David Werner

A selection of Articles by David Werner that focus on the political aspects of health.



Global Assembly on "Advancing the Human Right to Health"
Iowa City, Iowa, April 20-22, 2001


In the 1940s, the United Nations declared Health a Basic Human Right. The World Health Organization was created to help make that Right a reality. But during the next several decades, the Right to Health remained a distant dream for most of the world's people.

True, great advances were realized in medical science. The Western medical model, with its urban "Disease Palaces," costly doctors, and commercial pharmaceuticals, was extended into the Third World. But to a large extent, the benefits of Western medicine remained inaccessible to the poor majority living in rural areas and growing city slums.

During the same period (from the 1950s through the 70s), important public health measures to reduce infectious diseases were introduced through national and international campaigns. But, once again, these measures were unequally distributed. Millions of children continued to die from diseases that could have been prevented through clean water, immunization, and good nutrition.

It became clear that poverty and powerlessness were the underlying causes of poor health and early death.


In pursuit of Health for All

Hopes for a breakthrough emerged with the Alma Ata Declaration in 1978. The world's nations endorsed the goal of "Health for All by the Year 2000," to be approached through a comprehensive strategy called Primary Health Care. The Declaration not only advocated universal coverage of basic health services, but also called for a "new economic order" to assure that all people could have a standard of living conducive to health. To achieve greater equity in meeting health needs, it called for strong popular participation.

At that time there was lots of optimism. But the year 2000 has come and gone. And today the dream of Health for All seems more distant than ever. A reversal has occured of many advances made in earlier decades. The Third World has seen a resurgence of "diseases of squalor" such as cholera, malaria, tuberculosis, and even plague. New diseases such as AIDS are taking their highest toll in populations whose basic needs and rights remain grievously unmet.

Why is it that the Human Right to Health still remains so far from being realized? What are the necessary resources and prerequisites for this Right to be implemented? And what are the limiting factors?


The World Bank's "investment in health"

The World Bank -- the newest and strongest player in international health -- tells us that the key obstacles to approaching Health for All are economic. It points to the poor "cost-effectiveness" of Third World economies and specifically, of their health systems.

Figure 1. World Bank 1993 World Development Report

The World Bank has a very market-oriented concept of human health. It argues that good health is necessary for economic growth, and vice versa. The Bank's 1993 publication, "Investing in Health," advances a master plan for making health care cost-effective. (in terms of keeping a country's workforce free enough from illnesses to contribute maximally to economic growth). To figure out which health measures merit public support, the Bank invented DALYs, or "Disability Adjusted Life Years." It calculates how many DALYs can be saved by different interventions. In this scheme, the people of highest value are young adults, who are thought to work hardest. Infants, old people, and disabled persons have less value because they contribute little or nothing to the national economy; therefore they merit less public expenditure for their health (see Figure 1).

Dehumanizing? Absolutely! ... Yet the World Bank presents its regressive strategy with such beguiling doubletalk that it sounds deceptively progressive. So, watch out!

Since the mid-1980s, the World Bank has become the leading international agency for health policy planning in the South, relegating the World Health Organization to second-place. The Bank's health spending is now three times the entire WHO budget. It is an ominous sign when a giant financial institution (with strong ties to big business) bullies its way into health care. Yet with its enormous money-lending capacity, the Bank can force its health blueprint on poor countries.

In order to reduce government expenditure on health and make services "cost-effective," the Bank has pushed poor indebted countries to privatize public hospitals, and to introduce "cost recovery" schemes, including "user fees" for community clinics. Studies in several countries have shown that user fees have decreased utilization of medical services and increased child mortality, sexually transmitted diseases, and tuberculosis.

Figure 2. Outpatient attendance at Dwease Health Post, Ghana, before and after introduction of user charges in 1985.

In Ghana, Africa -- one of the Bank's high-profile success stories -- user fees in rural clinics were introduced in the mid-1980s, as part of Structural Adjustment. As a result, child mortality, which had dropped steadily for over a decade, almost doubled (see Figure 2).

The current trend of privatization and user fees burdens the poor with costs of basic services that used to be covered through progressive taxation. This is consistent with the conservative thrust of the globalized economy, which has consistently rolled back socially progressive policies of earlier decades. Put simply, health is no longer a human right. In the ethics of the global marketplace, you pay for what you get. If you can't pay, tough luck! Health -- and health care -- have become yet another profit-driven commodity. Its business as usual!


Inequity as a determinant of ill-health

The World Bank is correct when it says the major obstacles to Health for All are economic. However, the problem is not a total shortage of wealth. Rather it is the ruthlessly unequal distribution of wealth, and the misguided priorities of those who control most of the world's resources.

Figure 3. Global distribution of income

Graphically, distribution of wealth in today's world has the shape of a wine glass: the richest 20 percent of people control over 80 percent of the wealth, while the poorest 20 percent control less than 1.5 percent of the wealth (see Figure 3). Spurred by the inequity of the free-market system, the gulf between rich and poor continues to widen, both within countries and between them. Of the world's 100 biggest economies today, 51 are transnational corporations, which are wealthier than most nations. The world's 350 richest men have a combined wealth equivalent to the poorer half of humanity. Similar inequity exists in the world's richest nation, the United States, where one of four children lives below the poverty line. Bill Gates, Head of Microsoft, has an annual income equal to that of the poorest 40 percent of Americans. No wonder the US has the worst health statistics of the wealthiest 24 nations!

This growing income gap is a major concern for health. Studies in different countries, analyzed by Richard Wilkinson in his recent book, Unhealthy Societies, shows the clear relationship between ill-health and inequity. Comparison of the different states of the USA, and likewise the different nations of Europe, show that the level of health of a population is determined less by its total wealth or GNP per capita than by the relative equality, or inequality, with which that wealth is distributed. These studies convey an ominous forecast for our globalized paradigm of development, which is relentlessly increasing the huge disparity in wealth and power, worldwide.


Good health at low-cost

Historically, alternative models of development exist which put the basic needs of all people before the economic growth of the ruling class. In 1985, the Rockefeller Foundation sponsored a study called "Good Health and Low Cost," to find out whether certain poor countries had achieved levels of health approaching those of rich countries. The study -- which included China, Sri Lanka, Kerala State of India, and Costa Rica -- found these countries had indeed achieved child-survival and life-expectancy rates similar to much richer countries. But how? It was found that although these countries covered a wide political spectrum, they had 4 things in common:

1. An overall political commitment to equity;
2. Universal education with emphasis on the primary level;
3. Free and equal health services for the entire population;
and perhaps most important of all:
4. Provision of an adequate calorie intake (enough to eat) for all citizens, in a way that does not disrupt traditional agriculture.

Sounds great! But it must be pointed out that each of these four countries that achieved "good health at low cost," has recently suffered setbacks. Each has found it hard to sustain its commitment to equity and "health for all," and at the same time survive the pressures (and threat of trade sanctions) from the globalized free-market power structure.

One country the Rockefeller study did not include, but which has made even greater achievements in health is, of course, Cuba. By requiring relatively equitable distribution of resources, and by giving top priority to people's basic needs -- including education, free comprehensive health services, and adequate nutrition for all -- Cuba has obtained a level of health equal to and in some ways better than the United States. It has done so with a GNP per capita of only 1/20 that of the United States! More remarkable still, Cuba has sustained its good health in spite of the devastating U.S. embargo. What the US fears most from Cuba is the example it gives the world that good health is possible when limited resources are equitably allocated.


Key resources: political will and "power of the people"

There is little question that the resources exist to make health a basic human right. What is missing is the political will of the world's ruling class: that relatively small, elite minority who control most of the resources and decision-making power.

There's a lot of euphemistic talk about "Democracy." Our newspapers, TVS, and schoolbooks tell us that most countries have at last become democratic. But too often what passes for "democracy" is a wolf in sheep's clothing. Although national leaders are elected by popular vote, too often the electoral process is corrupted by big money. Nowhere is this truer than here in the United States, where half the citizens feel so disempowered they no longer bother to vote. Huge campaign donations from corporations and other wealthy interest groups have so distorted the electoral process that what we call "democracy" is now an oligarchy of the ruling class. "One person one-vote" has been subverted to "one dollar one-vote." Even our revered "Free Press" is now anything but free. It has become another multi-billion dollar industry. The mass media are owned by the same giant corporations that own the oil industry, arms industry, tobacco industry, and transnational drug companies. The "news that is fit to print" is part of a giant machine of propaganda and social control that expedites the economic growth of the rich, regardless of human and environmental costs.

The result is the unhealthy stratification we see in the United States today: a class system with growing economic, racial, and health disparities, where poverty and luxury exist side-by-side and where 46 million citizens have little or no health insurance. Talk about sickening priorities! While the White House continues to increase its astronomical military budget, it refuses to approve a National Health Plan to cover basic services for all citizens. How can we speak of "democracy" in a nation where, last November, less than a quarter of the country's potential voters managed to elect a gang of self-serving politicians who cut rich people's taxes while slashing welfare for the poor.

Worse still, as the world's remaining Superpower, the United States is relentlessly globalizing its unjust, undemocratic, unhealthy, and unsustainable model of top-heavy economic development. Driven by greed, not need, this shortsighted paradigm not only jeopardizes the well-being of the world's poor, but is endangering our global environment and plundering the non-renewable resources on which the health and survival of all life on this planet depend.

So, when we talk about "Insuring the necessary resources for the human right to health" we must talk about distribution of those resources. Sufficient wealth and knowledge currently exist to meet the basic health-related needs of everyone. What we need is fairer, more equal sharing of resources. And for this, we need fairer distribution of decision-making power. We need a truly participatory democratic process, through which ordinary people can take greater control of decisions that affect their health and their lives. This, in turn, will require a more empowering approach to education. Which means that those of us concerned about the Right to Health must join progressive educators to build more honest and empowering approaches to information sharing.


The need for mass mobilization by well-informed people

I would propose that the most important resource for making health a human right is the so-called human factor: the people themselves. But "people potential" is still underdeveloped. For people to join in realistic, well-organized action for a healthier world, we need an "alternative information revolution." Progressive health workers, activists, and agents-of-change can help to develop bottom-up (and sometimes underground) pathways of communication which can gradually help to raise people's awareness about the root causes of their health-related problems and growing psychosocial distress.

In short, many more people -- especially the underprivileged -- need to become politically more astute. They need to learn why their governments spend so much on military hardware and so little on human needs. They need to know why the leaders they elect systematically roll back socially progressive policies, and why they deregulate the practices of giant corporations at the people's expense. They need to question why the newspapers proclaim economic prosperity, when daily wages buy less and less. They need to demand that our schools encourage cooperation rather than competition. Instead of instilling conformity and obedience, schools need to teach students to think and to question, empowering them to make their own observations, draw their own conclusions, and take united problem-solving action. Through such transformation of the educational process (whether in schools, in the workplace, or through the Internet), the seeds can be sown for building a healthier society based on democratic action of a well-informed public.

All this will take a long time and hard work. But ultimately "Poder Popular," the Power of the People, is the key resource for assuring all people's Right to Health.


Actions for assuring Health as a Human Right

Let us look at some choices for action which a well-informed public might take to help make Health a Human Right:

1. An important first choice in many countries, and desperately needed in the United States, would be to: Organize a strong popular lobby for election finance reform. Health rights can become a priority only when big corporations and wealthy interest groups have less control over politicians and public policies.

2. Another key action would be to: Demand more progressive taxation. Heavily taxing the very wealthy reduces inequity and can produce revenue to provide better public services.

3. Combat the current trend to privatize health services and to shift the burden of costs to those whose needs are greatest. In backward countries such as the United States, the public must insist on a universal comprehensive health plan, paid for through progressive taxation.

4. Demand radical cut-back of military expenditures, and lobby for laws to prohibit or severely restrict the sale of weapons of war, especially those that cause indiscriminate personal harm (such as landmines). Such laws would reduce health-destroying casualties and free-up money for the common good.

5. Advocate new methods to redistribute wealth for public benefit. One method with great potential is the so-called "Tobin Tax." Every day more than 1.5 trillion dollars changes hands through the so-called "Global Casino," as rich people endeavor to multiply their wealth through speculative international trade of currencies and venture capital. Worldwide, 300 times as much money is traded daily through such non-productive speculative transactions as changes hands for actual services and production. The proposed Tobin Tax -- which would levy a 0.1 percent tax on all international financial transactions -- could provide more than one billion dollars of revenue per day. If well directed, this huge revenue could pay for the basic health- and poverty related needs of everyone on earth whose needs remain un-met.

6. Interventions like the Tobin Tax, at best, are stopgap measures. Our long-term goal must be to: Transform our cruelly inequitable economic order into one which is fairer, more health-promoting, and more sustainable. To approach Health for All, basic health services must become available to everyone, regardless of their ability to pay. And equally important, society must embrace policies which assure that all people can have a decent quality of life.

The first requirement for health is sufficient food. Today the world has more hungry children than ever before. A family's ability to feed itself with dignity and self-determination depends on conditions such as fair distribution of land, opportunities for employment, and fair wages. In short, health rights depend upon a spectrum of other human rights.


Conclusion: Health is not for sale!

In closing, I would like to stress that if health is ever to be a human right, it must cease to be a commercial product, bought and sold in the marketplace. Medical research and development should be guided not by the profit motive, but by what ails or endangers the largest number of people. It is unethical for pharmaceutical companies to reap huge profits through legalized price-fixing of life-saving drugs. It is equally unconscionable for money-hungry politicians to threaten trade sanctions against poor countries that dare to produce and distribute such drugs at affordable costs.

In last analysis, to assure health as a human right, the whole globalized market system -- with its byproduct of increased poverty and ill-health -- needs to be reexamined, regulated, and eventually transformed, so that well-being of the people and the planet becomes a top priority. As individuals, communities, and nations, we need to evolve a sense of concern and compassion for one another. Those of us who happen to be more fortunate today must learn to collectively give a hand to those who happen to be less fortunate. In short, humanity must become one big extended family -- celebrating our marvelous diversity, yet making sure that each one of us has the freedom, equal rights, and a fair share of basic resources -- so that we can determine our destiny and sustain our health.


