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Laura S. Gilchrest

2021

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mientras sobreviven a este.

CONTEMPORARY MEDICAL MISSIONS AND IATROGENIC VIOLENCE IN

HONDURAS

Laura S. Gilchrest

ABSTRACT

The goal of this dissertation is to assess the health and broader social effects of contemporary medical missions in Honduras. Though medical missions are a popular phenomenon that has garnered the attention of researchers across disciplines, existing literature has not provided a framework for evaluating how medical missions are filling gaps in local services, if at all. Nor does existing scholarship evaluate for potential or actual harms that may result from medical mission activities. I conducted participant observation among 11 medical missions and a Honduran health center in the Department of Colón on the northeastern coast of Honduras. This study considers the medical mission encounter through assessments of local health resources and consecutive medical mission clinics and interviews and participant observation with local healthcare workers, residents and mission volunteers. I demonstrate that contemporary medical missions are a revival of missionary medicine and the iatrogenic violence they engage in is directly related to the colonial roots of biomedical healing. I frame the mission encounter as a dialectic of self- and Other making and identify dominant discourses medical mission volunteers circulate to establish moral and intellectual authority and rationalize ongoing interventions, even when they are acknowledged to be ineffective. The mission organization and its volunteers engage in actions that are frequently misaligned with the needs, identified structural factors that complicate health and well-being, and the national priorities for improving access to healthcare identified by local healthcare providers and residents. As a result, the medical mission encounter leads to various forms of clinical, social, and cultural harm. By undermining or discursively erasing local healthcare resources contemporary medical missions contribute to the provoked crises in the Honduran public health system. I apply recent innovations in anthropological approaches to examine the missionary medicine encounter in Honduras as a dialectic and mutually constitutive process – putting the experiences and narratives of local communities at the same level of analysis as that of mission volunteers. This study contributes a much-needed framework for evaluating and analyzing the iatrogenic violence of medical mission encounters and may inform rubrics for monitoring and managing medical mission encounters in host countries.

ACKNOWLEDGMENTS

This research project and the resulting dissertation have been over a decade in the making, which means there are a great many people to acknowledge and not nearly enough space to do so. I will do my best to get it right in these pages. However, I will most certainly be thanking people in person for years to come.

Let me start by acknowledging the support of my friends and family. Many of you have endured me as an academic for years now. Dissertations and the research that accompanies them do not happen outside of our lives as social beings. In the grand scheme of things, they are but one aspect among many others. Sometimes the other chapters of our lives make dissertations seem like footnotes. And a lot has happened in the past ten years. In the midst of “finishing” my dissertation, I was thrown off course by harrowing personal experiences and one in particular that has forever altered who I am. In so many ways my friends and family encouraged me and supported me through the most unimaginably difficult moments of my life. Moments that, frankly, I would not have survived without you. In the face of that reality the dissertation seemed insignificant. I am so grateful to those who surrounded me with love, held me up, cleared a path, and gave me time to find my way back (if I wanted to). Thank you.

Tackling the research and dissertation involved the input, participation, support, and assistance of hundreds of people! I am grateful to them all. I want to thank the people of Playa

Felumi for welcoming me, befriending me, tolerating my questions and curiosities, for asking me questions and sharing your lives with me. Thank you for participating in this research, this dissertation and the degree it has earned me would not have been possible without you. There are a few people in particular for whom I am so grateful, I cannot name them here, but I am so glad we continue to be part of each other’s lives and that I can thank them beyond these pages as well.

Seremein! v

Without the friendship, support, and collaboration of Dr. Luther Castillo, this research would not have been possible. Thank you for your energy, your faith and trust in me, and your friendship. Thank you for sharing your resources, your time, your presence, and for the many, many animated conversations about medical missions, healthcare, politics, and revolution, we have had over the years. Seremein!

Thanks to my colleagues at American University, who read early proposals and chapters and offered insights and feedback. Thanks to the Center for Latin American and Latino

Studies at American University, and Eric Herschberg, for your support and invaluable connections. My gratitude to the Tinker Foundation, and the College of Arts and Sciences and the Office of the Provost at American University for funding support for pre-dissertation research, fieldwork, and writing grants. Thanks also to Lauren Tabbara, a font of wisdom and a behind-the-scenes advocate for students (especially in emergencies).

Thank you to Nikki Lane, Matthew Thomman, Nell Haynes, for your wisdom, guidance, and mentorship. Thank you also for your friendship and example. Special thanks to Joeva Rock,

Jeanne Hanna, Beth Geglia, Justin Uehlein for your friendship, collaborations, love, and accompaniment on this journey. Thank you for reading early drafts, later drafts, being soundboards, and writing partners. Thank you for the best brunches, impromptu babysitting, and pandemic provision deliveries! Thank you to Sarah Leister for your time, feedback, and keeping me on schedule! Thank you to Amy Ruddle for all of your help from babysitting, to pandemic provision delivery, to reading multiple drafts and offering feedback and support. I am honored and humbled. All of you inspire me! I am proud and grateful to know each of you.

Thank you to my parents for the variety of ways you have supported me my entire life, but especially in these last few relentless years. When I was a young child and people asked me

what I wanted to do when I grew up, I would answer “I want to go to college.” Today, I am the first person in our entire family to earn a PhD. Thank you for supporting me in making a career of being a perpetual student.

Finally, thank you to my committee for believing in this research. Thank you all for the compassion and patience you have extended to me as well. It has meant the world to me. I am grateful that you have all pushed and encouraged me, and that you have cared enough to do so.

Dr. Koenig, thank you for your sincerity and frankness, and for your extremely detailed readings of my work. Dr. Carruth, thank you for your guidance, mentorship, and expertise. Dr. Vine, thank you for your support and advice, and for your guidance during my fieldwork. Dr. Pine, thank you for your support, mentorship, and friendship and encouraging me to take this idea on when it was still just a spark.

Thank you all for encouraging and pushing me, and for caring enough to do so.

vii

TABLE OF CONTENTS ABSTRACT ...... iv

ACKNOWLEDGMENTS ...... v

LIST OF TABLES ...... xiii

LIST OF ILLUSTRATIONS ...... xiv

LIST OF ABBREVIATIONS ...... xv

CHAPTER 1 HELPERS AND HEALTH SEEKERS IN HONDURAS...... 1

The Research Problem ...... 1 Research Questions and Hypotheses ...... 2 Country and Fieldsite Context, Health Indicators, and Short-Term Medical Missions ...... 3

Playa Felumi ...... 5 Health Indicators ...... 9 Cotemporary Short-term Medical Missions...... 13

Organization of the Study ...... 17

CHAPTER 2 CONTEMPORARY MEDICAL MISSIONS: SELF AND OTHER-MAKING IN THE MEDICAL MISSION ENCOUNTER...... 19

Short-Term Medical Missions ...... 19 Measuring STMM Outcomes: Success is in the Eye of the Beholder ...... 23

Health effects and evaluation ...... 24 Mismatched Priorities: Where Communities Needs and Mission Activities Diverge ...... 31 Sustainability...... 35 Volunteers as Primary Beneficiaries ...... 36

Missionary Medicine Redux ...... 42 Making and Being the Subjects and Objects of Medical Missions ...... 51

Theories of Disease Causation ...... 52

CHAPTER 3 METHODOLOGY ...... 58

How to Measure Medical Mission Effects...... 59

Are Medical Missions Filling Gaps? ...... 60 Defining Health ...... 61 Defining Social Effects ...... 62

viii

A Quick Note about Names ...... 65 Positionality ...... 65 Data Collection ...... 70

Walking Around Town ...... 70 Participant Observations among STMMs ...... 72 Medical Records Review and Surveys ...... 74 Participant Observation at the CESAMO ...... 77 Collecting Data with Youth in Playa Felumi ...... 79 About Photos ...... 80 IRB Statement ...... 82

Data Analysis ...... 82 Tools for Understanding STMM Volunteer Discourse ...... 88

CHAPTER 4 HONDURAS, MISSIONING, AND POSTCOLONIAL LEGACIES ...... 92

Early Honduras ...... 93

Colonization ...... 93

The Many Forms of U.S. Intervention in Honduras ...... 97

Political and Economic Intervention ...... 97 A Brief History of Missioning in Honduras ...... 99 Medical Missions in Honduras ...... 104

Garífuna experiences with interventionism in Honduras...... 106 Conclusion ...... 109

CHAPTER 5 HEALTHCARE IN HONDURAS ...... 110

Building Health Infrastructure in Honduras ...... 110 Current Challenges in the Public-Private Health System ...... 112

First Popular Garífuna Hospital ...... 118

Crises by Design ...... 119 Discussion ...... 127

CHAPTER 6 THE CESAMO AND HEALTHCARE PROVISION IN PLAYA FELUMI ...... 130

Playa Felumi by The Numbers ...... 130 Healthcare Infrastructure ...... 135

The CESAMO Staff and Volunteers...... 139

Epidemiological Data for Playa Felumi ...... 143

La Maratón ...... 145 Vaccination Campaigns ...... 149 Papeleo – Neverending Paperwork ...... 153

Consultations at the CESAMO ...... 154 Diarrheal Epidemic ...... 159 CESAMO Patient Perspectives ...... 162 Discussion ...... 166

CHAPTER 7 HEALTH MISSIONS HONDURAS: AN ORGANIZATION AND ITS VOLUNTEERS IN HONDURAS ...... 167

Health Missions Honduras (HMH) in Playa Felumi...... 167

History...... 169 Clinica Blanca ...... 171

Team Leaders and In-country Staff ...... 175 HMH Volunteers ...... 183

HMH Missions: A Typical Day with a Volunteer ...... 189

Evangelical Circulations: Self-Making, Escape, and Sacrifice in Volunteer Motivations ...... 192

CHAPTER 8 WHEN HELPING HURTS: AN ANALYSIS OF CONTEMPORARY MEDICAL MISSION PRAXIS...... 195

Positionality: The Authors ...... 196 When Helping Hurts: A Review ...... 196 Critical Assumptions ...... 218

CHAPTER 9 THE LANGUAGE OF LACK: INFLECTIONS OF CONTEMPORARY MISSIONARY DISCOURSE ...... 222

Introduction ...... 222 Discourses Observed in Volunteer Language ...... 223

Divine Intervention and “Giving Back” ...... 223 Lack of Knowing: Knowledge as Primary Determinant of Health ...... 228 The Discourse of Perceived “Needs” ...... 234 Discourses of Distrust ...... 238

Manifestations of Self and Other through Medical Mission Discourse ...... 245

CHAPTER 10 DISSONANCE: PLAYA FELUMIAN’S KNOWLEDGE, DEFINITIONS OF HEALTH, AND ILLNESS NARRATIVES...... 248

“Estoy poco bien”: Illness Narratives, Idioms of Distress and Semantic Illness Networks...... 249 Bodyscapes – Linking Bodily Wellness to Land Loss and Ecological Destruction ...... 256 Healers and Healing ...... 260 Narrating (Illegible) Illness: Semantics and Idioms of Distress in Playa Felumi ...... 270 Playa Felumian’s Perceptions of Medical Brigades ...... 273 Conclusion ...... 276

CHAPTER 11 A BUG OR A FEATURE? MEDICAL MISSIONS, ANTIMICROBIALS, AND IATROGENESIS ...... 279

Missions in The Time of Malaria...... 280 Just in Case: Troubling Trends in Medical Mission Antimicrobial Use ...... 296

Deworming ...... 303

The Consequences of Anti-Cooperation and Cures in Search of Diseases ...... 309

CHAPTER 12 PRESIÓN Y AZÚCAR: MEDICAL MISSION APPROACHES TO CHRONIC DISEASE IN PLAYA FELUMI ...... 313

Diabetes...... 315 Hypertension ...... 327 Patient Subjectivity: Compliance, Agency, and the Deviance of Self-Care ...... 330 Pernicious Theories: Race, Genetics and Chronic Disease ...... 338 Conclusions ...... 340

CHAPTER 13 “BETTER” MEDICINE? ...... 343

Having Faith in Medicine – Meaning Response and The Social Contours of Healing...... 343 Fairness and Efficacy ...... 347

Fairness ...... 348 Distrust and Envy ...... 358 Efficacy ...... 362 “We All Want to Feel that We're Making a Big Difference” ...... 370

Structural Violence Within and Without ...... 378

CHAPTER 14 STMMS, THE "ORPHANAGE," AND THE POLITICS OF COMPASSION ...... 380

Casa Hogar Background ...... 380 “Orphans” ...... 385 Power Struggles ...... 389

Trust and Local Knowledge ...... 390

Discussion ...... 397

CHAPTER 15 RETHINKING SHORT-TERM MEDICAL MISSIONS ...... 399

Unfilled Gaps: MOH Identified Priorities ...... 399 Iatrogenic Violence ...... 401 Significance of the Study ...... 407 Challenges and Limitations...... 410

Ethical Considerations for Encounters with Violence in the Field ...... 412

What a Global Pandemic Tells Us About STMMs ...... 413

APPENDIX A RECOMMENDATIONS FOR THE FUTURE ...... 415

APPENDIX B SPANISH TRANSCRIPTION OF BUYEI INTERVIEW ...... 416

APPENDIX C CHILDREN’S ART ...... 423

APPENDIX D VOLUNTEER SURVEY QUESTIONS AND HOUSEHOLD INTERVIEW GUIDE ...... 427

Survey Questions (Mission Volunteers) ...... 427 Informal Interview Questions (Mission Volunteers) ...... 428 Houshold Interview Guiding Questions...... 429 Children’s Workshop Activity Prompts...... 430

REFERENCES ...... 432

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LIST OF TABLES

Table

Table 1. Selected Survey Responses: Why do You Volunteer on Short-term Medical Missions? ...... 225

Table 2.1 Survey Responses Indicating Lack of Education or Knowledge Deficits as Causes of Poor Health in Playa Felumi ...... 231

Table 2.2 Volunteer References of “Need” as Marker of Playa Felumian Subjectivity ...... 234

Table 2.3: Volunteer References to “Need” in Playa Felumi as Markers of Deservingness ...... 235

Table 2.4 Volunteer References of “Need” as a Measurement or Indication of “Lack” ...... 236

Table 3. Trends in Anthelmintic Treatments among STMMs ...... 307

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LIST OF ILLUSTRATIONS

Illustrations

Figure 1. Population Structure by Age and Sex, 1990 and 2015 ...... 4

Figure 2. Iatrogenic Violence ...... 85

Figure 3. Categories of Analysis for Iatrogenic Violence ...... 86

Figure 4. A Patient’s Prescription for Surgical Materials to Buy for Kidney Tumor Removal . 115

Figures 5. CESAMO Pharmacy Racks, Suspensions, Boxed Medicines ...... 138

Figure 6. Bagged Diphenhydramine (Left); Ferrous Sulfate Tablets 10-packs (Right) ...... 139

Figure 7. Auxiliary Nurses Give Flu Shots During “National Vaccination Days” Campaign .. 152

Figure 8. Sign-in Window at Clinica Blanca ...... 172

Figure 10. Breakdown of Volunteers by State of Residence ...... 184

Figure 11. Professions among STMM volunteers...... 185

Figure 12.1. Manchas ...... 253

Figure 12.2. Hay que quidar el ambiente ...... 254

Figure 12.3 La piña es dulce ...... 256

Figure 13. Filemon’s Injury During a Visit to Clinca Blanca (Sept. 2014) ...... 367

Figure 14. Iatrogenic Violence ...... 402

Figure 15. Categories of Analysis for Iatrogenic Violence ...... 404

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LIST OF ABBREVIATIONS

ACT Artemisinin-Combination Therapy AMR Antimicrobial Resistance CDA Critical Discourse Analysis CESAL Centro de Salud (Health Center) CESAR Centro de Salud Rural (Rural Health Center) CESAMO Centro de Salud Municipal con Medico o Dentista (Municipal Health Center with Doctor or Dentist) CMA Critical Medical Anthropology CMEP Centro Medico Especialización Pediatrica (Pediatric Specialization Hospital) COLVOL Collaborative Volunteer DOT Direct Observation Therapy DTap Diphtheria and Pertussis (Vaccine) HCTZ Hydrochlorothiazide HIV Human Immunodeficiency Virus HMH Health Missions Honduras IDB Inter-American Development Bank IDF International Diabetes Federation IFI International Finance Institutions IMF International Monetary Fund INSS National Social Security Institute IHSS Social Security Institute of Honduras JOH Juan Orlando Hernandez (current President of Honduras) JTFB Joint Task Force Bravo MOH Ministry of Health (Secretaria de Salud) MMR Measles, Mumps, Rubella (Vaccine) NGO Non-Governmental Organization NCD Non-Communicable Diseases OPV Oral Polio Vaccine ORS Oral Rehydration Solution PAHO Pan American Health Organization PHC Primary Health Care RDT Rapid Diagnostic Test RV Rotavirus (vaccine) SES Secretaria de Salud (Ministry of Health) SIA Social Impact Assessment STMM Short Term Medical Mission TSA Técnico de Salud Ambiental (Environmental Health Technician) UMVIM United Methodist Volunteers in Mission UNDP United Nations Development Program WB World Bank WHO World Health Organization

CHAPTER 1

HELPERS AND HEALTH SEEKERS IN HONDURAS

In a recent Global Health Security study Honduras ranked 156 out of 195 countries profiled across six key areas of healthcare provision and surveillance (“Honduras” 2019.).

Hondurans face numerous obstacles to maintaining health as a result of political instability

(Pastor 1985; Pine 2013), rising unemployment (Johnson 2010; Pine 2008), decreased food security (Boyer 2010), lack of access to clean water, environmental pollution caused by mining

(Instituto de Derecho Ambiental de Honduras 2013), impoverishment (Johnson 2010), and decentralization and erosion of the healthcare system (Gillespie 2004; Pine 2010; 2013), among other causes. In general, the Honduran healthcare system has not been a priority of the Honduran government, despite constitutional guarantees, and has been inaccessible and inadequate for most

Hondurans (Hernández Gómez 2002; Locklear et al. 2013; Low et al. 2006; Murillo and

Aparicio 2002; Sacks et al. 2010).

For the past 22 years, volunteer-based Short-Term Medical Missions (STMMs) have attempted to supplement this limited health care infrastructure through services ranging from pop-up general medical clinics and dental clinics to specialty surgery clinics and health education, among others. In some instances, STMMs can provide life-saving treatment to some patients. However, lack of preparation, inadequate training and experience, and limited resources mean that these missions also have the potential to provide ineffective treatment or to cause physical, psychological, and emotional harm (McLennan 2014, 175; Roberts 2006).

The Research Problem STMMs work with virtual autonomy in Honduras. Though they are a rapidly growing phenomenon (Howell 2012; McLennan 2014; Priest and Howell 2013), STMMs represent just

one among many existing incomplete and inadequate sources of healthcare in Honduras (Johnson

2010). When I first became interested in this research, I wanted to know why STMMs so often stuck to the same places and why, in the face of local suggestions and demonstrated need, they did not travel to more neglected destinations. I also wanted to understand whether and how organizations took the needs and suggestions of local residents into consideration. I was initially interested in identifying the methods of monitoring and evaluation STMM organizations used, and how they measured success or defined their goals. But each brigade organization is different and has its own system for conducting clinic and its own policies that determine how they collaborate with local health resources or community leaders, if they collaborate at all. How

STMMs affect the health of people they serve, and what their broader social effects may be, are questions not yet answered in the literature.

Research Questions and Hypotheses

I made more than a dozen trips to Honduras with a Texas-based organization between

2004 and 2012. Being fluent in Spanish allowed me to have more conversations with the

Hondurans I encountered on these trips. It quickly became apparent that what my North

American colleagues knew and understood to be the needs, desires, struggles, and hopes of the communities, were very different than what our Honduran hosts, collaborators, and intended recipients talked about. On one occasion, we were in a town that the organization visited several times a year. A woman, Maria, whom my parents and I had befriended over years of visiting the same town, was reading a daily newspaper and pointed to a headline about drought-related health crises in the southern region of the country. She told us and the other volunteers, "you should go there [another region in Honduras], that's where they really need help!" The organization did not send teams to that region, nor had they ever. Indeed, the Southern region of Honduras is one of 2

the areas of the country least visited by any STMMs, or volunteer groups of any kind, despite having consistently low health indicators and higher than national average rates of impoverishment (McLennan 2014).

After working with STMMs for more than a decade without seeing substantive evaluations of their effects, I decided to undertake this project. I sought to determine whether aid recipients experienced an improvement in their health as a result of sustained interaction with

STMMs and what sorts of impacts STMMs were reporting. I also wanted to understand the broader social effects of STMMs, including how they affect treatment-seeking behaviors, as well as social, economic, and political dynamics in the locations where they work. Relatedly, I focused on were the ways the various local participants in the STMM encounter understood and communicated their experiences. Ultimately, I wanted to find out whether general medicine

STMMs help, hurt, or have a null effect on their targeted recipients.

With an unclear picture of mission activities and limited, if any, regulation or evaluation of their activities, how can we know what kinds of effects medical missions are having in the places they visit? My research question thus asks:

What are the health and broader social effects of short-term medical missions in

Honduras?

Country and Fieldsite Context, Health Indicators, and Short-Term Medical Missions

Honduras is a small country, about 43,400 square miles, roughly the same size as Cuba,

Bulgaria, Benin, or the state of Ohio in the United States (Jackson 2005). It is home to approximately 9.9 million people, a 30 percent increase over the past 13 years (“UNFPA -

United Nations Population Fund” 2020). As shown in Figure 1 below, since 1990 population

trends have shifted from expansion, to a more regressive structure, due largely to decreases in mortality and birth rates (“Honduras” 2017). Since 2015, this trend has continued (UNFPA

2020). Average life expectancy for men and women is 71 and 76 years, respectively (PAHO

2017).

Figure 1. Population Structure by Age and Sex, 1990 and 2015

Image source: Pan American Health Organization, 2017

Income inequality in Honduras is the highest in the region and among the highest in the world. Data also show that the income inequality gap is increasing each year (World Bank 2020).

According to recent poverty line revisions, the World Bank calculates that 48.3 percent of the population lived below the national poverty line, and that 22.9 percent lived in extreme poverty

(2020). Using international poverty rates 16.9 percent of Hondurans lived below US$1.90 per day in 2018 (World Bank 2020). Just over half of Hondurans, 50.9 percent, lived on less than

US$5.50 per day (World Bank 2020). Rural poverty is even higher and has steadily increased since 2013 and just over 60 percent of rural Hondurans lived below the poverty line in 2018.

Poverty is projected to increase to 52.5 percent in 2020 and income inequality is also expected to rise (World Bank 2020). Extremely high rates of poverty and income inequality, as well as

inequitable access to healthcare based on income and relative proximity to urban centers are critical barriers to care and contributing factors to persistent poor health (PAHO 2017).

