Clean, well-equipped and free: health care during the revolutionary struggle
“Phu hang mii bo khaw khuk, phuu thuk bo khaw hoong mo” (the rich don’t go to prison, and the poor don’t go to hospital). Hung mentioned this saying as we walked towards his mother’s village. I had hired Hung that day to take me to some villages not accessible by road, and as we walked, he explained his perspective on poverty and the state in Laos. Hung lives in Vieng Say town, but he said that he could not afford to go to the hospital when sick: it simply cost too much. He has four school age children, and he must pay 60 000 kip per child each year just for tuition. As a farmer with no cash income other than the sale of rice, this cost alone tests his ability to find money. He said he certainly couldn’t afford for them to study outside the public system: for instance to take language lessons, or specialized skills courses. As a result, he feared that they would not be able to secure good jobs. And anyway, he continued, even if the children study very well and to a high level, he felt that all the good jobs and the university places go to the children of those in power. From Hung’s perspective, the rich may avail themselves of state services such as roads, schools, and hospitals. The poor rarely have the cash to make full use of these. But in addition, the rich rarely suffer in prisons, undergo the discipline of blame-based “development” projects, or are required to participate in resettlement programs: such “state services” are reserved for the poor. In sum, the rich don’t go to prison, and the poor don’t go to hospital.
When we reached Hung’s mother’s village, we found her squatting outside her home: a wood and thatch construction with a dirt floor. She is over eighty years old, and she is developing a goiter at the base of her throat. During our entire visit she carried her two-year-old grandchild strapped to her back. As my eyes adjusted to the dim light inside her home, I saw that a body was lying underneath bed covers in the corner. “Is someone sick?” I asked Hung. He seemed surprised, and spoke to his mother. She explained that she had taken in two grandchildren, a boy and a girl. Their mother (Hung’s sister) had died, and now the two teenagers were sick. They had come to live with her, because they had no one else to care for them during their illness. They had had a fever and cough for over ten days. Both of them lay prone, seemingly unable to move. The boy at one point managed to take some water and paracetamol, and later some food, but apparently with great effort. The girl did not move when we were there. Hung explained that they couldn’t go to the hospital because they are not strong enough to walk. It might be possible to hire a vehicle to pick them up, he said, but the dirt track is not a regular road, and the driver would charge a great deal. When I offered to pay, Hung declined by saying that even if they could go to the hospital, they could not afford the services there. It would cost 2 million kip (200 USD) to heal the two, he estimated. This is beyond even my budget. “It is just as I told you,” Hung reaffirmed, “The rich don’t go to prison, and the poor don’t go to hospital.”
It should be noted that Hung’s mother’s village is a resettlement village. The Hmong residents were relocated here over ten years ago. They have been allocated some “naa huay” (fields by streams), forest and upland fields. A village forestry plan was displayed on a board in the village, signed by the Mennonites (MCC). The board designated which lands can be used for forestry, for rice fields, and which must be retained as jungle. The resettlement of upland minorities has been part of LPDR policy since 1975. The policy has been justified by portrayals of upland agriculture as wasteful, destructive, inefficient and often illicit (when opium is involved). Resettlement projects attempt to assist these these minorities by moving them closer to government services (especially roads) and have them engage in wet-rice or cash crop cultivation.
A vocal section of international development professionals working in Laos have been arguing for some time that the resettlement programs, in tandem with rural development efforts, are creating poverty and aggravating forest degradation. They argue that resettlement has led to policy-induced poverty (Rigg 2006 provides a summary of this position, see also Chamberlain’s Participatory Poverty Appraisal and the report Aiding or Abetting by Baird and Shoemaker). Resettlement projects can be interpreted as an archetypal blame-based development intervention. In the name of poverty reduction and forest conservation, shifting cultivators are required to relinquish their traditional lifestyles and farming methods, settle closer to schools, roads, medical facilities and government workers, and to farm only in designated areas. Yet this had been repeatedly documented to result for many in lower yields and land degradation: in effect, poverty exacerbation.
But a focus on yields overlooks the aesthetics of poverty, the way poverty is often associated with certain kinds of activities or appearances, regardless of the actual profitability involved. Certain activities become stigmatized as poor. It is well-recognized, for instance, that cleaners in Australia earn more than many office workers per hour, but the industry nevertheless attracts less status. I suggest that for at least some Lao, upland shifting agriculture carries such a stigma. Regardless of the yields involved, it is perceived as a poorer activity than wet-rice agriculture. It can be speculated that international development workers, not sharing this particular aesthetics of poverty, instead perceive resettled people as being moved unnecessarily from one form of poverty to another, often worse, form.