What the pharmaceutical, tobacco, and narcotics trade have in common

 Keynote address for AMSA's 43rd Annual Convention:
"A Prescription for Action: Use, Misuse & Abuse of Drugs"
Miami, Florida, March 25-28, 1993

The American Medical Students Association has chosen a daunting theme for this year's annual convention. The rampant misuse of drugs -- both legal and illicit -- has become a major and growing threat to health: of individuals, of communities, and of society as a whole. Official campaigns to combat substance abuse have largely failed because professionals and politicians tend to "blame the victims" rather than to confront the systemic root of the problem.

To tie together the threads of this year's convention, I would argue that the current pandemic of drug misuse has its roots in the unfair economic and sociopolitical structures of our society. This implies that meaningful attempts to acheive more limited and rational use of drugs must be linked to a grassroots struggle for liberation from unjust social. economic, and political structures. In short, it means working toward a more people-friendly, more truly democratic social order. Thus all of us, as health workers, are faced with an enormous challenge.

In looking at the patterns of drug misuse in today's world, we must consider three major categories: illegal drugs such as heroin and cocaine, legal but equally addictive drugs such as tobacco and alcohol, and pharmaceuticals, or drugs used as medicine.

The market for all of these drugs -- pharmaceuticals, alcohol, tobacco, and illicit drugs -- is controlled by giant multinational industries. Each of these powerful industries, in unscrupulous pursuit of maximum profits, causes immeasurable damage to the health and well-being of hundreds of millions of people.

To better understand today's high levels of abuse, it is essential to consider the close ties between big government and big business. To the casual observer, it may seem ironic that the US government blatantly subsidizes some of the most unnecessary and dangerous drugs, fastidiously regulates others, and appears to wage an all-out war on yet others. But if we look more closely at the role of government in relation to each category of drugs, we find that it consistently puts the interests of powerful industries before the well-being of ordinary people. In last analysis, the War on Drugs is as phoney a facade as the Surgeon General's warning on cigarette packages. Just as the US government continues to subsidize and protect the tobacco industry, so its covert operations have spurred the traffick of heroin and cocaine into the United States. And, likewise, many governments' policies on pharmaceuticals do more to defend the profits of industry than the health of consumers.

Let us look at each of these three categories of drugs.
First, pharmaceuticals. World wide, but especially in poor countries, modern Western medicines are a two-edged sword. When used well and made available at prices people can afford, they can save many lives. But when overused and misused, or sold at prices that make them inaccessible or further impoverish those in greatest need, they can become yet another way of capitalizing on the suffering and powerlessness of disadvantaged people.

Multinational drug companies have flooded the world market with overpriced, irrational, dangerous, useless, and redundant medicines. More than 50,000 pharmaceutical products are peddled in most countries, of which the World Health Organization (WHO) states that only about 270 are really needed. Over a decade ago, WHO published a list of "Essential Drugs", largely as a guide for procurement. This list is important because many Third World countries spend up to half their health budgets on pharmaceuticals, many of which are either totally inappropriate or more highly priced than safer, more effective equivalents.

Part of the problem is the double-standard of multinational drug companies. Time and again, medications that have been banned or restricted in the North are "dumped" on poor countries, sometimes with the help of under-the-table bribes paid to health officers. Toxic and potentially dangerous drugs are routinely promoted in the South for everyday ailments. Warnings about their risks and precautions are often incomplete or omitted. Earnings from the world trade of prohibitted pharmaceuticals is increasing at an alarming rate, and now exceeds $20 billion per year.

The persistently high child mortality rate in poor countries is in part due to the unethical practices of multinational industries.

As all of you know, the biggest killer of children in the world today is diarrheal disease, which drains the life out of at least 4 million children annually. Studies have shown that in some poor countries the death rate from diarrhea in babies who are bottle fed is up to 25 times as high as in babies who are breast fed. ,

The multinationals that produce infant formula are partly to blame. UNICEF calculates that the continuing violations of the International Baby Milk Code by multinational producers of infant formula contribute to one million children's deaths annually.

But the multinational drug companies also contribute to high child mortality through the promotion of irrational and often harmful anti-diarrheal medications. These include every conceivable presentation and combination of antibiotics, stool-thickeners, and anti-motility drugs. Many of theses products cause dangerous side effects, mask signs of dehydration, or actually prolong the infection and aggravate the diarrhea. WHO has issued a strong condemnation of these "anti-diarrheals". But the drug companies continue to rake in $150 million per year from them, most of it from the pockets of the poor.

Although untoward side-effects are a problem, the biggest danger of these unnecessary medicines to children of poor families is their cost . Such costs are often substantial. In Lima, Peru, for example, medications and visits to the doctor for childhood diarrhea cost many poor families more than one third of their monthlly wage.

To quote the Director of Mexico's National Nutrition Institute, "The child who dies from diarrhea dies from malnutrition." When a poor family spends its limited money on useless medicines instead of food, the risk of death from diarrhea or other diseases of poverty increases. Thus the unscrupulous promotion of needless medicines for child diarrhea may be as deadly as that of baby milk products.

The United States government -- despite its claims of being for and by the people -- has a long history of defending the interests of big business, whatever the human and environmental costs. Remember that the US was the only country which refused to endorse the International Baby Milk Code. It has also aggressively protected the interests of the pharmaceutical companies at the expense of people's health.

In 1982, the health ministry of Bangladesh adopted a National Drug Policy compatible with WHO guidelines. Its stated aim was "to ensure that the common people get the essential and necessary drugs easily and at a cheap rate, and to ensure that such drugs are good quality and are useful, effective, and safe." It prohibited import of over 1600 useless, harmful, or ineffective products. In angry response, multinational drug companies warned that it might stop shipment of life-saving medicines. The US government -- backing the multinationals -- threatened to halt foreign aid to Bangladesh if it did not revoke its policy. Amazingly, with relatively few compromises, Bangladesh has so far stood its ground.

But recently Bangladesh's National Drug Policy has been under renewed attack, this time by the World Bank. The Bank's structural adjustment policies have already forced Bangladesh -- like other debt-burdened countries -- to make devastating cut-backs on health care, education, and food subsidies for the poor. And now the Bank -- according to Lancet -- has "suggested" that Bangladesh make "detailed changes" in its National Drug Policy to emphasize the importance of a "free market" approach to medicines control.

Second, let us look at the tobacco industry. (In our discussion of legal but dangerously addictive drugs we should, of course, also include alcoholic beverages. But for the sake of brevity, let us stick to tobacco.)

Tobacco -- as you know -- is as addictive as cocaine, and in terms of diseases and death, much more dangerous. Tobacco causes far more deaths than all illicit drugs combined. In the United States cigarette smoking is a contributory cause in one out of every 5 deaths. Unfortunately, smoking not only damages the health of active smokers, but also the health of those around them. Of nearly half a million smoking-related deaths in the US every year, more than 50,000 -- or one in ten -- are passive smokers. Secretary Sullivan says that 10%of infant mortality in the US can be traced to tobacco use by prgnant mothers. In addition to its high death toll, smoking also causes a wide range of permanent disability, ranging from developmental delay in fetuses of mothers who smoke, to cerebrovascular accidents and other circulatory disease. In England it is reported that 80% of leg amputations are related to smoking.

Joe Camel and the Marlboro Man have made it clear that children are a primary target of cigarette advertising. The tobacco companies must work hard to replace the 1200 smokers who die every day in the US. With the gradual decline of smokers in the North, tobacco companies are more aggressively targeting the Third World. Data shows that for every person who quits smoking in the industrialized countries, two persons start smoking in the Third World.

As with unnecessary medicines and infant milk products, it is the money that poor families spend on the tobacco habit that often presents its biggest threat to health. For the hundreds of millions of workers who earn less than one dollar a day, buying cigarettes means less food. A recent study in Bangladesh shows that child malnutrition and mortality are higher in families with father's who smoke.

Some countries have passed laws prohibiting import of tobacco, or have banned advertising. But the US government, claiming that such restrictions are a violation of the free market, has threatened these countries with trade sanctions. Yielding to this pressure, Japan, Taiwan, South Korea, and Thailand -- have opened up their markets to American tobacco. As a result, cigarette consumption in these countries has increased substantially. Inevitably, so will the rate of smoking-related disease.

The World Health Organization warns that if the present trend of increased smoking in poor countries continues, tobacco related deaths will soon reach pandemic proportions. In India nearly a million people a year now die from smoking.

It has become clear that in the United States more deaths are related to cigarette smoking than to any other single factor. From a purely economic view, tobacco now costs the US 52 billion dollars a year in medical costs, lost wages, and other losses.

Then why does the US government -- which criminalizes much less lethal, less addictive substances like marijuana -- not only tolerate over-the-counter sale of tobacco but continue to subsidize and under-tax the industry? Most other industrialized countries place a very high tax on cigarettes. This discourages use -- especially among teenagers -- and generates revenue for public services. Yet the United States has the lowest cigarette tax of all the industrialized countries. But why?

The answer lies, in part, in the powerful lobby of the tobacco companies. Government officials want to get re-elected, so they cater to the "political action committees" of big business. High ranking leaders in the presidential election campaigns of both Ronald Reagan and George Bush just happened to be important functionaries in US tobacco companies. After elections these tobacco potentates were given high ranking government posts where they could play key roles in policy-making. And don't think it is just the Republicans. Bill Clinton's campaign manager for this last election was a top-ranking lawyer with a tobacco company. However, such allegiances with the vested interests of corporate power -- which make a sham of democracy -- are not exclusive to the United States. When Margaret Thatcher left her position as prime minister of Britain, she reportedly moved into a million dollar a year consult job with a major British tobacco company.

In the words of former US Surgeon General, Dr. C. Everett Koop, "The support of politicians and political parties by those associated with the tobacco industry is unconscionable. How can Americans believe political promises for health care reform when both parties seem to be associated with an industry that disseminates disease, disability, and death."

We are faced with this disturbing reality. In today's so-called "New World Order" (which is in fact an entrenchment of the Old) the giant killer industries -- ranging from baby milk products to tobacco, to alcohol, to the entire military-industrial complex -- have more power in the decision-making process of so-called democratic nations than do the people themselves. Big business is no longer within the law. Rather, it reshapess the laws to fit its needs and greed.

Third, let us look at illegal drugs. Of course, the apparent hard line between legal and illegal drugs historically shifts back and forth; it is determined more by power games and politics than by rational concerns about personal health or social well-being. Some drugs that are legal today have been illegal in the past, such as alcohol during prohibition. And some drugs that are illegal today were quite legal in the past, such as marijuana, opium products, and cocaine. Recall that Coca Cola gets its name from the early formula, which actually contained coca, the unrefined base of cocaine.

In fact, looking back, the distinction between pharmaceutical drugs and illicit drugs becomes blurred. Heroine, a derivative of morphine, was for a time widely used in medical practice. Marijuana, too, has a wide range of medicinal uses, ranging from treatment of arthritis and glaucoma to the severe nausea of chemotherapy. And conversely, many modern pharmaceuticals such as amphetamines and diazepam (Valium) are often misused for kicks.

The question of decriminalization of illicit drugs -- together with greater investment in education and treatment facilities -- needs to be seriously considered. It seems to have worked reasonably well in Holland.

Certainly, the criminalization of the narcotics trade has inflated its price tag and helped turn it into the giant, ruthless and corrupting multinational industry it is today. As with many other powerful multinationals , the relationship and clandestine agreements between drug cartels and big government have become a major obstacle to a healthy and democratic social order.

During the last 40 years, covert operations of the US government have utilized international narcotics trade to help finance the destabilization of liberation movements and national democratic struggles that resist the dominant free-market paradigm. Here we cannot explore in depth the links between the US government, corporate powers, and the international narcotics trade, in their attempt to dominate global politics and economics. Lots of well-documented investigative research has been done on this subject -- some of it by congressional committees -- but very little has penetrated the mainstream media. Indeed, cover-up and disinformation have become the most effective weapon of social control.

Nevertheless, numerous observers -- including a number of official investigators, disillusioned drug enforcement officers, and CIA drop-outs -- concur that the US government's so-called War on Drugs is in large part a sham. Indeed, many critics allege that the US government itself, through its covert actions and arms-for-drugs deals, has done more to increase the flow of illicit narcotics into the United States than any other factor.

During the carefully staged Iran-Contra Investigations, great care was taken in the carefully staged public hearings to cover-up the arms for drugs deals. Yet a wealth of evidence indicates that various branches of the US government collaborated with drug traffickers to bring tons of heroine and cocaine into the US. To sidestep US Customs, some drug shipments were unloaded at the US air force base in Homestead, Florida. The airplanes that brought drugs into the US were reloaded with weapons and explosives and flown back to Central America to resupply the Contras in their terrorist war against the Sandinista government of Nicaragua. This was during the years when the Boland Amendment had outlawed miliary assistance to the Contras. Hence many of the arms shipments and land mines paid for by peddling drugs on the streets of America were disguised under the label of "humanitarian aid." In fact, the arms shipments, like the drug shipments, violated both national and international law.

Tragically, these abuses are not a bizarre exception to a system of governing which is essentially honest and benign. They are par for the course. When occasionally national scandal break out, mock investigations are conducted. A few rotten apples may be fingered to distract attention from the rotten barrel.

But if we want to get at the roots of the drug problem, and of the widespread deterioration of the economic and social fabric of our nation and our world, we must look at the structure of the barrel itself. Drug growing, drug trafficking, and drug use are symptoms, not the cause, of the social, economic, and political imbalance in our society.

With the advent of our so-called "New World Order", the US government has amplified its role as global policeman and power-broker. But too often, policemen are bullies. And in fact, the US has a long history of heavy-handed intervention, especially in the Third World. Over the years, through overt and covert actions, it has displaced or neutralized many of the most popular and more egalitarian leaders, and has replaced them with some of the most corrupt and authoritarian rulers. The number of lives lost, human rights violations committed, and children starved through these high and low intensity operations adds up to many millions.

In recent decades, the US Central Intelligence Agency (CIA) has been central to these global power plays designed to protect the interests of America's ruling elite. And as history has borne out, where the CIA is involved, the underworld of organized crime and drug trafficking often becomes entwined in the plot.