Honduras has been a large-scale, export agricultural society since the turn of the 20th century, not incidental to U.S. imperialism following independence from Spain. Standard Fruit

(Dole) and United Fruit (Chiquita) made quick and thorough work of Central American countries

(see Chapter 4), establishing plantations, upending agrarian laws, and meddling in statecraft to ensure favorable treatment by governments and laws that favored their business ventures

(Barahona 1994; Boyer 2010; Enloe 1990; Jung [Gilchrest] 2011; Smith-Nonini 2010). In every direction, as one leaves San Pedro, the vast monocrop plantations of bananas or African Palm and the CAFTA-era textile factories, or maquilas (Pine 2008), are impossible to miss. These artefacts of "development" shape the landscape of Honduras, as much as they shape its political economy (see Ch. 4).

There are three major cities in Honduras - Tegucigalpa (the capital), San Pedro Sula, and

La Ceiba - around which commerce, tourism, and politics circulate. Tegucigalpa is in the southern part of the country, San Pedro Sula is center-north, and La Ceiba is a coastal town situated in the northeast, once the main hub of banana companies and now a major tourism hotspot. Four to six hours from La Ceiba (depending on mode of transportation, weather, and conditions of the roads), is the small town where I conducted my research.

Playa Felumi

Playa Felumi is a historic Garífuna community. It is small coastal town located in the department1 of Colón. It is one of at least 46 communities established in four departments by the

1 There are 18 departments in Honduras, these are the equivalent of States in the United States or Provinces in Canada. 5

afro-indigenous Garífuna over the course of their 223-year history in Honduras, although the most recent census data only recognize nine of the communities (“OFRANEH” n.d.). From La

Ceiba, the third largest city in Honduras and the location of the public Hospital Atlántida, it takes about six hours by bus or about four hours by car to get there. The last two to four hours of the journey are on semi-paved, and then entirely unpaved roads. As a reference to this fact, and to acknowledge the history of discrimination and political and economic neglect the Garífuna have experienced at the hands of the Honduran state (Anderson 2009; Jung [Gilchrest] 2011, 2016), the Garífuna have a saying, "Where the road ends, Garífuna communities begin."

The town itself is situated on a stretch of land with views of the mountains in one direction and the Caribbean in another. Once covered in coconut trees, the beach is now wide- open, and due to the effects of climate change, several yards further inland than it was just two decades ago. The coconut trees that helped slow erosion and provided a variety of resources to residents were mostly destroyed by the effects of Hurricane Mitch in 1998 and what few remained died of blight. The white sands are beautiful and undeniably a draw for the volunteers who come visit, as many of them were quick to indicate during their week in Playa Felumi.

Indeed, the porch of the volunteer clinic and bunkhouse faces the beach and many of the volunteers snap photos with their digital cameras or iPhones.

Garífuna are included among nine other indigenous communities in the official census and account for approximately three percent of the total population (PAHO 2017). While they are often considered distinct from indigenous groups outside of Honduras, they are a recognized

Afro-indigenous ethnic group in Honduras and their language is recognized by UNESCO as one of the “Masterpieces of Oral and Intangible Heritage of Humanity” (UNESCO 2001). The

Garífuna are descendants of Black Carib and Arawak Indians exiled by the British from the

island of St. Vincent in the French Antilles in 1797 (Anderson 2009; Jung [Gilchrest] 2011;

Young 1971[1798]). West Africans being transported as part of French and Spanish slave trades, found their freedom in marronage (cf. Sayers 2012) through a shipwreck off the French Antilles, where they integrated with the local Carib populations. Carib men and Arawak women intermarried through raids and later trade in Arawak territories on what is today the coast of

Venezuela (González 1988; L. Jung [Gilchrest] 2011; Whitehead 1995). The Garífuna language is thus a blend of West African, Arawak, French, English, and Spanish words and sounds

(Gonzalez 1988; Whitehead 1995).

Prior to their exile by the British in 1797, the Black Caribs (only later known as Garinagu or Garífuna) maintained cordial trade relations with the French colonizers of St. Vincent. They maintained sugar plantations and sold crops and supplies to the French and negotiated several treaties that remained in effect until the French lost the Antilles to the British (Young 1971

[1798]). But, after more than a year of conflict, wherein the Black Caribs battled the British to defend their territories and protect themselves from imprisonment, British authorities gathered thousands of Black Caribs for exile from St. Vincent (Jung [Gilchrest] 2011; Young 1971

[1798]). The British transported them by ship from St. Vincent, to Haiti, then to Roatán, where the 3,000 Garífuna who survived the voyage were abandoned on the then-uninhabited and inhospitable island off the mainland coast of northeast Honduras (Young 1971 [1798]). From there the Garífuna settled Roatán and moved onto the mainland coast, where they eventually established 48 Garífuna communities (Gonzalez 1988). Some Garífuna migrated as far north as

Guatemala and Belize, with a smaller group settling in Nicaragua.

Within a few decades, Garífuna had made Honduras their home. British control of

Honduras transferred to Spain, and Garífuna men gladly joined the efforts to defeat the Spanish

during the Central American fight for independence (Euraque 1996a). Afterwards Garífuna men and women worked for the banana companies (Anderson 2009; Euraque 1996a; 1996b; Jung

[Gilchrest] 2011)), both in the industrial farms that stretched across the Honduran coast, but also as skilled Merchant Marines (Gonzalez 1988), a tradition that continues today. Despite their involvement in the creation of Honduras as an independent nation, the Garífuna have consistently been excluded from full participation and rights in Honduras and have been systematically targeted for their land (M. Anderson 2009; Brondo 2013).

The Garífuna with whom I have worked for the past nine years have faced systematic erasure, structural inequality, and explicit state violence. In 2008, Dr. Luther Castillo along with

Dr. Wendy Perez, both physicians trained at the Latin American School of Medicine in Cuba, founded the First Popular Garífuna Hospital (Revolutionary Medicine;

OFRANEH(“Revolutionary Medicine: A Story of the First Garifuna Hospital” n.d.;

“OFRANEH” n.d.)) in Ciriboya, a neighboring town. It is an entirely free hospital and one of the two nearest hospitals to Playa Felumi, and the nearest hospital available to the Garífuna and

Miskitu who live east of Ciriboya. Prior to the construction of the First Popular Garífuna

Hospital – built entirely with donated funds, materials, and the physical labor of Garífuna residents – the furthest communities could be as far as 15 hours away from the nearest emergency care (Dr. Luther Castillo, fieldnotes, 2009; Revolutionary Medicine). Though it is free, and nearer to Playa Felumi residents, many still cannot afford the bus fare to get there, and several others are not aware that it exists as a resource available to them. I discuss this dynamic, and the medical history and current health indicators and resources in Playa Felumi in more detail in Chapter 5.

Health Indicators

In this section, I present the general health indicators in Honduras to provide context in which short-term medical missions justify their presence and Honduras. I provide a more in- depth analysis of the socio-historical and political economic contexts of the health system and local health situation Chapter 4. The Honduran health system is comprised of public and private sector institutions. The latter include for-profit and non-profit privately-run hospitals and clinics that cover an estimated 10-15 percent of the Honduran population (PAHO 2017). Just under three percent of the population has private health insurance, meaning that the majority of private sector patients pay out of pocket (Carmenate-Milián et al. 2017). This coincides with global health statistics reporting that 4.3 percent, fully half of the total gross domestic product (GDP) spent on healthcare in Honduras (8.8 percent), comes from costs paid by patients (PAHO 2017).

Public sector institutions are governed by the Ministry of Health (MOH), the Honduran Social

Security Institute (IHSS), and other special population services like the Armed Forces.

While the entire population is eligible for all levels of healthcare services provided by the

MOH, the Pan-American Health Organization (PAHO) estimates that only 50-60 percent of

Hondurans regularly access public health resources (Carmenate-Milián et al. 2017; PAHO 2017).

IHSS clinics and hospitals are separate from the MOH facilities. Coverage by the IHSS is limited to 40 percent of the employed and economically active population and their families. Less than half, 44 percent, of the population, falls into this category, meaning IHSS serves approximately

20-25 percent of Hondurans. An estimated 17 percent of Hondurans had no regular access to health care of any kind (Carmenate-Milián et al. 2017; PAHO 2017). Universal access to healthcare, regardless of the type of service delivery, and health equity are significant health challenges in Honduras.

Another leading health challenge in Honduras is insufficient health personnel

(Carmenate-Milián et al. 2017; PAHO 2017). There are an estimated ten doctors, less than one dentist, two nurses, and eight nurse auxiliaries to every 10,000 Hondurans (Carmenate-Milián et al. 2017). For context, the World Health Organization (WHO) recommends a minimum of 25 doctors and 50 nurses per 10,000 inhabitants. Carmenate-Milián et al. (2017) note that these numbers reflect an unemployment rate of 46 percent among the 10,995 registered physicians in the country. (I will return to this issue in Chapter 4). There are also critically low numbers of technical personnel in areas like radiography (x-ray technicians) and anesthesiology, phlebotomy, and pathology. Capacity-building, placement, and personnel distribution are major concerns.

It should be noted, however, that Honduras has excelled and is often considered among the more successful cases in Latin America for immunization, maternal and child health intervention implementation, deworming, and malaria prevention programs spearheaded largely by Community Health Workers (WHO 2015). Since 1990 Honduras has consistently reached immunization coverage for 90 percent or more of the population (PAHO 2017). As of 2015, immunization rates in all areas were 98 percent or better (PAHO 2017). Since 2012, the MOH has worked closely with PAHO and piloted the first deworming programs in keeping with global health consensus on effective methods for reducing malnutrition, especially among children

(PAHO 2015). Between 2014 and 2015 the MOH launched a comprehensive preventative deworming program that was regarded as “pioneering” (PAHO 2015). Its successful implementation at the hands of community health workers formed part of the basis for the World

Health Organization’s subsequent global recommendation for large-scale deworming and global

reduction in helminth-related illness and malnutrition by 2020 (“UN Health Agency

Recommends Large-Scale Deworming to Improve Children’s Health” 2017).

While maternal mortality still exceeds the global acceptable standard at 67 deaths per

100,000, and infant and child mortality rates were 24 and 29 per 100,000 inhabitants, respectively, these numbers have declined rapidly in the past 20 years and continue to trend downward (PAHO 2017). Similarly, malaria and other communicable disease prevention programs implemented since the 1970s have been extremely effective and substantially reduced incidence of malaria (Swanson 2019; Pan American Health Organization 2017). In fact, Gracias a Dios, one of the more remote departments in Honduras, received the PAHO regional “Malaria

Champions” award for sustained malaria management in June of 2020. In 2019, there were only

253 confirmed cases of malaria. In general, maternal child health targets, immunization and deworming, and control of vector-borne diseases like malaria are not considered to be among the leading health concerns for Honduras.

Non-communicable diseases (NCDs), especially diabetes and hypertension, however, are a major health concern and priority for Honduras identified by PAHO (2017) and the MOH

(Secretaria de Salud 2015). According to the Ministry of Health, NCDs account for 69 percent of deaths in Honduras (Secretaria de Salud 2015). Circulatory disease (18 percent), including hypertension, and metabolic, nutritional, and endocrinological diseases (9 percent), including diabetes, are among the top causes of mortality in Honduras (PAHO 2017). According to the

International Diabetes Federation, the proportion of diabetes-related deaths among people under

60 years old is 64.3 percent (“IDF Diabetes Atlas 9th Edition" 2019). The MOH estimates the incidence of diabetes mellitus in the adult population to be 6.2 percent, although there is some variation depending on the source (PAHO 2017; Secretaria de Salud 2015). The International

Diabetes Federation, for instance, estimates the incidence of Diabetes mellitus in adults to be 7.4 percent (International Diabetes Federation 2019). The Honduran MOH identifies NCDs as the primary causes of morbidity and mortality at the national level and note the high costs of care, poor health service response, and poor promotion of “healthy lifestyles” as major barriers to disease management (Secretaria de Salud 2015).

PAHO also identifies several structural factors, or social determinants of health, as leading health concerns for the country. Environmental factors like air pollution and solid waste disposal contribute to respiratory illness and soil contamination. Imported chemicals for agricultural, industrial, domestic, and public health use, including obsolete and banned pesticides have resulted in 60 tons of contaminated products and materials in recent years (PAHO 2017).

Nearly half, 42.6 percent, of poisoning-related hospitalization are due to pesticides (PAHO

2017).

Solid waste management is another social determinant of health included in PAHO’s list of leading health concerns. While there are some waste management systems, they are unevenly distributed, responsibility is largely decentralized to the level of the municipality (contributing to inequitable distribution among poorer municipalities). Less than 6 percent of the country’s solid waste is disposed of adequately (PAHO 2017). Most municipalities use open-air dumps, which contribute to the pollution of air, soil, and water (PAHO 2017). Which relates directly to access to improved water sources.

Though Honduras is a regional leader in deworming interventions, key structural sources of parasite infections and diarrheal diseases are insufficient. While access to improved water sources has increased dramatically, effective access to safe drinking water and sewage purification systems are hampered by infrastructural and systemic failures (PAHO 2017). Most,

or 90 percent, of the water supply is intermittent, and only 44 percent of the water supply is effectively purified (PAHO 2017). Contributing both to serious vectors for infectious disease and environmental degradation, approximately half of wastewater is purified before reaching the receiving body of water – meaning raw sewage is poured directly into water sources (PAHO

2017).

This is the current health context in Honduras, based largely on global health data that coincides with the period during which this study took place. I will elaborate further on the intricacies of the health system in Chapter 4. I turn now to a brief background for STMMs. I review STMMs in the literature in the next chapter and provide a thorough introduction and analysis of the STMM experience in Honduras in Chapter 6.

Cotemporary Short-term Medical Missions

A systematic review found that the top four STMM-sending countries are the United

States, Canada, the United Kingdom, and Australia (Martiniuk et al. 2012). STMMs do not solely emerge from these four countries. Indeed, individuals from numerous other countries, including countries that are targeted by the top four for assistance, also come together as small groups on a volunteer basis to provide medical and other volunteer services. However, most

STMMs originate from North America and Western Europe, with Martiniuk, et al.'s (2012) data suggesting that roughly one-third of STMMs worldwide originate in the United States.

In aggregate, STMMs worldwide most frequently travel to the African continent, although to no single country in particular. Short and long-term volunteer missions, NGOs, and other kinds of foreign intervention on the African continent have received considerable scholarly attention (cf. Benton 2016; Carruth 2011; 2014; 2015; Comaroff 1991; Comaroff and Comaroff

1986; Pierre 2013). It is possible that African countries are a popular destination for volunteer 13

missions in part due to the relationships and infrastructure that remain after centuries-long medical mission and volunteer activity related to its colonization and systematic underdevelopment (see Ch. 2). The connections between contemporary STMM efforts and colonial missionary medicine have not been thoroughly explored in the literature.

After Africa, Central America is the second most popular regional destination for

STMMs. The combined Central America/Caribbean region accounts for nearly 25 percent of total global short-term medical missions' destinations (Martiniuk et al. 2012). STMMs from the

United states most often travel to Central America, and specifically to Honduras (Martiniuk et al.

2012). As with the preponderance of UK-led STMMs in African countries, geography

(proximity) and colonial history likely play a role in why North American STMMs most frequently choose Honduras as their mission destination (see Chapter 4). The cities of San Pedro

Sula and Tegucigalpa in Honduras are just a short four-hour flight from Houston, Texas or

Atlanta, Georgia, two of the most common departure points for tourist flights to and from

Honduras. The Ramón Villeda Morales International Airport in San Pedro Sula receives at least one flight daily from major U.S. airlines (United, American Airlines and Delta) in each of these cities. Because each of these companies has pro-voluntourism policies for luggage, allowing a free second checked crate or suitcase with donated supplies, STMM volunteers most often take flights with these major carriers rather than with budget or other alternative carriers.

Honduras is also relatively easy to travel to as a strong business and political ally of the

United States. Because of this relationship (see Chapter 4), and because tourism is a significant part of the Honduran economy, no additional visas or permits are required for U.S. passport holders. While there are technically laws in place that would require medical missions to receive authorization and prior approval, this legislation is not enforced at Customs and Immigration or

beyond the airport, making it a much easier STMM destination than most countries in Africa or even neighboring Nicaragua, which has and enforces much stricter regulations on incoming aid groups (Casler 2016).

Prior to 1998, the number of medical missions to Honduras was unremarkable, although exact numbers are difficult to acquire. Following the devastation of Hurricane Mitch in 1998, the number of medical missions and the amount of aid they provided rose dramatically and continued to rise even after the intensity of the initial humanitarian emergency receded (

McLennan 2014; Swanson 2019). While there is no official accounting to date, by aggregating information from sites like Medical Mission Exchange (mmex.org), the Honduras Weekly mission calendar, and web searches for medical mission organizations sending teams to

Honduras, and interviews with health liaisons in Honduras, I estimate that there are over 300

STMMs operating in Honduras each year (prior to the 2020 COVID-19 pandemic).

It is hard to rely upon these numbers because they are calculated based on the relatively small numbers of medical missions that complete the registration and permitting process combined with rough estimates from informally aggregated tourism data and public recruiting.

That figure also reflects the number of organizations working in Honduras, not the total number of teams each organization sends to the country. The general consensus among Honduran physicians, NGO workers, and government officials is that there are likely many more missions that come through the country, bypassing registrations or otherwise going undocumented as medical missions while in the country—simply traveling as tourist groups. A more accurate count would be invaluable for future studies of medical missions and general voluntourism.

In general, 1.6 million people travel on short-term mission trips annually (Wuthnow

2009, 170).2 But, scholars and the general public have very little information about them outside of their own report-backs, op-eds, blogs, and thousands of images captured and shared across social media and other platforms. Medical missions are one form of short-term mission, and an increasingly popular way to provide more direct assistance or earn hands-on experience as a pre- med, nursing, or medical student, or as a contemporary evangelist (Occhipinti 2014; R. J. Priest and Howell 2013). Using 2007 census data, Lasker (2016, 2) estimates that there are at least

200,000 American medical mission volunteers annually. If there are few systematic studies about what short-term missions, in general, do, there are fewer still about short-term medical missions, how many of them there are, where and how they operate, or the effects they have in and on the places and people that they visit.

STMMs take many shapes. They may be formally organized by an NGO, like Global

Brigades or less well-publicized localized NGOs, like MEDICO, an organization for which I interpreted for over ten years prior to conducting this research. STMMs may be informally organized as a group of friends with specific skills through a church or loosely affiliated through another affinity group. One of the teams I observed organized a large group of volunteers (nearly

30 people) under the umbrella of the sending Methodist organization but had no affiliation with the organization or the Methodist Church outside of a personal contact. Typically, STMMs are groups of 10-40 people, primarily North Americans and Western Europeans (Martiniuk et al.

2012) with various skillsets. These medical professionals, paraprofessionals, interpreters, and

2 This number includes only active Christians participating in short-term missions abroad, so the number of participants in general is reasonably much higher, given the increase in high school and college students that are encouraged to participate on these trips as part of their career building and accrual of social and cultural capital. 16

non-medical laypeople travel to mostly rural locations, setting up temporary clinics for fewer than four weeks (Martiniuk et al. 2012; McLennan 2010; Tracey 2015).

Despite their ad-hoc and temporary nature, STMMs are often perceived to play a significant role in the provision of basic health care services, especially for people living in poor and rural areas. Despite the prevalence of STMMs, there has been little research into the efficacy of the health care they provide or their broader social effects – anywhere in the world. Thus, this dissertation study investigates STMMs regularly operating in Honduras and contributes critical missing data to the study of contemporary medical mission interventions.

Organization of the Study

The next three chapters present the theoretical frameworks, the methodological approach, and historical context that are critical to understanding the date presented in this dissertation.

Chapter 5 provides an overview of healthcare in Honduras and Chapter 6 details the healthcare infrastructure and an ethnographic account of the CESAMO and how and why Playa Felumians seek care there.

Chapter 7 follows with an introduction to the mission-sending organization, which I call

Health Missions Honduras (HMH), and the volunteers that comprised the teams I observed throughout my time in Playa Felumi. In Chapter 8 I examination When Helping Hurts, a text that several of the mission volunteers brought up in discussion and urged me to read in order to get a better picture of their rationales and processes in conducting their mission activities. The book turned out to be a rich textual source of data that laid bare the epistemological foundations upon which this organization and several others operate. Chapter 9 builds on the revelations of

Chapter 8, and explores the discourses of divine authority, “lack,” and “need,” that medical mission volunteers reproduce and conjure. Using critical discourse analysis, I identify the ways 17

in which STMM volunteers discursively erase existing forms of healthcare and resources in order to establish their own necessity. Chapter 10 juxtaposes the volunteer discourse presented in

Chapter 9 with the narratives and discourses generated by youth and adult residents of Playa

Felumi. The data demonstrate how medical mission discourses are not typically reflected in or representative of the narratives of the residents of Playa Felumi. The remaining chapters examine the link between discourse and resulting action. I conclude with a brief summary of the most significant data findings presented in this study and offer suggestions for medical missions operating in Honduras and elsewhere around the globe.

The next chapter provides the theoretical frameworks that inform this study and to analyze the effects of the medical mission encounter.

CHAPTER 2

CONTEMPORARY MEDICAL MISSIONS: SELF AND OTHER-MAKING IN THE MEDICAL MISSION ENCOUNTER

Short-term medical missions began working in Honduras in earnest as emergency responders to the devastation of Hurricane Mitch in 1998. As the acuteness of the emergency transformed into a new normal, medical missions continued to carry out their work, supposedly filling in the gaps in available healthcare services (S. J. McLennan 2005; Tracey 2015). In broad terms, the mission statement of STMM organizations and the goal of their volunteers is to “make a difference” and improve health, in short, to “help.” This research project aims to evaluate these claims through examination of the effects that contemporary medical missions have on health and social relations in Honduras.

This chapter presents the theoretical frameworks for the study. I rely on critical medical anthropological and global health literature to define health and situate biomedical approaches to care within ethnoscientific and ethnomedical contexts.

Short-Term Medical Missions

Before diving into thematic debates in the literature, the first issue to address is what to call the phenomenon. In the previous chapter I briefly explained the basic mechanics of STMMs, including how many people are involved, where they go, and who they are. In this chapter, I begin with a brief discussion about how they are classified in the literature, then address how they work and the concerns in the scholarship about the effects of that work.

How to classify the medical volunteers this study followed is an issue across the literatures.

As Sullivan (2016, 144) notes, “volunteer” subsumes a wide variety of practices as a category.

The people that work for Médicines Sans Frontièrs are “volunteers” working in medical

categories. The length of time those volunteers work, the conditions under which they volunteer, and the regulations to which they are beholden, distinguishes them from the scope of volunteering examined herein. My decision to call them STMM volunteers stems from a combination of how the participants in this form of temporary medical aid refer to themselves and the terminology readily available in the literature (Landa 2007; Montgomery 1993, 2007;

Occhipinti 2014; Priest 2009; Priest and DeGeorge 2013; Priest and Howell 2013; Priest et al.

