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Se acabó.

April 21, 2011

It has been two weeks and three days since the last post on this blog. And, as predicted, they have been a blur. It’s hard to believe that the semester is over. It’s harder to believe that I’m actually going home in three days. And it’s freakin’ impossible to wrap my head around the fact that now, technically, I’m a senior in college.

What’s there to say? Today has been a whirlwind of emotions: stress, euphoria, melancholy, excitement, relief, and exhaustion. It’s too much to process right now, or ever for that matter. But my overwhelming feeling is that now, having fulfilled my responsibilities for the semester, I’m just ready to go home. Especially after having said goodbye to my host brothers last night, and my Cimas family and classmates today, it’s hard to escape the feeling that there’s nothing left for me here.

This will be my last entry in this blog. I knew this post was coming, and I haven’t been looking forward to it at all. I’ve really enjoyed having this little blog, even though I’ve been bad at updating it. It has been great to feel like I could share my experiences with folks “back home,” using this blog as another way of staying connected. But perhaps more importantly, it has become an outlet for me, a chance to write about the things I think are important.

Because of this, I’m starting a new blog, which you can find here (though I can’t imagine why on Earth you’d want to). It will probably still have a fair amount to do with Ecuador (especially during the first few weeks of culture shock and readjustment to the States), since this little country has become such a big part of my life, though I will probably branch out into new and significantly more controversial territory, as well as use it as a space for more personal reflections. But the overall theme will be the same: how do we make sense out of this crazy messed-up world? And what the hell do we do about it?

I hope to see you there.


Before you know it

April 4, 2011

One week of furious data analysis and writing before our big presentation. Ten days until I leave Tena. Two weeks, three days until my last day at Cimas. And only two weeks, six days before I’m back in the States, for who knows how long. That familiar feeling is back, an uncertain mix of stress, sadness, and excitement. Stress over everything I have to cram into two short weeks. Sadness at leaving a country that has become one of my homes, tearing myself away from people that have become part of my family. And an excitement to get back to the States that I can’t quite explain. Beyond friends and family and sugary cereal, I can’t quite pin down what I’m looking forward to, exactly.

Yesterday we surveyed our last village, meaning data collection is officially over. No more last-minute copy making. No more phone calls to community presidents, no more showing up at government offices. No more head-scratching over how we’re going to get there. No more slogging through knee-deep mud, no more offerings of (probably) microbe-infested chicha. No more munching on guava while walking between houses. No more screaming, kicking children, no more teenage mothers. No more misunderstood questions. No more fists clenched in frustration, no more overwhelming mixes of emotions. No more sweating through the straps of our backpacks, no more getting drenched by sudden downpours. No more intruding into people’s lives across massive disparities of privilege and affluence. No more accepting boundless generosity in the midst of poverty. No more making games out of height measurements, no more pretending the scale is a choo-choo train. No more questionable bridges, slippery logs, isolated streams. No more ceaseless cacophony of jungle sounds.

Ten days in Tena. Ten days for late-night conversations over beers with my host brother. Ten days for salchipapas and leche Toni with my host nephew. Ten days to be interrogated by my host mother on the subject of my breakfast preferences through the hole in the wall joining my bedroom to the kitchen (“Scrambled eggs, no?” “Ok, thanks!” “Orange juice?” “Sounds great!” “Coffee? Bread? Milk? Yogurt? Granola? What else?”). Ten days of crossing the pedestrian bridge. Ten days of football (the real kind) with my host nephew. Ten days in a house full of constant noise and activity. Ten days left in the land of perpetual summer and no air conditioning. Ten days left at home, with my family.