Consider the events surrounding the US invasion of Panama to depose Manuel Noriega, who was accused of narcotrafficking. But how did Noriega rise to power? And who supported him? Those of you who have read Graham Green's Getting to Know the General are aware of the allegations that the CIA was involved in the mysterious death of General Torrijos, which left Noriega as de facto Chief of State. When George Bush was Director of the CIA, Noriega was on the Agency's payroll. During this same time -- with full knowledge of the CIA -- Noriega helped Panama become a major transit point for South American drugs destined for the US. With his earnings from the laundering of drug money, and allegedly under pressure from the US government, he helped to finance the Contra insurgency in Nicaragua. Noriega was neutralized not because he was a drug trafficker, but because he was a loose cannon, and had become too feisty. (Before the invasion he had bragged that he had George Bush "by the balls".)

The irony is that the puppet president who replaced Noriega, and whom the US government has backed so strongly through its continued military occupation of Panama, has just as dark a history in drug dealing and as close ties with the Colombian cartels as did Noriega. No wonder, therefore, the US Drug Enforcement Agency ( DEA) reports that "Cocaine shipments through Panama have jumped since Noriega's capture in 1989."

Throughout Latin America, the US sponsored War on Drugs rings just as hollow. In Peru, the US government has poured millions of dollars into its military, despite the evidence that large sectors of the Peruvian military are deeply involved in drug trafficking. And curiously, President Fujimori's former election campaign director -- who currently heads Peru's anti-drug initiative -- allegedly has a long history of ties to the South American drug mafia as well as links to the CIA.

In Bolivia in 1980 a gang of drug lords headed by general Garcia Meza and Colonel Arce Gomez took over the Bolivian government and, with direct cooperation of the Army, boosted the drug trade. There is evidence that this notorious "coca coup" was carried out with collaboration of the CIA and Argentinean intelligence.

A similar pattern can be seen in various countries in Latin America and South East Asia, where the US government provides weapons and assistance to local armies, ostensibly to combat the growing, processing, and trafficking of drugs, in spite of evidence that these military units are themselves deeply embroiled in the drug trade.

It has become increasingly clear that the so-called War on Drugs is promoted for other reasons than its stated objective. In the United States it has been used to justify forceful intervention in other countries, as well as to provide an excuse for continued our high military expenditures. Now that the Soviet Union has disintegrated and the Cold War has come to an end, new enemies are needed. A fearsome one has been created through the War on Drugs.

But is it a war the US government really wants to win? Probably not. The illegal drug trade -- like tobacco, pharmaceuticals, and weapons -- is a lucrative multinational enterprise tied into the global economy. Export earnings from drug trafficking into the United States are what have enabled many destitute countries to keep servicing their huge foreign debt to the Northern Banks. For example, several years ago the US State Department declared that 75% of Mexico and Columbia's export earnings come from drug trafficking.

In the current economic recession -- for impoverished nations in the South just as for the growing ranks of impoverished people in the USA -- drug dealing often seems to be the only viable option.

In Mexico, where I have worked with a villager-run health program for the last 27 years, I have seen how this happens. I have witnessed how poverty and exploitation drive poor farmers to risk growing drugs in order to feed their children. I have seen how the phoney War on Drugs has led to destruction of families, corruption of officials, and brutal violence. Narcotics control soldiers, armed and assisted by the US, have themselves provided mountain villagers with opium poppy seed, and encouraged them to plant. Then at harvest time the soldiers take their cut from some of the growers and ruthlessly bust others. I treated a man with broken ribs who had been beaten by the soldiers because he had refused to grow drugs. We amputated the hand of boy who was shot by the soldiers with a high velocity bullet. Use of these explosive bullets -- apparently supplied by the US for the drug control initiative -- is a violation of the Geneva Convention.

Human rights abuses peaked during a time when the World Bank made a forthcoming bale-out loan to Mexico contingent upon more aggressive drug control efforts. Former US "Drug Tzar" Bennett called for a "massive wave of arrests". As a result, men and boys in mountain villages -- some of them my friends -- were dragged from their beds at night, then tortured and jailed on false charges of growing drugs. This way the soldiers could meet their quota of arrests.

The US government vehemently condemns terrorism by the countries it dislikes. But it is guilty of extremes of terrorism not only to destabilize national liberation movements, but also to prevent exposure of its own deep involvement in international drug trafficking.

Do you remember 4 years ago (Dec. 21, 1988) when the White House demanded United Nations sanctions against Libya for blowing up Pan American Flight 103 over Lockerbie, Scotland?

Well . . . Pan Am's insurance company -- faced with $10 billion of claims for the passengers killed -- called for an independent investigation. It found that Libyan terrorist were not responsible for the bombing, but rather the CIA. For years the CIA had been using Pan American airlines to courier heroine into the US, with drop-offs in Detroit, St. Louis, Los Angeles and New York. Flight 103 was carrying 8 CIA agents involved in directing the drug traffic, and also a high-ranking operative of the Drug Enforcement Agency (DEA) who has been implicated with Oliver North in the Iran-Contra arms-for-drugs deals. What made Flight 103 exceptional, the investigation revealed, was that these agents were coming back to the US unauthorized, with intentions to blow the cover on the operation. An article in The Toronto Star, titled "Pan American Bomb Linked to Double-Dealing Drug Plot" states that, "The agents became outraged when they discovered that the Central Intelligence Agency operation in drugs and arms was going to be escalated. One of the leaders of the group, Maj. Gen. Charles McKee, had decided that it was time to expose the operation."

Appalling as it seems, apparently the US government -- to stop its own agents from exposing government complicity in the drug trade that it claims to be fighting -- blew up a whole jumbo jet full of innocent passengers.

After reading the 27-page investigator's report, Pan American Chairman Thomas Plaskett, said "You mean to tell me that the Central Intelligence Agency has been using Pan American planes to run drugs over a period of years, and I thought I was running an airline!"

Unfortunately, the bombing of Pan AM 103 is probably not an isolated incident. Events surrounding the mysterious crash of the Gander flight, over Newfoundland, are remarkably similar. The Gander plane was reportedly carrying members of the clandestine RDS force, another drug smuggling operation of the US government. According to Toronto's Sunday Star, the flight also carried bodies of US operatives who had been killed after they had been silenced for their role in the drug operations.

The financial magazine, Barrons, reporting on these events, spells out the close links between the drug trade and big business. It states, "The 'take' from the drug traffic is approximately $500 billion annually, and these funds are entirely integrated within the US banking system, processed through Morgan Stanley, Chase Manhattan, Citibank, First National. The $500 billion expresses itself in controlling shares in major blue chip US corporations such as Ford Motor Company, AT&T, General Electric. You cannot distinguish the operations of the mob or the drug traffic from the normal workings of finance capital in the United States."

Given this appalling scenario, what can be done to control the "drug problem"? Trying to control it by strong-armed force has clearly not worked. Today the jails both in drug-producing and drug-consuming countries are full to bursting. Hundreds of millions of dollars have been spent in police action and military operations to curtail growing and dealing. The results in terms of human suffering have been enormous, but in terms of reducing drug production or use have been negligible.

One thing has become clear. Worsening social and economic conditions aggravate the drug problem. As an example, when Mexico went into its extreme dept crisis in 1982, not only did drug growing and trafficking sharply increase, but the government -- desperately in need of export earnings -- was clearly less motivated to effectively combat the lucrative drug trade. Indeed, during the mid-80s, the few remaining signs of economic growth were the new 5-star hotels and discos built with drug money.

Clearly, the debt crisis and economic recession which began in the 1980s have done more to promote drug trafficking than the ruthless War on Drugs has done to stop it. A major set-back, which has pushed many more poor people into growing and dealing drugs, has come from the structural adjustment policies of the World Bank and IMF. These policies -- imposed on poor countries to make sure they keep servicing their debts to Northern banks -- have forced poor countries to cut back on health, education and other public services, while reducing the real value of worker's wages. In many countries, the earnings of farmers and laborers have fallen so low they can no longer feed their families. Hence the growing numbers of homeless people, street children, and poverty-related crimes.

The impact of structural adjustment and other aspects of so-called "free market policy" on the drug crisis is in some countries quite evident. In Colombia the economy depends on two export crops, coffee and cocaine. In 1989, the US government -- consistent with its free market agenda -- refused to renew the commercial agreement on coffee price stabilization. As a result, coffee prices collapsed and Colombian producers lost 52 cents on the dollar, with global losses of $4 billion. The sharp fall in coffee prices continued through 1990 and 1991, and more and more coffee growers begin to cultivate coca. The paltry amount of money the US government has put into promotion of "alternative crops" is nothing compared to the vast losses to the peasantry and labor force caused by the economic and so-called development policies imposed on them by today's global power structure.

Ironically, even in the world's wealthiest and most powerful nation, the USA, the events exacerbating the "drug problem" are very similar to those in the Third World. The numbers of homeless people, street children, and poverty-related crimes rise every day.

Indeed, the same sociopolitical and economic forces that are widening the gap between rich and poor, both between countries and within them, are at work right here in the United States. Here, too, "structural adjustment" policies have been applied similar to those imposed elsewhere. To sustain our huge military budget and build our dominion as "cop of the world", the White House has systematically gutted public assistance programs, low-cost housing, and other benefits for the poor. Over the past decade real earnings of working people have steadily fallen. Taxes extracted from the poor have risen, while those of the rich have been lowered. The result for many is a deteriorating standard of living. Today in the US, 1 of every 7 families, and 1 out of 5 children, lives below the poverty line. Infant mortality in cities from Washington DC to Oakland California is higher than that of China or Jamaica. Nearly 40 million people in the US have no form of health insurance, and daily 24 million people go hungry. Racial minorities -- especially Afro-Americans and Hispanics --- are systematically marginalized and scapegoated. Rates of crime, violence, suicide, school drop-out, and police brutality have soared. High-level corruption and disinformation have become institutionalized.

Such a deteriorating situation leads to an increase of both drug dealing and drug use. Is it realistic to try to control the problem by pointing guns at poor farmers in poor countries? Or by providing more policemen and more jails in the United States? Neither approach gets to the root of the problem. The peasant of Peru grows coca for the same reason that the street pusher in the US peddles cocaine. Both have been marginalized and deprived by a political and economic system that favors the haves at the expense of the have-nots.

The War on Drugs is in reality a War on the Poor. In the United States, as in the drug-producing countries, it is the little guys rather than the big guys who are the primary target. Many of the biggest drug dealers in the US have immunity from the law. They include mafiosos or drug lords from the Golden Triangle, Cuba, and elsewhere, who have collaborated with US covert operations abroad. If they happen to get arrested on drug charges, the police chief or judge soon gets a call from the CIA or State Department, requesting that charges be dropped for reasons of "national security."

But what kind of security does such action really provide to a nation? It seems to me that the most intelligent first step our nation could take -- for real security and to reduce the drug problem -- would be to dissolve the Central Intelligence Agency. Then maybe we could do something to stop the big guys in the drug trade, and get off the backs of the little guys.

The American "way of life" -- which too often places the greed of the strong before the needs of the weak -- is rapidly becoming a global "way of life" by imposing servitude to its "free market" world view. Yet for increasing numbers it is becoming a "way of death." The whole paradigm of the neoliberal New World Order needs to be seriously questioned, not only in terms of resolving the problem of drug abuse, but in terms of the quest for world peace and the sustainability of the global environment and ultimately of the human race.

It is becoming clearer that the American "way of life" is not sustainable. Today we the people of these United States, with 4% of the world population, consume 25% of the world's energy and resources. But we consume 60% of the world's illegal drug supply.

But why this hunger for drugs? What does it reflect about our consumer-oriented culture? About the loneliness and alienation from Nature of our compartmentalized lifestyle? How much real sense of community is left? For all our talk about democracy and people's participation, how much control do average citizens have over their government, or over the decisions and events that shape their lives? Why do nearly half of eligible voters not vote? Who really elects our national leaders? The people? Or the lobbies and PACs of giant industries: the weapons industry, the oil industry, the tobacco industry, the pharmaceutical industry ... and, of course, of the AMA? Why do we still not have an equitable national health plan? In a nation as wealthy as the United States, why is their so much poverty, hunger, homelessness, crime, and desperation?

These are the questions that I think we need to tackle in confronting the issue of misuse and abuse of drugs. It seems to me that the question of legalization or illegalization of drugs -- whether tobacco, alcohol, or the drugs that are currently considered illicit -- is not the key issue. To overcome the crises of our times -- the crises of poverty, environment, militarization, and drugs -- we need to work toward a fairer, more equitable, more compassionate world order. Resolution of the drug problem is, in last analysis, not an issue of crime and punishment but of social justice.

To say no to drugs, we must first say no to the social structures that perpetuate inequality.


Note: This article, originally printed in "Newsletter from the Sierra Madre" # 10, April, 1975, has become a classic of health care literature. The story tells the events leading up to the tragic death of a distressed village woman in Mexico. It shows the importance of coltural sensitivity and of taking the conerns of the ailing person seriously. This tragedy helped a lot of us involved with Project Piaxtla in Mexico to rethink our approach to primary health care, and to become not only better health workers but also more humble and compassionate human beings.

From Newsletter from the Sierra Madre # 10

"Men are cruel, but man is kind.'
-Rabindranath Tagore-

Those of us whom solitude entices to peer into the night skies of our own being, and thereby into Being in general, are often dumfounded by the didactic irony of fate. It is as if ‘blind’ luck and ‘pure’ chance conspired with our human sensibilities to pursue paths as clear yet inexplicable as evolution. Perhaps we are just imagining things, reading into events whatever significance we project upon them, as with inkblots. Be as it may, the chips do fall at times with awesome significance, stopping us short. The sleepless Fates, which once presided over Greek plays, weaving with the portentous shuttle of strophe and antistrophe the thread of the hero's Hubris until at last he snarled in the inextricable web of Nemesis -- even today ring within us a note of fearful recognition. Events in our daily lives time and again fall into momentous patterns, as if trying to teach us something we have long known, yet ignored; as if Fortune herself were half Poet and half Prankster, and our disquiet existence a tragic-comedy deftly designed to put us in our place.