2010; Rozier, Lasker, and Compton 2017).

Sullivan (2016; 2018) elects “clinical volunteer tourism” to describe the “pre-health” and medical students that her studies follow. While fitting for her volunteers, it is too narrow to include the many lay volunteers involved in short-term medical trips who are not participating for a medical learning experience, credential, or course credit. The presence of non-medical lay volunteers on these medical teams is another factor that distinguishes them from existing anthropological studies. The evangelical undercurrents also complicate matters.

STMMs are a form of temporary medical aid, however like the term volunteer,

“temporary” encompasses a wide range of possible meanings. When referring to official humanitarian aid, for example, temporary could be anywhere from six months to a few years depending on the crisis. Neither natural disasters, nor refugee camps are permanent (in theory), but each has its own temporal framework. “Short-term” borrows language from anthropological studies of contemporary missionaries (Howell 2012; Montgomery 1997, 2007; Priest 2009;

Priest et al. 2010; Priest and Howell 2013), which distinguishes the work of temporary mission from the traditional practice of long-term missionary placements in which volunteers live in their chosen or assigned location for at least a year, and often much longer, while also acknowledging

similar underlying motivational frameworks. Short-term, as defined in Chapter 1, refers to temporary activity lasting fewer than four weeks (Martiniuk et al. 2012; McLennan 2010).

The use of “missions,” too, is a deliberate choice that reflects the terminology in the anthropological and medical literature, and how this category of temporary medical aid volunteers refers to the teams on which they serve. This choice references the subtler connections to militarized discourses of development (cf. Barnett 2011; 2013; Bricmont 2006;

Calhoun 2010; Fassin and Pandolfi 2010; Lasker 2016; Mitchell 1991; Singer and Hodge 2010;

Smith 2008), and neoliberal professionalism lingo (cf. Prince and Brown 2016; Vrasti and

Montsion 2014). But, it is of particular importance because it links the phenomenon to its roots in colonial missioning (Anderson 1995, 2014; Comaroff 1991; 1997; Comaroff and Comaroff

1986; Hardiman 2006; Lasker 2016; McKay 2007; Sullivan 2016; 2018), and reflects that a majority of short-term medical teams are affiliated with religious institutions. While there is an apparent connection to the history of missionary medicine, few STMM volunteers refer to themselves as “missionaries.” The decision to identify these teams as “short-term medical missions” and the participants on them as “volunteers,” is therefore firmly rooted in the ethnographic realties and the existing literature.

In the available literature on STMMs, "short-term" refers from anywhere between two days and three months (Howell 2012; (Martiniuk et al. 2012; McLennan 2014; McLennan 2005);

Occhipinti 2015). However, the vast majority of STMMs and short-term mission work of any kind perform their services for five to fourteen days (Howell 2012; Occhipinti 2015; Priest and

Howell 2013). Most volunteers I have worked with over the past 13 years would balk at a month- long stint in situ. There are a couple of pragmatic reasons for the more common average STMM length.

First, most working professionals and college students in the U.S.—groups that make up a significant proportion of STMM participants—have one or two weeks of vacation at a time.

Students often take advantage of their spring or fall break to join an STMM. Whereas retirees may have more flexible schedules, health professionals and paraprofessionals use their available vacation time to participate in STMMs. Thus, for the latter, a trip longer than two weeks is impossible, given the minimal vacation time allotted to U.S. workers. Second, coordinating, organizing, and managing a group of 20 people for one to three months is a serious logistical challenge. It often proved difficult for team leaders to coordinate just a week's stay in Playa

Felumi.

Finally, STMM volunteers pay their own way. This often comes as a surprise to many people who have never been on a medical mission. On average, volunteers on both medical and non-medical missions pay between US$1,500 and $2,000 per trip. Students traveling with Global

Brigades, Engineers Without Borders, and church or organization-based short-term missions pay a "trip fee," which may or may not include the cost of roundtrip airfare. Many volunteers raise the funds from friends, family, neighbors, colleagues, and through gofundme-style crowdfunding campaigns. Many medical professionals also have access to funding programs through the hospitals or institutions for which they work that will sponsor their trip in part or in full.

Fees usually include the cost of food, transportation, accommodations, temporary travelers' insurance, and an administrative or transaction fee that goes directly to the organization, church, or educational institution sponsoring the trip. Transportation generally entails a rented vehicle, contracted by a tourism company, unless the organization has invested in its own minibus, which was the case for the volunteers with whom I worked. Accommodations usually include lodging in hotels offering amenities and comforts to which typical U.S. travelers

are accustomed, at the beginning and end of the mission trip. Most teams include a nicer or luxury hotel at the end of the trip for one to two days to reward volunteers for their work. Nearly all of the teams I observed in Playa Felumi spent one or two days in Roatán, a global tourism hotspot with prices to match, exemplifying how STMM volunteers are part of the global voluntourism phenomenon.

STMM volunteers, in addition to being predominately young and women, are also overwhelmingly white. The whiteness of STMMs (and similar teams) is inextricable from the broader history and legacy of colonial missionary work (Comaroff and Comaroff 1986; Hallum

1996; Priest 2012). White European, and later North American Christians—especially

Methodists—set out across the world to help "civilize" peoples in countries deemed uncivilized, directly facilitating colonization and exploitation (Comaroff 1991).

Measuring STMM Outcomes: Success is in the Eye of the Beholder

Anthropological studies of short-term missions have varied in their foci, but most are concerned with mission volunteers as a broad category. Few of the studies address the health effects (Alghothani, Alghothani, and Atassi 2012; Maki et al. 2008; Montgomery 1993, 2007;

Naujokas 2013; Landa, 2007), or medical mission evaluation, specifically (Berry 2014;

McLennan 2005). Of those that do, most are critical of the projects. A narrow subsection of this literature identifies the discordance between medical mission activities and host organization and patient priorities (T. Green et al. 2009; Rozier, Lasker, and Compton 2017). There is also research that attempts to evaluate the financial, political, and moral economies of medical mission projects (Caldron et al. 2016; Crossley 2012; Lasker 2016; Wendland, Erikson, and

Sullivan 2016). Other researchers have focused on the volunteer experience and the benefits and

social capital short-term mission trips bestow upon the volunteers (C. Campbell et al. 2009;

Occhipinti 2014; R. J. Priest and Howell 2013; R. Priest et al. 2010).

Health effects and evaluation

With the few exceptions I present below, most of the literature on short-term medical missions produced in the past thirty years has been descriptive (Berry 2014; Martiniuk et al.

2012). Less than ten percent of the literature in anthropology or global public health in that time includes data regarding health outcomes (Sykes 2014). Of the literature that does report outcomes there are significant concerns about the metrics used to collect that data (Bauer 2017;

Berry 2014). The most recent studies and systematic reviews of the literature on STMMs acknowledge that there is no consensus on standard of care (Roche, Ketheeswaran, and Wirtz

2017), and there is “limited evidence of long-term benefits to local communities, colleagues, or health systems” (Bauer 2017, 6), among numerous other ethical, social, and economic concerns.

As Rozier et al. assert, “whether STMMs do more ill than good remains an open question”

(2017, 6). As a result, most of the literature evaluating STMMs does not explicitly address health outcomes. It is a glaring omission within the literature that has remained unfilled for nearly thirty years. Instead, there is literature that evaluates various other aspects of the STMM encounter.

Montgomery (1993, 2007) and Landa (2007) were pioneering in their research on

STMMs in Latin America, and adopted a critical perspective early on, questioning their efficacy and calling for STMMs to collect the necessary data to evaluate their effects on health.

Montgomery (1993) explicitly noted that STMMs do not collect the necessary data to determine their efficacy in terms of change in disease prevalence or long-term improvement to healthcare access. McLennan’s (2005) thesis study drew upon Montgomery’s earlier work and assessed the effects STMM presence has on local health resources and the potential consequences for the 24

National Health Service (NHS) in Honduras. McLennan’s findings suggest that rather than improving health outcomes through “filling gaps” in existing healthcare infrastructure, teams were likely delaying rather than reducing morbidity and mortality (2005). Like Montgomery

(1993, 2007) and Landa (2007) McLennan’s study also suggests that people would delay or suspend care until the next time they saw a medical mission, which could directly contribute to worsening health (2005).

Montgomery (2007) and Landa (2007) similarly observed that STMMs often unwittingly create distrust of local healthcare providers. In Montgomery’s study, Honduran physicians expressed concerns that patients would wait to seek out healthcare until “better” physicians from the United States arrived (2007, 94). Montgomery (1993, 2007) and McLennan (2005) both suggest that this unintended consequence could further contribute to poor health outcomes because it might discourage people from seeking treatment when it is needed.

McLennan’s study also highlights a concern raised in the literature about how teams are measuring their effects. A decade after Montgomery’s (1993) first study of STMMs questioned their evaluation metrics, Berry’s (2014) study among STMMs in Guatemala found that not only do medical missions not collect the data necessary to evaluate their effects on health, the evaluations they do make are based on self-selected criteria and their perceptions of their work rather than empirical data (2014, 327). Berry suggests this represents a conflict of interest and prevents a reliable evaluation of medical mission impacts.

The problem of perception-based evaluation presents itself in McLennan’s study, which showed that while teams often believed they were helping “the poorest of the poor,” team distribution did not overlap with heat maps showing areas with the highest rates of poverty

(2005, 115). McLennan also found evidence that suggested that suggesting that STMMs were

competing with and duplicating available resources, drawing patients and customers from areas with reasonable health coverage, troubling STMM perceptions about who their services reach

(2005, 116).

Maki et al. (2008) attempted to develop a standardized tool for STMM evaluation, called the Harvard evaluation tool, in hopes that it would improve quality of care and foster data sharing and communication among STMMs. However, the authors recognize that the criteria for their evaluation tool also relied upon the “medical mission directors to honestly evaluate their own mission” (Maki et al. 2008, n.p.), underscoring Berry’s (2014) concerns about conflicts of interest and limited empirical evaluation of health outcomes. Maki et al. (2008) also note the limitations of their evaluation system due to the logistical challenges involved in interviewing patients, meaning that local feedback about impacts is largely missing.

Tracey’s doctoral research among STMMs in Honduras attempted to implement a modified version of the tool, which she called the Revised Harvard Model (2015, 105). The modification included interviews with STMM clients pre-, during, and post-STMM visit – a factor missing from the original model. Although the data collected shows that clients conditionally accept STMM efforts, but view them as insufficient overall, outcomes were negatively affected by the lack of follow-up and structural factors that prevented client compliance with recommended courses of treatment or therapies and severe limitations to clients affected their ability to pursue referrals (Tracey 2015). Though important additions to the literature, the study further confirms that among STMMs there are still no health outcome measurements and no way to measure those outcomes against medical and nursing professional standards of care (Tracey 2015, 186).

Missing from these health evaluations is a discussion of iatrogenesis. The idea as used in social theory by Ivan Illich in the 1970s has recently experienced a renewal within medical anthropology. It is particularly useful for evaluating whether and how medical interventions, particularly in medical mission contexts, have negative physical, social, and cultural effects.

Illich characterizes "all clinical conditions for which remedies, physicians, or hospitals are the pathogens, or 'sickening' agents" as clinical iatrogenesis (Illich 1975, 27). Illich identifies four categories of clinical iatrogenesis. Category one includes malpractice, negligence, and professional callousness. Category two includes accidents or human error. Category three includes specific risks that are accepted, whether or not they are considered acceptable in a broader social context or the individual(s) to which they pertain. The fourth category is injury that occurs as a result of “defensive medicine,” or medicine practiced in an intentionally guarded or limited way that protects the practitioner or their institutions from accusations of malpractice.

Importantly, “sickening” here is not limited to medicalized pathologies. Indeed, the tendency to pathologize or to only recognize those symptoms or expressions of distress or disease is among the problematics identified as part of the biomedical encounter. The literature adopts a much more anthropological understanding of harm to health and wellbeing in its treatment of iatrogenesis (cf. Kleinman 1989; Kleinman, Das, and Lock 1997; Mattingly and

Garro 2000). The issues of malpractice, negligence, human errors, “accepted risk,” are useful markers for understanding the effects of the medical mission encounter. The potential for social and cultural iatrogenesis, however, may be even more significant in the context of medical missions.

Social iatrogenesis has several features. Medical bureaucracy “creates ill-health by increasing stress, by multiplying disabling dependence, by generating new painful needs, by

lowering the levels of tolerance for discomfort or pain, by reducing the leeway that people are wont to concede to an individual when he suffers, and by abolishing…the right to self-care”

(Illich 1975, 41). Illich adds that other examples of social iatrogenesis are evident when homes become “inhospitable to birth, sickness, and death” via the hospitalization of care, the language in which people could experience their bodies is converted into “bureaucratic gobbledegook,” and when suffering, mourning, and healing outside the patient role are labeled a form of deviance (Illich 1975, 41).

More recently, scholars have connected the concept of social iatrogenesis to structural violence. Structural iatrogenesis is a kind of structural violence that inflicts disproportionate harm on people via large-scale forces like resource distribution and re/production of social hierarchies of race, gender, and language (Stonington and Coffa 2019, 703). Iatrogenesis results from the bureaucratic systems under the control of health systems and clinicians that re/produce these social harms.

For example, Dasgupta and Ghanashyam (2012) identify the potential for public health iatrogenesis, particularly when global standards for care in vulnerable or high-disease burdened situations are disregarded. In their approach, the authors were most concerned about the dismissal of well-established, WHO promoted protocols for Multiple Drug Resistant

Tuberculosis (MDR-TB) in favor of “conventional wisdom” approaches (Dasgupta and

Ghanashyam 2012, 79). Their observations have broader application for other public health interventions that relate to the effective treatment of illnesses with high risk of developing drug resistance, including malaria and other antimicrobial treatments.

Lorenc and Oliver (2014) echo the concerns of Dasgupta and Ghanshyam (2012) that the adverse iatrogenic effects of public health interventions are underexamined in the literature.

Rather than identify a specific case of public health iatrogenesis, Lorenc and Oliver offer a framework for evaluating adverse effects of public health interventions. The categories they propose include direct harms, psychological harms, equity harms, group and social harms, and opportunity cost harms (Lorenc and Oliver 2014, 288–89). Despite these potential effects being diffuse and hard to measure, they advocate for the inclusion of areas of concern such as attitudes, emotional reactions, social relationships and norms in evaluations, to more fully understand the impacts of public interventions.

Building on Lorenc and Oliver’s framework, Bonell et al. (2015, 97) suggest that evaluations incorporate “dark logic” models to detect harmful externalities and paradoxical effects, their terms for iatrogenesis, and enable evaluations to identify the underlying causes of such effects. The dark logic approach can be applied in pre-planning or in post hoc evaluations of interventions to assess what harm may have already occurred. The authors propose three approaches for constructing the dark logic model. The first is based on Robert Merton’s (1936) theory of the unanticipated consequences of purposive action and Giddens’ (1987) theories about the social structure of society. Using this approach, evaluators would identify the agency of providers, recipients and stakeholders, and the social structures that enable and constrain that agency (Bonell et al. 2015). They specify that the structures may include the institutions through which interventions are carried out, manuals that guide how to conduct the intervention, or the resources available for such interventions.

The second approach is to build comparative understanding across similar interventions.

In the context of medical missions, which fit into the category of public health interventions the model aims to evaluate, this could have significant implications for long-term studies to better ascertain the breadth of these interventions and the consequences of their encounters. As the

literature notes, the available data has largely been ad hoc and, like other public health interventions, have not been evaluated for their potential for iatrogenic outcomes. The third approach, Bonell et al. assert, is to consult with individuals and groups who know the local context and how interventions might function within these specific contexts (2015, 97).

Another promising theory for evaluating the effects of medical missions within the literature is cultural iatrogenesis. Illich (1975, 33) claims that cultural iatrogenesis occurs when health professions "destroy the potential of people to deal with their human weakness, vulnerability, and uniqueness in a personal and autonomous way.” Illich’s primary focus was biomedical health systems, specifically in the United States. He observed that, “professionally organized medicine has come to function as a domineering moral enterprise that…has thereby undermined the ability of individuals to face their reality, to express their own values, and to accept inevitable and often irremediable pain and impairment, decline, and death" (Illich

1975,127-128).

Iatrogenic violence synthesizes characteristics of social and cultural iatrogenesis and extends it beyond Illich’s narrower focus on the health professions, and somewhat nihilistic angle. In the context of international interventions, McFalls (2010) and Daniel (2014) use the term iatrogenic violence to describe interventions that cause social disruption disproportionate to the intended benefits of aid. McFalls argues that a feature of iatrogenic violence is therapeutic domination, wherein the power differences between donor and recipient mirror those in the doctor-patient relationship (Daniel 2014, 417; McFalls 2010, 319). Therapeutic domination depersonalizes and decontextualizes social relationships, stripping social agents of their historical and cultural contexts, rendering them mere bodies (McFalls 2010, 323). For McFalls, iatrogenic violence is an inherent feature of international aid interventions.

Daniel (2014) concurs with McFalls’ assessment and adds that the process of defining vulnerability and categories of need, as well as the creation of dependency and stripping people of their agency are examples of iatrogenic violence. In Daniel’s own case study, aid distribution logics and schemes in Tanzania resulted in increased social stress. Although some individuals received some form of aid, it did not fit the needs they prioritized for themselves or their families. In another instance, the criteria for participation (inclusion or exclusion) created barriers to access or resulted in would-be participants feeling as though they had been treated badly.

The creation of dependency that Daniel refers to is distinct from the common tropes of dependency invoked in neoliberal theory and anti-welfare approaches to aid. Instead, Daniel argues that because local participants are not part of the decision-making process about what comprises aid and how it will be distributed, they are forced wait and see what the organizations bring and to passively accept what is provided (2014, 428). If they do not accept what aid is provided, they risk being classified within the therapeutic domination framework as non- compliant or prone to “irrational outbursts” (McFalls 2010). The end result of this pattern is that local participants eventually give up on taking active roles in seeking solutions (Daniel 2014).

Daniel’s observations of these effects or characteristics of iatrogenic violence coincide with the medical mission literature that attempts to identify the slippages between the needs identified by host communities and mission organizations.

Mismatched Priorities: Where Communities Needs and Mission Activities Diverge

Green et al. (2009) and Rozier, Lasker, and Compton (2017) attempt to better understand the relationship between medical mission activity and patient and host perceptions of STMMs.

Green et al. (2009) conducted in-depth interviews among Guatemalan actors involved in or affected by STMM work. While their respondents generally expressed appreciation for STMM presence, they also identified several areas of concern and articulated specific areas of improvement or conditions for continued STMM projects. The study found a considerable mismatch between mission goals and the needs and priorities identified by local physicians,

NGO staff, and patients.

Respondents in Green et al.’s study identified public health measures, including healthcare infrastructure, preventative health care, and regular access to primary health care as the main healthcare needs (2009, n.p.). However, there was a general consensus among respondents that STMMs are not equipped to address these needs, given their short stays and focus on curative (rather than preventative) care (2009). Green et al.’s results also suggested that

STMM volunteers put labor and financial burdens on the local organizations or institutions that host them (2009). For example, when surgical teams occupy hospital space to perform surgeries, they disrupt local care schedules and increase local hospital staff workloads. If teams do not bring their own supplies, interpreters, or support staff, this creates additional financial and labor costs for the facilities. Green et al. also found that serious problems arise when surgical teams do not coordinate with local providers and make plans for patient follow-up. Even in the case of non-surgical medical teams, healthcare providers and host organizations declared that STMMs that do not coordinate or cooperate with local providers represented “the worst kind of care” and those volunteers “may as well stay home” (Green et al. 2009, n.p.).

Similarly, Rozier, Lasker, and Compton’s (2017) collected survey and interview data from over 500 respondents from countries in Latin American and the Caribbean, Sub-Saharan

Africa, and India. Across this expansive geography, their data authoritatively show that medical

mission goals and activities often do not align with the preferences and needs of actors in host countries. In terms of health impacts evaluation, Rozier et al. found that only one in four teams attempted any type of evaluation of STMM impact on the host community, and that fewer than one in five teams used evidence related to health outcomes to determine a medical mission’s

“success” (2017, 5). They also found that host communities most important priorities were opportunities for local healthcare workers to be included in every area of STMM patient interaction from triage, to prescriptions, to primary and specialty care (Rozier et al. 2017). The authors referred to this as capacity-building, however host-country participants’ responses about respect and willingness to learn from local community (Rozier et al. 2017, 4) and the authors’ own conclusions about the “power differential” inherent in the STMM encounter (Rozier et al.

2017, 6), suggest that a desire for collaboration and knowledge-sharing may more accurately reflect host community priorities.

This power imbalance comes up in the literature regarding the substantial sums of money spent on trips and questions about whether it would be better instead to invest those funds directly into healthcare infrastructure, medical and pharmaceutical supplies, or the salaries of local health workers. Caldron et al. (2015) estimate that annual physician expenditures on

STMMs trips alone account for US$3.7 billion, equivalent to 5800 physician salaries in the

United States. This is substantially higher than the conservative estimates made by Maki et al.

(2012) that suggested expenditures were near US$250 million. For context, Caldron et al. note that official Humanitarian Aid funds from the United States equal US$4.1 billion, and that like those funds, STMM expenditures are 100percent tax deductible (2016, 6). As a result, there is a de facto state and federal tax subsidy for STMM activity that to date has no monitoring and evaluation of outcomes and is not subject to oversight or sanctions (Caldron et al. 2016, 6). They

also note that there is little data available on the health or economic impacts of STMM on hosting communities and that continued participation of physicians should take those findings into consideration.

While Maki et al. and Caldron et al.’s respective studies to date make estimates based on invoices and self-reported expenditures, most of the studies express concern about the dynamics of medical mission economies. Berry (2014) found that the ways that STMM funds dictated whether local NGOs were able to continue their work, represented an important conflict of interest in evaluating STMMs. If local organizations’ funding is dependent on STMM fees or volunteer fundraising for programmatic needs, they are not likely to be critical of the STMM and may be obligated to shape their programs around STMM desires rather than patient or community needs (Berry 2014, 349).

Many of the respondents in Green et al.’s (2009) interviews wondered whether investing the enormous sums spent on travel to and from host countries would not more effectively address public health needs. Similarly, McLennan’s (2005) findings similarly suggested that while there may be evidence that medical missions act as a type of subsidy for health care in Honduras, they may also present a barrier to local economic development (116). By acting as a subsidy and being treated as one by the Ministry of Health, medical missions disincentivize the Honduran government from improving expenditures and investment in critical primary health care infrastructure (McLennan 2005, 116). McLennan reiterates the criticism that the significant monies spent on STMM travel might be more effective if redirected into healthcare infrastructure, medicines, supplies, and equipment, and paying local healthcare providers

(McLennan 2005, 117).

