Invisible Heroes: Rural Health Care Providers

Without a doubt, the single most recognized member of the community in small villages is the rural doctor. While there are rural physicians who commute to the villages regularly during the week and lend their services a little in spite of themselves, most rural doctors who work in small remote communities, do so consciously as a result of their commitment to the profession and their neighbors. Health care providers are indispensable not only because they cure and prevent disease, they are important because they have the intelligence, ability and leverage necessary to transform  their communities, whether this be by creating centers for villagers of special needs, acquiring hard to come-by medicine or equipment for the local health facility, or simply by being there when they are needed to provide comfort and security for the weak and sickly. They are brilliant entrepreneurs, with a heart.

What They Do

Doctors, sanitary agents, and nurses tend to work on a fixed schedule, while specialty doctors such as children’s doctors, eye doctors, therapists, kinesiologists and dentists commute and staff the local health center at least once a week. While in rural villages with standard population pyramids, the demand is for the services of doctors and nurses to vaccinate and control newborns and young children, in villages with inverted population pyramids the focus is in the care of the elderly. Some of these villages even offer small-scale geriatric housing services for those who can no longer live by themselves, those who don’t have a family or those whose families live far.

Doctors are revered. Even many years after they are gone, doctors, pharmacists and midwives stay in the minds of the older generation with affection and melancholy. Why? They brought virtually everybody there to life and saved many when nobody else was near. Back in the day, they were among the few who had access to means of transportation, and lent them selflessly whenever the need arose.

What Needs to be Addressed

For all their importance locally, I have been always received with a mix of curiosity and anxiety that I suspect, has a little to do with the sense of urgency that surrounds health care provision in rural villages. These professionals are often community referents and find interest from the “outside world”, be it from politicians, NGOs, religious groups or other non-profits, an important factor toward potentially channeling outside much-needed attention and resources into their communities. The Argentine Asociation of Rural Medicine goes further by outlining a specific policy agenda for the coming years based on their specific needs. I was fortunate enough to interview its then president, Dr. Arturo Serrano on one of my travels to the province of Santa Fe.

Rural Health Center in Santiago del Estero

Rural doctors are crusaders, with some villages counting on the services of one, for a population of over four thousand. In most villages, the situation is less critical. According to Dr. Serrano, villages face a lack not only of qualified professionals willing to lend their services in remote areas given harsh living conditions, but also a lack of the equipment necessary to attend to the specific needs of villagers, and an all around absence in public policy at the national and provincial level focused on retaining qualified doctors and health care providers. There are other problems, such as insufficient or inappropriate supply of medicine that sometimes gets caught in the middle of cross party politics and personal antipathies, although to a lesser degree, than do funds that go towards investment and infrastructure development.

All in all, doctors, as the most celebrated referents in rural villages, need greater attention, and would be one of the most efficient and effective channels through which to funnel resources.

The Costs of Isolation in Rural Villages

ArgeDirt Roads Complicate Access to Some Villagesntina is the eight largest country in surface area, yet unlike many nations of comparable extension, it is also a megacephalic state. This means that roughly one-third of the country´s population lives in Buenos Aires City or in the Province of Buenos Aires, and nearly three fifths or more in large urban centers. This is bad news for the thousands scarcely populated  rural villages scattered through its vast territory, because it means that they are physically isolated from the largest national urban centers, and only a select few are blessed with a medium-sized city less than a few miles away.

Not to say being away from civilization doesn’t have its charms; remote locations have their benefits, especially for city-dwellers who want to retire and spend a weekend in touch with mother nature, away from the stress of city routine and office work. But for the inhabitants of the villages, living far from a city more often translates into additional costs, including paying premiums on goods and services, taking discounts on the payments they receive, seeing relatives and friends far away less often, and sometimes putting their lives at risk in emergency situations or when the weather is foul.