“....And Lord, if too obdurate 1,
Take thou, before that Spirit die,
A piercing pain, a killing sin,
And to my dead heart, run them in.”
-Robert Louis Stevenson-

Medically and technically, we did everything we could for Maria. But it wasn't enough. If we had reached out a little more with our hearts, if we had let our response to her agonizing pleas be a little more visceral, more human, still she might have died, but differently. As it happened, we became so involved, frustrated and at last fatigued by the complexities of her physical problem, that somehow the frightened woman trapped in that sick body was lost in the shuffle, even before her death. As one first notices the loud ticking of a clock only when it stops, so, of a sudden, we wakened to Maria. But a heart cannot be rewound like a clock, although -- heaven knows! -- we tried. And in the warm stillness that followed, we in turn wakened to ourselves, and shuddered.

If Maria had been the victim and we the villains (would it had been as simple as that!) there would be little justification in telling her story. But we, the medics and doctors who attended her, were also, in a sense, victims, half-blinded and swept along by that glittering army which, through years of study and discipline, we have recruited to serve us. If we acted unwisely, reader, forbear. If we were unkind, remember that we endorse kindness wholeheartedly, that each of us had come to this little Mexican clinic voluntarily, with the will to help others. If we were self-complacent and you could condemn us, recall, at least, that you may be in the same boat.

This, then, is the account of how a group of humanitarian medics and doctors, propelled by the intensity of events, trapped in the maze of technological and medical acumen and discouraged by their own ineffectiveness, were marched along by their cumulative strengths and weakness, step by irrevocably step, until -- truer to their decisions than to life -- they sat to one side and watched their patient struggle to her end.

* * *

In retrospect, the stage seemed ominously set for this unhappy play of events (or was it our minds were set?). Even the fact that we called our patient Maria echoes our key flaw. She had been baptized ‘Maria Socorro’, and to her friends she was Socorro. For all our medical skills, we somehow missed the name she went by. An excusable error, yet the irony remains: ‘Socorro!’ is the Spanish cry of ‘Help!’

In this account I shall continue to call her Maria. It is too late to correct our mistake.

Maria, as you may recall from the last newsletter, was the young wife of Marino, one of the two brothers killed at a dance in Guillapa on Christmas Eye a year ago. It was she who, crowded in the back of our power wagon with the corpses, authorities and wide-eyed children, had lifted the edge of the blanket and gaped at the stiffened gaze of her husband until someone ordered her to cover him up again. On reaching Ajoya, Maria had collapsed, moaning and stroking her chest, and had needed to be carried, along with the bodies, through the quick throng of curious, pushing villagers. At the time, I had not thought there was anything physically wrong with Maria, and perhaps there was not, for her collapse had every sign of grief and hysteria. Many other women, likewise, verged on hysteria, a few from genuine grief, but most from sheer contagion. There is something in a Mexican village which thrives on tragedy and comes alive with Death.

Following Marino's death, Maria and her children had taken asylum with her aging father, Juan, at his isolated rancho called ‘El Amargoso’ (The Bitterness), 12 miles upriver from Ajoya. A long time passed before we heard from her again.

On the morning of September 15, three little boys burst into the Ajoya Clinic like startled ravens, shouting that someone was being carried into town on a stretcher. Moments later, a small knot of sweating, tired campesinos maneuvered through the doorway a cumbersome homemade litter. On it lay a handsome, very pale, young woman with dark wild eyes. It was Maria. The men had carried her through the stormy night from El Amargoso, following the precarious ‘high trail’, so as to avoid the treacherous fords of the river.

Old Juan, her father, had come too, and stepped forward to greet us. Wrinkled and resilient as a peach pit, he had perennially sparkling eyes and huge friendly hands. He begged us to do what we could for his daughter who, he explained, had begun to hemorrhage from her “obscure parts” the day before, and had lost “at least two liters” of blood.

Maria was anxious and petulant. It took a lot of coaxing and explaining before she reluctantly submitted to a pelvic exam. The results, however, were unremarkable; no apparent evidence of pregnancy, infection, abortion or tumor. She was, however, very anemic, we supposed from blood loss, and was going into congestive heart failure.

We kept Maria under observation for two days. She lost no more blood, but neither did her clinical picture or her anxiety improve. We felt she needed transfusions as well as a thorough gynecological exam, and recommended taking her to Mazatlán. Old Juan was reluctant, partly because of cost and partly for his native fear of cities and hospitals, but Maria was willing and at last so was he. Risking the weather and bad roads, Martín, our chief village medic, drove them to Mazatlán in the new clinic Jeep, and placed Maria in the care of a first-rate physician, one who has provided treatment or surgery for many of our patients, often at minimal charge.

Barely had Martín made it back from Mazatlán, when a furious ‘chubasco’ (thunder and wind storm) struck the Sierra Madre. During most of the summer the monsoons had been mild, leaving river and roads more or less passable. Now at the end of ‘las aguas’ the Weather poured it on with full force, as if bent on meeting a seasonal quota. Roads turned into rivers, the river into a sea. Corn and squash grew overnight, the jungle burgeoned. The clinic roof leaked.

* * *

Day after day the rain gushed from a wild, churning sky. On the afternoon of September 23 a waterlogged wayfarer, arriving on foot from the world outside, reported that a couple of Gringos destined for our clinic were stranded in San Ignacio. They had tried to hire portage to Ajoya in a four-wheel-drive jungle buggy, only to get stuck in the first arroyo crossing this side of San Ignacio.

The Gringos, we supposed, would be Mike and Lynne, a young pediatrician and his lab tech wife, who were planning to help for a month at our clinic. (Mike had first taken interest in the project when, last Spring, he had helped care for a severely burned baby boy whom our Ajoya team had flown to a San Francisco Burn Unit.) Roberto offered to fetch the stranded couple with the clinic mules. These took some finding, however, and he was still saddling up the mules when Mike and Lynne, sore but radiant, plodded into Ajoya on borrowed mules.

“How bloomin' far is it, anyhow, from San Ignacio to here?” asked Mike, gingerly dismounting.
“Seventeen miles,” I answered. “Seem longer?”

The Texas-bred pediatrician shook his head slowly and grinned. “Reckon it’s about the longest, bounciest damn 17 miles I ever swam!”

We laughed and welcomed them in.

* * *

The Patron Saint of Ajoya is San Gerónimo. The Día de San Gerónimo was now only a few days away, and the young men of the village had begun to wonder if the rain, would subside in time to truck in the cerveza (beer) for the grand fiesta. As for myself, I crossed my fingers for a deluge. But on the 27th, the weather calmed. On the morning of the 29th, three ex-army ‘commandos’ loaded to the gunnels with beer lumbered into the village plaza. Tents and tables went up. The dance would go on! For two nights.

After dusk the ‘ruta’ arrived, for the first time since the chubasco. This is a backwoods ‘bus’, actually, a 4-wheel drive flat-bed truck with wooden benches and a solid canopy. That evening it carried so many passengers that they spilled over and were hanging onto the roof and sides. One of these passengers was Miguel Angel, our first village dentist.

He had played hooky from the ‘preparatoria’ (a sort of junior college) in Culiacán in order to attend the fiesta. I was frankly delighted to see him.

“You wouldn't believe it!” exclaimed Miguel Angel. “The road is that bad....! And Toño, what a great goat! He made everybody get out and wade across the fords and up all the hills, so the truck wouldn't get stuck. Half the time it got stuck anyway and we all had to push. Hijuela! And the priest -- you know, the one from San Ignacio who gets drunk at every fiesta -- was along too. Moteo and I had to carry him piggyback across the fords. Hijole, my back aches! But instead of thanking us, he’d just get mad and scold. Finally, Moteo got fed up and ‘accidentally’ dropped him in midstream...” Miguel Angel gave a low whistle, “Ever hear a priest curse?”

Everyone laughed uproariously. Miguel Angel, a born entertainer, grinned appreciatively. Then suddenly a shadow crossed his childlike countenance and he turned to me. “Know something, David, Toño is a true beast. When I say he made everybody get out and walk, I mean everybody. Well there was this real sick woman on the ruta. She had a terrible cough and trouble breathing. Toño made her get out like the rest of us, and the more she had to walk, the worse she got. On the steep hills she’d hack and gasp something awful, like somebody drowning. Even back in the truck she couldn't get her breath. I tell you, David, she looked like she was about to drop over. And still at every hill the brute made her walk. A fool would have shown more compassion!”
“Who was she?” I asked, guessing.

“Marino's woman, the one who collapsed in the Power Wagon last Christmas .... I think her name’s Socorro.”

“Maria”, I corrected him. “Doesn't sound like she’s much better.”

* * *

I half expected to see her at the clinic that evening, but she didn’t come. That night, despite intermittent showers, the festivities continued nearly until dawn. In the plaza three different musical combos competed with each other and the thunder. Trumpets blared, clarinets squeaked, drums thudded, lightning flashed and the villagers -- those who could afford to and many who could not -- drank and danced. Staccato joy shots punctuated the merry chaos. As the night wore on, there were the usual scuffles. The only significant injuries, however, were those inflicted by the Municipal Police; they had Come from San Ignacio ‘to maintain law and order’, got drunk and --among other indiscretions -- gunwhipped a campesino who had given them, they said, lip. We stitched up the poor fellow's face at the clinic and he hurried back to the dance. All in all, the fiesta was a booming success.

* * *

Next morning our first patient was Maria. Weak, wide-eyed, gasping for breath, she arrived supported by her father and her 7-year-old son, Benjamín. As they came into the clinic, Maria began coughing and sank, exhausted, on a bench. Although the tropical morning heat was only just beginning, her face glistened with sweat.

“Air!” she gasped between coughs. “Benjamín! Give me air!”

Her small son took off his tattered sombrero and solemnly flapped it in her face. The boy shared his mother’s broad, attractive features, yet his puerile countenance was as imperviously calm as hers was wildly agitated. Into my mind sprung the dark memory of this same waif jammed with his siblings and cousins in our Power Wagon beside their father’s body that fateful Christmas morning. Small wonder he looked strangely grown-up for his age.

“Faster, can’t you!” Maria's gasping voice had the frustrated urgency of the captain of a floundering vessel shouting to his men on the pumps. Benjamin fanned faster.

While Martín helped Maria into the examining room, I questioned old Juan. No, he had not brought a physician’s report from Mazatlán. All he could tell me was that his daughter has been given 2 1/2 liters of blood and a “scraping of the mother” (D & C). With this, she had seemed to get a bit stronger, but her feeling of ‘drowning’ had failed to improve. After ten days she had been released from the hospital, still very ill.

“So I reckoned I’d bring her back to you fellows in Ajoya,” said old Juan. “The trip was kind of rough on her, though. I’d have brought her here to the clinic last night except that she was that bent on watching the fiesta. You see, the silly girl claimed it would be her last and she was not about to miss it. She didn’t either. Damned if she didn’t even down a couple of cervezas! Fool child! Everybody knows cerveza’s the demon for a person with ‘susto’. I warned her it’d do her harm. But she said..... Hesitating, he looked bewilderedly at his wild-eyed daughter.

“Said what?” I encouraged.

The old man frowned. “She said it meant ‘mother’ to her.... But that’s her way. Sullen.
Stubborn as an ass. Too proud to hear what’s good for her. She’s always been that way, even as a tot. But now she's worse, since her ‘susto’.”

“Snare?” I said. (‘Susto’ is a mysterious folk malady, a state of self-consuming, irrational anxiety usually precipitated by a terrifying experience and often considered to be the doings of the Devil.) “Do you mean since Marino was killed?”

“That was the start of it”, said old Juan, “But the crowning touch was just after that, when her father-in-law stole her six cows and the beans.”

“You mean Nasario robbed Maria?!” I exclaimed. I have known Nasario only as a kind and generous old man; I could not imagine him otherwise. Yet I've knocked around enough to know that every person, like every story, has more than two sides.

“But why?” I demanded. (Perhaps I shouldn't have asked, for I was anxious to examine Maria, yet I wanted to hear out her father, and it was important to him that I do so.)

Old Juan's gentle eyes clouded with anger. “Because the old python knew he could get away with it,” he said. “You see, Marino when he was alive had never bothered to get his own branding iron; he’d always used his father’s. So when he was killed, Nasario just up and took the cows, simple as that. What could my daughter do? The cows had the coward’s brand.”

“Nasario did that!” I puzzled.

“That's not all!” Old Juan spat angrily on the clinic floor. “He sent his son, Celso, like a lone coati to rob her whole winter's supply of beans, said they’d been planted on his land, the fox.” The old man’s eyes narrowed. “Do you follow, Don David? They broke her like a sprig of cane. Within eight days the poor girl lost everything; husband, cows, beans! What else is there? All they left her was a handful of hungry children.”

The old man laughed wryly, “And a crotchety old father on his last legs.” He spat defiantly. “But God hear me, while I live, I eat!” The old man put a huge hand on his grandson’s slight shoulder, “And Benjamin here's going on eight. Couple of years and he'll man his own cornfield and plant his own beans. Right, son?”

The boy tilted up his quiet face and answered his grandfather with a fleeting half-smile that would have bolted Leonardo to his easel.

Maria’s case, we knew, would be tough. I was grateful we had Dr. Mike with us, and asked his help. He consented gladly, but when, on examining her, we found Maria had a dangerously fast pulse and a possible pulmonary embolism (blood clot in the lungs) he began quite wisely, to shy from the responsibility.

“I’m only a pediatrician”, he protested. “And besides, she should be in a hospital, not a backwoods clinic. Can't we get her to Mazatlán?”

“We already got her there”, I explained to him. “They discharged her from the hospital two days ago. That's why she’s back with us.”

Dr. Mike’s jaw dropped. “You've got to be kidding. What sort of hospital is that?”

“Busy”, I said. “Understaffed. It's sometimes simpler just to dismiss an indigent patient with an extra difficult or demanding problem. Happens all the time.”

“That's incredible!” said Dr. Mike. “That's barbaric!”

“For an awful lot of folks”, I said, “that's life.”

“Air!” panted Maria. “Where's Benjamin?”

“In the hall”, said Martin, “I'll ask him to come in.”

Dr. Mike took a deep breath. “O.K.”, he said, “I guess I'm game. Let's keep her here. We'll do everything in our power for her.” He looked doubtfully at Maria. “But I sure wish a specialist in internal medicine would drop by about now.”

