los días.
-Si se le diagnostica la hipertensión en un paciente de menos de 20-25 años, puede haber otra causa de la presión alta, por ejemplo chequear: glucosa, orina, electrolitos, urea, creatinina, TSH (tiroidea), electrocardiograma.
-En las embarazadas, referir de una vez para tratamiento bajo observación médica. Hay dos razones por hacer esto: primero, las medicinas para presión alta pueden provocar problemas al feto, así que se tienen que buscar medicinas diferentes; segundo, la presión alta durante el embarazo puede ser parte de la toxemia o preeclampsia, la cual provoca convulsiones y muerte tanto a la embarazada como a la criatura.
-Para la hipertensión, si no es un caso avanzado, empezar aconsejandole al paciente que no eche sal a la comida, y que salga a caminar una hora todos los días.
-En estos casos, si sigue alta la presión después de dos meses, empezar con un tratamiento: hidroclorotiazida (HCTZ) 25mg al día.
-Después de dos meses, si todavía sigue alta la presión, agregar otra medicina: para empezar, enalapril 5mg, una vez al día, o captopril 25mg, tres veces al día.
-Si el paciente empieza a sufrir una tos seca y necia, o si se le hinchan los labios al paciente, es un efecto secundario del enalapril, y se debe de cambiar enalapril a otra medicina: atenolol 25-50mg, una vez al día. OJO: el parar atenolol de un día al otro, puede provocar un ataque cardiaco.
-Para la hipertensión avanzada, primero sacar las mismas pruebas de arriba: glucosa, orina, electrolitos, urea, creatinina, TSH (tiroidea), electrocardiograma. Si todos los resultados salen normales, entonces empezar el tratamiento de una vez.
-En estos casos, empezar de una vez un tratamiento con dos medicinas: 1. hidroclorotiazida 25mg al día y, 2. enalapril 5mg una vez al día o captopril 25mg tres veces al día.
-Para una crisis hipertensiva, referir de una vez porque el paciente corre riesgo de un ataque cardiaco, derrame cerebral, o fallo renal muy pronto.
...
Diabetes
Es una enfermedad silenciosa por problemas de la pancreas que va directamente el azucar en la sangre y provoca varios problemas en el cuerpo.
SINTOMAS:
Mucha sed, perdido de peso, visión borrosa, dolor de cabeza, y orina frecuentamente.
Pacientes chequeo de azucar en ayunas mas de 126 mg/dL a mas es hiper-glucosa , si es menos de normal es hipoglucemia o depende del caso y los sintomas que presentan.
También se puede diagnosticar la diabetes después de haber comido (no en ayunas) si sale la glucosa más de 200 mg/dL en dos ocasiones.
También la “pre-diabetes” se puede diagnosticar en ayunas si la glucosa sale más de 100 mg/dL, y después de haber comido (no en ayunas) si sale la glucosa más de 140 mg/dL.
Estos pacientes necesitan exámenes de presión arterial, orina, y, si tienen mucha tos, pruevas de B.K. (baciloscopia) y radiografía.
Si el paciente de diabetes tiene su presión aterial más de 130/80, ya es presión alta. En estos pacientes, se debe empezar con captopril o enalapril de una vez para la presión alta.
TRATAMIENTO:
Empezar con metformina de 500mg 2.veces al dia dosis maximas es de 2,000 mg 2 veces al dia.
Plan educacional sobre su dieta
Si la paciente tiene los niveles de azucar alto despues del tratamiento de la dosis maxima de metformina entonces se puede agregar la glibenclamida 5mg al dia. A tres dias se puede aumentar la dosis a 5mg dos veces al dia si sigue alta la glucosa, de allía cada tres días se puede subir la dosis según la glucosa en ayunas. La dosis maxima es 8 tabletas de 5mg de glibenclamida (es decir, 40mg) al dia. Y si la paciente todavia tiene los niveles de azucar alto entonces referirla a la clinica paroquial porque puede ser necesario recetarle inyecciones de insulina.
Electrolitos, urea,y creatinina tres examenes hacerlo a un mes despues del tx de metformina
En caso de embarazo referir para cuidado médico. Durante el embarazo la única medicina para diabetes que se debe utilizar es la insulina, es decir no se debe de seguir la metformina, la glibenclamida, etc.
Ojo. Con los diabeticos, chequeos de los pies , hemoglobina, presión arterial, hacer electrocardiagrama.
Observacion: todos lo hombres con mas de 50 anos y mujeres mas de 60 anos deben tomar aspirina 325 todos los dias siempre y cuando que no tiene síntomas de gastritis ni sangre oculta en los heces. También a todos los pacientes con diabetes darle un diente de ajo todo los dias; nuestros compañeros de Wuqu’ Kawoq prefieren esta última estrategia a la aspirina, ya que es menos riesgoso.
