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C h a p t e r 4 Health Systems as “Core Social Institutions” The health system is not simply a mechanical structure to deliver technical interventions the way a post office delivers a letter. Rather . . . [it] functions at the interface between people and the structures of power that shape their broader society. —Lynn Freedman, “Achieving the MDGs: Health Systems as Core Social Institutions,” 2005 Of all the forms of inequality, injustice in health care is the most shocking and inhumane. —Martin Luther King, Jr., speech to the Second National Convention of the Medical Committee for Human Rights, March 25, 1966 The day I arrived in Quibdó, in May 2010, was a typically steamy-hot day, which left us drenched in sweat within minutes of leaving the airport. Quibdó is the capital of Chocó, an impoverished, jungle department of Colombia. It is a place that illustrates how “magical realism” in some Latin American literature often merely records observed reality, a place where one feels that “plagues of insomnia and forgetfulness”1 could surely rival more mundane public health threats.2 The enormous army barracks on the outskirts of town were teeming with young soldiers whose menacing automatic weapons and camouflage-covered bravado contrasted sharply with the adolescent roughhousing they could be seen indulging in with each other. But the menace was very real; according 100 Starting Points to human rights organizations, soldiers posted here had been raping local girls with impunity for years. In the shadows of the barracks stood the recently constructed middle-class homes, with their fake Corinthian columns attached to the cement facades, streaming everything from loud cumbia rhythms to FloRida as the owners sat on their fake terraces, drinking real whiskey, heatedly debating for whom to vote in the upcoming election, and erupting into dancing whenever those debates threatened to devolve into fisticuffs . Then there were the rotund, Botero-esque figures3 crowding through the muddy, unpaved streets in impossibly tight garb and high heels, seemingly unfazed by the extreme heat and humidity. Years of an entrenched drug trade and successive decommissionings of paramilitaries had left the promenade along the river and other public spaces in Quibdó filled with sinisterlooking armed men, and gave the unshakeable sensation that one was always being watched. Chocó is one of the subnational “departments” (states) of Colombia that has been most heavily affected over a half century of armed conflict between the government and guerrilla groups. The long conflict has ravaged the country , killing approximately 220,000 people and internally displacing an estimated 5 million or more. In 2013, the Fuerzas Armadas Revolucionarias de Colombia (FARC) and the Colombian government reached a partial peace accord and as of early 2015, the ongoing peace talks, although extremely contested politically, had advanced considerably. The population of Chocó is highly Afro-descendant, a result of the slaves who escaped from the slave-trading port of Cartagena in the 1800s and fled eastward into the jungle.4 Compared to much of Colombia, there are also significant populations of indigenous groups, and they have been particularly adversely affected by the combination of the armed conflict and the mining industries, which have destroyed large tracts of jungle and polluted both soil and water.5 The area had been relatively peaceful prior to the early 1990s, when an increased presence of the FARC and the Ejército de Liberación Nacional (ELN) drew an army response and brought terror and violence against the indigenous civilian population. The influx of paramilitaries threatened their control over resources, as well as their territorial control and their cultural practices.6 A few days before I got there, an indigenous woman, Isabel, had died of obstetric complications in the district hospital. Isabel lived in a small village in the jungle hundreds of kilometers from Quibdó. She had developed protracted labor and in order to reach the district hospital had to be transferred Health Systems as “Core Social Institutions” 101 first by boat for two days and then carried through the jungle on a stretcher for the better part of a third. The travel was made all the more treacherous by the landmines that are buried in that part of Chocó and the fact that guerilla and paramilitary operations did not respect standards of medical neutrality .7 By the time she arrived, Isabel’s child had died inside of her. A cesarean section was performed, but it was too late and Isabel passed away as well. When I asked the director of maternal health...


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MARC Record
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