Here in Uganda, we’ve finally left the rainy season behind us. We still get occasional cooler, overcast days with interspersed showers but a few weeks ago it was like clockwork:
Wake up to raindrops slashing the windowpanes and drumming on rooftops…
Get ready for the day, pack a rag to wipe rain and clay from my shoes post-commute…
Set out on the 15-minute walk to work beneath a big green-and-white umbrella…
Choose between rocks and mud.
Let me explain that last step in my morning routine. Street-side paths and unpaved roads turn into to a thick red paste when it rains. With a couple of hasty paces, the slippery mess will take you down. And forget about keeping clean—that mud is bound and determined to cake itself onto your shoes and maybe feet or ankles, layer by layer with every step. It also won’t hesitate to splatter onto your clothes or bag if given the chance. But most paths are also littered with rough rocks and roots which can offer you some traction. If it wasn’t for their impressive capacity for dismantling shoe soles, this would be the obvious strategy to follow (case in point: I have laid to rest three pairs of shoes in just 11 months and two more are barely hanging on). So it all comes down to a choice between rocks and mud—rocks provide short-term comforts of dryer and cleaner feet but often lead to long-term damage that may be irreversible, and mud brings an immediate mess that’s inconvenient for a bit, but probably won’t detract from the overall life of my shoes.
Why am I talking about this anyway? Well, I started thinking about this choice between acting for short-term convenience or planning for long-term sustainability underneath my umbrella one morning. At that moment, millions of low-income families in Uganda, the U.S., and around the world were making the same “short-term vs. long-term” choice about something far more consequential than shoes. They struggle to access appropriate and timely healthcare due to insufficient finances, insurance coverage, infrastructure, or transportation to reach a facility. Even if they feel their need for medical attention, maybe their money is already demanded by school fees, a family wedding or burial, home repairs, and food. And perhaps their time is already divided between raising children, finding and keeping a job, collecting water or firewood, earning a degree, and running a farm or a home.
There are over a billion people in our global community whose limited resources have them stuck in the hard spot of choosing between rocks and mud when it comes to their own health. Choosing to step in the mud might mean enduring a painfully tight budget for the sake of gaining an immunization or a prescribed medication, but would hopefully lead to avoiding irreversible damage later on. It’s never a guarantee, though—which leads most people in this situation to choose the immediate convenience, or the rocks. Poverty prevents them from making future-facing choices because they literally can’t afford it. This may mean ignoring the root cause of a nagging cough, adding another spoonful of honey to the tea to temporarily dull the pain… until it returns with more intensity and serious implications days or weeks later.
This dilemma of choosing between a “somewhat risky” option and an “even riskier” option is just one example of how health inequity plays out. Infectious disease/HIV expert Dr. Michael Saag provides many more examples, especially from the perspective of the U.S. healthcare system, in his new book Positive. He notes that lower income and less educated patients often show up for care “much later in the course of their illnesses. Because these folks avoid seeking medical care for as long as they can, the severity of their condition is striking… ulcers are bigger, heart failure more severe, tumors more advanced. Patients come late for all kinds of reasons: the hassle of getting off work or finding transportation, no primary care physician to refer them, no habit within their family of [preventive care].” Returning to the context of Uganda, the WHO reports that this year in its African region, 70% of all years of life lost are due to infectious diseases and maternal, neonatal, and nutritional causes. In high-income countries these account for only 8% of all years lost… because these countries can afford to focus on prevention.
The unfortunate truth here is that prevention is a privilege. Even though it also comes with some uncertainties, it’s a privilege to choose the mud over the rocks, to face the brief inconvenience of sitting in the doctor’s office waiting room for a check-up, to have a sore arm from getting a vaccine or to pay for an easily accessible drug before symptoms become severe. As global health equity advances, I’m optimistic that we’re slowly moving toward a system that provides more options, more assurance than the choice between mud and rocks. Even though right now we’re still feeling the effects of a rainy season, it’s wonderful to be a part of a movement that will really shine when the sun comes out.