“In a week one will”, I said. “Literally! 0n October 8 a medical/dental team from California should be flying down by private plane. The pilot’s an internist, and really sharp.

“Tremendous!” exclaimed Dr. Mike with restored optimism. “Let's get on with it then. Martin, can you and Roberto get an X-ray of her chest. David, does that old E.K.G. machine work? Good. We'll see if we can't get this young lady breathing a little easier.” He gave Maria an encouraging smile. She looked away and started coughing. “Think I'll ask Lynne and Ramona if they can do an acid test on her sputum”, mused Dr. Mike, “Maybe she's got T.B.”

Back in the hall, I spoke again with old Juan. He must have sensed my concern. “Tell me straight, Don David”, he said “because well ... if she doesn't have a chance, I'd just as soon tote her back to El Amargoso straight away.”

I grasped the old man’s dark, sinewy arm. “She’s a strong woman, Don Juan”, I said. “You know we’ll do all we can.”

“I know”, he said with a frowning smile. “Yet something tells me...” Instead of finishing his phrase he looked at me squarely and asked, “Can you Gringos cure susto?”

I thought of all the things I might or might not say, and repeated simply, “We'll do all we can.”

We set up a cot for Maria in a small room open to the patio. As is our custom, her father and son also moved in to help care for her. We provided them with a narrow burn bed and a miniature gurney, which was the best we could do.

* * *

I won't go into all the medical details of Maria's case, lest the reader get bogged down in them -and lose track of the human side. Let it suffice to say that from first to last we were baffled by Maria’s clinical picture. We took X-rays, endless electrocardiograms, analyzed and reanalyzed her blood, urine, excrement and sputum, and kept track of her vital signs and fluid intake/output. Yet the more we learned, the less we really knew. One day we suspected pulmonary embolism, the next ‘wet’ beriberi, the next thyrotoxicosis, the next rheumatic fever, etc. Time and again we mesmerized ourselves into believing we were on the right track. On the third day for example, when we thought Maria’s breathing seemed easier in response to digitalis, Dr. Mike exclaimed cheerfully, “I think we did the right thing to keep Maria. She's gonna get better!” That evening, however, Maria took another turn for the worse, and we recognized in her ephemeral improvement the mirage of our own wishful thinking.

Sick as she was, Maria retained a strong sense of pride. She had the traditional campesina modesty, which made examinations and tests unnerving both for her and for us. Most of all she hated being wired up, open bloused, to the E.K.G. machine. Every time we wanted an E.K.G., Dr. Mike and Martin had to spend 10 to 15 minutes cajoling her to lie quietly and keep from covering her breasts. She would start coughing and beseech us to wait until she caught her breath, which she never did. Although she always made us carry her to the porch for the E.K.G.s, protesting that she was too short-winded to walk, once the tests were over, she would jump up and run back to her cot.

During these tests, Maria’s dread of asphyxiation always seemed to get worse. Fear is, of course, the tinderbox of fury. One morning when Maria was wired up for an E.K.G., the mother of a sick child made the mistake of peeping in through the doorway.

“Chinga to madre!” exploded Maria. Aghast, the mother withdrew. We marveled that someone with so much trouble breathing could muster such an ear-shattering curse.

It was hard for us to tell how much of Maria’s distress was physical, and how much was due to her fear. She had the eyes, the breath, the heartbeat -- and at times the bared teeth -- of a cornered animal fighting against the odds for its life. Her cough, although unproductive of phlegm, had something exaggerated about it, even vocal, as if Maria, while too proud to beg for help directly, was pleading succor through coughing.

Frustrated by the fact that Benjamin fanning her helped so little to ease her distress Maria thanked her small son largely with abuse. One afternoon I heard her gasp, after a fit of coughing, “More air! Come closer, damn it!” Benjamin, who was already almost flicking the sweat drops from her brow, accidentally grazed her with his sombrero.

“Can't you ... be careful ... you son of a slut!” she gasped.

Without a word, and with the same immutable look of concern, the boy kept flapping his tattered sombrero.

Perhaps, I mused, he is so used to her scolding him he takes it for granted. Or, perhaps, with a child’s instinctive wisdom, he takes her cruelty as a proof of love.... Whatever the case, Benjamín needed no defending. Yet my heart went out to him often, as did the hearts of the others in the clinic. With his quiet compassion, the small boy led us all. Would he had led us further!

Maria's respiratory distress seemed to get worse not only when we wanted to move or examine her, but whenever her father or Benjamín left her side or were trying to get a little much needed sleep. Her worst and loudest paroxysms of coughing occurred between 1:00 and 3:00 A.M. Benjamin would dutifully get up and fan her. Martin, Ray (an American paramedic) or I -- often all three -- would also rise, give her appropriate medication, and try to calm her. I found it did a lot of good -- more, in fact, than the medicine -- to sit quietly beside her, speaking softly and reassuringly, encouraging her to relax. First she would be resentful and taciturn, but little by little her breathing would grow easier and sometimes she, too, would begin to talk of her children, Marino and things past. Never of things to come.

One night at the second crowing of the cocks (about 3 A.M.) I was aroused by Maria's vociferous coughing. Between coughs I heard her frantically call, “Benjamin .... wake up .... Hurry!”

I quickly pulled on my boots and waded across the dark patio toward her room.
“Benjamin! ... Wake up!” she gasped, her agitation mounting. “Don't you care if I die?”
I found I was the only one who had wakened, (No matter how tired, I sleep lightly.) Maria had kept us all running too many days and nights. Old Juan’s big chest heaved rhythmically on the burn bed. Ray’s musical snore came drifting from the adjacent room. Benjamín, still sandaled and clad, lay in a fetal question mark upon the small gurney, his tattered sombrero clutched in his small hand, sound asleep.

“Benjamín!” gasped Maria with increased terror, “For the love of God... give me ... air!”

I carefully lifted the sombrero from the small relaxed hand and began fanning Maria. “Let him sleep”, I said softly. “He needs it. Try to be calm, for his sake.”

Maria shook her head in frustrated fury, and staring into the darkness gasped, “More air!” The Flickering of the kerosene lamp accentuated the terrer in her wide, sunken eyes. She looked like a woman possessed. I kept fanning.

“He needs ... I need ... air ... sleep ... can't go on!”

“Maria”, I begged her, “Try to relax. Your body needs less air when it's relaxed. Try to be calm.”

“You don't understand”, gasped Maria. “It's their fault ... Air! ... The beans!” She made an angry gesture, as if trying to push back the darkness.

“Take it easy, Maria”, I said in a reassuring voice. I thought: she's right, I don't understand. “The beans?” I ventured.

“Give me air!” she demanded. I fanned harder. Benjamín stirred in his sleep. I looked down at him and yawned longingly. Somewhere a toad was singing. The night was cooler now, before dawn, yet Maria’s distraught face was sculpted with golden rivulets of sweat. After a long silent spell, she began to speak, spacing her words between air-hungry gasps.

“Morning ... they buried Marino ... afternoon I went back ... our hut... Guillapa getting dark ... alone ... More air! ... going inside ... jumped out of the shadows something ... male ... straight at me Air! ... waving his hands ... I thought it was ... his ghost looked just like ... the darkness...ran past me ... Air! ... out the door ... Give me air! ... in the light it was ... Celso...
Marino’s brother the devil ... Nasario ... sent to rob ... the beans!” She began to cough again, and fishing the sticky mucous out of her mouth with trembling fingers, wiped it on the bed sheet.

“What happened then?” I asked.

“I don't know”, she panted. “My heart ... pounded ... like crazy ... my legs ... More air! ... I fell ... Since then ... Give me air!” I kept on fanning her. She gave a light sigh and shut her eyes.

“Maria”, I said cautiously. “What do you think your illness is?”

She opened her eyes and stared at me as if I were a child. “Susto”, she snappcd. “What else?”
With a pained grunt she turned onto her side with her back toward me. Her breathing, however, seemed to grow a little easier and a few minutes later she apparently fell asleep. I took up the kerosene lamp and examined her carefully. Even in sleep, I noticed her breath was strained and rapid, her face anxious. Cautiously, I took her pulse. It was 150 per minute. Perplexed and wary, I stumbled out into the dark patio and looked skyward.

Not a star.

* * *

One of our ongoing battles with Maria was trying to keep track of her fluid intake and output. Time and again we asked her not to empty her bed pan, but whenever we weren't looking she made Benjamín sneak it out, for she had diarrhea and was embarrassed to let us see it. Equally difficult, was trying to keep tab on how much Maria drank. Because we suspected pulmonary edema (water on the lungs) contributed to her respiratory distress, we felt it imperative to restrict her fluids. Her thirst was insatiable and she was forever having Benjamín sneak her water from the communal urn. Dr. Mike tried patiently to reason with Maria, explaining to her that drinking less would mean easier breathing. Maria nodded that she understood and would cooperate, but the moment the pediatrician turned to leave she gasped very audibly, “Benjamín, bring me water!”

Dr. Mike stiffened as if slapped, then returned to her bedside and sat down. He looked into her pale, perspiring face and said gently, “Maria, do you want to die?”

Her dark eyes narrowed, and in a tone whetted with ire, she snapped, “Yes!”...

Next we tried to reason with Benjamín. This put the child in a serious double bind: whom to obey. It was, of course, easier to deceive us than disobey his mother. Maria’s breathing continued to get worse and we were at our wits’ end. At last, Martin took Benjamín to one side and had a boy to boy talk with him. They arrived at a peace treaty whereby Benjamín, could continue to ‘sneak’ water to his mother, but would first ‘sneak’ the glass to Martin so that he could limit and measure its contents. Each time the boy brought him the glass, Martin showered him with praise for taking such good care of his mother. Needless to say, the treaty held. Little by little, Maria’s breathing began to improve. And so, temporarily, did her state of mind ... and ours.

Her heart, however, kept beating at frantic double time, and by the end of the first week, we were more baffled than ever. We could scarcely wait for the arrival of the flying doctors.

* * *

On the afternoon of October 8th, at long last, a small Cessna buzzed over the village, dipping its wings in a greeting. Ramona, our apprentice lab tech, ran into the patio and looked up. “It’s them!” she shouted jubilantly. “The Gringo doctors! They’ve come!”

Dr. Mike, Martin and I looked at each other with shared joy and relief. “Thank Heavens!”

Miguel Angel, the younger dentic, had left in advance with the Jeep for San Ignacio to meet the plane. The road was still an obstacle course, although the rains had calmed; it was well after dark by the time the visiting crew arrived. There were two doctors, a dentist, an oral hygienist, a journalist and her husband, a photographer.

The pilot and leader of the group was John, a radiologist, with a long background in internal medicine. Over the past several years Dr. John has been an invaluable help to our village project. He obtained most of our X-ray equipment for us and trained us in its use. He has helped us get patients into a number of hospitals in the Bay Area. He has also assisted in the education of our village apprentices, both personally and financially. And he has flown to our area many times with visiting medical/dental teams. Having worked with him in many situations, I have gained the highest regard for Dr. John both as a doctor and a friend. He is abrupt on the surface and warm underneath.

The other doctor, an intense young surgeon named Robby, was new to our project. We found he had a vast amount of medical know-how at his fingertips, and was a gifted instructor. Taking to heart our motto that “The first task of the visiting doctor is to teach” Dr. Robby held classes and bent over backward to our young volunteers and village apprentices. The dentist and oral hygienist likewise did a splendid job in instructing our apprentice ‘dentics’.

Welcoming in the visiting team, we took them onto the back porch where the air was cooler. Everyone was seated on chairs, gurneys, boxes or the floor. From her open room on the far side of the patio, we could hear Maria’s distraught coughing.

* * *

“Sounds like you've got a pretty sick patient back there”, said the journalist, lighting her notebook with a small flashlight.

“That’s Maria, whom I told you about”, said Martin.

Wanting to waste no time, I turned to Dr. Mike. “Why don’t you explain Maria’s case to the other doctors.”

Dr. Mike, as eager as I to share our responsibility for Maria, began to describe her case with all the systematic detail of a ‘grand rounds’. As he talked, Maria’s cough grew louder and more urgent. The journalist whispered something to Martin, and a moment later the two of them softly made their way across the dark patio toward Maria’s room.

The new doctors listened intently to Dr. Mike: the history, the signs and symptoms, the lab reports, and our attempts at diagnosis. When Dr. Mike mentioned pulmonary edema, Dr. John interrupted sharply.

“Her? Pulmonary edema?” His voice had a note of slightly scornful incredulity. “Anybody who can put on a cough like that couldn't possibly have pulmonary edema. You can't blow a horn without wind.”

Dr. Mike laughed sheepishly, and said, “It's mighty good you're here. We needed somebody with more experience...”

I, too, felt foolish, but relieved. Already, without even having seen the patient, Dr. John had shed new light on her case. In simply hearing her cough, he had been able to put his finger on something we had half known all along, but never come to grips with; irrespective of how sick she might or might not be, to some extent at least, Maria was putting us on. To be sure, her physical problem was serious enough, but perhaps we could cope with it better if we didn't let ourselves get entangled in her melodramatics.

And so it was that Dr. John’s first of f -the-cuff judgement of Maria was the germ of a shift in our attitude toward the woman and her illness. From that evening on, we grew more stern with Maria, for we felt that if we catered to her hysterical fears, we would only intensify them. When we had to examine or test Maria, we no longer coaxed her as much or played up to her illness. We no longer waited as patiently for her to catch her breath (which she never did) before taking an X-ray or E.K.G. Dallying, we agreed, would only encourage her theatrics. We must be gentle, but firm.

However, it wasn’t always easy to be both. Sometimes, our firmness became more harsh than gentle. I vividly remember how one night, very late, when everyone in the clinic was trying unsuccessfully to sleep and Maria’s cough sounded deliberately loud, I went to her bedside and said firmly, “You know, Maria, if you didn’t cough so loud, maybe some of the people around here could get a little slcep. Just because you can’t sleep, doesn’t mean nobody else should, now does it.” In the muted glow of the kerosene lamp Maria turned her sweated drawn face toward mine and looked at me briefly with fatigued, haunted eyes. I had never before spoken to her like that. She turned her head away, gave me a couple of muffled coughs, and gasped, “Air, Benjamín!” At once I wanted to take back what I had said, to beg her pardon, to explain that I was cross because .... Instead, I gave her her medicine and stumbled off through the darkness and the mud.