However, both McLennan (2005) and Tracey’s (2015) study in Honduras suggest that simply redirecting or fundraising specifically to support permanent health centers and local healthcare professionals is not so simple. McLennan argues that repurposing funds this way is questionable because volunteers are unlikely to be able to collect (i.e., funders are not inclined to give) money for infrastructure and other long-term projects (McLennan 2005, 116). Yet another example of medical mission priorities that do not align with host country needs.

Tracey’s doctoral research among STMMs in Gracias a Dios estimated medical mission costs at approximately $64,000 per team (2015, 185). However, Tracey argues against the common proposition in the literature (Green et al. 2009; Landa 2007; Martiniuk et al. 2012;

McLennan 2005; Montgomery 2007; Sykes 2014) that these funds might be better spent if directed to the regional offices for medication and supplies. She suggests that this approach is impractical due to lack of human resources and organizational factors in rural settings that complicate the utility of “single” donations (Tracey 2015, 185). Ultimately, Tracey acknowledges that the greater need is for sustainable, long-term solutions for improved healthcare systems, which falls outside the capacity of STMMs (2015, 185).

Sustainability

A recurrent theme throughout the STMM literature is the question of sustainability. All of the studies in the literature, even those that generally support the practice of medical missions, acknowledge that STMMs are not a sustainable solution to the effects of strained or inadequate health systems. Many scholars question, especially in light of insufficient evidence, whether medical missions have significant positive health outcomes over the long term. Concerns in the literature about sustainability are most clearly articulated in the context of prevailing global approaches outlines in the 1978 Declaration of Alma-Ata at the International Conference on 35

Primary Health Care (PHC). Montgomery (2007, 93) argued that medical missions fail to meet these global health priorities for PHC, reaffirmed as effective by the Pan-American Health

Organization thirty years later, because STMMs do not achieve regularly available and sustainable care at the local level or access to healthcare and improved health outcomes in resource-poor settings.

In McLennan’s study the National Health Service officials she interviewed often treated

STMMs as extensions of the National Health Service, rather than stop-gaps, despite their considerable limitations in providing specific, sustainable care (McLennan 2005, 136). Tracey’s critiques of STMMs in Honduras are similarly based on the principles of PHC (2015). Tracey finds that the Honduran participants are generally accepting of STMM activity in the region of

Gracias a Dios, but that STMM referrals often create additional social and economic hardships for clients and that deficiencies in standards of care are “profoundly evident” (Tracey 2015, 157).

Tracey also asserts that “STMMs themselves are not a sustainable entity and should not be considered a predictable element in a country no matter how poor or disadvantaged” (2015, 151).

Volunteers as Primary Beneficiaries

While there is a paucity of data on the benefits of medical missions to local actors, there are several studies that examine the benefits to medical mission volunteers. There are numerous autobiographical accounts of mission experiences abroad written by volunteers in the form of blog posts, opinions pieces, or self-published books (cf. Carlson 2012; Gebauer 2012; Igoe

2008). The medical journals emphasize the value of medical mission to the education of pre- medical and nursing students, cultural competency training for medical professionals, and as an effective treatment for healthcare worker “burnout” (Campbell et al. 2009). The perspectives in the anthropological literature vary, but largely address the experience of volunteers within the 36

context of agency, self-making, or neoliberal subjectivities (cf. Frenopoulo Gorfain 2012; Lasker

2016; Mostafanezhad 2014; Vrasti 2013). This section reviews the literature on the known benefits of STMM participation for volunteers.

Withers, Brown and Aghaloo (2013) note the emotional and psychological benefits as well as the professional and career benefits that volunteers attain through medical missions.

Their findings indicate that medical volunteers experience emotional boosts indexed as feelings of “happiness” and a “sense of satisfaction” (2012, 380). This perspective echoes that of other anthropological studies that look more broadly at volunteer work, which note a stronger sense of self and personal satisfaction as a common benefit of short-term volunteering (Vrasti and

Montsion 2014; Wearing 2001; Wearing and Neil 2000). For Wearing and Neill (2000), the experience of volunteer tourism is constitutive of the self through interaction with the Other.

Wearing (2001) argues that this process of self-making is inherently valuable and that the positive benefits of such identity creation ripple out into an individual’s community and the communities where they volunteer. Wearing’s solo scholarship and co-authored works largely dismiss postcolonial critiques that question the value of self-making through the Other.

Professional and social benefits also accrue to volunteers. For younger volunteers, like undergraduate (Berry 2014) or pre-health (Sullivan 2016, 2018) students, the volunteer experience translates into a stronger resume or graduate school application (Withers et al. 2013).

Older volunteers claimed benefits from being able to mentor and be network resources for younger volunteers, as well as receiving recognition and accolades for their efforts from their community, employers, and professional organizations (Withers et al. 2013).

Other professional benefits include a reduction in burnout among caregivers (C.

Campbell et al. 2009; Withers, Browner, and Aghaloo 2013). Campbell et al. (2009, 629),

explain that rates of burnout, defined as emotional exhaustion, a sense of depersonalization, and limited personal accomplishments among medical professionals, is linked to increasing demands on medical personnel in the United States. Fewer organizational and institutional restraints give medical professionals increased latitude in patient interactions, without having to worry about insurance, quality assurance, or consumer-driven patient demands (Campbell et al. 2009, 629).

Similarly, the same conditions allow pre-med undergraduate students, nursing students, and early-stage medical and dental students to practice and get hands-on experience, sometimes with the guidance and direction of established practitioners, but very often on their own, in ways otherwise unavailable to them in the United States (Sullivan 2018). Indeed, numerous arguments are made within medical literature that one of the most important functions of medical missions is in their value as practical learning laboratories (Campbell et al. 2011). For example,

Werremeyer and Skoy (2012, 1) found that a medical mission in Guatemala made for “a rich learning environment for pharmacy students.”

Critiques of voluntourism characterize it as part of contemporary neoliberal power structures and governmentality (Crossley 2012; Mostafanezhad 2014; Schech 2017; Vrasti 2013;

Vrasti and Montsion 2014). Some scholars complement that underlying theoretical foundation with discussion of the spatial politics of volunteering (Crossley 2012) and “geographies of care”

(Sin 2010) or compassion (Schech 2017) through which the otherwise obscured machinations of neoliberalism and late capitalism become legible, tangible, and measurable.

In her discussion of “popular humanitarianism in neoliberal times” Mostafanezhad characterizes voluntourism as one way that capitalism has accommodated social resistance to social injustice by reframing “questions of structural inequality as questions of individual morality” (2014, 4). Individuals are responsible either for bearing their misfortune or giving back

because they have been fortunate. Volunteer tourism accomplishes the imperative to give back by rekindling “sentimental colonialism,” which coopts compassion as a fundamental tool of the state to obscure systemic inequality and structural discrimination (2014, 92). In Vrasti’s (2013,

3) estimation, voluntourism implicates biopolitics and capital within the context of neoliberal governmentality. Vrasti and Mostafanezhad’s analyses suggest a closer look at missionary medicine’s role within neoliberal mechanisms would be instructive.

In an intensive study of its history, Barnett (2013) identifies three key eras of humanitarianism that help contextualize the current trajectories of voluntourism theories and bridge them with missionary literatures. The first era is imperial humanitarianism, which describes the intersections of colonialism and compassion. From the outset, humanitarianism has been full of contradictions. Imperial humanitarianism was characterized by paternalism directed at slaves, formerly enslaved individuals, and the peoples of countries colonized by Europeans. In keeping with the “spirit of the times,” imperial humanitarianism meant that “colonialism,

Christianity, and commerce could…provide the will and way to emancipate slaves, save sinners, and position backward societies on the path of civilization” (2011, 74). White Europeans involved in these undertakings called upon the very same systems that created and justified the trans-Atlantic slave trade, colonization, and racial hierarchies, to ameliorate suffering resulting from them. In this context, humanitarianism was a way for a cadre of white North Americans and

Europeans to reshape the social and moral conduct of certain Western peoples and non-Western peoples. The need to “civilize” and provide “salvation” to foreign “heathens” is demonstrative of the way imperial humanitarianism worked as a method of social control, especially with regard to bringing peoples of the world in line with the labor market and capitalist commerce.

Eventually this form of humanitarianism turned to civilian aid during the US Civil and

World Wars and began to shift focus from identity-based intervention to need-based intervention. This shift marked the transition between imperial humanitarianism and neo- humanitarianism. Neo-humanitarianism arose at the end of World War II in conjunction with neocolonialism and attempts to preempt communism (Barnett 2011, 104). This era of humanitarianism was increasingly characterized by its interdependence on the State and relief was widely viewed as an instrument to further foreign policy goals, rather than an end in itself

(2011, 104). Neo-humanitarianism was heavily bureaucratized and kept alive the tradition of paternalism, although in a slightly different guise than in the previous era. Neo-humanitarian paternalism took the form of expert knowledge and technocrats to exert authority over the targets of aid (Escobar 2005; Esteva 1992; Mitchell 2002; Murray Li 2007). Where imperial humanitarians believed God was on their side, neo-humanitarians had science on theirs

(2011,130). Even in this era, humanitarianism still focused on positioning exploited populations into the global capitalist market system. Paternalism, expertise, and aid exchange work to push individuals, communities, and at times entire states into a specific trajectory.

Finally, Barnett (2011, 212) describes the current era as one of “liberal humanitarianism.”

During this era, the humanitarian sector (still couched in market-based terms) became modernized, standardized, and professionalized. Professionalization, however, often results in further distancing between the aid worker and the aid recipient (Benton 2016a; Fechter 2011;

Scherz 2014). Barnett also adds that in this era humanitarianism splits into political organizations and entities like the UN organizations, and groups (like NGOs) that embraced a sort of “anti- politics” (2011, 212; cf. Ferguson 1994). The anti-politics stance is strategic, but it is not apolitical or neutral. It functions more like ideological blinders, allowing actors to ignore or

deflect attention from the broader social, economic, and political contexts - structural factors - that create the very conditions they intend to address.

In the past decade, anthropologists began to question the propriety of duty-based ethics in humanitarian practice, which hold that some actions are inherently good, regardless of the consequences. At the same time, there is growing concern about the unintended consequences of humanitarian intervention and whether it does more harm than good (2011:215). As Benton

(2016b, 199) explains, when organizations fail in their attempts to resolve a crisis (that they have chosen as the most pressing), it is not “simply because things are more difficult and complicated than first appeared; it is also because they could have intervened better with the proper support and dedicated attention from the people they mean to help.”

Although Barnett (2012) addresses colonialism and the practice of slavery, he, like most of the anthropologists in the literature, does not explicitly address the construction of race and racial identities inherent to humanitarianism in any of its phases (Benton 2016a, 2016b). Benton

(2016a, 2016b) has recently raised this issue in the humanitarianism literature. As she notes, race may be mentioned briefly, but structural racism and white supremacy are largely missing from the discussion. If it is acknowledged, it is typically at the level of discourse rather than explicitly in terms of racialized practice and identifications. Benton (2016a, 268) calls anthropologists to intentionally attend to the ways that professional humanitarianism and development work “is organized along racial lines alongside those of nationality, citizenship, and class.” For example, we cannot talk about the era of neo-humanitarianism and the rise of technocrats and experts without also talking about the ways that race, and anti-Blackness in particular, are embedded within global hierarchies that associate whiteness with international expertise (Benton 2016a;

Pierre 2013).

Missionary Medicine Redux

There is a subtle and continuous theme throughout the contemporary literature on

STMMs that alludes to the history and reflection of missionary medicine, and which merits closer review of corresponding literature. While there are notable differences between the

STMM encounter and the missionary medicine of the colonial era, there are also striking similarities. This study makes interventions into these literatures by demonstrating the ways that

1) STMMs are a revival of missionary medicine and 2) current missionary medical practice and malpractice are related to the colonial roots of biomedical healing.

The literature on missionary medicine relevant to this study analyzes the development of biomedicine (referred to in the literature as Western medicine) in the context of colonial projects

(Fanon 1965; Greene et al. 2013; Lock and Nguyen 2018; Tilley 2016)), and how missionary medicine was similar to, but also different from colonial medicine in that it was part of the

Imperial and biomedicalization of life and the foundation of contemporary global health programs (Comaroff and Comaroff 1997; Green et al. 2013; Hardiman 2006; McKay 2007).

Only a handful of scholars have explicitly considered STMMs within the missionary medicine literature (Handman 2018; Howell 2012; Montgomery 1993, 2007; Landa 2007; Wuthnow

2009).

Missionary medicine began in part over outcry that colonial powers were not fulfilling their moral obligation to “care for their subjects” (Tilley 2016, 745). Tilley argues that paltry funding in the colonies played a significant role in colonial doctors’ disproportionate attention to infectious disease at the expense of broader public health programs (2016, 746). Indeed, as

Hardiman notes, colonial powers were largely unwilling to spend their budgets on medical facilities “for the masses” (2007, 5). However, this may have had less to do with a lack of interest or the flattening of colonized peoples into “collective Others,” as has been popularly 42

argued by some scholars (Greene et al. 2013, 46; Vaughan 1991), than with the prevailing liberal economic ideology which held that colonial states should generate their own revenue (Tilley

2016, 745). It was not that colonial doctors were deliberately neglecting the proven importance of public health, but that they were forced to choose the more acute issues in the face of insufficient resources.

This political economic reality created an opening for missionaries. McKay argues that although missionary doctors may have been “motivated by Christian compassion, they held strong prejudices against many aspects of local culture,” (2007, 41). Indeed, the literature suggests that medical missionaries largely believed that “indigenous religions and social systems were backward, immoral, and unclean,” but that Christianity and so-called Western civilization were remedies for illness and the path to salvation (Greene et al. 2013, 47; cf. Comaroff 1991;

Hardiman 2006; McKay 2007).

Medical missionaries acted in accord with prevailing colonial ideologies about colonialism as a kind of “hygienic enlightenment,” but their approach was quite distinct from colonial medicine (Greene et al. 2013, 47). While colonial doctors were forced to address epidemic disease at the population level, missionaries engaged in an “intimate colonialism” via hygiene campaigns at the level of the individual (Summers 1991; cf. Hardiman 2007, Hunt 1999;

Lock and Nguyen 2018). These campaigns focused intensely on teaching Black and brown women “‘proper’ and ‘hygienic’ motherhood” (Hunt 1999; Summers 1991; Lock and Nguyen

2018) and transforming African domesticities (Lock and Nguyen 2018, 93).

Further distinguishing medical missionaries from colonial doctors was that improved physical health was a welcome side-effect of biomedicine, but it was secondary to missionaries’ primary goal which was saving “heathen” souls (Greene et al. 2013, 47). This emphasis on

salvation over corporeal wellness was due in part to the fact that medical missionaries did not begin as well-trained doctors and early biomedicine was not particularly effective (Greene et al.

2013, 47; Hardiman 2006, 11). But even as biomedicine improved and medical missionaries were professionalized near the turn of the 20th century, evangelism remained the priority.

Medicine became a key missionary conversion strategy and also a key source of biomedical training in colonized regions (Hardiman 2006, 14; McKay 2007, 41). Missionaries thought the “rational order of the clinic” would persuade people to relinquish their faiths and convert not only to Christianity, but also to European notions of modernity (Greene et al. 2013,

47). However, the adoption of biomedicine did not result in mass conversion or the elimination of indigenous healing practices associated with “false religious systems” (Hardiman 2006, 14;

McKay 2007, 80). Through the marrying of biomedical technologies and evangelism, medical missionaries were able to transform consciousness and affix moral discourses onto bodily experience (Lock and Nguyen 2018, 94). So profound were these transformations that contemporary global health politics concerning sanitation, hygiene, and maternal and child health are traceable to the moral economies of missionary medicine (Green et al. 2013, 46).

Jean Comaroff’s (1991, 2007) work establishes the ways that the medical missionary encounter was mutually constitutive. Comaroff suggests that scholars, “have grossly underestimated the pervasive significance of Christ’s foot soldiers, at home and abroad, with regard to the role of the cultural in the transformation of the modern world” (1991, 3). The symbolically charged missionary encounters, Comaroff argued, are as important as explicitly military and political conquest were because these were the intimate pathways through which

“each party sought to situate the other in [their] own narrative,” (Comaroff 1991, 8). According to Comaroff, “conversion” was not the goal, so much as the conversation, because it is in the

conversation that the dialectic of self- and Other-making takes place, “for the bearers of each culture came to objectify the other, they invented for themselves a novel self-conscious, even as they accommodated to the relationship that enclosed them (1991, 15).

The anthropological literature has picked up this thread anew in order to better understand contemporary missionary projects. Recent trends decenter the role of missionaries in postcolonial periods, characterizing them as an historical artifact and shifting focus to the ways that formerly colonized peoples had shaped Christianity to their own uses and meanings

(Handman 2018). Handman argues that this tendency complicates efforts to highlight the ways in which evangelism remains a central and ongoing concern for many Christians (2018, 151). She suggests that “Christian cultures of circulation” are a useful way to understand the experience of contemporary Christian missionaries (Handman 2018). Handman’s argument underlines how

Christian “speech and interpretive frameworks move through time and space and the ways in which people understand themselves and others” through these circulations (2018, 153). She notes Howell’s (2012) study of short-term missions as an example.

Howell’s study declares that short-term mission trips are important sites for the formation of American Christian identity, through which people comprehend their relationship to the global church, difference, and inequality. In the process, these contemporary missionaries pick up and circulate narratives of revelation and transformation as hallmarks of their short-term experiences

(Handman 2018, 158; Howell 2012). Evangelism emphasizes the repetition and fulfilment of divine promises, for example that God is present in one’s life, and missionaries travel the world trying to fulfill these promises (Handman 2018, 153). In the process, missionaries use a variety of tactics and train themselves to recognize the voice of God in their own lives, or when a

particular event constitutes divine intervention or a miracle (Coleman 2015; Handman 2018;

Luhrmann 2012).

The literature on missionary medicine also highlights another aspect of identity-making particular to the medical mission encounter. As Greene et al. (2013) note, medical missionaries became iconic figures. Bolstered by the circulation of their own narratives in European media, missionary doctors were often seen as heroes in European countries, and many medical students sought out positions on remote medical mission stations as a potential pathway to medical fame

(Hardiman 2006, 42). Everyone wanted to be the next David Livingstone (Comaroff 1991;

Greene et al. 2013, Hardiman 2006; McKay 2007). Comaroff adds that medical missionaries valued the respect of their spiritual authority and technical progress in colonial settings, especially in contrast to social upheavals and flagging religious adherence in their home countries (1991, 11). The medical mission encounter brought the missionary power, prestige, potential fame, and secured their own salvation.

The missioning literature, with few exceptions, views voluntourists on a spectrum from benevolent good Samaritans, a stance shared in some humanitarianism literatures (cf. Barnett

2011; Fassin 2011), to well-intentioned, if flawed, necessities of contemporary global development (Priest et al. 2010; Priest and Hall 2013). Within that spectrum, some research seeks to complicate the altruism-egotism dichotomy with a structuralist approach. The latter situates voluntourist agency within the context of neoliberal structures (Mostafanazehad 2014;

Vrasti 2013). Still others theorize voluntourist subjectivity within the frameworks of affect and desire (Crossley 2012; Frazer and Waitt 2016). Vrasti (2013) traces voluntourism back to colonial missioning and the Grand Tour, which brought the effects of early globalization to the sudden attention of wealthy traveling Europeans in the 19th Century. The popularity and profit

of contemporary volunteer tourism are unprecedented and result from its renewal and adaptation to emotional regimes and economic injunctions (Vrasti 2013, 1).

Whether it is a neocolonial (Palacios 2010; Sin 2010), or neoliberal (Crossley 2012;

Frazer and Waitt 2016; Mostafanazehad 2014; Schech 2017; Vrasti 2013) institution of hegemonic culture (Frazer and Wait 2016), scholars have centered on the subjectivities voluntourism creates. In a review of volunteerism literature in anthropology, Wearing and

McGehee (2013, 123) explain that current research positions voluntourists on a spectrum from

“pure altruism” to “pure egotism.” Anthropologists and philosophers alike have established that altruism is an ideal, and thus largely unachievable in practice and complicated by power dynamics that reinforce social hierarchies. Indeed, volunteers produce and reproduce a discourse of healthcare as a gift — of themselves and of material and psychic goods originating from them to the Other-in-need. There is a dialectical tension that emerges within this discourse of the gift, wherein STMM voluntourists perpetuate cycle of poverty tropes and place artificial limits, not only on the kinds of care they provide, but the individuals to whom they provide it. They enact a kind of linguistic violence while acting “altruistically.”

Marcel Mauss (1990) exploration of “the gift” is deeply embedded in humanitarian practice and theoretical analyses of humanitarianism (cf. Bornstein 2003, 2012; Bornstein and

Redfield 2011; Fassin 2011; Scherz 2014). For Mauss (1990), the obligation to give functions as a kind of welfare to ensure the adequate distribution of resources but can also create rewards and incentives for those who have access to more resources. Within this moral economy (Bornstein

2012; Fassin 2011; Nguyen 2007; Redfield 2013), there are implicit, and at times even explicit, hierarchies involved in giving aid and recognizing suffering. The person giving aid is almost always in the dominant position. Someone in the position of giver or “healer” asserts his or her

power over the recipient. The givers are able to distinguish themselves from the suffering of the other and elevate their moral and social position (Fassin 2011; Jung [Gilchrest] 2014; Sin 2010).

Furthermore, the giver or healer is able to determine who is worthy of compassion and aid, also indicating their power over the legitimacy of life – the healthy and wealthy get to choose who among the poor and the sick are worthy of assistance, and indeed survival. The person receiving aid is a supplicant in the hierarchy. The recipients must perform through speech and action the role of the sufferer, and as such they do not have the right to make demands on those providing aid (Fassin 2011, 112-114). These are relationships are reflected in the process of therapeutic domination (Daniel 2014; McFalls 2010).

These imbalances of power on structural and interpersonal levels are important, and concern with power dynamics pervades the anthropological literature. Power, however, does not exist in a vacuum, and understanding the people and mechanisms through which it is expressed, granted, rescinded, and flexed enables a nuanced analysis of the voluntourist and aid recipient interaction. Voluntourist identity is tension-filled and their intersubjectivity with aid recipients only deepens the contradictions.

Crossley (2012, 239) argues that to understand voluntourism, it is necessary to understand the desires and motivations at the “level of tourist subjectivity.” Crossley (2012, 248) contends that voluntourists are “invested” in definitions and representations of self, arrived at through their encounters with the Other. Schech (2017, 2) claims that voluntourists are motivated by 1) “ethical, faith-based, and/or political commitment to assist distant strangers,” 2)

“cosmopolitan aspirations to contribute to inter-cultural understanding,” and 3) “a desire to transform North-South relationships.” Other scholars also note the desire to “give back”

(Mostafanazehad 2014), gain “appreciation” for (Crossley 2012) and “reflect” on (Frazer and

Waitt 2016) what they have, and “bring about positive impacts” (Sin 2010). These motivations and desires separate voluntourists from the casual “relax-and-escape” tourists (Vrasti 2013).

