What's Luck Got To Do With Health Care? A Heck Of A Lot
It took more than two hours for the team of health workers to reach Antonio, a 6-month-old suffering from severe malnutrition in rural Guatemala.
The journey started on a Friday morning in May in the mountain town of Tecpán, with a harrowing hour-long drive over the hairpin turns of the Pan-American Highway. Then came a rough stretch of unpaved road to the tourist hub of Panajachel on the shores of Lake Atitlán.
In a stunning landscape surrounded by volcanoes, the team hired a boat captain to take them on the seasickness-inducing, 40-minute ride to a small village, where people spoke only Kaqchikel, an indigenous Mayan language. Under a searing sun, they carried their equipment for about 15 minutes up the mountainside to the two-room house that Antonio shares with his mother, father and four older siblings. The kitchen could barely hold four people shoulder to shoulder. Chickens roamed outside.
Antonio, whose mother was unable to produce enough breast milk to support his growth, weighed less than 12 pounds. Despite being fed formula and a corn-based gruel, he'd already missed major developmental milestones like sitting up without support, says Grace Fletcher, a graduate student in public health and Latin American studies at Vanderbilt University. She spent three months working with an NGO called Wuqu' Kawoq, which provides health care to Mayan communities in native languages, and recently wrote an essay for the Global Health Hub, about the unexpected ways that serendipity intervened to transform Antonio's future.
"Since returning to the United States ... I've been thinking about how messy and random global health delivery — even when it's really effective — can be," she wrote. "I'm talking about that moment when a patient walks out of the clinic and you sit back and think about all of the stars that had to align in order for that patient to get the care she needs."
For nearly two hours that day, the team worked with Antonio's mother, Maria, to teach her how to prepare solid foods for the baby. He eventually stopped fussing enough to eat some mushed carrot puree. All seemed well until the team was packing up to leave, with a full load of home visits ahead of them. In a whisper, nutrition program manager German Obispo asked Fletcher if she thought something seemed wrong with Antonio's eyes. Nobody was sure, and they left.
Over lunch a short while later, the subject came up again and after some discussion, the team headed back to Antonio's house. They told Maria that the chief doctor would be in Panajachel on Monday and gave her boat fare for the trip, which would require the 40-minute ride and a 15-minute walk on either end. To everyone's surprise, she showed up to see the doctor, who determined that everything was fine with Antonio's eyes but instead found a heart murmur that may have helped explain why he was struggling to grow. Surgery is the likely next step.
When Fletcher reflected on that day's events, she was struck by all the little moments that could have led to a different outcome. What if a storm had kept the boats from running the day of the visit? What if the team had been delayed with another patient and hadn't made it to Antonio's village? What if Obispo had decided not to mention his hunch about the baby's eyes — a false alarm, as it turned out, but a pivotal moment that led to an important, if different diagnosis?
Antonio's story is far from an isolated case, adds Fletcher. She remembers a 16-month-old girl named Julia the team visited only because they ran into a nurse on the side of the road who mentioned that the child had been sick. Julia was nearly a year older than Antonio but weighed barely over 12 pounds and measured just two feet long, suggesting severe malnutrition. The team suspected she had pneumonia and coordinated follow-up medical care and nutritional supervision.
"I don't have the right words for this, but it's good luck, or serendipitous, or the stars aligned," Fletcher says. "I don't think people are used to talking about this kind of thing in public health."
Fletcher respects the scientific terms used to standardize methodologies and measure outcomes in public health research. But the stories of Antonio, Julia and thousands of others like them, in her view, highlight the way lucky moments can make the difference between health and sickness, even life and death.
She's well aware that healthcare providers can't schedule luck into their plans. But they can create environments that make lucky moments more likely to occur. That means allowing health workers to invest the time needed to build trust, ensuring follow-ups and communicating in languages that people feel most comfortable with. Flexibility to adapt to individual situations is also essential.
Of course, serendipity applies to healthcare situations beyond the developing world. Here in the United States, in both rural and urban areas, luck matters when it comes to finding the right doctor who asks the right questions about mysterious symptoms, being near a hospital when a heart attack occurs, being communicating across language barriers or simply making a decision about whether to get a strange feeling checked out.
And sometimes, you're stuck with bad luck. A clinic might have to close at dark for safety reasons, notes David Lauter, a surgeon at the Skagit Valley Hospital in Mount Vernon, Washington, who has traveled to the Central African Republic and the Democratic Republic of Congo with Doctors Without Borders. And there will always be people stuck on a bridge when a big earthquake strikes.
On one visit to Africa, he was working in a clinic when a girl with a large abdominal tumor arrived — a lucky break for her because he has a lot of gastrointestinal experience. If it were some other week, she may have been met by an orthopedic surgeon or a urologist.
"There is always going to be somebody who is undeservingly unlucky and someone who is undeservingly lucky," Lauter says. You can't worry too much about that kind of unpredictability, he says, but you can try and make things go your way.
"As a surgeon, I believe you make much of your own luck by being careful in making a diagnosis, paying attention to details in the OR while still moving quickly and efficiently and watching carefully for post-operative problems that are better addressed early than late," he wrote in a blog post for Doctors Without Borders. "But even the best surgeon has complications with missed injuries or unexpected post-operative bleeding or the severely injured patient that just doesn't make it. And even the most careful person can find themselves in the wrong place at the wrong time."
"Good systems can create and then take advantage of lucky circumstances," Fletcher adds. "This is everywhere. That's why we talk about global health."