* * *

In spite of our temporary increase in staff at the Ajoya Clinic, we were more swamped with work than ever. Apart from the enormous amount of time we spent on Maria, we found that our patient load had increased by leaps and bounds. People from San Ignacio and surrounding villages had seen the plane land and were coming to consult the ‘flying doctors’. Some were patients who knew Dr. John from his previous visits and had confidence in him. Among these were a mother and son from San Ignacio. Five years ago, the mother, Agustina, had to come to the Ajoya Clinic complaining of a breast lump which had proved to be cancer. Her suspicions verified, she had gone to pieces, terrified by the fear of leaving her children orphans. Deeply touched, Dr. John had gone to great effort to arrange surgery for her in California, as well as to see that she was comfortable during her visit. Two years later, when her eight-year-old son, José Antonio, developed a bone tumor in his arm, Dr. John had helped make similar arrangements for the boy. Both operations had proved successful. Now mother and son had returned for check-ups and to greet their old friend.

Apart from our increased patient load, another thing that slowed us down -- and justifiably -- was the visiting team’s unstinting commitment to teaching. Doctor John feels strongly that visiting doctors’ time is best devoted to training the paramedics who provide the continuity of care, and he had primed his team to this idea in advance. The team did most of its instructing through serving as clinical consultants. In addition, as I have mentioned, Robby conducted a number of excellent classes and seminars.

However, the visiting doctors were unable to devote as much time to teaching as we had planned, largely because of the time and energy they devoted to Maria. Concerning her condition, the number of opinions had increased with the number of doctors, This, of course, meant more tests and more electrocardiograms. For the E.K.G.s, we decided Maria should walk to the porch rather than be carried.

Though she would invariably complain that such walking was too exhausting for her, we felt it was better to be firm.

* * *

At long last we made a major breakthrough, Drs. Robby and John had noticed, by comparing the cardiograms over the last several days, that Maria’s heart rate was always a constant 150 per minute, no more and no less. They speculated that this could be due to ‘paroxysmal atrial tachycardia’ (or PAT, a sort of electrical ‘short circuit’ of the heart in which an unregulated point of discharge stimulates a very rapid but constant rate of contraction). In order to confirm this suspicion, and at the same time, if possible, interrupt the PAT and return Maria’s heart beat to normal, Dr. John injected a vasopressive agent (Aramine) into a vein of her forearm. The rest of us crowded around the E.K.G machine to witness the results. They were dramatic. Within the space of two heart beats (less than a second) her second heart rate dropped from 150 to 60 beats per minute. Maria uttered a gasp of terror and turned grey. On the E.K.G. machine her heartbeat leveled at 80 beats per minute for about two seconds, than flipped back to 150.

“It's a PAT!” cried Robby jubilantly. “What'd I tell you!” He pointed at the squiggly line. “See that sudden drop!”

Maria, trembling and clutching her chest, gave little grunting sighs with each strained breath. Benjamín, a faint frown on his innocent face, fanned his mother furiously with his tattered sombrero.

Dr. Mike, who had doubted that Maria had PAT, was less elated. “I guess you guys are right”, he said. “But she flipped right back into the paroxysmal beat. What have we gained?”

“That often happens”, explained Dr. John. “We’ll put her on Quinidine. If she doesn’t come out of the PAT in a couple of days with that alone, we’ll give her another shot of Aramine and she should convert and stay converted.”

All of us felt encouraged. We had, we supposed, at last tracked down the cause of Maria’s distress, and knew how to treat it. For the next two days, impatient for the Quinidine to take effect, we anxiously monitored her heart beat on the E.K.G.

By the end of the second day, however, there was still no response. Maria’s heart kept on pumping desperately at double time. That evening the thunder growled and it began to rain again.

About ten o’clock that night, a boy arrived on horseback from Carrisal (a small village on the way to San Ignacio) to tell us that a Jeep Wagoncer full of Gringos was bogged down in the mud near ‘la cruz’ (a wooden cross by the side of the road which marks the site where many years ago a young woman had been dragged to death by a mule). I was very tired, but my eagerness for a change of scene got the better of me, and I said I would go to the rescue with our Jeep. Dr. Mike, although as weary as 1, also jumped at the chance. After an hour or so of slithering up the badly washed out track, we came to the mired vehicle. Parking on somewhat more solid ground, we hooked up the winch of our Jeep to the Wagoneer, and wound it in like a floundering catfish. It was after 1:00 A.M. by the time we made it back to the clinic.

The arriving group of Americans was a lab tech (Ann), her husband, a mechanic (Bill) a young friend of theirs, and a new paramedic (Memo). (In case the reader is astounded by the number of Americans we had here at one time, so were we! We never plan to have so many at once, but sometimes it happens. Actually, the two groups overlapped for only three days.)

The next morning Maria was still the same -- rapid breathing, perspiration, fear of suffocation, pulse of 150/minute. We told her we wanted to get another E.K.G. As ever, she protested that she was too out of breath and begged ‘to wait a minute’. Yet this was the day we were to ‘convert her heart’ (bring it back to normal rate) and we were too eager to show her much patience. Dr. Robby and old Juan helped her, protesting, to her feet and ‘walked her’ to the porch. When she was hooked up to the leads, we crowded once again around the E.K.G. machine, eyes riveted on the rapidly jumping needle, while Dr. John prepared to inject her. Maria, recalling with terror the shock of the last such injection, pleaded that we not give it again, but Dr. John assured her it would not harm her, and was necessary if she was to get well. Unconvinced, Maria tried to restrain his hand, and her father in a sharp tone ordered her to behave. At last she submitted, calling with a weak voice, “Air, Benjamín!” The call was now less of a petition than a rite. The small, unfailing boy leaned forward and vigorously flapped his tattered sombrero. Dr. John injected the medicine.

Nothing happened.

Again, we were baffled. Three days before, her heart beat had "converted" -- though temporarily - with Aramine alone. Now, with Quinidine in her system, it was supposed to have converted yet more readily, and to have stayed converted. Instead, no change. The needle on the E.K.G. machine jittered rhythmically at 150/minute, as before.

“Maybe that means it’s not PAT after all”, suggested Dr. Mike.
“It has to be PAT”, insisted Robby, pointing to the stack of electrocardiograms.
Dr. John, concerned but still unflustered by Maria’s failure to ‘convert’, speculated, “We still might be able to block the PAT with Prostimine. Do we have any?” We had. We injected Maria with the appropriate dose and impatiently watched the E.K.G. machine. No response. “It often takes a while”, noted Dr. John, still not discouraged. And sure enough, at about 10 minutes, Maria’s heart rate began to drop. After half an hour, it had dropped to 120 per minute.

Everyone was ecstatic. Everyone, that is, except Maria, who continued to gasp for breath and call to Benjamín for ‘air’. Still, to us she looked better. Her blood pressure, which had been low, was back to normal, her pulse was at long last stronger and slower. Obviously, she was better!

“How do you feel, Maria?” asked Dr. Mike with an encouraging smile.
“Bad.” said Maria.
“But you do feel a little better, don't you?” he persisted.
She coughed and turned her head away. “Benjamín!” she gasped, “Give me air!”
Benjamín, who had trapped a fly on his bare arm by clapping his small hand over it, now held it carefully by the wing and was dreamily watching it twist and buzz.

“Give me air!” cried Maria with renewed anguish. “Or I'll die!”

The boy released the hapless fly, which spun in a drunken spiral to the floor, and snatching up his tattered sombrero, returned to fanning his mother. Old Juan, who stood planted beside his daughter like a wistful cypress, took hold of her long, thin, hand and gently massaged it in his own big ones.

“My poor, lost daughter!” muttered the old man wearily. “But if it's God's will to take her, so be it.”

Dr. Mike gave him an exasperated look, opened his mouth as if he were going to say, “Damn it, can't you see she's getting better!”, thought better of it, humped his wide shoulders and walked away.

“David”, said the journalist, who had spent most of the morning typing in the back room, “If you could spare me just a few minutes of your time...”

* * *

Later that same morning, the three doctors approached me with their recommendation:

“We have talked it over and decided that we’ve done just about all we can do medically for Maria here in this clinic. There is obviously a strong psychological element to her illness which has grown dependent upon and is aggravated by all the medical attention she has been getting here. If she is to get better, she should be elsewhere.

“Furthermore”, they continued, “We doctors came here with the understanding that we were to give priority to the training of paramedics and village apprentices. And just look at us! Ever since we arrived, the major efforts of this entire health center have been poured into one extraordinarily complex case: Maria!”

“In short, we feel that the advantages of moving Maria to a private house far outweigh the disadvantages. For the good of Maria as well as the clinic ... Agreed?”

Their points, I thought, were well taken. “When”, I asked, “do you suggest we move her out?”
“The sooner the better. Now, if possible.”


“Right now. This very morning.”

“But we just started the Prostimine this morning. Her heart rate is still dropping. Oughtn’t we to keep an eye on her for a few more days?”

“If she stays at a house here in town we can check on her as often as we need to.”
I nodded.
“Then you'll tell her father?”
“Yes”, I said. “It’ll take him a while to arrange a place to stay. I'll ask him to be ready by this afternoon. He should bring a couple of men to carry the stretcher.”

“Why a stretcher? As you know, that just reinforces her dependency. Better she walk...”

“Pardon me again”, said the journalist, who had been trying patiently to get a word in edgewise. “Do you mind if I quote from your introduction to the Ajoya Manual, this part right here.” She pointed to the very beginning, which reads:

The overall value of our medical efforts in a village health
program, is at best debatable. The value of ... human kindness is
unquestionable. Let this, then, be our first goal...

“Sure”, I said to the journalist, “Quote it if you like.”

“And wonder if you’d mind looking over what I've written so far...”

“As soon as I talk with old Juan”, I told her.

* * *

Old Juan accepted the news mutely. Yet when I told him we thought Maria would improve more quickly in a private home, his eyes grew moist and he put a friendly hand on my shoulder. I could tell he thought I was lying in order to spare him, and was grateful to me. He was sure we considered his daughter's case fatal, and were sending her out of the clinic to die. I tried to tell him otherwise, but it was hopeless.

* * *

I can't remember everything that happened during the next few hours, except that I was kept so busy that I missed lunch.

About 3:00 P.M. I was returning to the clinic from an errand. Hearing loud voices from the porch, I went there. Dr. Mike, Dr. Robby and old Juan were standing beside the examining couch on which they had propped Maria into a sitting position. The time had apparently come for her discharge. I remained in the doorway.

“That’s a girl, Maria”, said Dr. Robby. “You can make it if you take it easy. It's just a short way down the street.”

“No! ... Please! ... I can't do it! ... Air!” gasped Maria, “I need air!”

Like an injured bird, a tattered sombrero slipped out from between the two doctors and fluttered at Maria's perspiring face.

Next Dr. Mike spoke. His voice was gentle, but stern. “Now pull yourself together, Maria. You're getting better, you know that. Let us help you up.” He pulled gently on her arm.

“No! No! ... Please don't ... make me ... No! ... Not ... just now!” whimpered Maria. “Air!”

Dr. Mike took a deep exasperated breath and turning to Robby, said in English, “Every bloomin’ time we want to move her or treat her, she suddenly gets worse.” In his frustration, he turned back to the patient and said in Spanish, “What is it with you, anyway, Maria?”

“I'm dying”, Maria panted. The tattered sombrero flapped harder.

“David!” Maria cried out suddenly. She must have spotted me in the doorway. This was the first time she had ever called me by my first name, and it struck me as odd. I moved forward. “What is it, Maria?”

“I can't ... get enough ... air!”

There was nothing new about that. I moved closer and looked at her more carefully. The same terror and exhaustion were in her eyes. But something struck me as different, though I was hard pressed to know just what.

“It hurts ... me here”, grunted Maria, putting her hands to her chest.

I put a stethoscope over her heart. At first all I thought I heard was a faint fluttery sound, like a small moth trapped in a kerosene lamp. But almost at once I picked up the rhythmic ‘lud dub’ of a regular, fast heart. I looked up and saw that Dr. John had joined the group.

“What's the problem?” he said.

“Have a listen”, I said. “I think at first I heard a flutter.”

He listened, frowning, then shook his head. “Same as ever -- a steady fast heartbeat. A lot slower than it was at its worst, thank heavens.”

“She said she's dying”, explained Robby. “Complains of increased chest pain.”

“When did this begin?” asked Dr. John.

“When we said it was time for her to go, of course”, said Dr. Mike.

“Just what I thought”, said Dr. John. “Well”, he added abruptly, “We made a decision this morning. Are we going to keep it or not?”

I looked at Maria again, more closely. “Doesn't she look more cyanotic than she was? I ventured. Everyone examined her.

“Looks about the same as she always has”, said Dr. Mike skeptically.

“But look at her lips and nailbeds”, I insisted. I could have sworn they were bluer.

“It's probably just the afternoon light. It's terrible in here”, suggested Robby.

“Let's play it safe”, decided Dr. John, “And do another E.K.G. just to be sure.”

For the last time, we wired her up to the magic leads. This time I did not stand around the machine with the others, but squatted by the edge of the examining couch, carefully watching Maria. She looked at me, then suddenly reached out and caught hold of my hand, like a drowning person lurching at a bit of floating jetsam.

“No, Maria! Don't move!” snapped Dr. John. I quickly withdrew my hand, knowing that the contact between Maria and myself would upset the values of the machine.

“Great!” cried Robby, bending over the hieroglyphic verdict scribbled across the long scroll. She’s even better than the last time. Her heart’s slowed down to -- let me see -- 112!”

“No sign of any new problems?”

“Not a sign of any here!”
“Well then”, said Dr. Mike, “Let's hurry up and get her out of here.”
“Air!” gasped Maria.

I took a deep breath. “What do you fellows say we keep her here another day or so?” I suggested hesitantly.

They turned and looked down at me as if I were a child. “Trouble with you, David, you're too soft. You let Maria’s dramatics turn your head.”

'It's just what she wants. She's got all of us wrapped around her little finger.'

