I am writing from the Island of Brava, in Cape Verde, where I worked for a week with a great little organization called Project Health CV, which brings American volunteers to Cape Verde a few times a year to augment the health care that people in Cape Verde get from the government and the tiny private healthcare sector.
The similarities and the differences in health care between Cape Verde and here are striking. Cape Verde is an island nation of 550,000 people living on ten Islands in the Atlantic, off the coast of Senegal, so just more than half the population of Rhode Island. It was uninhabited until it was colonized by Portugal in 1462, and was then used as a way station in the whaling industry and the slave trade, and has people of both African and Portuguese descent. It won its independence from Portugal in 1975, after a revolutionary movement in Guinea-Bissau and Cape Verde led by an anti-colonialist revolutionary named Amilcar Cabral, who was assassinated before both places became independent of Portugal, and the fall of dictatorship in Portugal, in 1974.
Both Rhode Island and Massachusetts have large Cape Verdean populations, probably because whaling captains recruited sailors in Cape Verde on their stops there and brought them to New Bedford. Cape Verde is one of the better-off African nations, but it is by no means wealthy: the average annual salary is about $2100 a year, and many people live in poverty. Many people on Brava have family in New England or spend time here and some are English speaking, but most people who live on Brava are Creole speaking.
Brava, population about 5600, is the smallest and least accessible Cape Verdean Island. It is just over half the size of Aquidneck Island but is intensely mountainous, so it is hard to travel from place to place. There is no airstrip. There is no easy way to get to Brava from other islands: a ferry runs two or three times a week but is unreliable — it is frequently broken or can’t run because of rough seas. The population of Cape Verdeans in Rhode Island is about 20,000, half of whom live in Pawtucket and Central Falls – the population of people who live in Rhode Island and are descended from people born on Brava is thought to be greater than the current population of Brava itself.
First the differences: the life expectancy of people in Cape Verde is 73.2 years — five years shorter than the life expectancy of people in Rhode Island. The infant mortality rate is 9.2 per 1000 live births, about twice the rate in Rhode Island (4.8). Most people walk from place to place or take little buses. There is a Health Department and five small health centers staffed by one Cape Verdean and two Cuban doctors, nurses, one psychologist and other health workers, but no dentist, no optometrist, and no way to get glasses on the island. The Health Department has a laboratory and a pharmacy. There is one private pharmacy on the island. People can stay overnight in the Health Department when absolutely necessary but all that they can get is fluid and medication by vein and some oxygen, of which there is a limited supply. There is a simple x-ray machine but it is often broken, but no operating room. Babies are sometimes delivered there but most pregnant women go to another island to deliver.
There are many stories on Brava of people who died because they couldn’t get off island for emergency treatment, or died on a ferry, or died at the health department without explanation or because there isn’t enough expertise or capability to treat emergent life-threatening illness. The hospitals on the next island are also limited in terms of what they can do. There is a very limited formulary – just a few drugs but a good range of medications. But essentially no medical record at all. No one can look up what medication you are on or when you were treated last and by whom, at least at the Health Department, although nurses and other staff sometimes maintain their own records at the smaller health centers, which help take care of people in some of the harder to reach communities.
Now for some similarities: there’s lots of mental illness – lots of anxiety and depression in both adults and teenagers. Lots of obesity and high blood pressure, from too much junk food and too little exercise in both countries. Neither country has a usable electronic medical record for everyone who lives there. (In Brava, there is no medical record at all, on paper or in the cloud, which makes medical care tricky. In the US, hospitals have records and doctors have records but these records often don’t talk to one another, and people who don’t go to either doctor or hospital have no medical record at all.) Neither country has a well-organized system for maternity care that makes sure women can deliver babies safely near home. (Newport, for the moment, is an exception.) And both countries governments have failed to take responsibility to provide good health care for everyone.
One of my colleagues on the trip to Brava was French and was heartbroken when she saw how few medical and health care resources there are for people in Brava compared to what she was used to in France. The European and American governments should step up, and fix this for developing nations, she said. Wrong, I thought. Health care is a responsibility of nations, for their own citizens. You can’t fix health care from the outside. You can’t fix anything by pouring in resources, because if you try, those resources will be diverted or wasted, human nature being what it is. (There is a story that a foreign government once sent a million dollars to build a new hospital on Brava, money that somehow disappeared. I don’t know if that is true or not. But I do know that you can only fix health care when people organize themselves to provide health care for themselves, and demand more from their government.)
People in both countries think that “someone should do something “ –- but don’t act to do something for themselves. That’s crazy. The only way to fix health care is when people organize themselves and fix it themselves, and quit waiting for some foreign volunteers or some congress or legislature to fix it. They won’t. We can. If and when we step up.
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