Discursively, voluntourists are identified as “savvy, resourceful, sophisticated, cultured, sensitive, spontaneous, adventurous, and creative” (Vrasti 2013, 7). Similarly, Schech (2017, 5) explains that volunteers believe they are exercising “global responsibility” through taking vacations to “disadvantaged communities” in the Global South.

Additionally, voluntourism presents itself as an alternative to “destructive” mass tourism

(Vrasti 2013, 2). According to Sin (2010, 983), the “idea that volunteer tourism can and should bring about positive impacts” is central to the rhetoric surrounding volunteer tourism. The branches of scholarship that take up this stance advocate for and celebrate the expansion of volunteer tourism (cf. Withers et al. 2013; Zahra and McGehee 2013). While few of them contend that voluntourism is a panacea for global inequities, they align to the core ideology that the Global South is “better off with ongoing interventions,” than without them (Mostafanazehad

2014, 1).

The structural approach (Crossley 2012; Mostafanazehad 2014; Schech 2017; Vrasti

2013) argues that these motivations and identities are entwined within neoliberal power relationships. Schech (2017, 5) explains that neoliberal emphasis on partnerships between state, corporate, and civil society “has also led to the marketization of state-society relations, whereby gaps in public services are increasingly filled by non-state actors.”

Vrasti (2013, 3) argues that the normative desirability and motives of volunteers’ actions is less critical than understanding the “moral and material weight” volunteerism carries. It is a phenomenon taking place at the intersections of subjectivity, biopolitics, and capital with the context of neoliberal governmentality (Vrasti 2013, 3). Vrasti contends that the voluntourist, like

Comaroff’s medical missionary (1991), is engaged in Orientalist processes of affirming their sense of self by traveling through other people’s everyday lives (2013, 3).

The medical mission volunteers observed in this study are like the estimated 10 million volunteers and millions more professional humanitarians strewn about the globe. They are culturally constituted, part of a complex web of social relations (Geertz 1973), and their agency is mediated by these socio-cultural factors (Ahearn 2001). The intersections of their identities, and the historical contexts of those identities - their whiteness, and Americanness - are important factors in how they do what they call humanitarianism. Voluntourist and humanitarian subjectivities tell us about the agents engaging in short-term missions. They also reveal pathways to unintended consequences and the justifications for engaging in these practices, even when things go wrong. Understanding these subjectivities helps explain how clinical, social, and cultural iatrogenesis (Illich 2013 [1976]) occur despite good intentions. It tells us how volunteers produce and replicate colonialist ideologies and the systemic racism that organizes the institutions of humanitarianism and voluntourism (Benton 2016a).

Thinking through the experience of short-term medical mission volunteers in this way also allows us to understand how they embody, and carry with them, postcolonial racialized tropes, and in drawing on those tropes pose “significant risks to the very health facilities and patients they aim to assist” (Sullivan 2018, 315). As the literature reviewed here suggests, the postcolonial legacies have become encoded into the bodies, not only of the formerly colonized, but also into present-day volunteers who “inhabit this unmarked white postcolonial subjectivity”

(Sullivan 2018, 315).

Making and Being the Subjects and Objects of Medical Missions

If the medical mission encounter was a dialectic of self- and Other-making (Comaroff

1991), then how those on the receiving end of the encounter define themselves and embody, resists, or refuse their subjectivities must also be considered. How do medical mission volunteers, whether medical practitioners or lay volunteers know what they know about

Hondurans or about what constitutes good health? Similarly, how do Playa Felumians know what they know about health or the significance of the STMM encounters in their communities?

And how are their respective knowledges valued among each other and more broadly?

Epistemology, or how we know what we know, is rooted in socio-historical and culturally mediated ideological contexts. The production of knowledge, and the politics inherent to that project, as well as the link between power and knowledge, are critical to understanding the dynamics in the contemporary medical mission encounter. Identifying where and how complicated hierarchies of knowledge are reproduced (C. L. Briggs and Mantini-Briggs 2016), and how competing knowledges align, bypass one another, or conflict within the STMM encounter, is critical to the aim of this research project to ascertain when and how such hierarchies reinforce stereotypes, stigma, and unequal social relations thereby resulting in various forms of iatrogenic violence.

With few exceptions, studies about missionary medicine, volunteers, and aid broadly defined, have focused on either the aid recipient or the aid worker (volunteer, missionary,

“official” aid staff), but rarely as a panoramic. This study is there therefore distinct in its emphasis on the dialectic experiences of the medical mission encounter. Most studies consider the production and reproduction of aid recipient identities. Aid recipients have been theorized as biological citizens (Petryna 2010) or therapeutic citizens (Nguyen 2005; Nguyen et al. 2007),

who call upon the categorizations of disease or articulate their experiences in terms that render them eligible for aid. They are also called therapeutic clients (Whyte et al. 2013) who leverage the conditions of their body and relationships with state and non-state aid providers to maximize access to needed resources. They may be assigned and perform the role of sufferer (Fassin 2011;

James 2010). How individuals embody their subject positions and articulate their needs within as part of the medical mission encounter is part of how their own self-making process.

Theories of Disease Causation

Western biomedicine was developed and advanced via the crucible of medical missioning in the context of European colonization (Comaroff and Comaroff 1986; Green et al. 2013;

Mitchell 2002; Tilley 2016), and later through the public health projects associated with U.S. interventionism in Latin America and Pacific island countries (L. Briggs 2002; C. L. Briggs

2005). Medical practices, therefore, are also ideological practices (Singer and Baer 1995, 41) that reflect their colonial origins (Comaroff and Comaroff 1986; Green et al. 2013; Mitchell 2002;

Tilley 2016.) Recognizing biomedicine as one among many forms of ethnomedicine and ethnoscience (Good 1977, 26) forces us to reconsider the ways that illness and disease are characterized and the primacy of (bio)medical diagnoses as the only legitimate basis for understanding disease.

Contemporary biomedicine and its adherents may also attribute disease to dysfunction of the racialized body itself (McLean 2020), following popular models of biological determinism in biomedicine. Thus, genetic or racial difference is frequently invoked to explain the incidence of disease, especially diabetes and hypertension. For example, one of the most prevalent ideas within the biomedical literature is the “thrifty gene” theory, which suggests that fixed genetic makeup is the culprit of this metabolic disorder. Geneticist James Neel proposed the theory in 52

1962, suggesting that a gene provided a selective advantage among hunter-gatherers because it was especially “thrifty” in the utilization of food, which could be scarce or inconsistently available (Neel 1962; McDermott 1998). The theory further asserts that when these hunter- gatherers were rapidly shunted into westernized industrialization and foodways the so-called thrifty gene loses its advantage and increases susceptibility to obesity and diabetes. Neel’s theory offered a simple and seductive hypothesis to explain the high prevalence of diabetes among indigenous and other colonized peoples around the world (McDermott 1998; Moran-Thomas

2019). However, his theory has been unable to explain the increasing incidence of non-insulin dependent diabetes. Moreover, evidence that a “thrifty” gene exists in human biology has not materialized. This approach continues to dominate biomedical practice despite critiques and the availability of stronger theories (McDermott 1998; Moran-Thomas 2019).

One consequence of biomedical theories of disease is that explanations for disease must be contained within the body – ignoring or erasing the influence of external factors on the body – simultaneously shifting responsibility for disease onto the individual. According to Singer and

Baer one of the primary political benefits of this approach to medicine is the fact that disease would not be seen as “an outcome of specific power relations,” but rather the result of an immediately observable factor in the body, the bacteria (1995,13).

Whereas social theories of disease consider the role of a variety of environmental, social, political, and other structural factors, biomedical theories of disease often place responsibility for the burden of disease on the individual. These theories manifest as discourses of compliance and non-compliance or deviance (Lyon-Callo 2000; Smith-Morris 2006; Whitmarsh, Ian 2013).

Those seeking healthcare from medical missions are also often interpellated as compliant or non- compliant (Whitmarsh, Ian 2013). The consequences of these discourses are two-fold. First, this

language reinforces the authority of biomedical ways of knowing and healing, dismissing or erasing other forms of healing as inferior or illegitimate. Cultural meanings of illness impact how people experiencing an illness are perceived by medical practitioners and their wider community.

Cultural meanings mark the sufferer, potentially stamping them with stigma or even death depending on the illness (Kleinman 1989).

Second, it either positions the patient as behaving badly - in intentionally maladaptive ways - by willfully refusing to listen to or comply with the authority of biomedical knowledge and its practitioners, or it positions patients as ignorant, not knowledgeable about their health and healing, unable to take care of themselves without intervention. Some scholars have noted that the skill with which individuals seeking care are perceived to be compliant has a direct relationship to whether medical missionaries (and other care providers) view and treat them as

“deserving” and worthy of aid and care (Bornstein 2012; Froyum 2018; Nguyen et al. 2007;

Whitmarsh, Ian 2013).

While biomedical approaches have had a more myopic focus on the body (Foucault

2003) and disease causation and emphasized individual responsibility, this project situates

Honduran health within a framework of social suffering (Kleinman, Das, and Lock 1997), rather than as a purely biomedical phenomenon marking the absence of disease. Anthropologists have long noted the causal relationship between structural inequalities and the physical health of individuals, a trend gaining now traction among some in the medical community as well.

Structural violence describes the ways that social systems (to include the political and economic) cause injury to individuals and populations (Farmer 2006; Galtung 1969; Tilley

2016). Embodiment theories explain the ways that the effects of structural violence become inscribed on the body, as well as the ways that people’s bodies convey or resist the realities of

their social and physical environments (Nguyen and Peschard 2003). The framework of social suffering considers the wider societal context and the political and economic conditions that individuals and communities embody in the form of illness or that complicate the expression or experience of illness (Budrys 2010; Kleinman, Das, and Lock 1997; Fassin and Rechtman 2009;

Singer and Baer 2012, 90).

Biomedical theories of disease causation posit that the specific pathological cause of disease, noted by Foucault (2003) and Singer and Baer (1995), is the bacteria (or virus), that is immediately observable upon the body or via a particular symptomology (Good 1977).

Biomedicine tends to focus on the microbial cause of disease and ignores the social and cultural context of illness and the practice of medicine (1995, 13). This view marked a shift in medical approaches that decontextualized and depoliticized the body and the causes of disease (Foucault

2003). Ultimately, medicine has become disembedded from its social contexts. One of the consequences of this fact in North American biomedical practice is that the social causes of distress become obscured through the focus on symptoms and result in a focus on the personal responsibility and lifestyle of the individual experience illness (Kleinman 1989).

Likewise the process of diagnosis is informed by the position of the biomedical practitioner (Kleinman 1989). Biomedicine is not just a powerful system with social control functions, but also is deeply embedded within the capitalist world economy (Singer and Baer

1995, 5), as it was during its colonial beginnings. Thus, the political-economic and social forces that comprise biomedicine, including the exercise of power, are inherent in the processes and exchanges that shape health, disease, illness experience, and health care (Singer and Baer 1995,

5). Thus, the ways that biomedical practitioners listen to a patient’s retelling of their illness experiences is pre-informed by that practitioner’s personal interests and biases, which impact not

only what and how they hear the account, but also how they interpret it (Kleinman 1989, 124).

As Kleinman notes, “the priorities of the practitioner lead to selective attention to the patient’s account, so that some aspects are carefully listened for and heard (sometimes when they are not spoken), while other things that are said—and even repeated—are literally not heard” (1989,

124-125). This in turn influences how people shape their illness narratives.

Illness narratives are thus one of the key methods by which individuals communicate their embodied experiences and their needs in the medical mission encounter. Illness experiences usually involve multiple meanings and each is significant in its own way (Kleinman 1989). The symptom-level meaning of illness is the most superficial. Diagnosis, in biomedical ethnomedicine, is the process of linking symptoms to a disease category through interpretation of those symptoms (Good 1977). If symptom meaning of illness is a superficial signal of distress, and cultural meanings assign meaning to the sufferer from outside themselves, illness also accrues meaning from the lived experience of the sufferer (Kleinman 1989). “Acting like a sponge, illness soaks up personal and social significance from the world of the sick person”

(Kleinman 1989, 85).

The ability of individuals to effectively cope with, resist, or rework the cultural meanings of their illness experience depends on the resources available to them (Kleinman 1989). Nichter has argued that idioms of distress are semantic strategies for coping with distress (1981, 2010).

Idioms of distress are metaphors of the body that communicate the physically felt clashes between cultural expectation and socially and culturally relevant ways of expressing and experiencing distress in local worlds (Nicther 2010, 405). Idioms of distress index past trauma, current stressors, anger, powerlessness, social marginalization, insecurity, and future or anticipated sources of anxiety, loss, anger. They may be not only idiomatic expressions, but also

present as medicine-taking behavior, use and reframing of biomedical terminology, use of diagnostic tests and healthcare seeking (Nichter 2010). They build on Good’s (1977) theory of semantic illness networks that reshape the meaning of medical language, and therefore illness and cure, within specific social and cultural contexts. Good’s (1977) theory demonstrates the iterative process in medical encounters and offers a way to understand how individuals experiencing distress help to interpret and shape the meaning of the very medical terms taken for granted within biomedicine.

These are strategies through which individuals experiencing illness or other forms of distress exert their own agency, make sense of their illness experience, and engage in the process of self- and Other making from their perspective. In the next chapter I discuss the methodological approaches and the practical application of the literature to the medical mission encounter.

CHAPTER 3

METHODOLOGY

This research addresses the effects of short-term medical missions on the health and broader social, economic, and political context in Playa Felumi and Honduras. Throughout this research project I aimed to examine the research question from various points of agency. Much of the existing research has focused solely on volunteers. A few studies have focused on the perspective of the people seeking aid (Berry 2014; Carruth 2011; Citrin 2012; Green et al. 2009).

In either case, we get only a fraction of the whole picture. For this study, I wanted to collect as much data from community members - patients, health workers, administrators, educators, youth, elders, and intellectuals - as from medical mission volunteers. I wanted to design a study that would allow aid recipients to share their own illness and health experiences and give them space to offer feedback to missions and researchers. Critically, I wanted to ensure that in assessing medical mission effects, the metrics included the ways that Hondurans, and specifically

Garífuna, define and experience health and illness. I also wanted to understand whether and how medical missions become part of the social fabric of the places where they work.

To understand what effects the medical mission encounter has on health and social realities, I conducted mixed methods ethnographic research among eleven medical missions in the town of Playa Felumi between July 2014 and June 2015. In this chapter I first outline the conceptual framework for this study, how I define the key research question concepts of health and social effects, and the rationale for the use of mixed methods in this ethnography of the contemporary medical mission encounter. Next, I explain my positionality as a researcher before proceeding to a detailed discussion of the mixed methods approach used to collect and analyze these data.

How to Measure Medical Mission Effects

As mentioned in Chapter 2, to date there have been unnervingly few studies across disciplines on the health effects or outcomes of short-term medical mission interventions around the world. There are only two studies that suggest a rubric by which to make such an evaluation, though neither conducts nor presents the results of any such evaluation (Martiniuk et al. 2012;

Montgomery 2007). The is one study that uses the Primary Health Care model as a framework and attempts to conduct the proposed Harvard evaluation methods with a variation to include pre- and post-mission interviews with community members (Tracey 2015). Notably, all of these studies took place in Honduras.

Martiniuk et al. (2012) propose what is called the Harvard Model, a survey and interview-based evaluation model. However, as several scholars note, it relies on self-evaluation and does not include an effective method for collecting data from medical mission attendees. It does attempt to collect some data, but it still critically relies on medical mission volunteers’ perceptions of their work. Both Montgomery (2007) and Tracey (2015) frame their analysis in the context of the principles of Primary Health Care (PHC) championed by the Pan American

Health Organization (PAHO). Tracey combined these principles to develop the Revised Harvard

Model and incorporate mission attendee’s stated needs and evaluations of medical mission outcomes. Although Tracey’s work includes survey and interview responses from the various actors involved in the medical mission encounter, the study is not ethnographic. This study is therefore among the first ethnographic works to evaluate the health and social effects of contemporary medical mission encounters.

Are Medical Missions Filling Gaps?

It is clear from both the form and function of short-term medical missions and the available research – largely descriptive though it may be – that medical missions do not and cannot provide primary or preventative health care, nor according to their own mission statements or individual volunteer statements do they intend to do so. As such, while it is important to keep the principles of PHC in mind and consider the ways in which STMMs may actually act as barriers to the effective deployment of this healthcare model in host countries, it also seems to make attempts to test the health and social outcomes of medical mission encounters in Honduras (or any country) against PHC moot.

Instead, I frame my evaluation of the medical mission effects on “the gaps” identified by the local health system authorities, the Ministry of Health, and the Pan American Health

Organization. In Chapter 1, I outlined the leading biomedical and social health concerns as identified by the Honduran MOH and PAHO. If medical missions are meant to complement or supplement the existing services in Honduras, evaluating the extent to which missions coordinate with local health workers and incorporate these pre-identified needs and public health priorities into their interventions can tell researchers about the extent to which they are (or are not) filling the gaps, duplicating services, or impeding efforts to effectively address the leading health priorities. Moreover, this information is typically available to the public about all countries included by the World Health Organization and the Western Hemisphere arm, PAHO, and usually the country’s health authorities (and in English, so language is not a barrier to medical mission organizations, for example). Using the identified health needs of a given country as a starting point for analysis of effect and social impact seems an accessible and appropriate way to assess medical missions wherever they may be operating in the world.

Similar to other studies (Greene et al. 2009; Berry 2014; Tracey 2015), I used ethnographic methods of participant observation and semi-structured interviews to ascertain the stated needs of medical mission visitors at the site of the specific medical mission encounters I studied. These too formed the basis for measuring medical mission outcomes and whether contemporary medical missions are meeting the needs of Hondurans as claimed or intended.

Defining Health

Depending on one’s worldview, influenced by one’s dominant culture and education, what constitutes “health” or good health, may vary significantly. One of the tensions within the

STMM encounter is the supremacy of the biomedical approach to health and well-being. Critical

Medical Anthropology (CMA) reintegrates biomedicine into its socio-cultural context. CMA argues that western ideological assumptions tend to be the default measure, even among some medical anthropologists (Singer and Baer 1995, 4). Ethnomedicine, for example, is often measured according to the standards and measurements of Western biomedicine, rather than biomedicine more accurately being included within the category of ethnomedicine (Singer and

Baer 1995, 4). Therefore, rather than solely using biomedical definitions of “health,” the absence of disease, as a baseline or treating biomedicine as distinct from ethnomedicine, this study incorporates the ethnomedical perspectives, knowledges, definitions, and illness narratives of everyone involved in the medical mission encounter.

There were also competing definitions of health and well-being among biomedical practitioners. Despite each country in the world having its own specific benchmarks and specific measurements of health metrics, like nutrition, North American medical missionaries use U.S.- based health standards uniformly. This frequently resulted in contradicting diagnoses or frustrations among Honduran biomedical personnel with the presumed superiority of medical 61

mission personnel. Definitions of health in this study, therefore, also include variations in biomedical approaches of the participants. I collected local demographic and health statistics and reports from the CESAMO and Mayor’s office, as well as reviewed medical records in both the medical mission clinic and the CESAMO, in addition to the health data I gathered through participant observation and interviews.

Establishing how health is defined allows for evaluating the effects that medical mission have on health, and whether those effects are positive, negative, or inconsequential. I used the health priorities identified by the Honduran MOH and PAHO, in conjunction with the definitions of health identified by medical mission volunteers, Honduran healthcare providers, and

Hondurans seeking healthcare, to evaluate whether and how medical missions are meeting their stated goals and effectively “filling in gaps.” I observed practice and discussions about treatment protocols and paid careful attention to discussion and administration of medications in order to compare those to Honduran pharmaceutical formularies (the list of approved medications that are included in MOH hospitals, CESAMOs, and CESALs) and best practices for treatment of key illnesses (e.g., of parasites) as determined by PAHO and adopted by the MOH.

Defining Social Effects

The social effects of medical mission encounters are often explored in abstract terms in the literature but primarily focus on the medical mission volunteer. In terms of the effects on local communities, McLennan (2005) and Montgomery (2007), for example, identify concerns about ways that medical mission activities detrimentally impact local health practitioners and change health seeking behaviors among residents. Others note locally expressed concerns about or data suggesting patterns of behavior and discourse among medical mission volunteers that disrespect or erase cultural variation or have negatively impacted resident self-perception (Berry 62

2014; T. Green et al. 2009). This study addresses social effects explicitly. To do so, I draw on social impact analysis (SIA) frameworks (Dietz 1987; Goldman 2020) to evaluate the broader social effects of medical missions in Honduras. Typically, the scope of social impact analysis is at the macro level or is looking specifically at the potential short- and long-term effects of development projects, e.g., a hydroelectric dam, on a particular location and its inhabitants. This study is not a social impact analysis but borrows from SIA’s well-established definitions of social effects to evaluate the short and long-term effects that short-term medical missions have on these same variables. While I focus on the micro or local level of analysis, the findings suggest that medical mission activities are also implicated in macrolevel political economic processes.

I define social effects as measurable impacts on 1) ways of life, such as how people live, work, play, and interact with one another; 2) Effects on culture, including shared beliefs, language, values, and customs. Such effects might manifest through changes in ways people use

(or do not) use their own language, shift language, shift values, or change, modify, or abandon ancestral and indigenous knowledgeways regarding health and healing; 3) Community, particularly the effects interventions have on locally available healthcare services and facilities and collective shifts in beliefs about those resources.

These elements of SIA correspond nicely with the structural approach that Bonell et al.

(2015) suggest for constructing the “dark logic” model for evaluating the potential or actual adverse, or iatrogenic health effects of medical interventions. One differentiation is that Bonell et al.’s model allows for a panoramic view of interventions, identifying the agency of all actors involved in the encounter and the social structure that enable or constrain that agency.

Furthermore, the dark logic model builds on Lorenc and Oliver’s (2015) categories for the

evaluation of the public health interventions. These categories provide a tool for defining harmful health and social effects of medical mission encounters. Direct harm and psychological harm correspond to health effects defined above, and equity, group and social, and opportunity cost harms correspond to social/structural effects (psychological harm overlaps with the social effects category as well). Direct harms are those where the intervention produces a directly harmful effect. Lorenc and Oliver identify psychological harms as negative impacts resulting from false-positives in diagnostic testing, health education campaigns that generate worry, guilt, and otherwise negatively impact well-being and health-related behaviors (2015, 288). Equity harms are those that result in worsening health inequalities. They note that these are particularly relevant to individualistic and “responsibilizing” approaches, or those that target specific groups rather than broader population-level applications (Lorenc and Oliver 2015, 289). They add,

“Equity harms raise complex ethical and methodological questions, since they may exist even where no individual in the population is worse off as a direct result of the intervention. However, given the evidence that inequality at a societal level is itself harmful across the population as a whole, it is clear that effects on equity are an important dimension of the potential harms of interventions” (Lorenc and Oliver 2015, 289).

