I just finished reading the chapter of Jeffrey Sachs’ book, The End of Poverty, in which he discusses the idea of “clinical economics,” and his ideas resonated deeply with the reactions I’ve been having to my immersion in the rural community of Bukeye, Burundi.
The essence of “clinical economics” is the idea that the world of development economics could benefit from an overhaul that would align its practices more closely to those of the thorough and deep diagnostic process associated with clinical medicine. Sachs suggests that the afflictions of a human body and an economic system can be analyzed in a similar fashion, and implies that the failure to examine economic problems in such a way can have devastating consequences for the populations involved—just as a doctor’s incomplete surface diagnosis of a patient can lead to larger health problems for that individual down the line. He argues that perception among development practitioners regarding the gravity of their profession also stands to be elevated.
Sachs’ ideas help me to contextualize the intersection between economic development and public health that I’ve been witnessing in Bukeye, where I’m helping my placement organization to prepare for the establishment of a health center. Over the past few months, my co-fellow and I have conducted a series of focus groups with community leaders in nearby villages and interviews with staff members at other health centers in the vicinity in order to catalogue the resources for healthcare currently available (or lacking) in the area, and our sometimes surprising findings have led the process to feel like an investigation at moments.
For example, there is a health center in the middle of Bukeye in a central and accessible location, managed by qualified and dedicated group, offering a relatively inexpensive rate for a consultation with a nurse and a higher but not unreasonable rate for a consultation with a medical doctor (the only MD in the area). We were understandably stumped to discover that beds at this health center are often empty and that many community members are choosing to walk a much greater distance to a facility in another commune when they need care.
However, in our focus groups we learned that the reason for this preference is not about an untruth in any of the factors above, but about associated costs that we hadn’t considered: the price of medicines and the cost of any extended hospitalization, both of which are very high at this particular health center—prohibitively so for the majority of the local population.
The theory of “clinical economics” reminds me that the solution to this problem is not to simply find a way to subsidize lower-cost medications and hospitalization at this health center—though there’s no doubt that such a move would benefit many, at least initially—but to pull out a doctor’s clipboard and trace the steps backwards: family history, system interactions, risk factors, etc. The challenges indicated by the pricing at this health center are rooted in a myriad of structural and systemic problems: high transport costs for medications along dangerous and sometimes low quality roads because pharmaceuticals must be supplied from distribution hubs at least 40 minutes away, due to a shortage of pharmacists in the country’ rural areas; frequent stock-outs at those pharmacies even when they can be accessed; unwillingness to offer certain government programs for free care because of long tag time in receipt of reimbursement from the Ministry of Public Health, plagued by its own funding challenges; and the need to fill a perpetual budget deficit because of the large number of patients who are unable to pay at all, due in part to the high percentage of subsistence farmers handling little to no cash in a year. And there are, of course, many other causes. At their roots, though, even these issues can be traced further down to gaps in governance, education, infrastructure, etc.—which perhaps makes this problem too large for one NGO to solve, but shows us what we’re up against and allows us to consider these issues knowingly as we plan our coordination with the government and the local community moving forward.
In truth, the diagnosis (or lack thereof) of every medical patient in Bukeye is, in some way, inherently linked to a deeper malady rooted in development economics—and that’s a thought process that we ought to consider. I was grateful for the reminder.