I used to play a game with myself as a kid. It started one day on the road between Murree and Mansehra, coming home from boarding school for vacation (Home, at that time, was located in Pakistan’s North West Frontier Province). A boulder sticking out above the road caught my eye, and I thought to myself: next thing you know, vacation will be over, and you’ll be back at school already. And sure enough, the next time I remembered that moment, thinking of the way that boulder hung perilously above us, I was back at boarding school, my vacation having passed like a fleeting dream. Ever since then, I’ve thought back on that moment, now buried at least 12 years deep in the past, and thought of how everything has changed, how quickly long-awaited events turn into half-forgotten memories. Life hurtles past us at its breakneck speed, and I guess this is just my little way of trying to hang on. Next thing I know, I’ll be home, and Ecuador will come with me only in my memories.

Before we know it, who knows where we’ll all be? Before we know it, our last chance to live will have passed. So let’s take it now, while we still can.

“Structural Violence” and the $ocial Determinants of Health

March 19, 2011

The title of this post refers to the single most important lesson I have learned since coming to Ecuador.* Anyone who has read “Mountains Beyond Mountains” is likely familiar with the first term; it is Dr. Farmer’s (and by fanboy extension, my) chosen way to conceptualize the damage caused by poverty and social injustice. I’ll start with the definition Farmer himself uses in his essay on “Structural Violence and Clinical Medicine”:

In the influential view of sociologist Johan Galtung, structural violence is “the avoidable impairment of fundamental human needs,” embedded in longstanding “ubiquitous social structures, normalized by stable institutions and regular experience.” Because they seem so ordinary in our ways of understanding the world, such violent structures are almost invisible. Disparate access to resources, political power, education, and health care as well as unequal legal standing are just a few examples. Such arrangements do violence to society’s losers; the arrangements are structural because they are embedded in the economic organization of our social world (emphasis mine).1

I find the following statistic from the World Health Organization helpful in understanding how health inequality can be viewed as violence: “A girl born in Sweden will live 43 years longer than a girl born in Sierra Leone.”2 Imagining the huge loss of life implied by this statistic, it’s hard to see how such early deaths could be seen as anything but violence. But, as Farmer points out above, it’s invisible violence, because it’s become such a normal part of our experience and way of understanding the world.

What are the mechanisms of this violence? They are the “large-scale social forces—racism, gender inequality, poverty, political violence, and war, and sometimes the very policies that address them—[that] often determine who falls ill and who has access to care.”1 Simply put, they are the social determinants of health. Their reality is seen most readily through statistics. Johns Hopkins University professor Vicente Navarro, concluding that “the evidence that health and quality of life are socially determined is undeniable and overwhelming,” writes:

“In Glasgow, an unskilled, working-class person will have a lifespan 28 years shorter than a businessman in the top income bracket in Scotland”2… In East Baltimore… a black unemployed youth has a lifespan 32 years shorter than a white corporate lawyer. Actually, as I have documented elsewhere, a young African American is 1.8 times more likely than a young white American to die from a cardiovascular condition. Race mortality differentials are large in the United States, but class mortality differentials are even larger. In the same study, I showed that a blue-collar worker is 2.8 times more likely than a businessman to die from a cardiovascular condition.3

University of Michigan professor George Kaplan summarizes his article on poverty’s effects on health in the United States by stating:

[There are] many ways in which the health of the poor is put at risk on a daily basis and from generation to generation. The result is a kind of crazy quilt of risk, weaving together lack of access to quality education, medical care and other health-enhancing resources, low wages, embattled physical and social environments, and work that produces poor health. At the same time, a vicious cycle of disadvantage leading to poor health that in turn leads to further disadvantage and further poor health plays out over the life course and across generations.4

All this may seem fairly obvious. Of course poor people tend to have worse health than rich people; we’re not exactly breaking new ground here. So why even say it in the first place, and come up with terms like “structural violence” and “social determinants of health”? There are two reasons, one for each term used.

First, the term structural violence is galvanizing. If dying of poverty becomes normalized, seen as an inevitable consequence of “the way the world works,” we tend to lose both our sense of agency as well as our moral responsibility to do something about it. If, however, we learn to view inequality as violence, then it logically follows that if we benefit from the power and privilege at the top of the social order without doing anything to change it, we are guilty, however indirectly, of perpetrating and perpetuating that violence.** And my hope is that if enough of us develop guilty enough consciences, someday something might change.

