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Student Notebook

Global citizenship

By Stanley J. Weinberger III, M.D.

In his book Pathologies of Power, Dr. Paul Farmer explains a concept that he calls "structural violence." What he means by the term are the social inequalities, lack of economic opportunities, and activities of oppressive states that influence the "nature and distribution of extreme suffering." Structural violence robs people of the freedom to satisfy hunger, to obtain remedies for treatable illnesses, or to be adequately clothed and sheltered. Farmer concludes that suffering in the form of poverty, human rights violations, and disease disproportionately affect the powerless. These inequities are especially relevant to physicians, and Farmer's lifework has been devoted to helping direct health services to the poor.

Many other doctors and even medical students are striving to provide such services in impoverished regions of the world. But how can we be sure that we are doing it well? Recently, I visited Nicaragua, one of the poorest countries in the Western Hemisphere, as part of Dartmouth College's Cross-Cultural Education and Service Program. Our group of doctors, faculty members, medical students, and undergraduates headed to the small communities of Hormiguero and Santa Rosa, near Siuna, a town of about 11,000 people that lies in the poor and long-neglected North Atlantic Autonomous Region.

Machete: We flew by jet from the United States to Managua, Nicaragua's capital, and from there in a small propeller plane to Siuna. Soon after we landed in Siuna, we were bouncing along in the back of a hulking Russian truck to the clinic in Hormiguero. Our work began the moment we pulled in. Our first patient arrived immediately, then two more. They had been in a machete fight and had walked five hours to get to our clinic. If we had not been there, they would have walked on to Siuna. Night was falling and nothing was unpacked, but everyone pitched in, doing his or her best by flashlight.

This part of our work involved direct patient care—and Farmer would argue that relief of current suffering is important. But we were only treating the symptoms.

Our group headed to the small communities of Hormiguero and Santa Rosa, in a poor and long-neglected part of Nicaragua.

Why had the fight happened in the first place? Later on we were able to piece together a story involving abuse, emotional instability, and alcohol. Without systemic changes, this story is bound to repeat itself.

The second part of our work was to conduct a survey with Egdomelia Inez, the community health worker in Santa Rosa, helping her evaluate a comprehensive development project. During this part of the program we were looking at intermediate outcomes—things that influence health, such as sanitation, food production, and education—as well as at the ultimate outcome of the citizenry's health status.

Even though houses in the region were separated by up to an hour's hike on rough dirt trails, the sense of community in Santa Rosa was palpable. The houses, most of them just one room, were made of wood. Some had thatch roofs, some tin. Some were on stilts, some had dirt floors. Most had open-air, open- fire pits for cooking. We asked probing questions, played with the children, and then tried to weigh and measure the kids.

Profound: We were working under the direction of Don Inez, Egdomelia's husband and Santa Rosa's elected community leader. Being in the position for the past five years had made such demands on his time that he and his wife and their six children were poorer than

most of their neighbors. One of us asked, "Why do you do it?" He replied that he did it for his children—so that their community and their opportunities would be better and so that they would see how to improve their situation. It was a simple decision and yet one clearly buttressed by deep understanding.

This understanding and dedication surfaced again in our publichealth seminars, the third part of our work. I had arrived in Nicaragua feeling cynical and unenthusiastic about this part of our program. We were supposed to teach two-day seminars on maternal and infant health to local community leaders and midwives. They came from villages that were up to an eight-hour walk away, and they astounded us with their questions and attentiveness. We questioned them back. At the end of the day, they remained, copying word for word the posters we had made.

We then hosted a small community health fair, where those leaders taught what they had just learned. The results were better than we could have imagined. Over and over again, the leaders repeated how important this education was and how grateful and excited they were. It was one of the most profound moments of the trip for me.

Healing: Upon our departure, as the plane rumbled and skidded down the runway in Siuna, I thought about what we had done. We had made connections, however brief. We had participated in healing, even though we may not have changed the ultimate outcomes. We had helped to lay the groundwork for future improvements. I hope Farmer would agree with these conclusions.

I also thought about what one of the villagers had asked us: "Does it make you happy or sad to be here?" I thought, on the one hand, of the malnourished children I had seen in the clinic, but, on the other hand, of the smiling and proud community leaders after the health fair. No one word could sum up all the feelings I had as we soared up into the clouds. And I feel certain that my time in Nicaragua would have been wasted if, in my soul, I had felt any other way.

The "Student Notebook" essay shares word of the activities or opinions of students and trainees. Weinberger graduated in 1998 from Dartmouth College and in June 2005 from Dartmouth Medical School, where he was the recipient of a Syvertsen Fellowship. He also holds a master's of science degree from Dartmouth's Center for the Evaluative Clinical Sciences. He began his residency in pediatrics in July, at the University of Minnesota in Minneapolis, and he hopes to continue doing international and public health work.

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