Increased Costs

Added economic stress in the form of farther distances may be the most obvious contender in the battlefield of reasons why being isolated is bad for a rural village, and it takes more forms than is apparent to the naked eye: Being far means often having to pay the cost of transportation to travel to larger towns. Taxis are expensive and in some regions prohibitive for the average cost of living in rural areas. Carpooling is common. Traveling to distant urban centers is necessary, not only to acquire manufactures, which may not be available in the local market, but also to receive retirement payments, social security benefits, social pensions, or pay for services like gas, electricity, telephone and even internet.

The increased distance also means factoring transportation costs for the products that are sold within the village, and the creation of a speculative market of price setting that makes acquiring the most basic staples an added challenge in meeting daily expenses for the less wealthy, especially because, in such small villages there are often monopolies of butchers, grocery stores, supermarkets, drug stores and such. The roads and paths to the nearest urban or semi urban center may not be paved which may quickly deteriorate the means of transportation that are available to the villagers, resulting in additional maintenance costs for scarce durable goods like cars, bikes or vans. Acquiring medicine or transporting the sick to the nearest town is also a hardship and, in emergency situations, reaching a medium complexity hospital in less than thirty minutes may be the difference between life or death since rural hospitals or health centers are often minimally equipped and provide only the most rudimentary health services.

Attitudes and Politics

Isolation is however not recognized directly by villagers as an evil in itself. Many of them are enamored with living away from the crime and insanity of urban centers. Add to this the fact that the actual monetary costs may not be apparent on a cursory look. In addition, knowing no other reality, costs may be taken to be the natural result of living in their place of birth, much in the way citizens of corrupt and inefficient countries develop tolerance for bad service and invisible added transaction costs in routine operations. But the problem, just as the problem in those countries, is real, and its costs quantifiable. Isolation brings many other problems that are less apparent. Being far is often coupled in the poorest provinces with lacking a voice in decisions that affect the daily lives of villagers. Being far and disconnected means being invisible to the people who make decisions, and to those who can hold them accountable. Depending on the type of political representation set forth to the villages by provincial constitutions – a factor that often depends in theory with their population size, and in practice with other factors such as political goodwill, favoritism and dirty politics- the degree of actual representation of these people varies greatly. Isolated, poor and silent, many villages have not seen public works within their territories in many years.

A Long-standing Problem and Poor Planning

The problem of isolation in rural Argentina is a result of a gradual process of disinvestment and replacement of railroads as means of cargo transport with paved roads and trucks. The problem is that the design of many roads and highways, where those were created, often overlooked the importance of traversing small villages, worsening their state of isolation in many cases. Establishment of industrial centers close to the roads and gas pipelines far from the villages often worsened the problem as employment prospects tend to be better in places where the necessary infrastructure is set and not close to the villages.

These are the costs of isolation, a factor which at first glance appears to be inversely correlated with the degree of development and standard of living in many villages. Tackling the problem accepts many solutions which could include a rethinking road infrastructure works, gas pipelines, and the reactivation of the railway system, which would be a cost efficient solution in the sense that many of the villages that are isolated today were born as stations for cargo loading and unloading and bringing railroads back to life would connect many villages, quickly. The problem of isolation in terms of connection to media such as the internet, cable tv, or phone services may be seen as different from that of geographic separation, but compounds the problem of isolation of many of these villages, where cell phone signals reach only treasured and seemingly arbitrary hot spots in the middle of the street, and where having cable tv is expensive given living standards.

A comprehensive development strategy for rural villages should pay attention to the costs of isolation. The solutions require long term planning and investment, and the involvement of higher spheres of policymakers. But the costs merit the immediate attention of those in power to provide solutions or discuss alternatives.

Rural Youth: Overcoming Apathy, Creating Opportunity

Rural Youth Recreational ActivityMaking generalizations when it comes to the social profile of rural youth in Argentina is problematic. Social conditions, infrastructure and opportunities differ vastly among regions, and within regions the degree of isolation of each village has implications that affect the reality of young people in different ways. In many villages, those below eighteen years of age comprise more than half of the total population. Youth in those villages typically have access to the least resources and opportunities. Families of six or more people rarely have sufficient income to cover much beyond the basic needs of the children, and this impacts the local economy as well. But in other villages, especially those with higher development indexes, chances of advancement for the younger generation are not scarce. Work and recreational opportunities as well as social clubs and organized activities help keep them engaged and active within their communities. But again, while in some villages youth are met with a wealth of opportunities for community involvement and recreation, in others there is only one sport to play, one social activity to participate in, or one festival, once a year.