Group and social harms overlap with the aforementioned harm categories and are concerned with the potential to reinforce entrenched stereotypes or increasing stigmatization of targeted intervention objectives. Finally, opportunity cost harms relate to other potential solutions and resulting benefits being missed out on because resources are already committed to ineffective, less effective, or less serious public health problems (Lorenc and Oliver 2015).

To gather data about the social effects I relied primarily on participant observation in

Playa Felumi, as well as household interviews and follow-up in-depth interviews, art and discussions with children and youth. I asked questions about everyday life and any periodic, gradual, or rapid changes among people, places, and institutions over time, and their experiences

in Playa Felumi and beyond. I also listened carefully to people’s illness narratives (see chapter

2), which often contained important social, political, and economic information.

Conducting research in this way presents several methodological challenges. However, the ethnographic incorporation of so many moving parts ultimately reflects the complex and multifaceted nature of medical mission encounters.

A Quick Note about Names

Throughout this study the people, places, and organizations have been assigned pseudonyms. The exceptions to this naming convention are major cities and towns in Honduras, the names of sponsoring organizations and individuals, and when a place has a common title that does not include identifying characteristics, for example CESAMO is the common abbreviation and colloquial name for Municipal Health Centers located throughout departments and municipalities in Honduras. All names of short-term medical mission staff, volunteers, clinic and organization, as well as the names of CESAMO staff, residents, and the name of the town where the study took place have been changed.

Positionality

In taking a dialectic approach to the research question that incorporates research participants often observed independently of one another, my role as researcher in this study meant something different to each group of participants. My involvement with Honduran social movements over the past twelve years, in addition to my experience as a “veteran” STMM volunteer, makes my position relative to the participants in this study and the topics I explore complex.

I began this research after many years of involvement with STMMs. I embarked on the first of nearly 20 medical missions 17 years ago. My parents signed me up after returning from a mission trip to Honduras. I had never traveled abroad up to that point, so I was excited, even if I had no idea what it meant. I was finishing an undergraduate degree in Spanish, so I went as a lay volunteer and “interpreter,” though I certainly did not have the fluency of a medical interpreter. I quickly learned this was the norm, as it is rare for STMMs to have a professional interpreter on these trips. I went on two trips a year nearly every year over the next decade. My relationship with STMMs changed as I began to wonder why the voices of the Hondurans that we encountered rarely figured into the mission organization’s interventions.

It shifted further still, as I became more involved with research about and solidarity with social movements in Honduras. In 2009, I met Dr. Luther Castillo who was visiting Chicago on a human rights delegation shortly after the coup d’état in June of that year. Dr. Castillo is a

Garífuna doctor trained at the Latin American School of Medicine in Cuba, community leader, and founder of the First Popular Garífuna Hospital. He was my contact and research participant in my Master’s research, and served as my in-country sponsor and a vital resource in helping establish my fieldsite and credibility in Playa Felumi for this research project.

My experiences as an STMM volunteer and my identity as a white American woman reveal the subjectivities I share with the STMM participants I observed. So, in addition to studying the “up” and “down” power relations between STMM volunteers and STMM patients

(Nader 1972), I also studied sideways. Following Hannerz (1998) and Plesner (2011), I acknowledge the cultural and social similarities – including race, ethnicity, education, and social class – that I share with STMM volunteers, and the importance of my extensive experience with

STMMs in my interactions with them, particular in the dynamics of our conversations and

interviews. Unlike my Playa Felumian participants, I could go into the “private” spaces of the

STMM clinic – the kitchen and common rooms. I was allowed to join teams for morning coffee, meals, “downtime” games and interactions.

My experience with STMMs and my fluency in Spanish and familiarity with how

STMMs work in stations, the typical routine, and their hierarchy, made it easier for me to conduct participant observation once I gained access. Despite being something of an “insider” into the world of STMMs, my desire to study STMMs and understand their effects made many volunteers nervous and my unfamiliar face marked me as an outsider to the organization. A few physicians adamantly opposed my research and declined to participate in interviews or direct observation of their consultations. They argued that I was unqualified to evaluate their activities and that the qualitative nature of ethnographic fieldwork held little scientific value. Other physicians, nurse practitioners, and lay volunteers were curious or even encouraging. STMM volunteers are not accustomed to outside observation of their work, and during my visits with them to explain my research and request permission to observe them and work among them, some expressed concerns over how I would “report” their activities. For example, lay volunteers were concerned about the common practice of dispensing prescriptions. I assured them that who dispenses medications is not an issue, although how decisions get made about what prescriptions to give does figure into my analysis. Ultimately, I received the permission of team leaders, many of whom are on the Board of Directors, to carry out participant observation in the clinics and the permission of individual volunteers to observe and interview them directly – I avoided any of the volunteers who declined to participate. The HMH board of directors also granted explicit permission for me to review the clinic’s medical records.

Unsurprisingly, Playa Felumians recognized my similarities with STMM volunteers immediately. My whiteness, my North Americanness, and my proximity to and study of

STMMs, led many residents to assume I was medically trained and part of the STMM organization. It took several months for residents to refer to me by my name or as an anthropologist, instead of “doctora.” At times, residents asked me for medical advice (I abstained), or for prescriptions (I declined). The CESAMO staff, despite knowing I was not medically trained beyond some basic first aid, but that I had worked with STMMs for a long time, sometimes asked me to perform procedures, like suturing wounds (I declined!).

Initially, I had hoped to conduct multi-sited research. However, within three months I realized I would need to spend much more time in the community in order to gain the level of trust necessary to elicit community members' genuine appraisals of medical mission volunteers and their activities. Community members were adept at performing the role of the grateful recipient and therapeutic citizen, and until I was able to disentangle their perception of me from the mission volunteers' activities, it was difficult to convince my interlocutors that I sought and welcomed their frank analyses of medical mission activities and volunteers. So, rather than stick with my original research plan to relocate to a second site at the six-month mark, I stayed in

Playa Felumi.

Even people who came to know me well, like the staff at the CESAMO who were asking for my help, conflated my white American identity with medical expertise. This is a reality that many STMM volunteers take advantage of at worst and are unaware of at best – anyone on a medical mission is deferentially referred to as “doctor” and assumed to have medical knowledge.

This is partially due to the fact that STMMs often operate in ways that blur the roles or positions of volunteers. If everyone wears scrubs as practical, easy to wash and comfortable clothing,

rather than a marker of their professional knowledge, that is known only to them. To everyone else, the symbolic meaning of these garments is already established. For this reason, I never wore scrubs or anything that could explicitly mark me as a medical professional. And yet, the persistent association of whiteness with medical brigades and these symbolic slippages over two decades, meant that my skin color in conjunction with the spaces I moved in and out of was already associated with medical expertise in Playa Felumi.

Despite my obvious foreignness, fluency in Spanish and my interest in learning and speaking Garífuna, even in a limited form, facilitated good communication with residents of

Playa Felumi and helped me build rapport. My sponsor, Dr. Castillo, vouched for me and helped settle me in housing with a respected community leader and teacher, which gave me added clout when meeting new people in town. My knowledge of and experience with popular struggles in

Honduras and Garífuna land repatriation and activism opened doors to conversations that might have otherwise been more guarded. The trust I earned and rapport I established granted me invitations to birthday parties, novenarios (ritual wakes on the first anniversary of a death), funerals, religious mass, and to just “hang out” with people in their homes or on their errands.

While few STMM volunteers have kept in regular contact, I maintain relationships with several people in Playa Felumi. Other challenges I encountered were not so easily mitigated.

Safety was a major concern throughout my time in the field, and lethal violence reached intense levels that shook the Playa Felumi community and has had lasting effects on my health and the health of many of my research participants and friends. During my time in Playa Felumi, there were several deaths. There were three violent deaths, some violent altercations resulting in grave wounds, and deaths of sick children and adults that directly affected my interlocutors, and in some cases directly affected me. In collectively experiencing traumatic events and in the

process of bearing witness to the traumas experienced by my interlocutors, I also experienced trauma. These experiences exclude any instances of trauma among the medical mission volunteers I encountered; in my observations, they were usually unaware of local traumatic events. I observed doctor-patient interactions that might have been conducted differently had volunteers been more aware of related social and political trauma.

Data Collection

This study entailed 11 months of continuous fieldwork in Playa Felumi, a Garifuna town in rural Honduras on the Northeastern coast in the department3 of Colón. I rented a room in a house from a Garífuna woman who currently lives in New York most of the year. Her house is part of a three-house compound shared with her sister and mother, who each have their own houses. I never met my official landlord, but negotiated instead with her sister, a charming woman who became a good friend and offered her insights as a cultural expert and respected member of Playa Felumi. I lived in a central location in town, near Clinica Blanca and the Centro de Salud Municipal (CESAMO).

Walking Around Town

I conducted nearly all of my ethnographic research around town by foot in the way that the vast majority of Playa Felumians do every day. Very rarely, I traveled by mototaxi, a three- wheeled buggy with a small engine. As a result of walking the town, I was able to note the landscape, average walking distances from every vantage point of town, and the level of difficulty to get to and from Clinica Blanca, the CESAMO, or other necessary services. These

3 In Honduras, Departments are the administrative, cadastral equivalent of states or provinces in other Republics. 70

data were particularly useful in assessing obstacles to healthcare, including what individuals would or could tolerate in order to pursue health-related activities and the kinds of social and financial costs incurred as a part of regular healthcare activities. With this information, I was also able to contextualize 1) the imperative of CESAMO staff to accommodate health-seekers who lived much farther away than others and 2) the frustrations and dwindling patience of those enduring long waits at Clinica Blanca in the face of very long walks home in the dark, often with small children.

My goal was to observe STMMs as they worked in the community and, when STMMs were absent, to observe healthcare provision at the CESAMO. In addition, I conducted a total of

51 semi-structured interviews among households selected from among the seven neighborhoods that make up Playa Felumi. I conducted interviews by neighborhood. I approached each house I walked by, and if the house was occupied, I asked the resident if they were willing to participate.

If the resident consented and allowed me into their home, I conducted the interview, spending anywhere from 15-45 minutes with an interviewee. My stay depended on the length of their responses to the survey questions and willingness or interest in speaking with me. If the home was unoccupied or no one answered I moved on to the next house. Similarly, if a potential participant declined to be interviewed, I made a note and moved on to the next house. Due to work and school schedules of residents and their children and to the often-scorching heat, I conducted home interviews in the mornings between 8am and 12pm. Children were either retrieved or arrived home (walking) from school at 12pm or left home for the afternoon cohort of classes.

Most of my interviewees were women, with only a few men, which is a function of the gendered division of labor in Playa Felumi. Women heads of household who still work in the

subsistence fields left home between 3am and 5am to work out of the heat and often returned between 8am and 9am. Men often work between the hours of 3am and 12 or 1pm as these are the best hours for fishing and crabbing. There are a few dozen men and women who are employed in bureaucratic positions in the Playa Felumi municipality, and thus work between the hours of 8am and 4pm (more or less). Men are not typically counted as head of household in Garifuna communities, due to the matrifocal nature of Garifuna society (González 1988), however, there are a few male heads of household in Playa Felumi.

Garifuna women are considered heads of household more frequently than men and it is customary for women to retain title to communal lands and rights to determine how that land gets used and disbursed as inheritance. Changing land tenure laws, uneven development, and intimidation and land usurpation on massive scales are rapidly affecting Garifuna communities and Garifuna women disproportionately (Brondo 2013; OFRANEH, n.d.).

Participant Observations among STMMs

I organized my research around the planned schedule of the mission-sending organization that recruits and maintains the mission site in Playa Felumi. Teams travel to Playa Felumi between late February and late October annually. Teams will not travel to the area between late

October to early February, during “el tiempo de lluvia” (the rainy season), because tight travel schedules leave little room for the capriciously timed inconveniences of flooding and washed-out bridges. I arrived in Playa Felumi on August 3, 2014 and remained there until June 27, 2015. In that time, I observed 11 STMMs as part of my primary field site.

There are several challenges to on-site observation and interviewing in any brigade clinic.

Brigade clinics are often set up in local churches, primary or secondary school rooms, or other makeshift spaces. And the focus on seeing as many patients as possible in a day, makes space for 72

extraneous conversation scarce. Health Missions Honduras (HMH) are also a bit different from the norm in their physical setting because they return to the same place multiple times a year and have built their own dedicated clinic space in Playa Felumi. Although some teams will split up their volunteers or dedicated one or two days of their trip to daytrips to villages further afield, the majority of their visits take place in Playa Felumi. Some teams even opt to use the repurposed school bus HMH owns that to pick up people from nearby villages to attend the clinic rather than leave their base. All of the teams and volunteers return to Clinica Blanca in time for dinner – and generally before dark. Fortunately, years of traveling with missions and an understanding of their flow allowed me to adapt my study to those particularities.

Direct observations of clinic interactions allowed me to gather data about both medical mission visitors and volunteers, often in the same encounter. It also allowed me to talk to some volunteer physicians and nurse practitioners in more depth about their decisions, their beliefs, and their perceptions about their work and their patients. I was also able to observe the power dynamics among volunteers in the clinic and non-clinic volunteer spaces. The clinic space is extremely hectic most of the time, so while I could manage a few in-depth conversations in the interludes between patients or during break times, like lunch or the post-clinic pre-dinner space, it was difficult to complete semi-structured interviews without multiple interruptions. Based on my experiences with medical missions, I anticipated this would likely be the case, and asked mission volunteers to complete journals as well. I also incorporated a survey to supplement the ethnographic data.

I closely observed 13 medical professionals as they consulted, diagnosed, and prescribed treatment patients: eight physicians, three nurse practitioners, one physicians’ assistant, and one dentist. I usually sat with these doctors for a minimum of three hours and up to six hours in a few

cases. I also worked in the triage area during most brigades, and eventually in the pharmacy. I observed the waiting room on numerous occasions and conducted brief informal interviews with individuals sitting or standing in the queue. I also often worked as a consecutive interpreter for the physicians and patient (with explicit permission from the patients) while observing consultations.

I observed and interacted with STMM volunteers when they were not "on duty," during their breakfast and devotional times (for those who held religious devotionals), during their lunch breaks, at dinner and recreational times, while playing games or simply conversing. As a participant observer, I played cards and board games, I joined conversations, and shared meals with STMM volunteers. Where volunteers consented, I conducted informal interviews during these downtimes, and when permitted, made audio recordings of the conversations, although many volunteers expressed unease at being recorded.

I did not travel with STMMs to other towns in the municipality to do one-day clinics.

Instead, on those days I worked in the CESAMO, taking special note of patients whom I had already seen at the brigade clinic, or with whom I had conducted household interviews. When the teams returned in the afternoons, I joined them for dinner and to listen to their narratives and descriptions of their day in what the teams often term the "outlying clinics."

Medical Records Review and Surveys

I also obtained permission from the Board of Directors of Health Missions Honduras to review patient medical records at the STMM clinic. It is a rarity that STMMs complete, much less store and maintain, medical records in the places where they operate. This often has to do with the temporary and itinerant nature of STMMs that I describe in Chapters 4 and 5. Clinica

Blanca maintains approximately 3,000 patient records, although if someone dies or moves away, 74

their records are quickly destroyed (usually in the burn pit with the biohazard materials and waste and selected expired medications). The documents go back a little less than half of the time the organization has been operating in Playa Felumi. Medical records were not kept for patients prior to 2004. All records are stored in a locked room in Clinica Blanca in manila folders, ordered alphabetically by first name and by town. Records for individuals diagnosed with diabetes are separated, regardless of residence, and kept in a different section altogether.

This preferential ordering is partly to facilitate the STMM team that comes once a year and focuses specifically on diabetes (see chapter 10).

I was unable to obtain consent from patients. However, I reviewed all records alone and no identifying information aside from age and gender was recorded in order to protect the privacy and anonymity of the patients. I took a sample of ten percent of the records. I took every

30th record and reviewed the age and gender of the individual, the diagnoses, the number of visits to Clinica Blanca and the duration of time over which these visits were sought. I also evaluated the completion of the records, whether there were annotations in the record, and whether a treatment plan was included, and what, if any prescriptions were written. Some volunteers, usually physicians, and sometimes other medical personnel, were skeptical of my ability or qualifications to conduct a medical records review. I explained upon questioning that I was not reviewing them to decide whether a diagnosis or treatment plan was correct or incorrect since I am not a physician and cannot authoritatively make that determination on my own.

Instead, I was reviewing them to understand what kinds of diagnoses were most often made, if there were any changes in diagnoses to the same individuals or clusters of symptoms over time, what the frequency of antibiotic prescription was, and whether, and how consistently, records were completed. This assessment included documenting whether there was any consistency in

patient charting. I also would use the information to determine the similarities and differences within the medical records kept at the CESAMO based on the same values: age, presenting illness, physical exam notes, diagnoses (if any), plan of care and prescriptions (if any). I also ultimately compared the methods for making diagnoses and care plans with current best practices in Honduras and as defined by PAHO.

The goal was to have an empirical basis for evaluating the kinds of concerns for which individuals have sought healthcare from STMMs in Playa Felumi, how the same symptoms and health complaints are typically treated, and whether there were any changes in frequency of visits or health complaints over a 9-year period (from 2005-2014). These data could then be compiled and assessed in the context of other data to answer my guiding research question about the effects of STMMs on health outcomes. In the decade before I began my field research,

STMM volunteers I travelled with often expressed concerns about "continuity of care," and it was no different while I worked in Playa Felumi. Thus, a qualitative review of patient medical records offers concrete evidence with which to discuss continuity of care and practices that either help or hinder STMMs in addressing this common concern of healthcare practitioners.

I collected 53 surveys from STMM volunteers. Initially, I had hoped to collect journal entries from STMM volunteers. There was promising initial interest from volunteers in writing about their experiences. They were given the option to free-write or to follow some prompting questions if they were not sure where to start. Ultimately, I was able to collect 10 journals. Some volunteers expressed disinterest at the initial request, while others agreed but were unable to complete journals because of the long hours and mental and emotional fatigue that volunteers often experience while on STMM trips. To put it plainly, people were just too tired and

overwhelmed to put pen to paper after a long, hot day. The journal entries collected from the 10 volunteers who participated provide excellent supplemental data.

I developed surveys as a solution to the insufficient journaling data. The surveys asked a variety of questions in both closed and open-ended format. I administered them electronically, via SurveyGizmo. The survey included 22 questions that asked for general demographic information about volunteer background, experiences in Playa Felumi, and finally asked them to answer a few reflection questions. Volunteers could finish the surveys at their own pace, from any electronic device. I sent out 103 survey invitations to all of the volunteers who agreed to participate in the study (79.2 percent of total STMM volunteers (130) on all trips), signed consent forms, and supplied their emails to receive the survey link. Over 50 percent of those volunteers participated in the surveys, and respondents, although they self-selected, were representative of the STMM volunteer population and division of labor as a whole (see chart in chapter 6), yielding an excellent data set. While 55 volunteers began a survey, I removed two surveys that were initiated, but ultimately cancelled by the participants.

Participant Observation at the CESAMO

When STMMs were not in town—every two to four weeks between February and

October and for the entirety of November, December, and January—I conducted similar participant observation at the CESAMO. I queued up with visitors, sat in the waiting room and conducted informal interviews, sorted and distributed prescriptions in the pharmacy, observed and conducted triage intake, observed consultations, assisted with inventory of supplies and medications, and attended staff meetings. I also joined the CESAMO staff on vaccination

"campaigns" and follow-up home visits.

As at the brigade clinic, I also was granted permission to review CESAMO patient records. Because of the way that medical records are kept at the CESAMO, each file I obtained included the entire family associated with that file. Medical records are kept and ordered by household, not solely by individual, as is customary in U.S. medical record-keeping practices. As a result, I selected only one record from within each file, in order to keep the sample representative of the larger population. I chose the first record in the file both to try and maintain randomness and to keep the health center's medical files in order.

At all times when I worked in the CESAMO (or in the brigade clinic), I made clear to care providers, patients, and family members that I am not a medical professional and could not provide medical advice or prescriptions, and that if I was working in the pharmacy, I could not give them additional medications or supplies that were not prescribed or approved by one of the

CESAMO staff. I never administered injections, vaccinations, or performed medical procedures.

I was once asked if I could make "pretty" stitches, the patient in question had a nasty gash on his face and the nurses were concerned about leaving an unnecessary scar. I answered with a sympathetic but emphatic no. As instructed, I would assist CESAMO staff by holding or finding medical instruments, solutions, supplies, or medications, and on occasion I set up and administered nebulizations (breathing treatments) to patients of all ages (I am intimately familiar with the procedures as a childhood asthmatic and adult with frequent respiratory illness requiring nebulization). No breathing treatment contained medicated solution, only saline solution. When I worked in the triage area, I took axillary and oral temperatures per instruction, measured height and weight, used a sphygmomanometer (blood pressure cuff) to record blood pressure according to CESAMO procedure and at the direction of CESAMO staff, and completed the intake forms as instructed and in accordance with CESAMO policy.

Collecting Data with Youth in Playa Felumi

It was also critical to this research project to incorporate children and youth perspectives.

Indeed, some of my exchanges with youth participants were among the most insightful.

Researchers often talk about representative sample sizes, referring to distribution of binary gender or socio-economic status. But children are often overlooked unless they are the specific population being studied (Hunleth 2011; 2013a; 2013b; 2017). In research on STMMs, and arguably any research that is concerned with humanitarian intervention, we must consider children and youth part of our representative samples. In the case of STMMs, children are the primary "targets" of aid. Adult treatment is treated by missions as secondary to the attention to children. Volunteer photos are most often of children, and those are the photos most often circulated to donors and social circles (Bornstein 2012). Special attention, treatment, and consideration is given to children (Bornstein 2012), often at the expense of older children or adults and elderly. “Innocent” young people have special status in the eyes of volunteers and within the realm of humanitarian aid more broadly (Bornstein 2012). Children and youth, to put it simply, are an enormous part of the STMM experience. To leave them out of my research would have been a significant oversight (Hunleth 2017).

I obtained consent from parents as well as from students for their participation in my research. To obtain consent from parents, I sent students home from school with a written letter and request for permission via signature. I read the letter aloud to students and told them they could read the letter to their parent or guardian in the event that they were unable to read it themselves. I also included my phone number so parents or guardians could call me with questions or to have me read and explain the letter, which some parents used. Students then brought the forms back on a given day and we planned the dates for youth workshops. Given the cultural context and because I was meeting with students during school hours, I also obtained 79

permissions from the school director and instructors and coordinated with them to determine the best dates and times so as not to interrupt class or testing schedules and not overlap with school holidays.

With 19 high school youth, I conducted workshops about health in the community. I was able to spend more time with the older youth because we could meet during their free period.