Dr. John cleared his throat, and the younger doctors grew silent. “I thought we reached a decision his morning, all together, that Maria was to leave this afternoon. It was established that this would be best for Maria and best for the clinic. Maria now says she feels worse. This is just as we might have predicted, considering her past performance every time she’s been asked to move or to cooperate with us. Unless we can put our finger on something specific which demonstrates that she is in fact in worse condition, I vote we abide by our earlier decision and move her out at once.”

“I agree.”

“I agree.”
“David!” called Maria in a weak voice. “I need...”
“What do you say?” asked Dr. John emphatically.

I looked down at my empty hands. I didn't have a reason. I had a feeling. But you can't wire an E.K.G. machine to a feeling. I thought of giving up and saying, “All right, take her away.” But there was something inexplicable inside me, like the voice of a child freshly wakened...

“I can’t give you any good reasons”, I said awkwardly. “I just have a strong feeling that Maria is on the edge of a crisis.”

“David!” called Maria again, in the same haunted voice. I gestured to her that I was busy.

The doctors stared at me in silence. Finally Dr. John said, “We must respect your judgement. However, if Maria is to stay here, I think that for her good as well as ours we should change our system of caring for her. We’ve been suffocating her with attention. She doesn’t need three doctors, five medics and four nursemaids. I think we should appoint one person only to care for her, apart from her father and the boy.”

Dr. Mike shook his head. “I agree with you 100%, but darned if its gonna be me.”

“Well then who shall it be?” asked Dr. John, looking from one to the other of us and mostly, I thought, at me. I thought of the mountain of other work I had to do, and said nothing.

“I'll be glad to do it”, said a voice from behind us. We turned to look at Martin, who had come onto the porch a few minutes before, and had been silently listening.

Everyone was relieved. “Good!” said Dr. John. “But remember, Martin, it’s essential that we wean Maria from the excessive attention she’s getting. You'll want to follow a strict regimen with her. Take her vital signs at regular intervals, see she gets her medicines, and that’s about it.”

“But whatever you do”, added Dr. Robby, “Don't fuss over her and make much of her complaints. It only precipitates her coughing and hysterics and generally makes things worse.”

“David!” called Maria. “Help me!”

“I know that”, agreed Martin, and to show us that he did, added, “We’ve spoiled her enough.”

“Then why don't you start now by walking her back to her ward”, suggested the doctors. “It’s high time we got on with something else.”

“Air!” gasped Maria.

“Walking her?” asked Martin dubiously.

“Certainly. And remember, you've got to be firm. Don't let her talk you out of it.”

“Help me”, cried Maria in a weak voice.

We all nodded our agreement, even old Juan, though we had been speaking in English and he could not have understood.

“I can’t ... breath ... any longer”, gasped Maria. “Benjamín...”

Benjamín, standing alone now beside his mother at the head of the couch, fanned faithfully with his tattered sombrero.

“Weren't you planning to conduct a class this afternoon?” asked Dr. John, turning to Robby.

“I’d thought of presenting something on extreme medical emergencies”, said the young surgeon.

“I tell you...”, whimpered Maria between gasps, “I ... am ... dying.”

Dr. John turned to me for confirmation. “What do you say we get the class started at once?
Martin can get Maria back to her room, and the fewer of us who hang around kibitzing, the better.”

“Marvelous.” adjoined Ann, the lab tech whom we had rescued out of the mud the night before. “On with the class.”

“Sounds fine to me”, I said.

The rain had stopped and the sky was dappled with high harmless clouds. The day was waning, so we decided to hold class in the patio, where the afternoon light was better. Carrying out benches and chairs, we put them in a circle. Twelve or so of us assembled -- Mexicans and Americans, doctors, medics, and lab techs. We all sat down except Robby. As he began the class, over his shoulder, in the shadows of the porch, I could see the dark shapes of Martin and old Juan trying to lift Maria to her feet. As they did so, their voices became louder and harsher. My mind strayed from the lecture.

First, Martin’s voice, “Come on, Maria. We can’t wait forever.”
Then old Juan, his voice trembling with anger, “I said get to your feet, girl. Now do it.”
“In a life threatening situation”, proceeded Robby, “it is imperative that one be able to recognized at a glance...”

“I can't .... go on another .... step...” Maria stood, supported by Martín and her father, at the top of the stairs leading down from the porch into the patio. Her breath was a succession of rapid, exhausted grunts.

Martín and her father half carried Maria down the steps and began to guide her, stumbling, across the patio. Benjamin, his tattered sombrero in his hand, remained at the top of the steps, small and alone, watching uncomprehendingly.

When the strange triad reached the center of the patio, just ten feet from our study circle, Maria was caught by a paroxysm of coughing. The next moment she slumped to her knees in the mud.

The lecturer continued, “The first thing you must be sure to do is check...”
“Come on, Maria”, shouted Martin. “Up with you.”
“Stand up, child”, commanded her father.
They hoisted her to her feet, only to have her sink again to her knees.
At this moment Ramona, arriving later for the class, hurried into the patio. She stopped in her tracks at what she saw, and cried, “My God, Martin, what are you trying to do to her? Poor Socorro! Can't you see she has shit all over herself!”

My eyes lowered to the yellow much on Maria’s legs. This, for sure, was no act. I jumped to my feet and ran toward her. The others followed.

Her breathing at first was irregular; short series of rapid, strident gasps, separated by long ominous silences, as if she were holding her breath. To our relief, the intervals gradually grew shorter, until her breathing was again more or less as it had been before. Weakly, she lifted her head, looked searchingly about and gasped. “Air.” Her father took off his sombrero and fanned her despondently.

Maria’s gown and legs were smeared with yellow diarrhea. The newly arrived lab tech hurriedly brought a damp rag, and dropping to her knees, scrubbed off a bit of excrement which had soiled Martin’s pants cuff.

Suddenly our callowness hit me like a club. Here was Maria, whom I had known as a proud and beautiful woman, reduced to kneeling in her own excrement while a pack of gaping onlookers milled about her, like flies around offal. I recalled how, only a few days before, she had made Benjamín empty the contents of her bedpan, embarrassed should we see it.

“Hey”, I urged, “Why don't all of us menfolk get out of the way, and let the womenfolk help clean her up.” I began walking to the porch.

“Talk about a male chauvinist pig”, chided the new lab tech.

I pivoted and blurted out, “If I thought it would be less humiliating for Maria, I would clean her up with my own shirt. Can't we just for once think of her.” My anger was out of proportion, and left the poor lab tech bewildered.

We menfolk had just reached the porch when one of the women cried, “My God! I think she's stopped breathing.”

Swiftly, the medical team jumped into action. Dr. Robby ran up with a plank and he and Dr. Mike rolled Maria onto it. Dr. John began heart massage while Robby, holding her nose, blew into her lungs after each five compressions of the chest. “Adrenalin!” cried Dr. John, “and a three inch 20 gauge needle!” When they were brought (the latter took some tracking down), Dr. John counted down the right number of ribs and thrust in the long needle. It bent. “Another three inch needle”, he demanded. This proved harder to find. Our volunteers tore open boxes looking for one, for it is something we rarely use. “Hurry up with that needle!” shouted Dr. John. Not finding the needle in the operating room, I ran back through the patio, across the porch and into the dispensary, where I remembered having seen a spinal anesthesia kit in one of the drawers. Locating it, I ripped it open, snatched up the needle, and ran back. In the doorway to the porch I nearly collided with Benjamín, who stood clutching the wooden door frame, sobbing hysterically.

As I ran down the steps, I thought to myself, “Another child would have been simply baffled by the immediacy and confusion of death, but not Benjamín, he knows the scent.” And across my mind flashed once again the image of his small form bounding along in the back of the Power Wagon beside the stiffened body of his father last Christmas morning.

As Dr. John thrust the needle into Maria’s silent heart, I placed my hand on her damp forehead and whispered, so low that only she might hear me. “Come back, Maria. Please come back.” But she was gone.

Each of us, I am sure, knew it (the dogs inside our hearts had begun to howl); yet none of us had the courage to face up to it. The loss was too great, the implications too threatening. So it was that our team continued to work on the body, thumping at its silent heart and breathing into its vacant cage, for a full ten minutes after its pupils had dilated and its skin had turned to wax. Throughout our pointless heroics, Maria's blank, unwavering eyes fixed challenging upon us, as if to say, YOU WHO KNOW SO MUCH AND ARE SO SURE, WHO NOW IS THE PRETENDER?

Benjamín, who had nothing to hide from -- nor behind -- howled from the doorway as uncontrollably as a kicked puppy. Finally ... we, too, admitted defeat. We carried Maria’s body onto the porch, where a couple of elderly village women dressed in black, who had materialized on the spot as mysteriously as genies, began to bathe and change her. They dressed her in a white gown which Ramona brought from her home across the street. Meanwhile, Benjamín continued to sob inconsolably. I stood back. Already, there were too many well-meaning and disillusioned adults trying to force their way across the no man’s land into that lonely naked world of the orphaned child. Benjamín buried his face into the unyielding door frame and shook off the hands that sought to comfort him. Old Juan, standing as silent and rent as a lightning- struck oak, looked mutely down at his big hands. Dr. John, who would have felt awkward trying to comfort the boy, said to me, “Oughtn't we to ask her father if we can do something...”

Interrupting, I blurted stupidly, “We ought to ask his forgiveness!”

I turned and stumbled into the darkroom, shutting the door behind me. There I wept as I have not since my childhood. My weeping, I know, was selfish. It wasn't so much Maria’s death that wracked me -- her death was perhaps inevitable -- it was the way she died. In her hour and moment of greatest need, we had done it so stupidly! So complacently, so blindly! How could we have let it happen? How could I have let it happen? Well, it was done.

And the blood on our hands was no longer mortal; it was universal. No, I wasn’t weeping for Maria, or even for Benjamín. I was weeping for the death of something inside of me, something I had believed in: the death of Kindness, the death of Love....

Slowly, as I crouched in the darkness, a new light began to glimmer from the ashes of despair.
With a start, I realized that Kindness and Love had not died; rather, they had been rekindled by Maria’s death; they were in the throes of rebirth. What had died had been something false and petty and obdurate within us, something which needed to die, to be wrenched from our breasts so that Love and Kindness could find more room in our lives. Unwillingly and unwittingly, Maria had been the martyr to the cause of our knowing ourselves. To this end, her untimely death could not have been better timed. I shook my head in baffled and respectful amazement.

Strained voices reached my ear from outside the darkroom, and I went out. Martin was sitting on the edge of the examining couch, his moist face pressed into his hands. Dr. Robby and Dr. Mike were standing beside him. Robby said, “Come on now, Martin, it’s not your fault.”

“But I was shouting at her, dragging her, like an animal”, choked Martin.
“You were doing what you thought was right”, insisted Robby.
Martin shook his head. “No, I wasn't. I knew that wasn't right. It's never right to be cruel. I can't understand what came over me.”

“Maybe it’s truer to say”, said Dr. Mike, turning to address Robby, “that Martin did what we thought was right. After all, we set the example.”

Robby nodded slowly. “That's true, Martin. It was our decision to be so strict with her. And to make her walk. Don't blame yourself.”

“I know, I know”, said Martin. “But even so, I should have known better.”

“We all should have known better”, said Robby.
“Don't reckon it’s ever too late to learn”, said Dr. Mike.
Martin stared at his slender hands, and whispered, “Poor Benjamín.”

We carried Maria’s body up the street to the house where, earlier that same afternoon, we had intended to dispatch her on foot. She was laid out on a burlap cot, decked with bougainvillaea and dahlias, and the noisy wake began. I convinced old Juan to let us take care of Benjamín for the meantime, as I could see no advantage of having him sit through the long night with a covey of wailing women; of tears, he had already shed his share. The journalist took the boy to the house of Martin's family, but unable to suppress his hysterical sobbing by the end of two hours, brought him back to the clinic.

It was Martin who was finally able to bridge the gap to the suffering boy. He simply took Benjamín by the hand and led him to a cot in the back room, where he lay down beside the boy and let him weep, not sympathizing, but just there. When the child was at last empty of tears, they both got up and went over to the typewriter. Benjamín had never touched such a strange and many-buttoned thing, and his child’s curiosity was sparked. Martin taught him how to peck out his own name and, within a quarter hour, the boy was laughing. It may have been hard on the typewriter, but it did wonders for Benjamín .... and for Martin. Although the typewriter was mine, I did not protest. It was high time a machine came second to our feelings.

* * *

Maria’s death had a profound effect on all f us. It stopped us in our tracks, forcing us to stand back and take a sharp look at ourselves, what we are about and where we are going. It pricked the bubble of our self-assurance and left us all, I think, a little more humble. In the couple of remaining days before the visiting team flew home, we had many soul-searching discussions.

Dr. Robby, in one of these discussions, shook his head and said something like this: “It's hard to believe we could have been so blind. So callous. And on purpose! ... that's the frightening part of it. We held at bay our natural urge to give Maria the compassionate support she begged for and we could have so easily given, because we were so set in our opinions about what was best for her and the clinic. At the end we were actually paying more attention to our decisions than to Maria!”

Robby frowned self-consciously, “You know, I used to take pride that in my brief career as a doctor I had never, to the best of my knowledge, committed any technical errors. Now, all of a sudden, I realize the biggest errors a doctor can make aren't technical, but personal. It's so easy in modern medicine, with its endless maze of techniques, technology and technicalities, to lose sight of the patient altogether. We tend to get hung up in the details of illness ... The science of medicine endangers the art. Believe me, from now on I'm going to listen a little more closely to what the patient is trying to tell me, and show a little more genuine feeling.” Dr. Robby knocked on the edge of the table on which he was sitting. “At least, I hope so.”

The morning after Maria's death, Dr. Mike approached me where I stood alone, to tell me how badly he felt about the way things had been handled at the end. “I know we can’t undo what’s done”, he said. “But I just wanted to tell you, David, that I think all three of us M.D.s are going to be one heck of a lot better doctors for what happened to Maria. I know I will be.” He extended his hand. "Well, I just wanted to say thanks."

“Thanks for what?” I asked him, taking his hand.

“I guess thanks for letting Lynne and myself come down. I'm not sure if you guys wouldn't have done better without us, but it's given me a whole new outlook on medicine, and where I'm at...”