The second reason is to put the focus back on the social determinants of health, to give them a name. When we think of “health,” too often our thoughts are limited to germs and doctor-patient visits, without asking ourselves why some people are always sick and why others never make it to the doctor’s office in the first place. If we accept the mandate of a physician as being “to heal the sick and to promote health (not just the absence of illness),” then we must broaden our focus in medicine to include poverty in addition to pills.


*Granted, I had already heard of “structural violence” before coming here, but the idea of social determinants of health was new to me (probably because I decided for some reason to major in the physical sciences). And being in Ecuador has given me the chance to see for myself exactly what Farmer is talking about.

**A related idea in the feminist movement is that just by exercising male privilege, one perpetuates gender inequality.


1. Farmer, Paul, et al. “Structural Violence and Clinical Medicine.” Farmer, Paul. Partner to the Poor: A Paul Farmer Reader. 2010. 377-8. (The original version of the article can be found online here.)

2. World Health Organization. “Commission on Social Determinants of Health- Final Report.” Geneva, 2008.

3. Navarro, Vicente. “What We Mean By Social Determinants of Health.” International Journal of Health Services (2009): 423-441.

4. Kaplan, George A. “The Poor Pay More- Poverty’s High Cost to Health.” 2009.



March 15, 2011

Mount Cotopaxi, an active volcano in Ecuador’s central Sierra that towers 5897 meters above sea level, is the second-highest mountain in the country. It’s a popular site for climbing, since you generally don’t need much experience to reach the summit, just as long as you go with a guide who knows the way up (ensuring that you don’t fall into a crevice, among other unsatisfactory outcomes). Knowing this, my partner Julia and I decided it would be our best opportunity to, you know, climb a freakin’ mountain. When else (in the foreseeable future) would we ever get the opportunity to do it?

We found an agency through the brother of my host father in Tena, and made arrangements to go on Saturday, in the last days of our spring break. They agreed to provide everything we needed: warm climbing clothes, boots, headlamps, cramp-ons, ice picks, etc. So late Saturday morning we left their office in Latacunga, reaching the mountainside parking lot at 4500m at about 2 PM. From there, we had to hike through the volcanic ash up to the “refuge” at 4810m, a small mountain lodge for hikers to rest and prepare for their midnight departure up the slope. At this point we were at over twice the altitude we had been all week, and our lungs could feel it. Gasping our way up those first few hundred meters, watching families with children above us climbing with apparent pack-less ease, we wondered how we would ever make it to the top.

After spending a few hours drinking hot chocolate, eating dinner, and passing the time with other people in the lodge (including some fellow gringo college students on a day trip; one of them was wearing shorts!?), we headed upstairs for an unsuccessful attempt at a few hours of sleep. It was 1 AM by the time we got out the door, the second group among some 25 hikers to hit the slope, trailing only a young German woman and her insane German guide. By then the clouds had cleared away, and as we started up the mountainside in the pitch dark I managed to steal a few glimpses of the star-filled sky. At a higher vantage point for stargazing than ever before in my life, I was distracted by the sudden desire to stop and marvel at the unfamiliar constellations visible from the equator. But my vision was obscured by the hood I was wearing, and I had to pay attention to where our guide was leading us.

The first hour and a half passed in silence, following our guide’s mechanically steady pace. Step step, pause. Breathe. Step step… We were the only visible objects on the mountain, illuminated by the tiny cones of light from our headlamps, our guide charting a zig-zagging course through the snow, more by feeling and instinct than by sight.

Then the wind started to pick up. Flakes of snow started to blow off the ground, soon joined by fresh snow from the sky above us. I looked up, around; everything was now obscured by a white haze, the light from my headlamp only reaching out a few meters into the impenetrable darkness. Above us, the two Germans were only visible as tiny, diffuse points of light through the fog.