Asma
Menores de 8 años:
Etapa 1: Diagnostico nuevo
-Albuterol/salbutamol tomado
Etapa 2: si usa albuterol/salbutamol o tiene síntomas de asma más de dos días a la semana, o si tiene tos nocturna más de dos veces al mes
-Seguir albuterol/salbutamol cuando hay muchos síntomas
-Empezar una medicina de control: montelukast (4mg al día para los niños entre 6 meses y 5 años; 5mg al día para los niños entre 5 años y 14 años, 10mg al día para los mayores de 15 años)
Etapa 3: si a pesar de usar la montelukast, todavía sigue con síntomas o usa albuterol/salbutamol más de dos días a la semana, o si tiene tos nocturna más de dos veces al mes
-seguir albuterol/salbutamol, y montelukast
-medir fiebre, escuchar los pulmones y respiraciones para descartar una neumonía
-si no hay neumonía, es precisa una referencia antes de buscar otros tratamientos
Mayores de 8 años y adultos
Etapa 1: Diagnostico nuevo
-Albuterol/salbutamol tomado
Etapa 2: si usa albuterol/salbutamol o tiene síntomas de asma más de dos días a la semana, o si tiene tos nocturna más de dos veces al mes
-Seguir albuterol/salbutamol cuando hay muchos síntomas
-Empezar una medicina de control: montelukast (5mg al día para los niños entre 5-14 años; 10mg al día para los mayores de 15 años)
Etapa 3: si a pesar de usar la montelukast, todavía sigue con síntomas o usa albuterol/salbutamol más de dos días a la semana, o si tiene tos nocturna más de dos veces al mes
-seguir albuterol/salbutamol, y montelukast
-medir fiebre, escuchar los pulmones y respiraciones para descartar una neumonía
-si no hay neumonía, empezar segunda medicina de control: esteroide inhalado (por ejemplo, beclometasona, mometasona, budesonide)
Para ataques de asma:
-pensar en una referencia para sacar al paciente
-usar esteroide tomado o inyectado
-prednisona 1 mg/kg dos veces al día x 7 días (60mg dosis máxima en un día)
-prednisolona 1mg/kg dos veces al día x 5-7 días (80mg dosis máxima en un día)
-dexametasona 4mg inyectada para niños o 8mg inyectada para adultos x 2 días
-usar albuterol/salbutamol cada 4-6 horas todos los días por 5-7 días
Para cualquier paciente con asma, evaluar por reflujo gástrico y rinitis alérgica:
-para reflujo gástrico, si tiene dolor de la boca del estómago, considerar un tratamiento por H. pylori
-amoxicilina, metronidazole, omeprazole/lansoprazole, peptobismol (2 semanas)
-amoxicilina, claritromicina, omeprazole/lansoprazole (2 semanas)
-metronidazole, tetraciclina, peptobismol, ranitidina/famotidina (2 semanas, después del tratamiento, seguir ranitidina/famotidina por 2 semanas más)
-para reflujo gástrico sin dolor de la boca del estómago, se puede tratar con ranitidina, famotidina, o en casos más graves de reflujo gástrico, omeprazole, lansoprazole
-para rinitis alérgica, se puede tratar con loratidina (5mg para los niños entre 2-5 años, 10mg para los mayores de 6 años)
...
Enfisema
Sospechar enfisema en los adultos ancianos (mayores de 55 años) que se han quedado expuestos a mucho humo durante el transcurso de su vida, o que han fumado puros/cigarros, o que han tenido muchas infecciones respiratorias (neumonías).
Los síntomas de enfisema son lo siguiente:
-tos por más de 3 meses
-tos crónica con flemas
-dificultad de respirar
Los signos de enfisema son lo siguiente:
-chispas y sibilancias en los pulmones
-muy lenta la expiración comparada con la inhalación
-deformidad de los dos lados en forma de un barril
-saturación baja de oxígeno de forma crónica (menos de 94%)
OJO 1: si hay fiebre con los síntomas y signos mencionados, o pérdida de peso, o escupen sangre, se tiene que sospechar la tuberculosis.
OJO 2: los pacientes con enfisema, por ser mayores de edad, se tienen que hacer exámenes generales porque muchas veces hay otra enfermedad común también, por ejemplo: anemia, diabetes, presión alta, infecciones urinarias, dislipidemia, ataques cardiacos, fallos cardiacos etc.
Para enfisema, los tratamientos principales son:
-esteroide inhalado dos veces al día
-tiotropium inhalado dos veces al día
-formoterol inhalado dos veces al día
-albuterol/salbutamol inhalado cuando hay más síntomas
-omeprazole/lansoprazole a diario, aunque no hay síntomas de reflujos gástricos ni de gastritis (esto baja la incidencia de infecciones respiratorias, según un estudio reciente)
-para los casos muy graves (saturación de oxígenos menos de 89%), se puede buscar oxígeno inhalado para la casa
-evitar el humo (por ejemplo, a traves de un poyo mejorado con chimenea)
-también si fuera posible, ponerles sus vacunas de PPSV23 cada 5 años, y de Influenza viral trivalente cada año
-si al paciente con enfisema se pone el flema muy blanco (color de papel), se puede probar un tratamiento de antibiotico: doxiciclina (200mg por 7 días) o azitromicina (500mg por el primer día, después 250mg por 4 días)
...
Epilepsia
-para todos los casos de epilepsia, se deben de sacar los siguientes estudios en algún momento: resonancia magnética, electroencefalograma, electrolitos, urea, creatinina, bilirubinas, ALT y AST, fosfatasa alcalina, albumina, amonio
-para los niños, se debe evitar el uso de fenitoina y de fenobarbital; en cambio unas medicinas con menos efectos secundarios son carbamazepine y ácido valproico (depakene)
-cualquier mujer con epilepsia que toma una medicina para epilepsia debe tomar su suplemento de ácido fólico y seguir su tratamiento durante el embarazo bajo observación médica. Si una mujer embarazada está tomando fenitoina durante el embarazo, durante los últimos meses, debe recibir inyecciones de vitamina K.
-cualquier mujer con epilepsia que está mamando a un niño debe evitar la fenobarbital y la fenitoina. Es más seguro tomar la carbamazepine, y ácido valproico, pero siempre bajo observación médica.
Dosis de las drogas anti-epilepticas:
Carbamazepine:
Para adultos, empezar 200mg dos veces al día.
Para niños, empezar 10mg/kg dos veces al día.
