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Q&A: Filling the Gaps

November 22, 2005

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    Carlos Cardenas is Mercy Corps' director of health programs. Photo:

Carlos Cardenas started his medical career in the hospital emergency rooms of his native Peru. What he witnessed there horrified him: young women crowded the wards, sick and dying from misguided, borderline abusive treatments.

"The numbers were staggering," Cardenas recalls. "And in every case, you found that the root cause was some lack of knowledge or misconception about the most basic health issues."

Trained as an obstetrician, Cardenas began working with private, non-profit efforts to improve women's health education in the country. ("This was at a time when the government wasn't doing anything," he says.) Soon, he quit his doctor's practice to take on the pervasive health care problems of the developing world full-time.

Eighteen years later, Cardenas became director of Mercy Corps' health programs in April, 2005. Cardenas' three-person office coordinates a wide array of efforts around the world: training paramedics in remote Himalayan villages; monitoring children's health in rural Azerbaijan; setting up clinics in indigenous communities in Guatemala.

As the world wakes up to the ravages of HIV in Africa and the looming threat of an avian flu pandemic, it's clear that health care plays a crucial role both in developing individual communities and safeguarding global security. Cardenas took a few moments to talk about the guiding principles of Mercy Corps' worldwide health programs, tapping native healing traditions, and how medicine can open the door to dealing with many other issues.

Q: Carlos, Mercy Corps' disaster-response efforts really found themselves in the spotlight this year. By comparison, the agency's on-going health-care efforts maybe aren't as flashy. Can you tell me how health issues fit into Mercy Corps' mission?

Carlos Cardenas: Health is a critical component for the quality of life of the people we work with, and there are serious gaps in the health-care systems in most communities we work in. It wouldn't really make sense to work on other issues - whether it's economic development or civil society or whatever - without recognizing that health is a major issue in almost every case.

Sounds like you're saying that health issues fit into a broader context.

In my experience, health is a really good door-opener. It's hard to start a conversation about income levels when you don't know people. Let's say I barely know you, and the first thing I want to sit down and talk about is how much money you make, how you can improve your income and your professional life. You might say, well, that's not really something I want to talk about. But if it's how do we improve the health of your children, that's a discussion we can have, right? Once you have programs up and running for a year or two years, discussions about everything else become very easy.

Can you think of any examples where a health initiative has led to progress in other areas?

Indonesia springs to mind. There, we started talking about something called positive deviance. You find that 80 percent of the kids in a given community are malnourished. But 20 percent are not. So what's going on? You identify that 20 percent, you sit them down and you try to make those connections, so they can tell the other 80 percent what they're doing wrong. It's a long process, but it creates a sustainable and practical way to address other issues.

Water is another great example. Water and sanitation are maybe the most basic, fundamental issues we deal with in health interventions. You can go into a community where there are lots of problems, lots of divisions - I mean, real nightmare scenarios - and say, hey, what if we did some work to improve your water? You find that most differences go away. So you can use that one issue as a foundation, because as you solve water problems, trust builds.

You mentioned "gaps" in health care systems around the world. Can you elaborate?

In most countries we work in, there's a huge gap between the urban and rural communities. In urban areas, you can look at just about every health indicator and see huge improvements in the last ten years. You see that in child mortality, in vaccination rates, just about everything. But it's a very different picture in rural areas. So why is there this huge gap? And when you start to answer that question, you start to get into the issues that provide the framework, I guess, for most of the work we do.

A framework? Can you flesh that out a bit?

There's simple availability - are needed services even available in that region or country? And issues of access, which can be very different. Maybe there is actually a health station or clinic very near to where we're working, but for some reason people can't access it. It might be an issue of language or of culture, or simple affordability and transportation. And finally, people might not be using services that are actually available and accessible. Let's say you have a woman who's six months pregnant, and she's bleeding. Any woman you or I know would be on the phone in five minutes, and in the hospital immediately. But if she doesn't know any better, maybe she thinks, well, I guess this is how it goes.

How do you begin addressing those issues?

In nine out of 10 cases, we're talking about very basic, primary health care needs. These are not things that require very complex health infrastructures, so a community can take a lot of action in a short time. If it's something like vaccination, obviously that has to come in from outside. But often it's a matter of setting up a community organization that just wasn't there before—like organizing a stretcher team, or a rotation of people who will be on call if someone needs to make the eight-hour walk to the clinic, whatever it might be.

To what extent is education a piece of that?

In just about 100 percent of our projects, you encounter some lack of knowledge or misconception surrounding a critical health issue.

If that's the case, do you run into conflicts with traditional healing methods, or are you able to tap into traditional resources and skills?

Oh, you have to do that. Maybe you have to give it a little twist to address the misconceptions—or more typically a lack of current information—that may be hindering them.

A really good example is maternal health. In most communities, in whatever country, you'll find there's someone who fulfills the role of a traditional birth attendant. That may not be what the people in that community call her, but there is almost always a woman who plays a role in delivering children. Maybe she's been doing it for 30 years, maybe she learned it from her mother. But maybe some parts of her practice aren't good. What do you do? Do you go tell her that she's fired, and that her practice is finished? Or do you try to incorporate her into the solution?

And it would seem, looking over the various health project Mercy Corps engages in around the world, that those people often end up playing a pretty key role.

Absolutely. Even if we had 10 times the budget that we actually have, our direct contribution on a broad scale is going to be a drop in the bucket. We have to use the resources available to us from our donors to build projects that can scale up. The crucial thing is to find partners who can do the scaling—and who can expand things after we are gone or beyond the immediate area we're working in. We try to find the kind of models, whether it's a training technique or a specific educational strategy, that work, so our partners in those countries don't waste their time.