During these workshops we discussed health care in the community, their perceptions of the health center, of the brigade clinic, of caseras (home remedies) and plant-based medicine. I asked the students what kinds of solutions they proposed for the concerns they identified during our discussions. I also asked them to perform skits about their experiences in Honduran health centers as well as with medical brigades. Finally, I gave them the option of writing a poem or drawing a picture that related to health (some of them opted to draw an image and write an accompanying poem). Among older primary school children (10-13 years old), we focused on discussion and art (all images are in the appendix). The decision to structure workshops this way was meant to least interfere with regular classroom activities, given class sizes, and available time. Unlike the high school students, younger pupils did not have a free period.

About Photos

Prior to leaving for my field site, I decided that I would not take photos as a regularized part of my research. I took a camera to Honduras, but primarily for personal use. I eventually took photographs to document certain medicinal plants and tonics, as well as biomedical remedies. I did not, however, take photographs of people for two very important reasons. The first is the simplest. Because my research is medical in nature and the vast majority of my observations took place in the clinic setting, I could not take photos and also meet my ethical obligations to ensure confidentiality for my research participants. Photographs would necessarily 80

identify patient-individuals and research participants and would thus compromise the confidentiality of STMM volunteers and residents of Playa Felumi.

The second reason I chose not to incorporate photographs has to do with what Sontag

(2001 [1977]) and others (Das and Kleinman 2001; Fassin 2011; James 2010) call trafficking in human suffering. A hallmark of aid interventions, particularly in the realm of voluntoursism, is the production and consumption of images of poverty, suffering, and otherness. In these images, white volunteers are routinely surrounded by brown and black children, or they zoom in on concerned faces and injured bodies. Photos are often taken without consent, shared widely on social media platforms, and used to garner various kinds of social, cultural, and economic capital. Social capital (Bourdieu 1984; Portes 1998; Sullivan 2018) accrues to volunteers whose followers "like" them or offer accolades or commentary on the merits of the volunteers' actions and on the appearance of the aid recipients portrayed. The photographs are evidence of the volunteers' worldliness and thus helps them gain cultural capital, which is cashed in for dates, employment, and medical school acceptance letters (Sullivan 2018). Finally, when organizations use such images in their reports and applications, they carefully curate them (Sontag 2001) in order to win financial funding for their ongoing efforts to organize and conduct missions. In short, volunteers profit from these images and use them to extract a specific emotional response, depending on the context.

I did not wish to contribute to this form of trafficking in human suffering (James 2010). I considered flipping the gaze of aid in the ways that other anthropologists, such as Jean Hunleth

(2011, 2013), have done in their research. I contemplated handing out disposable cameras to children, youth, and adult volunteers and asking them to take photos when the STMMs were in town. This would have allowed for visual representations of volunteers from the perspective of

residents of Playa Felumi - the view from the perspective of the aid recipient is one rarely seen in the humanitarian aid and voluntourism circles. Ultimately, logistics and funding (disposable cameras, once ubiquitous, are now very difficult to find and very expensive) prevented this experiment. Some variation of this, whether with cameras or viewing social media accounts of residents before and after STMM visits, would be a worthwhile option for researchers to consider for future studies.

IRB Statement

I acquired the necessary training, certifications, and approval prior to conducting research with human participants. The research design for this study was submitted to the Institutional

Review Board (IRB) of American University in June 2014. I received approval for planned interviews and surveys, as well as relevant permissions to conduct research with youth. In

November 2014, while in the field, I realized that I would need to modify the research design and request IRB approvals for use of updated methodological tools. I did so and received updated approval in November 2014.

Data Analysis

I used the data gathered through participant observation (fieldnotes), interviews, review of patient records, diaries and children's activities, to identify definitions of health. Community- based definitions of health are critical to analyzing the impact that brigades have on health outcomes from the perspectives of Playa Felumians. These data serve to answer my research questions about how Felumians and volunteers define health and whether brigade activities recognize and address health in culturally appropriate and sustainable ways (i.e., long-term solutions that incorporate community priorities and perspectives) and whether and how medical

missions “fill the gaps” in access to care in Honduras. To develop a rubric for evaluating this variable, I used the self-assessment data collected from brigade volunteers via diaries, informal interviews, and a survey, as well as the responses from Playa Felumians during informal and semi-structured interviews, supplemented by patient records data.

I entered all manually written field notes into Evernote, a secure, digital note-keeping tool. I began data analysis with manual coding of fieldnotes and transcripts, adding tags or other easily sortable codes for deeper analysis. I entered all interview responses into an Excel spreadsheet to facilitate easy comparison of responses and to identify emergent patterns. I then entered the spreadsheet into MaxQDA for more thorough coding and analysis. I also scanned all field notes and data into PDFs and uploaded pertinent scans into MaxQDA for further coding and analysis. I manually coded medical record data to identify health trends (particularly to determine the prevalence of diabetes and hypertension), and then I sorted it into spreadsheets to facilitate comparative analysis across records. After scanning diaries, I manually coded diary entries, tagging and identifying themes and patterns that occurred across the collection of texts.

By using Survey Gizmo to design and administer my surveys I was able to generate reports based on demographics and then sort survey question by relevant research theme. Once I generated the reports, I downloaded them as PDFs to be entered into my qualitative data analysis software. I entered the survey reports, as well as all scanned copies and spreadsheet data into

MaxQDA for further analysis.

I reviewed and coded health reports provided by the CESAMO in Playa Felumi. I also incorporated data collected from the National Health Ministry (MOH). I transcribed and coded interviews conducted with medical professionals in San Pedro Sula and Tegucigalpa, and

organized data collected from daily review of news and reports related to the public health system in Honduras into spreadsheets.

I then used the PAHO and MOH-identified health challenges and the concepts of clinical, social, and cultural iatrogenesis to evaluate if medical missions are filling the gaps and whether the effects of their efforts may be harmful. The challenges, as discussed in Chapter 1, are:

• Access to healthcare and health equity

• Insufficient health personnel

o Specialists

o Capacity-building, placement of personnel, and personnel distribution

• Non-communicable diseases – especially Type II Diabetes and hypertension with the

following barriers of care:

o High costs of care

o Poor health service response

o Poor promotion of healthy habits

• Social Determinants of Health

o Environmental factors, including climate change and chemical

exposure/pesticide poisoning

o Intermittent and unreliably purified water

o Water sources contaminated by raw sewage

In each instance, I consider how medical mission interventions may meet the stated goals. I also consider how they might miss the additional criteria or rely on approaches that further complicate efforts to close these gaps. For example, medical missions may treat patients presenting with diabetes and hypertension. But are they ultimately reducing high costs of care

with their approach (potentially, yes, although they may also inadvertently increase costs of care for patients in the long run), or providing quality health service response (perhaps not if their approaches vary among teams or diverge from globally established best practices for care in resource-limited settings)?

I use the concept of iatrogenesis to evaluate the potentially adverse effects of medical missions. Building on the literature discussed in the previous chapter, I identify forms of iatrogenic violence, which includes the three forms of iatrogenesis defined by Illich (2013): clinical, social/structural, and cultural (Figure 2). Iatrogenic violence is characterized by therapeutic domination (clinical, social/structural, and cultural) and may include forms of public health iatrogenesis (clinical and social/structural).

Figure 2. Iatrogenic Violence

Using the categories for evaluating the potential and real iatrogenic effects of public health interventions defined by Lorenc and Oliver (2015) and the “dark logic” model proposed by Bonell et al. (2015), I organized my data and evaluated the evidence for clinical iatrogenesis, social/structural iatrogenesis, or cultural iatrogenesis (Figure 3). Recall that Lorenc and Oliver’s

(2015) categories include: direct harms, psychological harms, equity harms, group and social harms, and opportunity cost harms.

Figure 3. Categories of Analysis for Iatrogenic Violence

Clinical iatrogenesis includes direct harms like malpractice, negligence, and human error that results in adverse health effects. Malpractice may be those approaches that defy established best-practices in the provision of care. It may also show up as misdiagnosis or over-prescription, for example. These direct harms may also overlap with social/structural iatrogenesis, and/or cultural iatrogenesis.

Social/structural iatrogenesis may include practices, discourses, and/or structures that promote the erosion of community-wide trust in local healthcare (equity harms, group and social harms), erasure of indigenous and culturally-informed, plant-based medicinal practice (group and social harms, also therapeutic domination), the disruption of cooperation between and among members of a community (group and social harms), or the undermining and destabilization of already precarious healthcare systems and infrastructure (equity harms, group and social harms, and opportunity cost harms). At the broader level I used the concept of structural iatrogenesis

(Stonington and Coffa 2019) to identify examples of large-scale forces of resource distribution and evaluate discursive and structural factors to evidence of re/production of social hierarchies

(equity harms, group and social harms). This also incorporates public health iatrogenesis, which may take the form of disregarding globally established standards of care at the population level.

Social iatrogenesis also occurs when people cannot suffer, cope with, tolerate, heal, or mourn on their own terms — that is, when the illness experience becomes standardized or “hospitalized,” or when illness narratives people use to make sense of their own bodily experiences becomes distorted (Illich 1975, 40). I coded the data I collected through household interviews, diaries, and participant observation for such examples to analyze iatrogenic violence that occurs through illness narratives and the discursive and semantic tensions that manifest in the medical mission encounter.

Tools for Understanding STMM Volunteer Discourse

To that end, I also used content analysis (Bernard 1994) to analyze data gleaned from interviews and diaries. I analyzed transcripts and narrative survey and journal entries using techniques from critical discourse analysis (Fairclough 2003; Morrish 2007). Critical discourse analysis (CDA) offers tools for examining affect, evaluation, and judgment in various written and spoken texts that will be crucial to understanding how Hondurans evaluate brigades. I also used CDA to review the HMH Board of Directors' foundational text, When Helping Hurts (see

Chapter 7). I also used narrative analysis (Bernard 1994; Hill 2005), which is particularly suited to the comparison of narratives gathered during informal interviews with both brigade and community participants and the skits conducted during children's workshops in both if my sites, as well as survey and journal entries.

According to Ahearn (2001), agency is the “socio-culturally mediated capacity to act”

(2001, 118). That is, the capacity to take an active role is predicated upon the social and cultural contexts that enable or inhibit a subject to make decisions for themselves, determine their own physical and emotional courses of action, to accept or refuse circumstances or offers, or in this case therapies. Within this framework, I employ Ahearn’s concept of meta-agentive discourse to analyze how medical mission volunteers talk about themselves and others, their actions and the actions of others, and to whom (and for what) volunteers assign responsibility. In keeping with

Bonell et al.’s dark logic model (2015), I use these tools to identify agency and the structures that enable or constrict purposive action.

Speakers can exercise agency through the act of speaking but also assign agency to others through narratives. The implication of meta-agentive discourse in medical mission-volunteer talk, as I will show, is one way the medical mission volunteer/humanitarian agent is able to reinforce a hierarchy of power through the assignment or denial of agency to the humanitarian 88

subject, in this case residents/patients of Playa Felumi. This hierarchy of power also helps establish moral and expert authority for determining what counts as "better" than the supposed nothing that is available in Playa Felumi. This correlates with McFalls’ (2010) concepts of therapeutic domination as a characteristic of iatrogenic violence.

Medical mission volunteers use a variety of strategies and techniques to establish a dominant discourse and their moral authority and position within that discourse. There are a variety of discourse strategies and themes that speakers can employ to “create alignments and oppositions among people and places” (Modan 2007, 90). The discourse strategies speakers may use to establish a moral geography include voice, appraisal, and metaphor.

Voice, Hill explains, is a “moral choice” that the speaker must make among the

“terministic and linguistic possibilities presented by the ‘heteroglossia’ of any community of speakers” (2005, 97). Hill is drawing on Volosinov (1986, 21), who explains that the social relations of the participants condition how the sign is interpreted. The sign, or the speech act or linguistic item, is not just a word. In the context of who says it, to whom it is being said, and in what context it has been uttered, both speaker and listener can assign additional meaning above and beyond the rote definition of the words. This is particularly important if the social relations among the listeners or between the speaker and listeners are unequal in any way. If the social relations are uneven, that unevenness will contribute to multiple readings of the same sign even within the same sets of social relationships. The concern of Hill and Voloshinov is that with a variety of words available at any speech act, the words chosen, especially in the context of unequal relations of power will have social meaning and constitute some kind of evaluation, or moral choice.

Just as voice can provide insight into the ideological assumptions and the power dynamics involved in talk, systems of appraisal can also tell us about the position of the speaker.

Appraisal is “a means of analyzing and describing evaluative language which is situated within a broad systemic functional framework” (Morrish and Sauntson 2007, 56). Evaluative language means the word choices made to “negotiate emotions, judgments, and valuations,” of people, places, processes, or any variety of things (Morrish and Sauntson 2007, 56). Evaluations are the word choices that tell us more about the speaker’s stance and how a moral geography is plotted out (Modan 2007). Appraisal is primarily composed of affect, judgment, and appreciation and these can be modified in strength through amplification or mitigation.

Affect is the category of evaluative language used to communicate emotion or evoke it from the reader or listener (Morrish and Sauntson 2007, 57). “I was so scared!” indicates the emotional state of the speaker and is designed to evoke a response – perhaps empathy, perhaps admiration if it is a harrowing tale of bravery – from the audience. Judgment is the category called upon to demonstrate approval or disapproval of behavior (Morrish and Sauntson 2007,

57). In a narrative, judgment might be represented in a statement like, “It’s just that she seemed ungrateful.” This example employs a mitigating token, “just,” and indicates that the speaker judges the subject’s actions to be subpar. Appreciation is the category used to construe aesthetic qualities of processes or natural phenomenon (Morrish and Sauntson 2007, 57). “The mountain is beautiful,” is an example of appreciation in action. Volunteer language includes tokens of appraisal and justification directed at themselves as much as the people around them.

* * *

This chapter has detailed the methods I chose in designing this study, as well as how I sorted and analyzed the mixed-methods qualitative data collected through participant

observation, surveys, interviews, discussion groups and children's art among medical mission volunteers and residents of Playa Felumi. In the next chapter, I provide a socio-historical overview of Honduras, with attention to political trends and the practice of missioning and its relationship to historical and contemporary foreign interventions.

CHAPTER 4

HONDURAS, MISSIONING, AND POSTCOLONIAL LEGACIES

Along with its Central American neighbors, the region that is today Honduras gained independence from Spain in the mid-19th century. Unlike most of its Central American neighbors, Hondurans has not experienced protracted civil wars, though there were a smattering of uprisings and small-scale civil wars in the early and mid 1800s that were swiftly and brutally repressed by military caudillos in service of the dominant bourgeoisie at the time (Euraque

1996). In general, and academically, Honduras has not been well-known for its indigenous populations, although attempts to boost tourism on the backs of indigenous Lenca, Maya, and

Garífuna in recent decades have attracted the attention of social scientists. With the exception of the ancient Maya, the indigenous peoples of Honduras are not central to the national narrative

(Anderson 2010; Euraque 2004). Perhaps these idiosyncrasies have made it a less popular research destination for anthropologists.

Though there are alternate (and compelling) theoretical frames through which the country can be analyzed, postcolonial and neocolonialist frameworks allow for an understanding of the lasting residues and imprints made by repeated and ongoing interventions by foreign countries and lending institutions into Honduran geography, economy, politics, and society. Upon achieving independence from Spain, Honduras almost immediately became a strategic interest for the United States government and large international businesses - and it did not stop there.

The country has been the target of missionaries, and later non-governmental organizations

(NGOs), in addition to the international aid and governance entities. Honduras is rife with intervention. This chapter expands on the brief history delineated in Chapter 1 while situating the country, and the Garífuna community where this research took place, in the context of recurrent interventions within a particular trajectory of colonization. 92

Early Honduras

Prior to European colonization of Honduras it was home to several indigenous communities primarily in the North Central and Northwestern regions of the country (Joyce

2014). As in many other places in the Americas, violent processes of colonization and enslavement destroyed documents and histories that might give us a clearer picture of pre-

Colombian history.

Colonization

Between 1502 and 1821, Honduras was a Spanish colony. The Spanish were primarily interested in mahogany, gold and silver, indigo, and cocoa. However, they were largely disorganized, outplayed by competing European traders, and with so few Spanish colonialists inhabiting the country (compared to indigenous and later mestizo/ladino populations), they were highly susceptible to rebellion, and vulnerable to skirmishes and incursions from competing colonial interests (Acker 1988). Indeed, the British frequently made incursions on Spanish- controlled Honduran territories (Acker 1988), including the exile of approximately 4,000

Garífuna to the island of Roatán in 1797 (Centeno García 1996; Jung [Gilchrest] 2011; Young

1971 [1798]).

Though Lenca inhabitants, a majority population at the time, initially resisted Spanish colonization, their population numbers dramatically declined. Given their smaller numbers and familiarity with local geography, they often resisted colonial rulers' attempts to force them into labor or reproduction, by retreating into the central mountain regions of the country (Acker 1988;

Barahona 2002). For some 300 years, as in the rest of the Americas, the Spanish established fortresses, towns, and trade enterprises through the labor of enslaved African and colonized and/or enslaved indigenous populations. In the early 16th century, scholars estimate that the

indigenous population in what is today Honduras was between 600,000 and 1.39 million

(Barahona 2002). By the mid-16th century, the autochthonous population had dwindled to just

32,000 (Barahona 2002). Disease was believed to be the primary factor in indigenous population decline (Acker 1988), in addition to the intensity of forced labor and the trafficking of enslaved indigenous people to Panama and South America (Barahona 2002). Euraque (2004) notes that the once-majority indigenous population hovered around 45 percent by 1804.

Symptoms of disease and the psychological and physical effects of enslavement, forced labor, and colonial occupation, were interpreted by the Spanish as lethargy, apathy, and reticence and thought to be essential characteristics of indigenous people (Barahona 2002). This and the rates at which indigenous (by comparison to the Spanish) became sick and/or died from disease, were used as evidence of indigenous inferiority. Today, though it is more subtly implied, presumed inferiority or character weakness continues to be central to the mindset of contemporary "civilizers," including humanitarian missioners. The actors continue to portray diseases of impoverishment and structural violence as the result of knowledge gaps, poor character, and biological inferiority; as such they constitute an invitation - even an obligation - to intervene (see chapter 7).

Honduran historian Marvin Barahona (2002 [1991]) explains how the colonial experience influenced identity formation, not only among specific enclaves, but also in what would eventually coalesce as a national identity. When the Garífuna were abandoned by the British on the island of Roátan in 1797, they were not the first Afro-descendant populations in Honduras, since English speaking blacks as well as enslaved Afro-descendants were counted in censuses as far back as the late 16th Century (Barahona 2002; Euraque 2004; Sheptak, Joyce, and Blaisdell-

Sloan 2011). Garífuna claims to indigeneity was not officially recognized for over 200 years.

Central American-born elites of Spanish ancestry, Criollos, eventually became disillusioned with the Spanish authorities and exclusion from political decision-making. Criollos and ladinos outnumbered the Spanish-born colonialists twenty to one (Acker 1988, 36), but it was Criollos who led the movement for independence from Spain in 1821, while ladinos and indigenous communities continued to be denied power. Indeed, as Euraque (1996, 1) notes, the

Captaincy General, which consisted of Criollos, declared independence from Spain "to prevent the dreadful consequences" lest the local (mestizo and indigenous) populations proclaim themselves independent.

By 1823 the elites of these newly independent territories joined together and formed the

Central American Federation in 1823. Within the Federation each country was a province within a single Central American nation (Euraque 1996, 2). It wasn't until 1838 that Honduras separated from the Federation and became its own independent, if struggling, nation (Euraque 1996). Like many places colonized by the major European powers, Honduras was "left utterly unprepared for...independence in the region. It was without a government infrastructure, a stable, established economy, or any sense of national integration" (Acker 1988, 35).

Euraque attributes this to the substantial amount of debt with which Honduras became independent (1996, 3). It did not pay off those debts until 1953 (Euraque 1996, 4). Unlike the narratives of most historians of Honduras, Euraque reinterprets the formative history of the country, acknowledging the ways that foreign intervention and local elite formation coincided to create the conditions characteristic of Honduras today. Honduras was not historically ruled by a landed oligarchy, as in some of the neighboring countries, but rather by factions of wealth- holding bourgeoisie, in conjunction with whatever political party happened to be in control of power at the time (Euraque 1996, 156). These members of the early capitalist class had three

primary sources of wealth between the 1770s and the 1820s -- tobacco manufacture, silver mining, and the domestic cattle market (Euraque 1996, 2).

Ultimately, says Euraque, early Honduran elites' adherence to liberal market exchange in

Honduras, commonly referred to as "free trade" today, meant that the financially significant exchanges of silver mined in and exported from Honduras were not taxed, resulting in a substantial loss of potential revenue to the nation. To be sure, the United States interfered in and manipulated local politics, but Euraque reminds students of Honduran history to acknowledge the active roles that these Honduran elites played in both acquiescing to and resisting U.S. interventions. By the 1870s, Honduran capitalists had aligned and developed lucrative relationships with U.S. banana imperialists in ways that enriched themselves (and the banana companies) and secured their control of capital (such as with Banco Atlántida and Banco de

Honduras) and positions of political power.

Accordingly, when global banana production began in earnest, neither bananas or silver exports (nearly 70 percent of total Honduran exports), were taxed as a result of concessions that benefitted Honduran capitalists invested in those industries as well as the U.S. "banana men"

(Langley and Schoonover 1995) and the companies they represented. These concessions and exemptions did not benefit the Honduran State. In fact, in a single eight-year period from 1927-

1935 they cost Honduras $64 million, an amount that would have nearly doubled the country's annual revenue over the same period (Euraque 1996, 8-9).

Contemporary economic conditions in Honduras continue to suffer from this longstanding system of concessions and exemptions. In lieu of domestic economic protections and enforcement of tax and revenue streams, the country incurred substantial external debt.

The Many Forms of U.S. Intervention in Honduras

Independence from Spain, and the expulsion of nearly all colonial powers in the region, created an opportunity for the United States to stake its claim to the region, albeit under the guise of hemispheric protection. The Monroe Doctrine was a warning to European colonial powers following the liberation of the Americas that the hemisphere was off-limits to external intervention (Acker 1988), and it was also a sweeping political policy that gave the United States putative authority over its newly independent neighbors in Central America - without their input

(Acker 1988; Langley and Schoonover 1995). The same year the Central American Federation was created, the United States sought out its first avenues for intervention and expansion of its own empire (Langley and Schoonover 1995).

Political and Economic Intervention

To date, the United States has considerable political, social, and economic influence in

Honduras. The same capitalist cabals that characterized the early days of U.S. interventions in the country are present today. As Langley and Schoonover (1995, 1) note, "the predicament of

Central Americans in our times...is rooted in their past. North Americans have had a great deal to do with the shaping of their history." Their assessment still holds true almost 25 years later. In the late 19th and early 20th century the United States viewed foreign policy toward Honduras as means through which to address North American economic, social, and political challenges. The

United States was in the middle of rapid industrial expansion and was also experiencing social and cultural upheavals. Its rulers were looking for new avenues for capital export and accumulation and means by which to consolidate power in the hemisphere. "Central America provided a means of exporting not only capital, but also the cultural and social conflicts that raged within the United States," (Langley and Schoonover 1995, 9). Those cultural and social

conflicts included racial tensions, immigration concerns, and labor issues such as high unemployment rates and low wages.