Antes de empezar carbamazepine, los pacientes deben sacar una hematología completa, bilirubinas, ALT y AST, fosfatasa alcalina, albumina. Si el paciente ha tenido cualquier problema de la sangre o del hígado en el pasado, no debe tomar carbamazepine.
Ácido valproico:
Para adultos y niños, empezar 5mg/kg dos veces al día.
Antes de empezar el ácido valproico, los pacientes deben sacar bilirubinas, ALT y AST, fosfatasa alcalina, albumina, amonio. No usar ácido valproico en los niños menores de 2 años, sin receta médica.
Fenitoina:
Para adultos, empezar 100mg dos veces al día.
Para niños menores de 10 años, empezar 4mg/kg, dos veces al día.
Para niños de 10 a 16 años, empezar 3mg/kg, dos veces al día.
Fenobarbital:
Para adultos, empezar 50mg, tres veces al día.
Para niños, empezar 5-6 mg/kg, una vez al día.
OJO: fenobarbital tiene muchos efectos secundarios, y sólo se debe usar en los casos que no se han podido controlar con otras medicinas. Desde nuestras observaciones, es muy común encontrarnos con pacientes con epilepsia que han tomado fenobarbital durante mucho tiempo, pero esto se da porque fenobarbital es una medicina muy barata, y no es por ser la mejor medicina para convulsiones.
...
Hipertensión (presión alta)
-Más de 140/90 es hipertensión (presión alta).
-Más de 160/100 es hipertensión avanzada.
-Más de 200/120 es una crisis hipertensiva.
-Pero, más de 120/80 es pre-hipertensión.
-En un caso de un embarazo, siempre referir cualquier mujer con presión alta.
-Para diagnosticar la hipertensión, tiene que haber dos veces que la presión sale alta.
-Para pre-hipertensión, se aconseja no echarle sal a la comida, salir a caminar una hora todos los días.
-Si se le diagnostica la hipertensión en un paciente de menos de 20-25 años, puede haber otra causa de la presión alta, por ejemplo chequear: glucosa, orina, electrolitos, urea, creatinina, TSH (tiroidea), electrocardiograma.
-En las embarazadas, referir de una vez para tratamiento bajo observación médica. Hay dos razones por hacer esto: primero, las medicinas para presión alta pueden provocar problemas al feto, así que se tienen que buscar medicinas diferentes; segundo, la presión alta durante el embarazo puede ser parte de la toxemia o preeclampsia, la cual provoca convulsiones y muerte tanto a la embarazada como a la criatura.
-Para la hipertensión, si no es un caso avanzado, empezar aconsejandole al paciente que no eche sal a la comida, y que salga a caminar una hora todos los días.
-En estos casos, si sigue alta la presión después de dos meses, empezar con un tratamiento: hidroclorotiazida (HCTZ) 25mg al día.
-Después de dos meses, si todavía sigue alta la presión, agregar otra medicina: para empezar, enalapril 5mg, una vez al día, o captopril 25mg, tres veces al día.
-Si el paciente empieza a sufrir una tos seca y necia, o si se le hinchan los labios al paciente, es un efecto secundario del enalapril, y se debe de cambiar enalapril a otra medicina: atenolol 25-50mg, una vez al día. OJO: el parar atenolol de un día al otro, puede provocar un ataque cardiaco.
-Para la hipertensión avanzada, primero sacar las mismas pruebas de arriba: glucosa, orina, electrolitos, urea, creatinina, TSH (tiroidea), electrocardiograma. Si todos los resultados salen normales, entonces empezar el tratamiento de una vez.
-En estos casos, empezar de una vez un tratamiento con dos medicinas: 1. hidroclorotiazida 25mg al día y, 2. enalapril 5mg una vez al día o captopril 25mg tres veces al día.
-Para una crisis hipertensiva, referir de una vez porque el paciente corre riesgo de un ataque cardiaco, derrame cerebral, o fallo renal muy pronto.
...
Diabetes
Es una enfermedad silenciosa por problemas de la pancreas que va directamente el azucar en la sangre y provoca varios problemas en el cuerpo.
SINTOMAS:
Mucha sed, perdido de peso, visión borrosa, dolor de cabeza, y orina frecuentamente.
Pacientes chequeo de azucar en ayunas mas de 126 mg/dL a mas es hiper-glucosa , si es menos de normal es hipoglucemia o depende del caso y los sintomas que presentan.
También se puede diagnosticar la diabetes después de haber comido (no en ayunas) si sale la glucosa más de 200 mg/dL en dos ocasiones.
También la “pre-diabetes” se puede diagnosticar en ayunas si la glucosa sale más de 100 mg/dL, y después de haber comido (no en ayunas) si sale la glucosa más de 140 mg/dL.
Estos pacientes necesitan exámenes de presión arterial, orina, y, si tienen mucha tos, pruevas de B.K. (baciloscopia) y radiografía.
Si el paciente de diabetes tiene su presión aterial más de 130/80, ya es presión alta. En estos pacientes, se debe empezar con captopril o enalapril de una vez para la presión alta.
TRATAMIENTO:
Empezar con metformina de 500mg 2.veces al dia dosis maximas es de 2,000 mg 2 veces al dia.
Plan educacional sobre su dieta
Si la paciente tiene los niveles de azucar alto despues del tratamiento de la dosis maxima de metformina entonces se puede agregar la glibenclamida 5mg al dia. A tres dias se puede aumentar la dosis a 5mg dos veces al dia si sigue alta la glucosa, de allía cada tres días se puede subir la dosis según la glucosa en ayunas. La dosis maxima es 8 tabletas de 5mg de glibenclamida (es decir, 40mg) al dia. Y si la paciente todavia tiene los niveles de azucar alto entonces referirla a la clinica paroquial porque puede ser necesario recetarle inyecciones de insulina.
