On Call in Amuru: A report from the margins of global health care

On most evenings, as midnight arrives at Amuru Peripheral Health Center in rural northern Uganda, a distant roar gently disrupts the peaceful quiet of the star-studded sky. The hum of noise belongs to the jet engines of the British Airways and KLM flights as they ascend to cruising altitude en route to London and Amsterdam from Uganda’s Entebbe International Airport.

Inside the planes, flight attendants roll service carts down the aisles offering sodas, wine, beer and orange juice. Passengers recline their seats and turn on their personal in-flight entertainment systems. Over the intercom the pilot welcomes them, announces a flight plan that traverses Sudan, Libya, the Mediterranean, Italy and France and invites all on board to relax and enjoy the comforts provided by the staff. Dinner, choice of chicken or beef, will soon be on its way.

On the ground below, at the brick-walled and tin-roofed clinic, the wards are outfitted with 25 metal-framed beds. The place bursts at the seams with 40 to 50 inpatients and their families, who search out patches of cement on which to unroll their brilliantly colored banana mats and rest their heads for the night. Kerosene lanterns light the wards. The night staff distributes evening medications to treat the cases of malaria, respiratory infections and diarrheal disease that afflict the bulk of patients admitted to the health center. But on any given night, some patients go untreated because the clinic runs short of certain medications, even though they are on the list of essential medicines described by the World Health Organization as the “minimum medicine needs for a basic health-care system.” Other patients, whose medications are in stock, wash the pills down with clean running water from a deep well drilled near the clinic. Dinner—if there is any—often consists of rice or beans and disappears all too quickly.

Despite these limitations, Amuru’s staff members, with whom I have been privileged to work over the last three years, remain committed to providing the best care possible to a community that was heavily affected by war during the 20 years between 1986 and 2006. On average, 150 outpatients arrive at the clinic every day, of whom 10 to 20 are admitted. In a recent letter to the clinic staff, a mother expressed deep gratitude for the committed, patient and thoughtful care provided to her son during his recent bout with malaria. A copy of that letter now hangs on the clinic’s notice board, proudly displayed for all to view.

A Patient With Asthma

Yet even with the benefit of a committed, well-trained staff, on most nights the challenges of providing health care in a resource-poor setting are crystal clear. On one such night, as the jets passed overhead, a 38-year-old woman named Mary (not her real name) arrived at the clinic wheezing because of tightened airways from an asthma attack. Despite Mary’s long struggle with asthma, she had never had an inhaler capable of preventing such attacks. She therefore walked for four hours with her breastfeeding child to reach the clinic.

Predictably, Mary arrived in extreme distress. Her breathing was labored. Her baby cried of hunger, prompting her to try breastfeeding while holding herself upright on a stretcher to maximize her ventilation. We measured her vital signs and listened to her lungs and heart, hoping that we could control the situation. We gave her a dose of steroids and salbutamol tablets, standard medications for an asthma exacerbation. We marshaled our best patient-doctor skills as well, trying to console her with a hand on the shoulder or a rub on the back and hoping that the art of medicine would relax the smooth muscle in her airways.

It did not. Her body required the benefits of oxygen therapy and inhaled asthma medications, neither of which was available. Without them, Mary sat bolt upright, struggling for each breath as she settled herself in a hospital bed for the night.

Mary’s experience represents a recurring storyline at the clinic: Children whose red blood cells have been extinguished by malarial parasites arrive in desperate need of blood transfusions, which the clinic does not offer. Women arrive with obstructed labor requiring urgent surgical intervention that can be had only if the women can pay $50 to reach a large hospital about an hour’s drive away. Others arrive with respiratory infections that induce severe shortness of breath, but they cannot be treated at the clinic for lack of oxygen therapy.

On the night Mary arrived, the overnight nurse woke me at four in the morning, saying, “That asthmatic needs more help.” After a brief respite, the tyranny of her uncontrolled asthma attack had returned. As Mary gasped for air in the lantern-lit ward, I had no idea what to do, despite all my training as a global health resident and years of experience in Uganda. We could not step up her therapy. No portable chest x-ray could be ordered to make sure we weren’t missing something else. No vehicles were available to transport her to the hospital an hour away. In that space, which felt so much the opposite of our promise to heal suffering and work for health as a human right for all, I simply sat with her.