The wind was blowing furiously now. I had to hold one glove beside my face to protect it against the horizontal bombardment of icy snowflakes, wielding my ice pick in the other hand. We came up to steepest ascent so far, digging the spikes of our cramp-ons deep into the packed snow along the side of a ridge. By the time we reached the top of the ridge we had to stop, resting our hands heavily on our knees and gasping for breath. It was 3:00 AM, and we were at 5200m, the highest elevation we would reach that day, completely at the mercy of the blizzard now raging around us. Our guide motioned for us to huddle under the lip of the ridge while he climbed up to inspect the condition of the route above us. Then, seeing how we were still being battered by the wind, he instructed us to climb back down to the base of the ridge, to wait with another group of hikers at the mouth of an ice cave.

Motionless, sheltered from the brunt of the wind, we huddled together as we felt our body temperatures dropping. After about ten minutes of looking around and consulting with the other group’s guide, ours came back with a verdict that made my stomach sink: we were not going to reach the summit in this weather. The other guide affirmed his decision. “You can’t go adventuring up here,” he said. “You have to respect the mountain.” So without a word we started our careful descent, exhausted and thoroughly disappointed, but at least grateful to get our blood moving again.

The pace was brutal. Our guide was in a hurry to get down and out of the weather, so we marched without pausing. You certainly go faster downhill, but in my opinion it’s just as difficult as going uphill, bent knees constantly holding the full weight of your body as you dig in your cramp-ons and struggle to keep from pitching forward down the mountainside. I caught myself wondering what would happen if I just let myself fall into the snow, how good it would feel to just lie face down and stop worrying about everything. But then even that thought was gone, as I poured all my mental energy into just planning the next step.

And then we got lost. When we were going uphill, I had wondered to myself how our guide knew his way up the featureless mountainside. It wasn’t a straight ascent either, but full of lateral movement, first to the right, then cutting back to the left. When we descended, however, we did so in almost a straight line, at times angling to the right. And visibility was no more than a few meters in any direction.

We came out onto an unfamiliar field of rocks, boots slipping through the ash mixed with fresh snow. At one point we stopped to catch our breath, and our guide left us to continue searching for familiar scenery below us. The other group went with him, fanning out slightly as they descended. We were too exhausted to follow them; without the summit to look forward to, I couldn’t muster the motivation to continue. So we watched them descend, waiting for one of them to turn around and signal that he had figured out where to go. But they didn’t turn around, and then one by one their lights disappeared over the ridge below us.

For a few terrifying moments, we waited for them to reappear, the horizon now total darkness. But they didn’t, so we heaved ourselves up to keep following them, trying to stave off the panic. Sure enough, they were still there ahead of us when we came over the ridge, carefully picking their way through the ash and snow and rocks. Just when caught up to them, the other guide yelled, “We’ve made it to the parking lot!” We had just missed the refuge by no more than 100m, and ended up right where we had started the previous day. Julia and I looked at each other, wondering how we were going to muster the energy to go back up the mountain again. But at least we knew where we were.

And when I finally looked up to see the faint outline of the refuge looming through the fog, I swore to myself it was a far more beautiful sight than any mountaintop sunrise. When we climbed into bed, a quick glance around the lodge showed that all the other hikers had made it back before us. Only the sleeping bags of the two Germans remained empty. Somewhere high above us, they were still fighting their way through the blizzard toward the summit.

After two short hours of sleep, we packed up our things and started the descent back down to the car. The clear skies showed no signs of the furious storm; it had passed as quickly as it came, only the snow-covered mountainside testifying to the danger in which we had found ourselves.