Electrolitos, urea,y creatinina tres examenes hacerlo a un mes despues del tx de metformina
En caso de embarazo referir para cuidado médico. Durante el embarazo la única medicina para diabetes que se debe utilizar es la insulina, es decir no se debe de seguir la metformina, la glibenclamida, etc.
Ojo. Con los diabeticos, chequeos de los pies , hemoglobina, presión arterial, hacer electrocardiagrama.
Observacion: todos lo hombres con mas de 50 anos y mujeres mas de 60 anos deben tomar aspirina 325 todos los dias siempre y cuando que no tiene síntomas de gastritis ni sangre oculta en los heces. También a todos los pacientes con diabetes darle un diente de ajo todo los dias; nuestros compañeros de Wuqu’ Kawoq prefieren esta última estrategia a la aspirina, ya que es menos riesgoso.
Monday, July 18, 2011
Subjectivation of Bare Life in the Post-Peace Concentration Camp
"Nearly half of preschoolers in Guatemala are malnourished. Malnutrition can hamper a child's performance in school, making them more likely to drop out, and children who are malnourished early in life can suffer long-term consequences in both mind and body. In order to combat this problem, MF has established six Preschool Nutritional Centers in different communities in the region, which provide 3-5 year-old children at risk of malnutrition with a healthy meal and a nutritious snack daily, as well as lessons on basic hygiene, and multivitamin supplements. The children, many of whom have not learned to speak Spanish at home, also get a head-start on learning Guatemala's official language before beginning school."
Saturday, May 21, 2011
"Normal" malnutrition = statistical normalization of structural violence
"Due to the high incidence of stunting among Guatemalan children, weight-for-age was deemed to be a more appropriate measure of malnutrition than standard height-for-weight ratios. Children with weight-for-age ratios at 90% or above the mean of the reference population were assigned a level of ‘normal’ malnutrition while those between 75% and 89.9% were assigned a level of ‘mild’ malnutrition, 60% to 74.9% were categorized as moderately malnourished, and those at 59.9% or below."
Cook D, et al. J Health Popul Nutr 2009;27(1):31-40.
Cook D, et al. J Health Popul Nutr 2009;27(1):31-40.
Wednesday, May 18, 2011
Wednesday, April 6, 2011
Monday, April 26, 2010
Ambiguity/Struggle
"Hay hombres que luchan un día y son buenos. Hay hombres que luchan un año y son mejores. Hay hombres que luchan muchos años y son muy buenos. Pero hay los que luchan toda la vida. Esos son los imprescindibles." ~Bertolt Brecht
I find comfort in mutual exhortations to "continue to struggle," to "keep fighting." Uttered by colleagues and friends, these words affirm the profound, often unspeakable yet always shared experiences that emerge in the crucibles of solidarity.
The ambiguity of Brecht's words, however, evokes the mystery of inspiration. What, or whom, are we struggling against? What is it about the outcome--or is it the process--of such struggles that make them "indispensable?"
Brecht reminds me that the unspoken may be unspeakable. What if, after all, our most formidable enemies are not external to us, but rather reside in our midst? What if the impulses to resist and revolt are traced to their origins? Do we dare admit our mundane familiarity, and even intimacy, with the spectral and grotesque horrors we have declared ostensibly to be our enemies?
I find comfort in mutual exhortations to "continue to struggle," to "keep fighting." Uttered by colleagues and friends, these words affirm the profound, often unspeakable yet always shared experiences that emerge in the crucibles of solidarity.
The ambiguity of Brecht's words, however, evokes the mystery of inspiration. What, or whom, are we struggling against? What is it about the outcome--or is it the process--of such struggles that make them "indispensable?"
Brecht reminds me that the unspoken may be unspeakable. What if, after all, our most formidable enemies are not external to us, but rather reside in our midst? What if the impulses to resist and revolt are traced to their origins? Do we dare admit our mundane familiarity, and even intimacy, with the spectral and grotesque horrors we have declared ostensibly to be our enemies?
Friday, April 9, 2010
Rune'y Lola
Lola was 9 months pregnant on Tuesday. Per her husband, who is a public health nurse and a community health worker, an ultrasound two weeks previously demonstrated a breech position, and they were advised by the physician that she would most likely require an operative delivery. The local Centro de Salud recently opened a maternity ward to much fanfare; nonetheless, despite a staff of 3 physicians and 6 nurse-midwives, they do not offer C-sections.
On Wednesday, Lola began to have contractions. They immediately contacted the Centro de Salud. Two hours later, in the back of a speeding ambulance on its way to the regional referral center at Hospital Nacional de Sololá, Lola gave birth to a little girl. Likely suffering from intrapartum asphyxiation, and because the "ambulance" was not fitted for any of the emergent diagnostic and therapeutic maneuvers that are required in such cases, the baby was dead at birth.
On Thursday, following an overnight vigil and baptism by one of the community's catechists, the little girl was buried alongside her deceased grandmother, in a small community cemetery on a neighboring plantation. Lola, thankfully, is recovering and has not suffered further physical complications from this harrowing experience.
I spoke to Lola's husband on Friday morning, the day after the funeral. He said:
"All of this is an experience for us; we are trying to start over.
"Despite the whole team of personnel, so many doctors and nurses, they work like midwives, nothing more. And we have no other alternative. This is an experience for us, and it motivates one to continue fighting to improve our healthcare system."
On Wednesday, Lola began to have contractions. They immediately contacted the Centro de Salud. Two hours later, in the back of a speeding ambulance on its way to the regional referral center at Hospital Nacional de Sololá, Lola gave birth to a little girl. Likely suffering from intrapartum asphyxiation, and because the "ambulance" was not fitted for any of the emergent diagnostic and therapeutic maneuvers that are required in such cases, the baby was dead at birth.