The Ties That Bind

I thought about the planes in flight, probably over the Mediterranean by that time, and the space between the cabins of those roaring jets above and the clamor of the packed wards at Amuru health center below. The space between is so vast. The privileges and opportunities in life afforded so many on the plane far exceed the opportunities for those who fill the wards below. Access to quality education, health care, sanitation and housing is often taken for granted by those who can come and go as they please, while that access is desperately sought after by the people in Amuru, down below. Community and familial ties among those in Amuru are tight in ways often unimaginable to those on the plane whose lives include living great distances from family and friends. Those in Amuru take time to greet all who pass on the road. In Boston, I often find an avoidance of eye contact or a rushed hello.

And yet that space between is quite small, too. Just down the road from the clinic, oil exploration by a European company has commenced, linking the physical land of Amuru with the fuel that powers the jets passing overhead. Generic drugs produced in India fill the shelves of the clinic in Amuru, circumventing the multinational-pharmaceutical- company restriction that would limit medications to those who can pay for them. Ugandan soldiers and rebels used weapons manufactured in China and Russia in a 20-year war that still haunts the minds and bodies of those who live around Amuru. And international aid, likely subsidized through the taxes of at least some of the airplane passengers, pays for the staff, vehicles, schools and conferences of nongovernmental organizations trying to improve health, education and governance in Amuru.

Morning arrived as rays of sunlight tumbled across the acacia trees on the plains of Amuru. Miraculously, Mary survived. We found her transport to the bigger hospital, where she received oxygen and nebulizer therapy. She then disappeared back into the mass of people living in resource-poor settings, who continually persevere on the margins. By then, the planes had surely touched down on British and Dutch tarmacs.

In an era of unparalleled global interconnections and expanded funding for global health, Mary’s story disturbs me. Northern Uganda teems with local and international N.G.O.’s that relentlessly offer health training programs, rove the land offering mobile outreaches and construct new office spaces equipped with the latest information technology. Global health professionals and students—so many of the passengers on those planes—come and go in the name of work, research and new experiences. Reports are written, research is conducted, and papers are published. Million-dollar contracts are awarded by donor countries to develop sustainable systems of health care delivery in concert with the government. Yet we are still unable to deliver basic primary care to people like Mary. Why?

I worry that those of us who say we “just want to help” are culpable. We continue to perpetuate a system of global health and development largely built upon models of charity, that, as Paul Farmer once wrote in these pages, presuppose that “there will always be those who have and those who have not.” While now frowned upon rhetorically, paternalism still holds us captive through the short-term, uncritical application of our answers to other people’s problems. We localize the problems of people like Mary with research papers and books citing “corrupt foreign governments,” “violent African settings,” “failed states” and “exotic cultural practices.” The list goes on. Rarely do we look to ourselves to see how we fall short in our commitments or how we participate in and benefit from global systems that perpetuate inequality and structural violence. According to the research of Alnoor Ebrahim, a Harvard professor, N.G.O.’s, beholden to the purse strings of their donors, avoid critical evaluation of their actions for fear of losing funding; instead, they glamorize triumphs in the most dire of circumstances.

Such factors result in a global health enterprise that often lacks long-term commitment, partnership and accountability to the communities we purportedly serve. At Amuru Health Center, local and international N.G.O.’s continually arrive without prior warning and present elaborate plans to address the health crises facing the population. They disrupt the daily workflow at the clinic, promise resources and are never seen again. The hollow legacy of such visits persists in N.G.O. annual reports, lauding the number of community outreach visits accomplished that year.

Business as Usual

Research shows that partly through the institutionalization and professionalization of global health and development, these ways of doing things have come to be taken for granted in international development and global health work. While this style of business as usual is great for marshalling resources, initiating projects and building résumés, the final criterion should be whether it helps people like Mary. Otherwise, we—out of concern for our advancing careers, published articles and comfortable lives—risk continued acceptance of lower standards of care for the poor, global economic inequities and the fallacy that good intentions are good enough. Within the current economic, political and social systems, the stark reality is that many people in Mary’s shoes suffer and die needlessly.

At a time when the fields of development and global health are continuing to emerge, the people of Amuru have taught me to pay close attention to all the connections between these plans, their lives and the spaces between. We can find many, if we start to look. It is in tracing those connections that critical questions arise; unease with the world’s inequality and injustice rattles us; and confusion about what to do next can overwhelm us. But it is also then that we see the spaces of shared humanity, settle upon coordinated efforts, however incomplete and imperfect, and envision opportunities for remaking a world grounded in social justice. It is then that we start to reclaim solidarity, a driving force behind Catholic social teaching.

Now, each time I board one of those planes myself, I must confront the question, “What am I going to do about the spaces between?”