Paternalism vs. Solidarity

February 21, 2011

When I explain to friends/family/acquaintances what the MSID program is, and what I’m doing here, every once in a while I get a response that kind of disturbs me. Some friends, meaning to wish me well, will say things like “Oh, it’s so cool you’re spending so much time down there helping people,” or “Have you saved any lives yet?” Obviously the latter response is mostly tongue-in-cheek (I say mostly rather than totally because of the prevailing phenomenon of the medical mission trip- in which untrained North American students head to Latin American countries to “get their hands dirty” doing real medicine best left to actual medical teams, taking advantage of the more relaxed ethical standards in countries that experience shortages of health care professionals in order to get “experience” to put on their med school apps), but I still think it reveals something about the way we as privileged members of the “First World” approach the concept of development in the “Third World,” the majority world.

To begin with, to even refer to my study abroad program (or any sort of short-term volunteer/service experience) as “helping people” reveals the implicit assumption that any North American volunteer automatically has something* to offer people in the majority world, just for being North American. It doesn’t matter if you have no experience in the field, simply by flying from north to south you are assumed to be helping. The most obvious and painful examples of this are the teams that travel to majority world countries to build houses, schools, etc., and actually do the manual labor themselves. Meanwhile, unemployed construction workers must sit by and watch the gringos do what they themselves could have done more competently for a fraction of what the northerners spent on airfare. (And then, more than likely, the newly finished school will sit unoccupied, for who will pay the teachers to staff it?) Likewise, MSID students find themselves with hands-on internships in hospitals and health centers despite having zero clinical experience, while such internships are almost certainly unavailable to Ecuadorians at the same educational level. It becomes clear that the focus is not on how to best improve the lives of them, the people living in poverty, but rather on what we can get out of the experience.

This is not always bad, however, especially if you make sure to keep that in mind, and seek ye first your own personal transformation, without patting yourself on the back for “helping people.” That’s why I’m trying to stay focused on what I’m really doing here: above all, MSID is part of my education, possibly the most important part so far. And I’m a little ashamed to think that part of a previous post may have implied otherwise.

True, this semester will likely have marginally more effective results. Our specific type of survey has never been done in this canton before. The Concejo’s practically non-existent budget certainly doesn’t have room to hire people to do the survey work we’re doing, and our “boss” is very enthusiastic about having the type of information we will produce (regardless of whether it will actually influence policy). And despite our lack of experience as survey workers, we have carefully developed our methodology and are relying on a network of support and resources that may not be available to our Ecuadorian counterparts. So the type of work we’re doing would likely be hard to come up with otherwise in Canton Archidona, and it may actually turn out to be slightly useful to someone. But: if I had spent the whole semester flipping burgers, and then taken that money (or the money that I’ve spent on this study abroad program) and invested it in a similar project, from simply weighing the benefits to the people of Archidona it’s hard to see why that wouldn’t be a better alternative. (Welcome to one of my endless cycles of self-doubt, by the way.)

So really, it all comes back to me: what am I getting out of this. Though I can hope that the things I’m learning here will better equip me to give back more effectively someday, to think that I’m making a real difference at this point would be little more than self-delusion.

There’s another problem with the idea of “helping people”: it objectifies human beings. Rather than being seen as fully human subjects, this kind of language treats the poor as inanimate objects, waiting to be “developed” by outside agents. Part of the reason why this paternalistic attitude is accepted is likely because poverty really does rob people of agency, discrimination does rob them of personhood. But that is precisely why development must be focused on people as subjects: it is only the first step toward restoring their dignity.

What’s the alternative? In Partners In Health jargon: pragmatic solidarity. The first part of that term is just as important (and could use an entire blog post of its own), but here I will focus on the second. Solidarity in this sense could be defined as “having the same goals as the poor.” Not only does the idea of solidarity tap into one of our deepest moral intuitions as social animals, but it forces us to recognize the subjectivity of our neighbors in the global community, rather than treating them as objects to be “fixed” by a public health or economic development campaign. An example of this type of objectification would be the common representations of Africa or Haiti in our media: images of emaciated children and their wailing mothers, bleeding disaster victims. While these images often do truly represent the horrific reality of extreme poverty, and can be very effective at kindling our moral energy, the downside is that they objectify the suffering of their subjects. The result is that when we think “Haitian,” or “African,” these images come to mind, rather than the idea of a person with thoughts, desires, and, dare I say it, identity.