On Thursday, following an overnight vigil and baptism by one of the community's catechists, the little girl was buried alongside her deceased grandmother, in a small community cemetery on a neighboring plantation. Lola, thankfully, is recovering and has not suffered further physical complications from this harrowing experience.
I spoke to Lola's husband on Friday morning, the day after the funeral. He said:
"All of this is an experience for us; we are trying to start over.
"Despite the whole team of personnel, so many doctors and nurses, they work like midwives, nothing more. And we have no other alternative. This is an experience for us, and it motivates one to continue fighting to improve our healthcare system."
Tuesday, April 6, 2010
Wednesday, March 24, 2010
Pain, addiction and The War on Drugs
Pain and addiction are two complex phenomena whose presentation and management in the acute setting are further complicated by synergies between symptoms and biological dependence, as well as by comorbid psychiatric and organic pathologies. Such interactions and the concomitant pitfalls that plague physicians are abundantly described in the medical literature and discussed in clinical situations. In particular, it is the highly subjective specificity of these interrelated forms of suffering that have resulted in quite a bit of attention on the part of outpatient clinicians and psychiatrists--both of whom are afforded substantial time and space, relatively speaking, to explore the affective and moral contexts of individual patients' lives. If there is any credence to the "humanistic" notion that the depth and quality of interpersonal engagement can be as or more important than frequency, the emergency physician's relative lack of familiarity with the anthropological specificities of context could be seen to hamper acute management. A salutary corrective to this potential disadvantage, I think, would be to approach patients in acute pain and addiction/withdrawal from a perspective informed by historical and social context.
When an attending bluntly opines that, "I don't give these people [alcoholics] anything because they just go out and overdose on Ativan, go on another binge and the whole thing starts again," wouldn't it be appropriate to critically examine the alternatives faced by alcoholics and other drug users once they leave the ER? If, as the same attending admitted, "people tend to hate Haymarket," doesn't the abandonment by the public sector of our addicted and withdrawing patients---who, after all, are usually in the ER because their money (or luck?) ran out---place a burden of responsibility on us? If I were homeless, unemployed and physiologically addicted, I'm not sure that being denied the means to pharmacologically manage my symptoms on the street would improve my chances of recovery.
But, mere empathy aside, there are broader considerations that might humanize the approach to acute care for "pain-seekers"---and reveal the violent contradictions of such epithets. As demonstrated by Ethan Nadelmann, JD PhD of the Drug Policy Alliance, histories of xenophobia, racism and classism have driven the contradictions and vacillations in anti-drug policy, from the outlawing of opiates with the influx of immigrant Chinese to the west coast, the illegalization of marijuana in response to fears of migrant Mexicans in the midwest, and the crackdowns on alcohol production and "public drunkenness" due to the "less White"--that is, poor, non-Protestant--communities of Eastern European and Irish refugees that took hold in American cities throughout the 19th and 20th centuries. Of even more contemporary relevance is the pernicious effects of the War on Drugs. Since its inception, this "War" has been highly racialized, with its differential repression and litigation of crack vs. cocaine, for example. It has also been made manifest in ways that are profoundly classist--again, as exemplified by differential treatment of "possession" (for personal consumption) vs. "intention to deliver" (for economic gain), as well as by the unconstitutional levels of police surveillance and resultant risks of incarceration in neighborhoods inhabited by a preponderance of young people of Color. The "War," as Nadelmann explains, has been central to the criminalization of drugs, transferring responsibility and power from the positive social institutions of public health and medicine, to the negative formations of courts and prisons.
It is a little known fact that William S. Halsted, the famed surgeon who was appointed Chief at Johns Hopkins in 1890, who developed the inguinal hernia repair and radical mastectomy, and who published 180+ scholarly articles during his career, was chronically dependent on cocaine--which his friend and colleague, William Osler, treated and managed through a chronic regimen of morphine injections. It is important to consider such precedents and contexts to avoid adding to the stigmatization and marginalization of our desperate--and often sick, poor and "pain-suffering"--patients who present acutely in the ER.
When an attending bluntly opines that, "I don't give these people [alcoholics] anything because they just go out and overdose on Ativan, go on another binge and the whole thing starts again," wouldn't it be appropriate to critically examine the alternatives faced by alcoholics and other drug users once they leave the ER? If, as the same attending admitted, "people tend to hate Haymarket," doesn't the abandonment by the public sector of our addicted and withdrawing patients---who, after all, are usually in the ER because their money (or luck?) ran out---place a burden of responsibility on us? If I were homeless, unemployed and physiologically addicted, I'm not sure that being denied the means to pharmacologically manage my symptoms on the street would improve my chances of recovery.
But, mere empathy aside, there are broader considerations that might humanize the approach to acute care for "pain-seekers"---and reveal the violent contradictions of such epithets. As demonstrated by Ethan Nadelmann, JD PhD of the Drug Policy Alliance, histories of xenophobia, racism and classism have driven the contradictions and vacillations in anti-drug policy, from the outlawing of opiates with the influx of immigrant Chinese to the west coast, the illegalization of marijuana in response to fears of migrant Mexicans in the midwest, and the crackdowns on alcohol production and "public drunkenness" due to the "less White"--that is, poor, non-Protestant--communities of Eastern European and Irish refugees that took hold in American cities throughout the 19th and 20th centuries. Of even more contemporary relevance is the pernicious effects of the War on Drugs. Since its inception, this "War" has been highly racialized, with its differential repression and litigation of crack vs. cocaine, for example. It has also been made manifest in ways that are profoundly classist--again, as exemplified by differential treatment of "possession" (for personal consumption) vs. "intention to deliver" (for economic gain), as well as by the unconstitutional levels of police surveillance and resultant risks of incarceration in neighborhoods inhabited by a preponderance of young people of Color. The "War," as Nadelmann explains, has been central to the criminalization of drugs, transferring responsibility and power from the positive social institutions of public health and medicine, to the negative formations of courts and prisons.
