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Four Wheel Drive

November 10, 2010

Hello from the Amazon! Things are kind of crazy for me right now- I’m in the process of switching from “working” in the hospital to “working” for the Ministry of Public Health in their community health programs. Why the sudden switch, almost halfway through my time here? That’s the subject of the rambly bit below. But before I lose you all to Acute Boredom Syndrome, I just wanted to share how excited I am for what my life is about to become. As I was walking with the director of the regional branch of the MSP to his office, he described to me how their teams head deep into the selva, to remote villages only accessible by canoe and on foot. Then, he suddenly turned to me and asked: “¿Eres cuatro por cuatro?” (Literally: Are you four by four? Roughly: do you have 4-wheel drive?) Having misheard him, I was about to explain that I don’t have any sort of vehicle, when I realized he was asking about me: am I equipped for offroading. That’s all I needed to hear to decide if I was making the right choice in leaving the hospital.

DISCLAIMER: I’m now going to subject you to some of my world-famous incoherent reflections, this time on the subject of the role of personal gratification in medicine. “A la mitad del mundo, Inc.” takes no responsibility for injuries or loss of personal belongings.

I started out having a blast in the hospital, getting to see and do really cool stuff. But that’s part of the problem: I didn’t come here to do cool stuff. It’s an unbelievable rush to help a real doctor stitch a patient’s hand back together, reconnecting severed tendons in the process, or watch an infant take his first breaths, but again, that’s not why I’m here. I’m here because little kids are dying for no good reason in this crazy messed-up world, and I want to know why, and what needs to happen for that to change.

After the second night in the ER, I found myself being strongly tempted by the field of trauma surgery. It’s a very attractive and gratifying way to deal with your ambivalence, going into pretty much any form of specialized medicine. You see a problem: a 7-year-old boy screaming with pain from a broken femur. And you can fix it. You can fix him- all you need are a few screws, an operating room, and a few years of specialized training and expertise. And voila! You have played God: a broken leg is now healed by your own two hands.

Infectious disease, I think, has a similar pull for me. A patient comes in with lungs full of TB, or hideous pustules all over his skin, and, if you can be just clever enough to get the antibiotics right, you can heal him.

You can be a cardiac surgeon, and extend by 20 years the life of someone who previously had less than a snowflake’s chance in Hell of seeing her grandson’s wedding. You can be a hero.

But look at this figure:

That, my friends, is UNICEF’s breakdown of the causes of child mortality worldwide. If you include neonatal deaths, diarrhea, a condition that should never be fatal (except perhaps in the most extreme cases), accounts for a full 17% of the total causes of child deaths, some 1.7 million every year.

And all you need in order to save them is some water with sugar and salt.

So what do you do? Diarrhea isn’t exactly the most glorious disease to treat- I almost lost my lunch in the hospital the other day when I examined the contents of one kid’s diaper. It’s also boring as hell in the hospital- kid comes in with dehydration, so you give him a rehydration solution, either by mouth or intravenously depending on the severity of the case. Then you watch him for the next few hours as the signs of dehydration slowly start to disappear, load up his mother with some zinc tablets and more packets of ORS, tell them to keep giving him food, and send them on their way.

Nobody should die of diarrhea. And yet they do. So what do you do?

You sit and think. You look at health statistics. You figure out what the strongest determinants of diarrheal infections are- poor sanitation, poor personal hygiene, etc. You discover that the poorest 20% of children in Ecuador are almost five times more likely to suffer an episode of diarrhea with severe dehydration than the richest 20%. Their likelihood is two times greater if their mother calls herself “indigenous,” rather than “mestizo,” and three times greater than the children of “white” parents in Ecuador. You haven’t found the relevant data yet, but you have a hunch that the mortality rates of diarrhea are far higher in remote rural areas, where educated parents are rare and access to medicine is limited, and water quality is inadequate, at best.

You’re still stuck though. What do you do with this information? How do you get packets of ORS into the hands of every community and into the mouth of every kid? How do you teach every mother how to check for signs of dehydration, that you’re not just wasting water by giving it to a vomiting child, and how to make adequate solutions of sugar and salt if ORS is unavailable or the kid won’t drink it? How do you fight social problems like paternal neglect? How do you end the grinding structural violence, the economic power systems that leave people without running water, or toilets, or electricity and fuel to boil water to drink?

And you can devote your life to this, and likely never see the results of your work. Gratification in public health is delayed, if it comes at all. The best you can hope for is a non-event: “nobody died during that cholera outbreak,” or slight changes in regional health statistics that may or may not have anything to do with your interventions at all. And after all, the grinding poverty and oppression and structural violence will still remain. Is this what you really want to do? Can you do anything else, though? It has to be done.

So you switch into four wheel drive.

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5 Comments leave one →
  1. Nick permalink
    November 10, 2010 10:31 PM

    You are a credit to humanity, sir. I cannot wait to see what amazing things you do in the future 🙂

  2. Tarini permalink
    November 11, 2010 8:36 AM

    David,
    I’m also really excited for what your life is about to become. Reading about your experiences and thoughts about this crazy world is incredibly humbling. Thank you for reminding me why we both made this completely insane decision. Yes, it does have to be done, and no, we couldn’t possibly do anything else.

  3. September 15, 2013 9:55 AM

    These are basically bag shaped pouches which contain see through jackets to hold CDS.
    Not only can they cost thousands of dollars, but
    the average person will typically spend many hours, day after day, looking at it.
    If we are talking about superb special effects in movies, this one wins hands down.

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