On a recent call with a small health organization in rural Uganda, I asked the director about the C-section rate in the community. In some private maternity centers, this procedure is performed far more often than one might expect. I’ve learned that while this practice may be financially motivated, the extra fees also pay for staff and encourage doctors to maintain practices in these remote areas. This, in turn, keeps more pre- and post-natal care in those communities, including family planning and HIV care. For almost every “best practice” cost in global health care, there is a benefit. One of the fascinating aspects of my work is to discern those rationales.
My Ugandan counterpart responded, “Oh yes, our rates are high — and much more so now, because of COVID.”
Why, I wondered — is there a COVID safety issue or concern of maternal-fetal transmission?
“Ah no, no — it’s all the very young teenage girls having babies. You see, everyone is told to stay inside, and there is no food or work. And the young girls, well, they are hungry, so they go with the older men. Of course, birth is difficult at that age.”
His matter-of-fact words illuminated just one of the overwhelming number of ways that COVID disproportionally affects the disadvantaged among us.
So many health care problems begin as solutions to immediate and pressing issues. Poor kids sniff glue so they can stop feeling hungry and get some sleep. Diabetes arises from a low-income family’s need to get inexpensive food on the table. Child prostitution is one girl’s way to protect herself amidst daily threats of violence.
All of these topics — and many more — are readily acknowledged in the underserved communities where I work. By openly discussing their realities, our “less-developed” global neighbors have a better sense of how hard things really are for the victims of the COVID response. Problems can be explored, even if solutions are extremely complicated.
Back home in our United States, these intimate and visceral topics are taboo. We shy away from terms that create visions of harsh realities, replacing words like “rape” with “sexual assault,” “fat” with “high BMI,” “poor” with “disadvantaged.”
As a society, we’ve been conditioned to respond with an aversion to asking about and naming our communities’ darker truths. Is this due to shame? Our discomfort with such a profound lack of equality? The desire to hide our own struggles? And so, for lack of honest communication, we may never really know how many child pregnancies, lost educational opportunities, or desperate situations our neighbors have endured.
COVID-19 has torn apart the social safety nets that are an unseen benefit to people in every type of community. The burdens of isolation, separation from work and school, and decreased access to medical and social care make it is harder than ever for the struggling to be seen and for medical issues to come to light. As always, the disenfranchised must create their own solutions to the many challenges they face.
Medical providers have the honor and responsibility to ask intimate questions and address difficult medical truths. We already break many of the societal taboos of communication. As we address the fallout from the pandemic, I hope we can be community leaders, facilitating honest and straightforward conversations with both our patients and our neighbors about the ongoing health inequities we all witness in our life’s work.
Ann Messer is a family physician.
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