It is a little known fact that William S. Halsted, the famed surgeon who was appointed Chief at Johns Hopkins in 1890, who developed the inguinal hernia repair and radical mastectomy, and who published 180+ scholarly articles during his career, was chronically dependent on cocaine--which his friend and colleague, William Osler, treated and managed through a chronic regimen of morphine injections. It is important to consider such precedents and contexts to avoid adding to the stigmatization and marginalization of our desperate--and often sick, poor and "pain-suffering"--patients who present acutely in the ER.
Tuesday, March 23, 2010
My notes: Michael Hardt, "On love [as political practice]"
The ways that love has been destroyed as a potentially powerful political concept:
1. The reduction of love to the space of the heterosexual family, that is, love as a closed social phenomenon, rather than an open, plural mode of pro-social being-in-the-world.
2.The identitarian ideas of love as love for the Same, or the creation of the Same through love: true love can be felt only for those who are essentially like us, or, alternatively, love as a hegemonizing force that transforms the object of love into the Same-as-Self. Rather than love being a kind of experiment with deep, lasting commitment to Other(s) without the presumptuous dissolution of difference and singularities.
3.The binarist division of eros/cupiditas vs. agape/caritas, or, what amounts to the same, the demotion of one pole vis-à-vis the other. That is, either caritas (charitable love for the holiness of the poor) is a side-product of libido; or, eros-libido must be "tamed" by the impulses of caritas.
4. The reduction of love to “charity,” specifically to the poor, which takes the Other as object, and not as subject. That is, a love whose terms and distribution are determined by those who are NOT poor, as opposed to a love defined and directed by the poor themselves, of which they are subject-agents, not passive thing-objects.
5. The trivialization of love as an involuntary passion or a sensation, not as a productive and incremental practice.
1. The reduction of love to the space of the heterosexual family, that is, love as a closed social phenomenon, rather than an open, plural mode of pro-social being-in-the-world.
2.The identitarian ideas of love as love for the Same, or the creation of the Same through love: true love can be felt only for those who are essentially like us, or, alternatively, love as a hegemonizing force that transforms the object of love into the Same-as-Self. Rather than love being a kind of experiment with deep, lasting commitment to Other(s) without the presumptuous dissolution of difference and singularities.
3.The binarist division of eros/cupiditas vs. agape/caritas, or, what amounts to the same, the demotion of one pole vis-à-vis the other. That is, either caritas (charitable love for the holiness of the poor) is a side-product of libido; or, eros-libido must be "tamed" by the impulses of caritas.
4. The reduction of love to “charity,” specifically to the poor, which takes the Other as object, and not as subject. That is, a love whose terms and distribution are determined by those who are NOT poor, as opposed to a love defined and directed by the poor themselves, of which they are subject-agents, not passive thing-objects.
5. The trivialization of love as an involuntary passion or a sensation, not as a productive and incremental practice.
Thursday, March 11, 2010
The experience of exception
I am struggling with what to make of personhood and subjectivity in contexts of extreme deprivation and concomitant suffering. When political-economic phenomena conspire with overt interpersonal violence in the lives of the sick and poor, what does it mean to try to describe the structure of experience? What does it mean, for example, to elaborate ethnographically (i.e. in person, and in text) on the experience of "social death"?
Much anthropological work on trauma and violence has dealt with the sequelae of such situations, but how might we approach an ethnography of ongoing violence? It seems too ethically and epistemologically simple to rely on the hackneyed and normalizing conception of current violence as just "another layer of complexity," as if the shedding of blood were a fresh coat of multivariegated paint. Such a metaphor, even in its more nuanced, less reified forms, implies the stability of an edifice (i.e., the structure of experience) that, on close inspection, does not provide shelter, at the very least, or worse still, that may not even be there, having been annihilated long since. When--and, more importantly, how--can we begin to admit that the rubble of culture is becoming an evanescent dust, so pulverized by violence that recognizably "human experience" itself seems to evaporate into thin air? If we acknowledge the profundity of the indignities implied by descriptions of "social death," and by the extreme physical suffering of the indigent sick (e.g., deadly "syndemics" of chronic starvation and gang-related physical violence), doesn't a sense of solidarity and concomitant honesty obligate us to repudiate facile formulas like "weapons of the weak?"
Put another way, this is my dilemma: Giorgio Agamben's descriptions of "bare life," at times, seems to me to describe with disturbing accuracy the contemporary lives of the indigent sick. In engaging with and attempting to represent the situations faced by many of my very poor patients in rural Guatemala, however, Agamben's "homo sacer" seems to recapitulate neo-colonial ideologies about "savage Indians" as nearly bestial "clean slates" where "civilization" must be inscribed. But when people are stripped violently bare of what even they themselves would "identify" as universal prerequisites of human dignity, and when, moreover, they are denied the materials necessary for mere survival by everyday structures of violence, what do we risk in describing and publicizing such a "state of exception that is the rule?" The dangers of such an interpretation seem to be magnified when dealing with contemporary "states of exception" that are structured by seemingly self-perpetuating processes of neoliberalism and extractive global capitalism--as opposed to the historically or spatially remote examples of mid-20th century fascist dictatorships that serve as primary material for Agamben's reflections.