The Hmong I spoke to in and around Vieng Say had expressed little opposition to living closer to services, or farming wet rice: many expressed a strong and explicit desire to engage in wet-rice cultivation and use services such as hospitals. None of them expressed what might be called a cultural aversion to such activities. Several that I met were indeed now strikingly successful lowland farmers, marketing their produce in Vieng Say. But I was repeatedly told that they felt constrained by structural forces, such as scarce wet rice paddies, inadequate market for their produce, and insufficient income to pay for the government services available. They were not opposed to resettlement, but they were opposed to their unequal access to income, land and services once resettled. It is possible that resource distribution, not resettlement, is the real issue of concern. This is most strikingly apparent in health care.
At present the poor, and even moderately well off people, feel excluded from the health care system because of the “pay as you use” system. Residents explained that usually when visiting a hospital payments must be made upfront before each item used – whether this is a bandage, a needle, rubber gloves for the health care provider, medicines or ointments. This requirement of upfront payments has instilled a sense of fear and uncertainty among the poor. They cannot be sure in advance if they will be required to pay $5 or $50 for treatment. Many people I spoke to in Vieng Say were under the impression that they would be required to pay hundreds of US dollars if they sought treatment at the local hospital.
Staff at Vieng Say hospital assured me that most treatments were not so expensive, but they agreed that the cost of the treatment varied depending on the situation, and they could not guarantee in advance a certain price. They also confirmed that many people did not seek treatment at the hospital even when they were very ill. Staff speculated that this arose from ignorance. I should clarify here that Vieng Say’s “hospital” is more aptly termed a clinic. There is one doctor who works on the premises, though during both of my visits he was not present. I did meet his assistant, a “nurse” who admitted he had learnt his trade on the job without any formal training. The clinic’s string of six, small rooms held basic furniture and no visible equipment.
It would be a mistake to view this understaffed, underequipped, and expensive health care system as a first step along a progressive road to improvement. Health care was free for many residents of Vieng Say until 1989. The large old hospital still stands, several kilometers out of Vieng Say town. This 46-room hospital was built with generous support from the Cuban government, and was also staffed partly by Cuban medical professionals. It stands outside the “hospital cave”, where the hospital was located during the U.S. air war. The Director of the Kaysone Phomvinhan Memorial Office describes this as, “the most beautiful of all the caves.” On the main entry to the hospital cave are written the words “Care for those in pain”: noble sentiments indeed. The great cavern inside could hold up to 500 patients. In a cave opposite was a training school for doctors and nurses. There were so many medical professionals that one former patient describes there being, “one doctor for every two patients.” Another cave housed a factory for producing medicine.
The hospital cave today has been gutted. The roofing, wooden support beams, and metal fittings have been looted, porcelain and glass items smashed. Scrap metal hunters have chipped into the wall and floors of the cave and outside hospital. Broken glass phials and test tubes lie scattered under foot. There is little sign now of the sophisticated equipment, trained professionals, and free health care that once animated this place. In all fairness, it must be admitted that the capital of Laos, and with it the best health care in the country, is now found in Vientiane, not Vieng Say. But the visual contrast is still striking. The hospital cave, and the old Cuban hospital building – now so disheveled and abandoned – stand as reminders of a noble ideal that has also been seemingly looted and abandoned.
Paul Farmer, a medical anthropologist, has argued that denial of health care is a form of violence, what he calls “structural violence”. He uses evidence from Haiti to argue that inequalities in health care provision inflict injuries on the poor just as surely as outright physical assault. He argues that cultures of “blame” – depicting the poor as ignorant or culturally incapable of engaging with modern health practices – allows a misrecognition of this structural violence as actually arising from the bad behaviour of the exotic other.
The saying that Hung reiterates – the rich don’t go to prison, and the poor don’t go to hospital – rejects this blame. It is not that the poor are ignorant or reluctant to seek medical care at the hospital, or make use of other lowland assets and services. It is simply that the poor recognize that they are effectively barred from real participation in beneficent state services. Health care is no longer free, and along with all the other products available in the marketplace, commodified health care is most available to the rich, and most restricted for the poor. The image of the poor’s exclusion from the hospital evokes the general feeling of exclusion from state services and the benefits of lowland lifestyles. The saying goes further: it aligns the poor’s disproportionate exclusion from health care with their disproportionate inclusion in prisons, the symbol of the state’s ultimate recourse to violence and repression. The saying is suggestive of how the poor are included in repressive state services while they are excluded from beneficial ones. The saying, then, encapsulates the multiple violences that intersect in the bodies of the poor, and how these are mediated by the multiple faces of the state.