Basic Formal Education, a Problem?

Even when generalizations are difficult to make, a few common trends emerge. First, youth in rural Argentina are schooled within the village or in adjacent villages for as long as they can until they finish secondary school. Attrition in primary school is null or near null in most communities, but once youth reaches secondary school the picture is different. In some schools, secondary school attrition is brutal, near or above fifty percent of total enrollment in any given year. The problem is particularly acute, it seems, for those students housed in residency complexes within the villages, who come from neighboring localities. Difficulties adapting to living far from home at such a young age, and longing to be with their families during the week, complicate their chances for obtaining a high school diploma at the end of the four, five or sometimes six year run.

Another common trend, presumably proportional to the degree of development in rural villages – and perhaps an interesting area for further inquiry-, is that students who leave school, or those who struggle most, do so for lack of accompaniment at home, either because parents didn´t receive formal education, or because education is not understood as important within families. Even when primary responsibility for formal training falls in the shoulders of the school system, the families of first generation school youth seem to be more absent and encourage less an active role on the part of the student, resulting in lesser committed and, confronted to academic challenges, more easily defeated young people.

To Leave or to Stay

Those students who finish high school, typically choose one of three paths: The most fortunate advance their studies, commonly in neighboring urban centers. But even those who leave can often find it difficult to return to the village due to lack of employment related to their field of specialization. Specializing in a rural related field is no panacea; a village of 2000 people only needs a handful of veterinarians, doctors or rural engineers. Those who cannot afford the cost of commuting and living far from home, choose to work for contractors, neighbors or with their families within the village or in neighboring localities. These youth typically make a living wage but may be unable to improve their social status after many years. The least fortunate, wander around performing petty work for small fees that allow them minimum living wages. Unfortunately, some of these also wander the streets of villages eventually succumbing to alcoholism, crime and drugs.

Social Entrepreneurs, Rural Heroes

What can possibly make a difference in the lives of these individuals? Surely, pre-existing social and economic conditions matter. Villages where opportunities abound, infrastructure is developed and families are educated, all have a positive bearing on successful outcomes for young people. An interesting factor, sometimes overlooked, however, are social entrepreneurs. These individuals exist in almost every village, although their number varies from one per village, to a handful of five or six, sometimes more. These individuals are creative enough, have been able to amass enough resources, have been sufficiently persistent and committed to the community, and are generous enough to donate their time to the youth and communities at large to make a difference. They are not identified in the literature as important contributing factors, yet in my observation during my travels, they seem to be one of the most important in defining outcomes.

These entrepreneurs organize social and community events to engage youth, they create enterprises that are able to generate employment for the dislocated and least fortunate, and serve as leaders to attract outside funding and attention from nongovernmental organizations, religious groups or provincial level authorities, especially when they cooperate with the local political authority. They are a key ingredient in the recipe to fighting the single most frequently mentioned obstacle to development recognized by the youth of rural Argentina: apathy. Apathy is important among youth because of a generalized lack of entrepreneurial culture pervading the villages, and in some, because of the lack of opportunities for involvement.

Lack of opportunities for rural youth are at the heart of the problem of sustainable development for rural villages. An apathetic, uninvolved and disempowered youth is not a bright omen of the future of these hidden communities. At the local level, this means the creation of opportunities to reduce disinterest in the form of productive activities that aid the local economy as well as the creation of trade workshops relevant to the local economy. At the human level, closer work between social entrepreneurs and political authorities is needed to maximize opportunities for involvement and community building. Advice in career choice is also in order, as well as programs – some of which are already in place in some villages – to substitute lack of help from families in education related issues.

At the heart of a sustainable solution, in my opinion however, is the channeling of existing resources through these key social entrepreneurs who not only have a deep understanding and connection to the reality and people of their villages, but also love and commitment to their communities, often forgotten, hidden from sight from the vast majority of Argentinians.