Does the ethnography of "bare life"--in all its dehumanizing, exploited nudity--verge on a grotesque "pornography of suffering?"
Much anthropological work on trauma and violence has dealt with the sequelae of such situations, but how might we approach an ethnography of ongoing violence? It seems too ethically and epistemologically simple to rely on the hackneyed and normalizing conception of current violence as just "another layer of complexity," as if the shedding of blood were a fresh coat of multivariegated paint. Such a metaphor, even in its more nuanced, less reified forms, implies the stability of an edifice (i.e., the structure of experience) that, on close inspection, does not provide shelter, at the very least, or worse still, that may not even be there, having been annihilated long since. When--and, more importantly, how--can we begin to admit that the rubble of culture is becoming an evanescent dust, so pulverized by violence that recognizably "human experience" itself seems to evaporate into thin air? If we acknowledge the profundity of the indignities implied by descriptions of "social death," and by the extreme physical suffering of the indigent sick (e.g., deadly "syndemics" of chronic starvation and gang-related physical violence), doesn't a sense of solidarity and concomitant honesty obligate us to repudiate facile formulas like "weapons of the weak?"
Put another way, this is my dilemma: Giorgio Agamben's descriptions of "bare life," at times, seems to me to describe with disturbing accuracy the contemporary lives of the indigent sick. In engaging with and attempting to represent the situations faced by many of my very poor patients in rural Guatemala, however, Agamben's "homo sacer" seems to recapitulate neo-colonial ideologies about "savage Indians" as nearly bestial "clean slates" where "civilization" must be inscribed. But when people are stripped violently bare of what even they themselves would "identify" as universal prerequisites of human dignity, and when, moreover, they are denied the materials necessary for mere survival by everyday structures of violence, what do we risk in describing and publicizing such a "state of exception that is the rule?" The dangers of such an interpretation seem to be magnified when dealing with contemporary "states of exception" that are structured by seemingly self-perpetuating processes of neoliberalism and extractive global capitalism--as opposed to the historically or spatially remote examples of mid-20th century fascist dictatorships that serve as primary material for Agamben's reflections.
Does the ethnography of "bare life"--in all its dehumanizing, exploited nudity--verge on a grotesque "pornography of suffering?"
Friday, February 5, 2010
the fetishization of regulation, and the secret thereof
Of the colorful characters who populate open-air markets and equally crowded public buses in rural Guatemala, one quickly identifies the ersatz physician by his charismatic, albeit illogical, sales pitch and his mound of medicines: "This little tablet, ladies and gentlemen," and a quick chortle for effect, "this tiny little tablet, will provide the 100 % cure for pain -- headaches, liver pain, kidney pain..."
Once, curious, I asked to look at the miraculous plastic blister pack that would cure multi-system organ failure: tetraciclina. "Holy shit," a responsible and self-respecting healthcare professional might say, and he'd be right, but not because he seems to have discovered the cause of novel antimicrobial resistance profiles in Central America, which he has not. Rather, his expression of dismay--"holy shit"--contains a metaphorical truth, insomuch as it recapitulates the fallacy of misrecognizing as transcendent and powerful something that is anything but. The obsession with Big (Bad) Pharma, just like our reflexive condemnation of ersatz physicians handing out low-dose antibiotics willy nilly in rural Guatemala, leads us to an upside down diagnosis of the causes of these predicaments.
Shall we turn things on their heads, right side up?
Amidst vociferous calls for increased scrutiny and regulation of pharmaceutical marketing and distribution strategies to curb the corrupting effects of competition, a paradox emerges: the Central American Free Trade Agreement (CAFTA-DR) was accompanied by "TRIPs-plus" laws, which, strangely, impose unprecedented restrictions on market competition in the name of intellectual property, by severely constraining National Drug Regulatory Authorities' (NRDAs') ability to acquire non-originator, or "generic," bioequivalent formulations to important new drugs (Health Affairs 28(5):w957). For example, as a result, Guatemala's national HIV/AIDS treatment program was obligated to begin purchasing two second-line antiretroviral medications from the originator, multiplying the total cost of one of them 15-fold. Life-prolonging medicines became impossibly unaffordable from one year to the next; put another way, a year's supply of Kaletra--and Abbott's intellectual property--was deemed of higher value than the relatively expendable life of an impoverished HIV+ Guatemalan.
We should be cautious, then, as the fetishization of regulation can lead to very divergent outcomes--either the assumption or disavowal of social responsibility. The fetish of "Pharm-Free," deposits and fixes responsibility for moral failures on individual actors--physicians, CEOs, biotech companies and salespeople--thereby magnifying their sins to the point of demonization. Banal, everyday objects are transformed by the activist fetish into the creeping manifestation of something evil, nearly supernatural--like sacred excrement.
In fact, these fetishes merely distract our attention, keeping secret another more abject one--the fetishization of commodities. The regulation of markets, as a solution, assumes the ontological inescapability of those markets. Indeed, the immoral strategies identified by "Pharm-Free" fetishists are merely distal expressions of the originary immoral presumption that Capital and caregiving are fungible.
Once, curious, I asked to look at the miraculous plastic blister pack that would cure multi-system organ failure: tetraciclina. "Holy shit," a responsible and self-respecting healthcare professional might say, and he'd be right, but not because he seems to have discovered the cause of novel antimicrobial resistance profiles in Central America, which he has not. Rather, his expression of dismay--"holy shit"--contains a metaphorical truth, insomuch as it recapitulates the fallacy of misrecognizing as transcendent and powerful something that is anything but. The obsession with Big (Bad) Pharma, just like our reflexive condemnation of ersatz physicians handing out low-dose antibiotics willy nilly in rural Guatemala, leads us to an upside down diagnosis of the causes of these predicaments.