Dr. John, being older and wiser than the rest of us, kept most of his ideas to himself, yet I could tell the event of Maria’s death affected him deeply, perhaps more deeply than any of us. Preferring actions to words, he quietly took up a collection to pay for the simple wood coffin which was prepared for Maria. This meant a lot to old Juan, for it showed him that we shared some of his feeling. One post-Maria comment by Dr. John has stuck with me: “When a patient says, “I'm dying”, assume he’s right.”

Martin was unable to talk dispassionately of Maria's death for several days, but one morning, after the doctors had flown home, he said to me, “I've been thinking, David, if we'd been alone here in the clinic, I mean with our usual group of medics and apprentices only. Maria might have died, but not like she did. Because we're not doctors, I guess we're not so sure of what we're doing. You know what I mean? We're forced to rely a little more on our feelings. We would have had to listen more to Maria and what she said her needs were, because we wouldn't have had quite so much trust in our own judgement. I know we aren't as highly skilled, and probably we wouldn't have practiced as good medicine. But for Maria, even the best medicine didn't work. Maybe kindness would have....”

“One thing I learned”, continued Martin, “is that doctors are just people like the rest of us. And you know something else I've learned?...”

“What?” I asked.

“That I should do what I feel in my heart is right. I knew I shouldn’t have treated Maria like that.”

“I knew I shouldn't either”, I said. “Martin, I think we learned the same thing. How did you put it?”

“To do what I feet in my heart is right.'

* * *

As for Benjamín, he must have learned something too, although I hesitate to think what. I suppose he learned that the behavior of adults is incomprehensible. But then he knew that already. In his philosophic way, he seems to be as understanding of our hardhearted treatment of his mother, as he was of his mother’s unfair treatment of himself.

One thing that Benjamín has learned since his mother’s death is that adults, at least in retrospect, can be kind. Martin has taken him to live with his own family and is like a father to him, although more gentle. Charlotte, the journalist, periodically sends him clothing, as well as funds to help with his living and educational expenses. Dr. Robby has made possible a cow, so that the youngster can have milk to drink. Short of a mother and father, what more can a small boy ask?

Old Juan would have answered, “Beans.”

-- 0 --

Note: The above story, "What we learned from Maria," was the main article from "Newsletter from the Sierra Madre" # 10, April, 1975. The articles in the first half of the seminal newsletter can be found in the paper, "Primary Health Care and the Temptation of Excellence."


Prepared for a forthcoming booklet by the International People's Health Council

David Werner, November, 2002

Increasing poverty, crime, and violence in rural and urban Mexico

The Ajoya Massacre. For the last 37 years the village of Ajoya in the foothills of Mexico's Sierra Madre Occidental, has been the nucleus of the groundbreaking community-based health and rehabilitation innitiatives, projects Piaxtla and PROJIMO. These programs have been the source of the widely used handbooks Where There Is No Doctor, Helping Health Workers Learn, Disabled Village Children, and Nothing About Us Without Us. But over the last several years the combination of drugs, violence, robberies, and kidnappings have plagued the village. At a festival and dance for Mothers’ Day last May (2002), a massacre resulted in the death of 12 person including 2 “Protection Police,” a 7 year old boy, and a grandmother in her 60s.

Tragically, the village of Ajoya is fast becoming a "pueblo fantasma," a ghost town. The same is true for many of villages of the Sierra Madre, and throughout rural Mexico. Since 1994 when the North American Free Trade Agreement was launched, over 2 million destitute campesinos (peasants) have left the rural area for the mushrooming city slums.

But in the cities, the situation is in some ways worse than in the countryside. Within the last few years crime and kidnapping have escalated, as have delinquency, drug trafficking, organized crime, and police brutality. Mexico City has kidnappings nearly every day. According to the New York Times (June 7, 2002) often the Police are themselves involved in the kidnappings. The promises of the new President, Vicente Fox, to clean up crime and corruption have proved as empty as his promises to combat poverty.



Who killed Primary Healthcare?

How the ideal of ‘health for all’ was turned into the reality of
worsening health for the world’s poor.

An instructor of community-health workers in Kenya once told me about a sobering experience she had when she was visiting a rural health post. In the heat of midday an exhausted young mother arrived on foot from an isolated hut several kilometres away in the savannah. In a colourful shawl across her back she carried her baby, Kofi, who – she explained – had severe ‘running stomach’ and was very ill. She begged the health worker for the life-saving medicine in the silver envelope that she had heard about on the radio. She was referring to Oral Rehydration Salts, of which 400 million packets are produced each year as part of the international campaign to reduce deaths from diarrhoea, still the biggest killer of children in many poor countries.

Lovingly the mother lifted little Kofi from the shawl then gave a sudden cry of despair. Kofi was dead. His wrinkled little body made it clear that he had died of dehydration. The long trip in the hot sun had been too much for him.

‘I felt partly responsible,’ sighed the instructor. ‘If we had only taught mothers to make a home-made rehydration drink instead of teaching them that they needed a “magic packet with a silver lining”, her baby might still be alive today. But we listened to the experts in Geneva and Washington.’

As a stop-gap measure for undernourished children Oral Rehydration Therapy (ORT) should certainly be given high priority. But it must be introduced in ways that foster self-determination, not dependency. On my travels to the villages of Africa, Asia and South America I have heard many similar stories of acclaimed technological solutions that have not lived up to their promises.

Primary Healthcare (PHC) as originally outlined by the world’s nations at the 1978 Alma Ata Conference did indeed seek to establish the accountability of health workers and health ministries, with guarantees to meet the basic needs – including food needs – of everyone. This commitment was based on the success of community-based health programmes that had sprung up in the Philippines, Guatemala, India and elsewhere. The barefoot doctors of revolutionary China had demonstrated that with political will for equity a state could achieve good health at low cost.1

Unhappily, the high expectations of Alma Ata have not been met. Three major changes have sabotaged them.

Selective Primary Healthcare
No sooner had the dust settled after the Alma Ata Conference than top-ranking health experts in the North began to trim the wings of Primary Healthcare. With global recession and shrinking health budgets they felt that such a comprehensive approach would be too costly. If health statistics were to be improved, they argued, high-risk groups must be ‘targeted’ with a few cost-effective interventions. This politically sanitized version was dubbed Selective Primary Healthcare.

UNICEF, which had been a strong advocate of the comprehensive original, now took the line that Selective PHC was more ‘realistic’. Through its so-called Child Survival Revolution’ (which some critics called a counter-revolution) UNICEF narrowed the focus to growth monitoring, ORT, breastfeeding and immunization. In most countries it was narrowed even further to the ‘twin engines of child survival’, ORT and immunization.

The global Child Survival Campaign quickly won high-level support. For those in positions of privilege and power it was safe and politically useful. It promised to improve a widely accepted health indicator – child mortality – while skirting in all but rhetoric the social and economic inequities underlying poor health. Many health professionals and governments jumped on the bandwagon. Even the World Bank began to lend its support.

But technological solutions can only go so far. Over 133 million children still die each year, roughly the same number as 15 years ago, even if this represents a smaller percentage of an increased child population. Most of these deaths are still related to poverty and undernutrition.

Reducing child mortality through selected technological interventions does not necessarily improve children’s health or quality of life. During the 1980s a disturbing pattern emerged in some poor countries: while child-mortality rates dropped, undernutrition and morbidity rates increased. The pattern was ominous. Sure enough, during the late 1980s and early 1990s, in many countries the decline in child mortality slowed or halted. While in some countries – especially in sub-Saharan Africa – child deaths began to increase.2

Even the ‘twin engines’ of child survival proved difficult to sustain. Immunization rates began to decline, with a corresponding increase in polio cases. Egypt’s oral-rehydration program, which has been upheld as a success story, saw usage rates for oral rehydration salts in the 1990s plunge from more than 50 per cent down to 23 per cent.2 Salts packets were originally given to mothers free. Their provision was then commercialized. Now poor families are brainwashed into spending food money on these products rather than using potentially more effective, less expensive, home-made cereal drinks. A ‘simple solution’ for child survival became yet another way of exploiting the poor.

Hilary Clinton beams: but dissent was the most interesting thing about the Social Summit in Copenhagen.

Structural Adjustment Programmes
The next big assault on Primary Healthcare was the introduction during the 1980s of Structural Adjustment Programmes (SAPs). Engineered by the World Bank and IMF, these austerity policies invariably hit the poor hardest. Public hospitals and health centres were sold to the private sector, pricing their services out of the reach of the poor.

‘User-financing’ and ‘cost-recovery schemes’ are among the most pernicious of these policies. The poorest families tend to get sick most often and so pay the most. They are often willing to spend their last pennies to care for their sick children. But they can ill afford to do so. In the Makapawa community-based health programme in the Philippines, health workers found that the money poor families spent on medicines instead of food contributed to child undernutrition and high mortality. By making remedies for common problems at home they spent less on pills, more on food, and their children’s health improved.

Studies in some countries have shown that when cost-recovery was introduced the use of health centres by high-risk groups dropped. In Kenya the introduction of fees at a centre for sexually transmitted diseases caused a sharp decline in attendance and an increase in untreated infections.3 In China user fees for tuberculosis treatment led to millions more cases of infection.

‘Investing in Health’
The third assault on Primary Healthcare came with the World Bank’s 1993 World Development Report, ‘Investing in Health’. A better title might have been ‘Turning Health into an Investment’. For when stripped of its humanitarian rhetoric its chilling thesis is that the purpose of keeping people healthy is to promote economic growth.4 If such economic growth were intended to serve the well-being of all then the Bank’s intrusion into healthcare might be more palatable. But the ‘economic growth’ which the Bank promotes has invariably benefited large multinational corporations, often at devastating human and environmental cost.

On first reading, the Bank’s strategy looks comprehensive, even modestly progressive. It acknowledges the economic roots of ill health, and that improvements are likely to result primarily from advances in non-health sectors. It calls for increased family income, better education (especially for girls), greater access to healthcare, and a focus on basic health services rather than specialist care. It quite rightly criticizes the persistent inequity and inefficiency of current Third World health systems. Ironically, in view of its track record of slashing health budgets, the Bank even calls for increased health spending.... So far so good.

But, on reading further, we discover that the key recommendations spring from the same paradigm that has worsened poverty and health levels. To save ‘millions of lives and billions of dollars’ governments must adopt ‘a three-pronged policy approach of health reform’:

  • ‘Foster an enabling environment for households to improve health’ – which really means requiring disadvantaged families to cover the costs of their own healthcare.

  • ‘Improve government spending in health’ – meaning trimming government spending from comprehensive coverage to a narrow selection of cost-effective measures.

  • ‘Promote diversity and competition in health services’ – which means turning over to private, profit-making doctors and businesses most of those government services that used to provide free or subsidized care for the poor.

One reviewer (David Legge) observes that the World Bank Report ‘is about healthier poverty’.5 It ignores the fact that in many countries with SAPs average per-capita income has plummeted. Even in countries whose economies have partially recovered, most gains have been pocketed by the wealthy.

The Bank’s new policy for the Third World sounds dangerously like the healthcare model of the US. It argues that private healthcare for individuals gives more choice and satisfaction and is more efficient. But there is little evidence to support this claim. The US health system, dominated by a profit-hungry private sector, is by far the most expensive in the world. Yet US health statistics are among the worst in the Northern industrialized nations. The city of Washington DC has higher child- and maternal-mortality rates than Jamaica.

It is an ominous sign when a giant financial institution with such strong ties to big government and big business bullies its way into the health field. According to the British medical journal, The Lancet, the World Bank is now moving into first place as the global agency most influencing health policy, even ahead of the World Health Organization.6

Despite all its humane-sounding rhetoric, the central function of the World Bank remains the same: to draw the governments of weaker states into a global economy dominated by large, multinational corporations. Its loan programmes, development priorities and adjustment policies have deepened inequalities and added to the poverty, ill health and deteriorating living conditions of at least one billion human beings.

Mexican model
I have seen for myself how community action can turn the tables. Based in the mountains of western Mexico is Project Piaxtla, a villager-run health programme. Analysing the factors behind the high death rate of children from diarrhoea and undernutrition, the health team there saw that a key cause was share-cropping – poor, landless families must give up half their harvest to the rich landowner.

They realized that conventional health measures were not enough to improve the survival and quality of life of children. By organizing peasant invasions of illegal holdings they succeeded in redistributing over half of the best, riverside land. With irrigation they doubled the yield, giving poor farming families more to eat. Their children gained weight and succumbed less to common health problems. The death rate of under-fives dropped from 34 per cent to around 6 per cent.

In explaining the dramatic improvement people gave some credit to better healthcare but said the big difference was their joint struggle to win their constitutional land rights. Such an interpretation of health is consistent with the Alma Ata Declaration’s insistence that health depends on equity. Most children can survive without medicine, none without food.

Unfortunately, in the 1990s the peasant farmers of Mexico are seeing the gains they made reversed. Mexico has an enormous foreign debt and in exchange for new loans has been subjected to stringent adjustment policies. Land-ownership is concentrating again into fewer hands – including those of US agribusiness transnationals. More than a million small farmers have lost their holdings and migrated to city slums, where unemployment soars.

The village health team in Mexico, along with thousands of concerned groups around the world, are coming to realize that new strategies – comprising local action with global solidarity – are needed to counter the transnational power structure. Although the obstacles are colossal, there are encouraging signs that such a groundswell is under way. The ‘50 Years is Enough’ international coalition, which opposes the exploits of the World Bank and the IMF, is a good example. Many networks focusing on health are striving to increase public awareness and to organize pressure from below on the world’s policy-making bodies. Two such grassroots coalitions based in the South are the Third World Network in Malaysia, and the International People’s Health Council in Nicaragua.

At the recent Social Summit in Copenhagen nearly 1,000 non-government organizations and people’s movements joined in protesting the official Declaration, calling for fairer distribution of resources and restructuring of the world order so that poor and disadvantaged people have a stronger say in decisions that determine their well-being.

In the final analysis, creating a healthier social order will depend on reaching across traditional barriers and replacing global pillage with a global village – where everyone’s basic needs are equitably and flexibly met.

This article appeared in The New Internationlist, 1995.

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