Infrastructural Violence and the Belizean Health System

The hospital in Punta Gorda Town, Belize
Photo by douglas reeser.

Views from the ANThill

by douglas reeser on January 19, 2013

Life in the southern Toledo District of Belize is full of contradictions. It has a tropical climate, and the beautiful geography of the Maya Mountains and the Caribbean Sea makes it an aesthetically pleasant place to live. There is a rich ethnic diversity in the district, and after a short time there, it often feels like everyone knows everyone else. This small-town rural feel and its distance from the more populous parts of the country have also served to insulate the district from most of the violence that has plagued larger cities in the north of the country.

Along with its rural location and low population density, however, the Toledo District has a fair amount of problems. Poverty rates in the district have historically hovered around 70%-75%, unemployment is usually over 20%, and jobs are always scarce. Additionally, there is a sense articulated by many of my research participants that the district is neglected in many ways by the State. Indeed, my research of the health system has revealed this perception to be a fair characterization.

The State has a National Health Insurance (NHI) program under which citizens typically make a small co-payment for most health services provided through the state-run clinics and hospitals. In the Toledo District, the co-pay has been waived, so that health services can be obtained for free. Despite this kind gesture from the State, there remain limitations to the services people have access to. In the understaffed clinics and hospital, there are only general practitioners available, and more serious health issues and emergencies require patients be transferred to a larger regional hospital that is about 3 hours away by vehicle.

For the most serious emergencies, there is a helicopter available to fly patients north; however, it first has to fly down to pick patients up, and is not always available. There is also an ambulance service at the hospital, although it is not always functioning. During my time in town, there have been two ambulances at the hospital, but only one that is ever running. The running ambulance – an older, used model from the U.S. – is constantly broken down and under repair. Often, the hospital must resort to renting a passenger van from a local bus company to handle emergency transports. Some patients are even sent north by bus.

This situation has presented quite a problem to the hospital administration. Due to a lack of supplies, equipment, and doctors, the transfer of patients is quite common, and it is not unusual for three or more transfers to occur in one day. In turn, the small crew of ambulance drivers is under a good deal of pressure and stress. They must drive old vehicles on a mostly un-lit, two-lane road dotted with small villages where the road is often crowded with adults and children. These pressures, in part due to the nature of the work, and in part due to the systemic reality of a health system under pressure, have resulted in the death of two ambulance drivers in the less than two years.

The most recent driver death occurred away from the workplace. While having a drink at a local bar, the driver met and began talking with a police officer from outside of the district. Reports say that the officer began beating the man in the bar, dragged him outside, and continued to beat him before throwing the man in the back of his pick-up truck and driving off. The driver was later found in a drainage ditch and was rushed to the hospital. Lacking the needed equipment and facilities, he was sent by air-ambulance to a second hospital in the north, where he passed away later that night.

The second driver death occurred just before I arrived in town, and was the topic of many conversations in my early days in the field. On his way to the larger regional hospital to the north, with a nurse and expectant mother as passengers in the back of the ambulance, the driver lost control of the vehicle and it flipped over into a river. The driver and nurse both passed, but miraculously, the mother survived and later gave birth. While an official version of the story was not released publicly, I was told by people very close to the event that the driver had asked to be sent home before this fateful trip. He was reporting a severe headache and needed his blood pressure medication. With an emergency on hand and no other drivers available, he was sent anyway. The expectant mother reportedly told my contacts that the driver had suddenly become unresponsive just before the ambulance went off the road. They suspect he had a heart attack.

These stories illustrate the violence of a system that is ill-equipped to carry out what it is charged to do. In a sense, they are a form of what Rodgers and O’Neill have recently defined as infrastructural violence (2012, Infrastructural violence: Introduction to the special issue). As an arm of the State, the public health system is a part of the nation’s infrastructure. Understaffed and without the proper equipment to deal with emergencies, and relatively isolated from the rest of the country, the health infrastructure in the Toledo District functions such that it produces intense social suffering.

The social suffering produced by the health infrastructure has been quite extreme, not only among those living in the community, but also among those that make up the infrastructure itself – the workers. The health infrastructure is such that people in the community are afraid to get sick or afraid to find themselves in a health emergency. Such sentiments imply that the health infrastructure is broken, yet the question arises whether infrastructure can be mended. While infrastructure by its nature can appear to be fixed, it is actually changeable, and can also be seen as a foundation upon which to build. By identifying and addressing the weaknesses of the health infrastructure, small changes and additions can allow for much social suffering to be alleviated.

This article also appeared in the January, 2013 edition of the American Anthropological Association's Anthropology News.