Shall we turn things on their heads, right side up?
Amidst vociferous calls for increased scrutiny and regulation of pharmaceutical marketing and distribution strategies to curb the corrupting effects of competition, a paradox emerges: the Central American Free Trade Agreement (CAFTA-DR) was accompanied by "TRIPs-plus" laws, which, strangely, impose unprecedented restrictions on market competition in the name of intellectual property, by severely constraining National Drug Regulatory Authorities' (NRDAs') ability to acquire non-originator, or "generic," bioequivalent formulations to important new drugs (Health Affairs 28(5):w957). For example, as a result, Guatemala's national HIV/AIDS treatment program was obligated to begin purchasing two second-line antiretroviral medications from the originator, multiplying the total cost of one of them 15-fold. Life-prolonging medicines became impossibly unaffordable from one year to the next; put another way, a year's supply of Kaletra--and Abbott's intellectual property--was deemed of higher value than the relatively expendable life of an impoverished HIV+ Guatemalan.
We should be cautious, then, as the fetishization of regulation can lead to very divergent outcomes--either the assumption or disavowal of social responsibility. The fetish of "Pharm-Free," deposits and fixes responsibility for moral failures on individual actors--physicians, CEOs, biotech companies and salespeople--thereby magnifying their sins to the point of demonization. Banal, everyday objects are transformed by the activist fetish into the creeping manifestation of something evil, nearly supernatural--like sacred excrement.
In fact, these fetishes merely distract our attention, keeping secret another more abject one--the fetishization of commodities. The regulation of markets, as a solution, assumes the ontological inescapability of those markets. Indeed, the immoral strategies identified by "Pharm-Free" fetishists are merely distal expressions of the originary immoral presumption that Capital and caregiving are fungible.
Saturday, January 30, 2010
Action, context, revolution.
"The same gesture, performed at a wrong moment (too early or too late), is no longer an act...what makes an act 'unconditional' is its very contingency: if the act were necessary, this would mean that it is fully determined by its conditions, that it can be deduced from them (as the optimal version arrived at through strategic reasoning or rational-choice theory). [...] The link between the situation and the act is thus clear: far from being determined by the situation (or from intervening in it from a mysterious outside), acts are possible on account of the ontological non-closure, inconsistency, gaps, in a situation." ~Slavoj Zizek ( 2008 In Defense of Lost Causes)
Monday, December 21, 2009
On "health reform"
A quick slippage can be traced from the 2008 US Presidential Election campaigns to now in the discourse on the allopathic healthcare system. At some point, any mention of the need for an "overhaul" became replaced by monotonous details of "reform." The metaphor of "revolution," on the other hand, barely got any play.
Soon after Obama's election, Gallup and other polls demonstrated that people were beginning to feel more comfortable about their ability to afford healthcare. The sense of corporal insecurity and dread of being abandoned in their senility was diminished by the simple fact that politicians were "finally taking healthcare reform seriously," meaning little more than that they were finally talking about it.
For some reason, interviewers and acquaintances think that I should have something particularly enlightening to say on the current debate. The people who are closest to me know that I am too intellectually pessimistic to respond with anything more than grumbles. Moreover, the people who are closest to me know that what is being touted as "reform," or even as "the public option," will do little to make easier our "bloody" struggles to ameliorate the gruesome realities faced by the indigent sick.
But my grumbling is just another shade of gray in the monochromatic swirl that is the debate on healthcare "reform."
A different, more radical pessimism is required, and for that purpose I will borrow from a friend:
"It's preposterous to think that someone should get paid to provide medical care -- 'Wait, you saved my life so you want me to pay you money???'"
Yeah, seriously: fuck you!
Soon after Obama's election, Gallup and other polls demonstrated that people were beginning to feel more comfortable about their ability to afford healthcare. The sense of corporal insecurity and dread of being abandoned in their senility was diminished by the simple fact that politicians were "finally taking healthcare reform seriously," meaning little more than that they were finally talking about it.
For some reason, interviewers and acquaintances think that I should have something particularly enlightening to say on the current debate. The people who are closest to me know that I am too intellectually pessimistic to respond with anything more than grumbles. Moreover, the people who are closest to me know that what is being touted as "reform," or even as "the public option," will do little to make easier our "bloody" struggles to ameliorate the gruesome realities faced by the indigent sick.
But my grumbling is just another shade of gray in the monochromatic swirl that is the debate on healthcare "reform."
A different, more radical pessimism is required, and for that purpose I will borrow from a friend:
"It's preposterous to think that someone should get paid to provide medical care -- 'Wait, you saved my life so you want me to pay you money???'"
Yeah, seriously: fuck you!
Monday, November 23, 2009
Perplexing insistence...
Please take a moment to look at the newest issue, "Killer Apps," page 30-32: The Atrium.
Tuesday, October 20, 2009
The 5 Laws of Infectious Disease
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.
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.
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.
Wednesday, September 9, 2009
Matyox chiwe.
Thank you:
http://www.globalgiving.com/projects/diabetesmaya/
Many Maya patients and families struggling against poverty, racism and diabetes have found solace through Wuqu' Kawoq's ongoing solidarity.
Much thanks to those who have already given!
These are uncertain times for everyone. Please help, as you are able, to ameliorate the insecurities that plague Wuqu' Kawoq's patients.
~Shom
http://www.globalgiving.com/projects/diabetesmaya/
Many Maya patients and families struggling against poverty, racism and diabetes have found solace through Wuqu' Kawoq's ongoing solidarity.
Much thanks to those who have already given!
These are uncertain times for everyone. Please help, as you are able, to ameliorate the insecurities that plague Wuqu' Kawoq's patients.
~Shom
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