Importantly, the above definition holds that our goals should be those of the poor, necessarily giving them a voice in the process, rather than coming up with our own goals and imposing them through development. It acknowledges the role of the poor in their own fight for liberation. And it hints at the need for change initiated at the grassroots, rather than assistance handed down by foreign experts from the “treetops.” This may seem like an arbitrary distinction, more wordplay than an actual difference in practice. But such distinctions are, in fact, fundamentally important, given the myriad examples of the damage caused by wrong-headed development.

Beyond that, what does “solidarity” mean, not just in words but in practice? I’ll have to get back to you on that…


*Money is, of course, the one blindingly obvious example of something that can be used to bring about effective change. It should go without saying, but it doesn’t get said enough, so here we go:

The problem, at least for me, is that giving to monolithic organizations like PIH, even when you are familiar with the incredible work they do, doesn’t make you feel like you are personally involved. You don’t feel like you “worked” for change, even when a simple donation of a portion of your earnings is often the most efficient and effective contribution you can make.

Blogging- am I doing it wrong?

January 30, 2011

In the past three weeks, I have moved to Tena, started working out of the Concejo Cantonal de Niñez y Adolescencia office in Archidona, designed a survey questionnaire, tested it twice with a total of 6 families (our goal is 100-200 total), sat in a dozen different government offices, gone out to the nearby villages four times, visited a cheese factory and a private waterfall, interviewed a former mayor, learned how to do random cluster sampling, applied random cluster sampling to select 20 populations from the 120 listed communities in the canton of Archidona, looked at a map to try to find out where the hell those 20 communities are, asked myself “How on Earth are we going to get to half of those?”, gotten sunburned three times, gotten attacked by biting insects more times than I can count, fallen in love with avena, fallen in love with guayusa again, downloaded Epi Info to record and analyze our data, cried upon opening its 300-page tutorial, started learning how to use Epi Info, cursed Epi Info for its very existence, fallen in love with Epi Info, found myself at a complete loss for how to do anything with Epi Info, taken advantage of the wireless internet in the Concejo office to avoid working on all of the above, shared a taxi with a Ministry of Public Health vaccine team, developed an addiction to Galak cookies, beaten Super Jewel Quest on my cell phone, said “chuta,” “chévere,” and “sigue no más” about 500 times, navigated river rapids in an inner tube, finished reading Pathologies of Power, eaten twice my weight in home-made bread, gone birdwatching, made a 16-hour round trip by bus to visit one of the 4 other remaining MSIDers for her birthday, developed an obsession with the artwork of Oswaldo Guayasamín, made arrangements to do our survey in two communities (18 to go!), sweat more than I did during my entire hockey career, and learned to sleep through thunderstorms, bulldozers outside my window, screaming kids, yelling adults, barking dogs, crowing roosters, and my alarm clock.

Put that way, this semester sounds almost productive.

New Post

January 13, 2011

A week and a half into second semester, and I am thoroughly happy about my decision to stay for the year. The first week was spent frantically planning and designing my research study–on which I am now collaborating with another student–before heading back to Tena last Sunday. Instead of diarrhea (it was a crappy topic anyway) we will be studying rates and determinants of malnutrition, and instead of being based in Tena, we will be working with the Concejo Cantonal de Niñez y Adolescencia (the branch of the local government charged with protecting the rights and health of children) in Archidona, a smaller town about 20 minutes away by bus.

So far we’ve mainly been focusing on making contacts in Archidona and the surrounding rural communities, as well as putting the finishing touches on the 60-question survey that will form the basis of our research. It’s been a busy and exciting week. I’ll be working on a longer post to reflect on this week’s visits to rural communities outside Archidona, though time will tell if that ever sees the light of day. More detailed updates (and maybe pictures) will come when I have time.