Lessons from Structural Violence in Ecuador's Rural Healthcare System
Martha Paola Vega, MD, MMSc '17
I am a member of the Los Angeles Unit CAL-MAT emergency response team. I have served as Paul Farmer Global Surgery Research Fellow in Harvard's Global Surgery and Social Change program. I have been involved in mobile health and medical missions since my training in medical school. Mobile health is a powerful tool that provides timely access to healthcare services to populations who otherwise would not have access to treatment. As a global surgery fellow, I've had the fantastic opportunity to work in Ecuador with the non-governmental organization Cinterandes Mobile Surgery Foundation. Through a mobile surgical unit, it provides free and low-cost surgical services to rural and underserved communities. Multiple surgical access barriers and delays are overcome by bringing surgical care into a community.
Through my participation in the MMSc-GHD program, I had the opportunity to deeply understand the complex barriers that rural populations in Ecuador experience when seeking surgical care. Although the Ecuadorian government runs its universal healthcare system, rural communities face significant obstacles and delays in accessing surgical services. It is commonly perceived that access to healthcare in rural settings is challenging due to geographic remoteness and, consequently, lack of hospital infrastructure. Although these are contributing factors, the MMSc-GHD program gave me the biosocial lens and research tools to help elucidate inconspicuous social and political barriers that directly threaten the rural population's health and access to medical treatment.
I would like to reflect on two "violent structures" that I believe will need to be addressed by South American countries like Ecuador to drive equitable healthcare access in the future. Andean and Amazon's rural population's health is affected by racism and by a country's extractivist practices. During my fieldwork, multiple rural patients told me that when they sought care at a clinic or hospital, they were dissatisfied with medical providers who did not resolve their illness. They often heard from healthcare providers to put up with the pain. Surprisingly, various healthcare workers in rural medical facilities told me that indigenous rural patients had a greater tolerance for pain than non-indigenous. For example, pain from an incarcerated hernia is experienced differently by people from different ethnic backgrounds. Racism within the healthcare delivery is subtle, but it is deeply rooted in Latin American colonial history and violent reproductive healthcare practices against rural women in more recent history. Such racism is evidenced in patient-provider assumptions and interactions. To improve healthcare in rural Latin America, healthcare systems should implement strategies to help abolish racism in doctor-patient interactions and assumptions.
Another structure that needs to be addressed in Ecuador and likely other South American countries is the impact of extractivism on Andean and Amazon community health. The lack of diverse job opportunities in rural settings pushes people to work in crude oil extraction and copper and gold mining, which inflict significant health risks among the rural workforce. Latin American countries with extractivist practices need to implement health system structures that guarantee access to timely and high-quality health and surgical care. It would be immoral for political stakeholders to withhold healthcare system development to benefit the rural mining workforce. The Central Bank of Ecuador forecasts that mining exports will provide $2.23 billion in sales this 2022, a 40% growth from the prior year.
As I reflect on my conversations with various members of rural communities, I conclude that geographic remoteness is not the main reason behind inefficient and underdeveloped healthcare systems in rural settings. Instead, political stakeholders lack the realization that investments in rural human capital and healthcare systems could drive sustainable national development, healthier populations, and a moral and just future.
I am incredibly grateful to the MMSc-GHD Program for giving me the tools to objectively study the complexities of global health. I aspire to continue my training as a surgeon and apply my research capacity toward improving healthcare and surgical care delivery systems in rural Latin America.
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