By the end of WWII (within 100 years of the first U.S. investment/intervention), the

United States dominated import, export, and foreign capital markets in Latin America (Langley and Schoonover 1995, 23). The U.S. government wanted development in Central America, as did many Central American liberals, but they wanted that development to coincide with specific economic and geopolitical interests (Langley and Schoonover 1995, 26). That meant land accumulation, liberal (open and exempt) trade with maximum concessions, and ultimately control over political powers. With few exceptions since Honduras's founding, the United States influenced presidential elections and length of office through financial backing or withholding and military intervention (Acker 1988; Euraque 1996; Jung [Gilchrest] 2011; Langley and

Schoonover 1995).

The most recent examples of this include the role the United States played in the 2009 coup d'état, and more recently still, the 2017 elections that Juan Orlando Hernandez won through blatant fraud that was legitimated by the U.S. State Department (which knew of his drug trafficking ties), thus granting him an unconstitutional second term. In 2009, President Manuel

Zelaya, whose agenda had aligned nicely with U.S. goals in the initial years of his Presidency, lost U.S. support when he began to focus on policies that benefitted the Honduran population at the expense of U.S. economic and political goals. Ironically, a primary political reason given for his ouster was his alleged unconstitutional attempt to seek re-election (a fiction). Scholars have suggested that the only consistent factor in determining U.S. support or opposition to any given

Honduran (or other Central American) president has been how well or poorly that leader aligns

with U.S. goals for economic and political gain (Langley and Schoonover 1995; LeoGrande

1998; Shepherd 1984; Tseng-Putterman 2018).

Past and present U.S. hegemony provides the broader context within which medical missioning in Honduras, voluntourism, and humanitarian outreach play out. The ways Central

American countries and peoples are viewed by contemporary visitors, be they missionaries, businesspeople, or mere vacationers, are similar to the ideologies of social imperialism expressed in early U.S. “adventurer” narratives describing the region. Those ideologies have been inculcated in the North American imaginary, and similarly reflect colonial era mischaracterizations of symptoms of domination and exploitation as the causes and justifications of impoverishment, "lack," and intervention. Voluntourism and other forms of humanitarian intervention are sometimes framed as distinct analytical categories, yet they are inherently related to the broader project of U.S. imperialism in Central America and beyond. While Langley and Schoonover (1995, 26) note the desire of the United States to see the region "developed," they also recognized that, "the materialism of the liberal order frequently triumphs over humanitarian and idealistic goals."

A Brief History of Missioning in Honduras

It was only once the United States had successfully consolidated its economic and political power in Latin America following WWII that post-Spanish colonial missioning formally began in Central America. Under dictator General Tiburcio Carias Andino, Franciscan missionaries (Catholic priests and monks of the Order of St. Francis) were granted permission to enter the country (Garcia 2011). Protestant and Mormon missionaries would not arrive in the region for a few more decades. Those Catholic missionaries who came, with the blessing of the

General Carias’ military Junta, implanted themselves in local communities. I choose that verb 99

deliberately as local communities usually had (have) no idea the missionaries would be arriving, or of their intentions to establish projects (in the case of the Franciscans, churches and parishes).

The missionaries, according to their own testimonies, arrived, often without any knowledge of

Spanish, and traveled to self-chosen towns where they then inserted themselves as permanent fixtures in the community. They often identified initial allies or interlocutors who could help them accomplish their self-assigned missions.

Even with sympathetic involvement, there has historically and generally been push-back, resistance, and refusal of foreign intervention in Honduras in all of its forms - including missioning. While many Hondurans were not opposed to Catholic priests, friars, or other religious missionaries, they did often reject foreign missionaries in general and demand

Honduran religious leaders instead (Garcia 2011, 70). These politics became more urgent and complicated as the Catholic church became entangled within Honduran political and economic struggles in the 1960s.

Catholic missionaries, particularly those of Fransiscan and Jesuit orders tried to enact liberation theology that corresponded to the Vatican Council II in 1963 and the coinciding ideologies of the Latin American Episcopal Council (Garcia 2011; Schall 1982). Liberation theology arose out of many Catholic missions' recognition of the structural conditions that are directly related to the poverty and inequality that the Honduran peasant classes faced on a daily basis. Liberation theologists recognized this as part of the work that they were "called" to do to relieve such social inequality and suffering.

This form of ministry was considered radical among the landed and business classes in

Central and South America. Once liberation theology took hold and became popular among the landless and subsistence classes over the next ten years, it became a threat to capitalist interests

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and land reform - geared not toward rectifying inequality, but toward limiting the access that foreign capital had to cultivable or otherwise profitable land as a result of the exemptions and concessions granted 50 years earlier. Initially the military dictator Gen. Lopez Arellano established reforms between 1965 and 1972 that would have improved land access for the peasant classes, but Lopez Arellano's policies and efforts did not coincide with the goals of the growing cattle and agro-industrial bourgeoisie (Euraque 1996).

After Hurricane Fifi ransacked the country in 1974, Lopez Arellano was removed in a military coup and replaced with Col. Juan Melgar Castro. Melgar Castro revisited the issues of land reforms and slowed or refashioned them to represent the interest of agro-export elites. He also, at the behest of the same elites, began a campaign to repress the liberation theologists and its followers. Though peasant movements and the new military junta and the ruling elite who controlled it all wanted land reform, the kinds of land reform and the beneficiaries they had in mind with such reforms were very different. Religious leaders, particularly those that embraced liberation theology, were accused of inciting rebellion. Several were arrested and deported back to their countries of origin, although many were also summarily executed (Garcia 2011).

While Catholic missionaries to Honduras were by no means united on liberation theology, and the Church formally maintained a conservative stance in support of and supported by business and landed elites, a significant number of priests and lay Catholic workers were in solidarity with local majority (peasant) populations. This history and this practice continues to distinguish Catholic missionaries from most Protestant missionaries in Honduras. Protestant missions and more secular manifestations of missioning in the late 20th and early 21st century in the form of NGOs claim to eschew politics. If they do not actively avoid local political and social conditions and machinations, they ignore them in public.

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Also affecting the missioning experience and the acceptance of foreign influence in

Honduran affairs was U.S. involvement in the Central American proxy wars during this same period. The land-owning wealthy elite and the military continued to benefit from these relationships. The United States, in the context of the Cold War and in the interest of protecting of United States financial interests in the region, had already begun training and professionalizing the Honduran military in the early 1970s (Euraque 1996). The United States had also begun working on necessary steps to establish foreign bases of operation in Honduras to protect their geopolitical interests and maintain a capitalist foothold in the region (Vine 2015).

The conditions in Honduras following the proxy wars and death squads of the 1980s, "the

Lost Decade," created vast opportunities for missioning and a new phenomenon, NGO projects and interventions. While Ronald Reagan and his administration were underwriting the Contra

War, they were also reorganizing U.S. laissez-faire capitalism and rewriting the terms and conditions of inter-American financial relationships in the process. NGOs were created in the context of this economic austerity system. A renewed liberalism, so ubiquitous in the early 20th century, took on a new dimension that similarly sought out open markets, concessions, and tax exemptions, but also determined that social services and services previously considered part of government responsibility to its populations, like education, healthcare, and social safety nets, were no longer viable to current capitalist interests. Instead, these socio-economic needs could be fielded by non-governmental organizations, which would absorb the responsibility of the government and simultaneously bolster the sense of individual responsibility for these needs.

Understanding the intersection between missions and NGOs in the late 20th century is critical to understanding how contemporary medical missions came into existence and function in Honduras and beyond. In 1985, churches, previously limited in their access to "faith-based"

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funding as a result of First Amendment separation of Church and State, could apply for status as a 501(c) organization, making them non-profit entities (even if they were in fact very profitable), tax-exempt, and in many cases qualifying these entities for certain types of city, municipal, state, and/or federal funding. Though churches are recognized as charitable institutions, NGO status has become important, if not essential, for entry and credibility in Honduras. Therefore U.S. churches desiring to send missions, or to get funding for those missions (since most private donors and foundations are more likely to donate funds or contribute gifts in kind with the guarantee of a tax write-off), to Honduras typically choose to apply for 501(c) status.

Honduran interest in NGO status is related to U.S. influence on Honduran economic policy and overarching political economic ideology - a recurrent theme when considering U.S.-

Honduran relations. Indeed, starting in the mid 1980s U.S. foreign aid instituted Structural

Adjustment Programs (SAPs), through the World Bank and International Monetary Fund. These programs required many previously colonized countries, including Honduras, to "liberalize trade" and cut out domestic investment in social services. This was ironic given that Honduras’s economic crises were a result of the already aggressively liberalized trade with the United States over the course of the century. In Honduras, as in the US, as the state began to reduce investment in or privatize programs like healthcare, NGOs emerged to attempt to fill in the gaps left by a shrinking state.

It is in this context that the explosion of medical and NGO missions and interventions should be considered. Medical missions are a result of and a necessary part of economic restructuring to maximize capital consolidation. In many ways, they enable the very concessions and exemptions - the dramatic liberalization - that for so long have benefitted the United States and cost Honduras and its citizens so much.

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Medical Missions in Honduras

Medical missions have a long colonial history to which contemporary medical missions are necessarily connected. Most medical mission histories focus on the African continent

(Comaroff 1991), while there is scant information available on medical missions in Latin

America until very recently. Many medical missions in Central and South America have been coordinated efforts of foreign (US) government or military projects aimed at conducting research on so-called tropical medicine (Farmer et al. 2013). This is part of the reason that Hondurans, given the context of military brigades, refer to medical missions as brigadas, rather than as missions. Those brigades were part of the colonial project, and also part of the politicizing of re- colonization of Latin America under the auspices of the Monroe Doctrine (Euraque 1996; Vine

2015).

Medical missions (or brigades) have used Latin American bodies as test subjects to improve medicine for (white) North American and Western European bodies. In 2010 the Obama administration felt compelled to issue a formal apology for the unethical study conducted by the

United States Public Health Service (today's Health and Human Services) on Guatemalans in the

1940s. Other studies are less infamous, but include research conducted among local populations in Brazil, Puerto Rico, and other Latin American countries regarding yellow fever, pharmaceuticals, and reproductive birth control, to name a few (L. Briggs 2002; Chalhoub 1993;

McManus et al. 2005).

The United States military still regularly conducts medical missions in Honduras as part of "training" and "good-will" efforts in the country through the United States Army's Joint Task

Force Bravo (JTFB) stationed at Palmerola (Vine 2015; Kelly 2014)). These missions, like civilian trips, are often to locations strategic to the goals and convenience of the teams. In the case of the military, JTFB travels to "hot zone" locations along the Northeastern and Miskito 104

Coast under the auspices of care provision, which double as surveillance missions as part of the failed U.S. War on Drugs (“Another US Spying Problem in Latin America: The US Drug

Enforcement Agency” 2014; Paley 2014; Vine 2015).

The kinds of missions my research focuses on began in earnest in the early 1990s. There were emergency humanitarian and relief missions from NGO organizations as early as 1974 in the aftermath of Hurricane Fifi, but they were far fewer in number and far less of an institutionalized norm. The explosive increase in short term missions around the globe corresponds to economic policy shifts that began in the 1980s. In foreign economic policy, structural adjustment programs forced countries indebted to the United States to cut funding to resources like healthcare infrastructure and social services. Countries in need of robust social safety nets, were being forced to dismantle them as part of profoundly unequal terms of debt- renegotiation (packaged as debt "relief").

By the 1990s these programs in conjunction with extreme market liberalization policies

(also applied in the US) meant that social services were dramatically reduced. The withdrawal of the state meant that service gaps emerged and champions of the ongoing neoliberalization of domestic and foreign economies encouraged non-governmental organizations - perhaps tacitly required them - to fill those gaps. Churches and secular organizations began incorporating into the newly established category of NGO and short-term missions grew out of this phenomenon.

In Honduras reduction of social services and privatization of common goods, combined with increased debt resulting from the SAPs and neoliberalization earlier in the decade magnified the devastating effects of Hurricane Mitch in 1998. The disaster also resulted in an enormous influx of short-term relief organizations that decided to send short-term teams on a regular basis, even after the initial state of emergency ended. Over the past 20 years the number of short-term

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missions in Honduras has exploded. Most organizations currently working in Honduras were established in 1999 or after, including the Health Missions Honduras.

The rise of volunteer missions and voluntourism is as much a part of disaster capitalism

(Klein 2008) as are corporate institutions. And just as public health and military-led aid missions were a century ago, these organizations are part of U.S. statecraft in the region. According to

Mostafanezehad (2014, 37) international volunteer programs are key to soft power and promoting U.S. security interests at home and abroad. Vrasti (2013, 1) observes parallels between voluntourism and the colonial missioning projects and "Grand Tour" of the 19th

Century. Volunteers are able to interact with the Other and affirm their sense of self while travelling through other people's everyday lives (Vrasti 2013, 3).

Garífuna experiences with interventionism in Honduras

Despite Garífuna involvement in the creation and political and economic development of the Honduran nation-state, Garífuna people have experienced systematic exclusion from

Honduran society (Anderson 2009). It was only in the 1990s, after 20 years of political struggle, that the Garífuna attained official recognition from the Honduran government as an afro- indigenous people (Brondo 2007; Jung [Gilchrest] 2011, 2016; OFRANEH). In 2003, UNESCO recognized the Garífuna language as part of "the Intangible Patrimony of Humanity," boosting their international recognition and their credibility as a protected indigenous community in

Honduras (Brondo 2007; Jung [Gilchrest] 2011; OFRANEH 2019). The Honduran state capitalized on the UNESCO status and the idea of state multiculturalism (Anderson 2009) to market centrally located Garífuna communities and cultural practices, such as dance, food, music, and ritual dress as tourist attractions. In the process, Honduran and international business owners have usurped Garífuna coastal lands through violence and coercion for industrial 106

agriculture and megatourism (resort) projects (Anderson 2009; Jung [Gilchrest] 2016; Brondo

2013).

Garífuna have been fighting encroachment on their lands since the introduction of industrial banana production began in the region. However, specific policies and discrimination against Garífuna populations increased in the 1970s. The Carías dictatorship encouraged mestizo and ladino Hondurans to migrate to the northern and northeastern departments and territories and

“settle” them as part of sweeping agrarian land reforms. Garífuna and other indigenous groups already lived on and had communal titles to the lands marked for reform settlements. In exchange for cultivating the land they would be granted land titles. But systematic racism against and erasure of Garífuna people and renewed nationalist attempts to establish a common

(imagined) mestizaje national identity made it easy to ignore Garífuna claims and dispossess them of their lands.

The legacies of this program are two-fold. First, it actively encouraged encroachment on

Garífuna and other indigenous lands that were communally titled and historically held, without protections for individual indigenous title holders. The consequence was settlement of non-

Garífuna peoples in Garífuna territories and erasure of Garífuna horticultural and conservation practices, in addition to a reduction of Garífuna-held lands. Second, policy favoring land grabs continues to drive peasant farming and agrarian conflicts in the Sula and Aguan Valley regions and throughout Garífuna territories. Such encroachment on communally held lands continues to be practiced by large- and mid-scale farmers and rubber-stamped by the Honduran state and municipal government officials (Brondo 2013). This is an issue that my interlocutors in Playa

Felumi regularly raised in conversation about losing their lands and their subsistence practices

(see chapter 8 and chapter 10). Playa Felumi is still a majority Garífuna community, but since the

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1970s an increasing number of ladino families have settled there, displacing Garífuna families, or building dwellings on land that was once used for subsistence farming. As small-scale and industrial cattle farmers moved into the region, once-sacred lagoons were enclosed with fencing or polluted by animal waste. Garifuna residents under the age of thirty have no recollection of these places, and most young people no longer participate in subsistence farming in any way, buying produce from roving pick-up trucks or local corner stores (pulperias) instead.

Regionally, Garífuna are embroiled in several land disputes across two Honduran departments, Atlántida and Colón. Vallecito, a Garífuna community near Playa Felumi protected by a communal land title, has been at the center of land disputes with African Palm company

Dinant. Garífuna political activists and organizers successfully recuperated the land in 1995 after the first Dinant land grab in 1992 (Jung [Gilchrest] 2011). Since the coup d'état in 2009,

Garífuna lands have been subject to more aggressive dispossession attempts. The communities of

Barra Vieja and Sambo Creek have both been forcibly evicted by police, military, paramilitary or private security personnel (of the African Palm or tourism companies) multiple times. During my fieldwork period between 2014 and 2015, Barra Vieja was forcibly evicted by the Xatruch special operations force of the Honduran military, despite having the appropriate land titles.

Vallecito has also come under threat of eviction.

While Garífuna organizers and activists continue to resist eviction, and use national and international (e.g., UN) legal mechanisms to assert their rights to ancestral lands, many Garífuna feel forced to leave or even sell their property as a way out of the constant pressure and threats of violence. Sales of lands to non-Garífuna is technically not allowed under communal titling, but longstanding corruption within the land titling agency and the state's systematic disregard for

Garífuna communal titles has facilitated extra-legal titling practices and Garífuna land loss.

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Conclusion

This chapter provided an overview of interventionism and missioning in Honduras, and provided context for the long legacy of dispossession, discrimination, and state violence to which

Garífuna communities in particular have been subjected. The history of interventionism and the political machinations of Honduran elites have also worked to intentional provoke crisis within the Honduran healthcare system. The next chapter provides an in-depth discussion of the public health system in Honduras.

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CHAPTER 5

HEALTHCARE IN HONDURAS

“All medical systems, including biomedicine, are cultural systems rooted in particular social traditions and socially constructed world views” (Baer and Singer 1995:12).

This chapter describes the origins, trajectory, and current structure of the Honduran healthcare system, an orientation to country health trends, and precedes a detailed discussion of the healthcare resources and indicators in Playa Felumi in the next chapter. Here, I expand on the overview of health indicators provided in Chapter 1 to illuminate the ways that health system issues of scarcity and underperformance are the result of historic indifference to healthcare as a feature of Honduran governance. I explain how indifference transformed into intentional strategies implemented since the 1990s to produce crises in the public health system as a precursor to privatization and as part of high-level government corruption and organized crime.

These contexts are critical to understanding the issues that short-term medical missions purport to address and the power dynamics inherent in these interactions, as well as their role in larger capitalist development logics that have informed the shape of the Honduran healthcare system.

This socio-historical perspective also contextualizes the narratives of Honduran health seekers who have had negative experiences in the public health system, express doubt and concerns about medicines and therapies, and rely on a variety of biomedical and non-biomedical resources to meet their needs.

Building Health Infrastructure in Honduras

The first national hospital in Honduras was not established until 40 years after the region won independence from Spanish colonizers. In 1861, General Santos Guardiola issued a decree

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to construct the Hospital of Tegucigalpa, but the project was abandoned in 1862 following his assassination and ensuing political turmoil (Bourdeth Tosta 1996). A second military president,

General José Maria Medina, attempted to revisit the hospital project in 1869, but it stalled again after a series of rebellions and political battles, and ironically by devastating epidemics of cholera and yellow fever in 1878 (Figueroa 1997). Two years later the civilian president and physician Marco Aurelio Soto established a public health campaign, approved the construction of the hospital in 1880, and finally succeeded in opening the General Hospital of Tegucigalpa in

1882 (Figueroa 1997). Four regional hospitals opened between 1900 and 1931. What became the

Occidental Hospital was initially founded by the Salesian Catholic religious order in 1912 but was subsumed into the regional hospital system in 1940, although the religious order continued to run the hospital until the 1970s (Bourdeth Tosta 1996). No new government-mandated hospitals appeared until 1950.

In the late 1940s tuberculosis was a serious concern in Honduras and continued to be a primary health concern through the 1990s (Bourdeth Tosta 1996). The National Thorax Institute opened in Tegucigalpa in 1950 as a dedicated pulmonary disease facility, initially focused on tuberculosis cases, but expanded to included cardio-pulmonary conditions by the 1970s

(Bourdeth Tosta 1996). Only one other hospital opened during this time, and while it would become an essential part of the healthcare system in Honduras, it is separate from the Ministry of

Health. The Honduran Social Security Institute (IHSS) was established in 1959, following the banana workers’ strike of 1954. The Great Strike (la gran heulga), one of the largest in Central

American history (see Chapter 4), was also the catalyst for the creation of the Honduran Ministry of Health during the Lozano administration in 1955. In 1962 the IHSS opened its own hospital to provide healthcare services.

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Between 1966 and 1987, fourteen hospitals opened in Honduras. The majority were smaller area hospitals in various departments but included four national hospitals erected in

Tegucigalpa. In 1990, the Catarina Rivas Hospital was the first national hospital built in San

Pedro Sula. All of the hospitals afterward were area hospitals, with the exception of the Pediatric

Specialization Hospital (CMEP), which began construction in 2004, but did not open until 2014.

It also did not extend healthcare coverage in Honduras. Instead, the MOH transferred budget, rooms, and health personnel from the existing Maternal Child Hospital to the new CMEP, weakening that facility in the process (Carmenate-Milián et al. 2017).

This brief overview of the establishment of hospitals in Honduras is illustrative of the ways in which healthcare has been a low priority as a state responsibility. Historically, it has been only when pushed by catalyzing events, massive strikes, or popular uprisings – or in conjunction with U.S. foreign aid mandates – that substantial new hospitals or investments in healthcare are made. Healthcare, despite being a constitutionally guaranteed right, has been an afterthought for the political elites in Honduras. This history also suggests that Honduran elites have been content to allow and encourage non-governmental organizations and religious orders to fill the gaps, that is until the acting government is compelled to assume responsibility for healthcare by popular action or the threat of losing already sparse coverage to closure of hospitals and health centers.

Current Challenges in the Public-Private Health System

This long-standing ambivalence to healthcare resources is notably demonstrated by the regionally and internationally low rate of investment per capita in healthcare in Honduras. It is also evidenced by the fact that aside from a few minor amendments, the healthcare and social

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protections (social security) models have not changed in fifty years (Carmenate-Milián et al.

2017). In the past two decades, catalyzed by hurricane Mitch in 1998 and then the 2009 coup d’état, that ambivalence transformed into more deliberate stance, policy, and action to the detriment of the broader health system. I will discuss those events and their relationship to the health system below, but I need first to present the current health system situation.

Currently, Honduras is among the lowest-ranked countries regionally and globally for public investment in health, spending 8.5 percent of Gross Domestic Product (GDP), or just over

$100 per citizen annually (PAHO 2020). However, that number is misleading, since the calculation includes the patients pay half of that amount, 4.4 percent, out of pocket. There are 10 physicians, 3.8 nurses, and 0.3 dentists per 1,000 inhabitants, and less than one medical technician for every 10,000 patients in Honduras – more than four times lower than the regional average (PAHO 2020). However, as Carmenate-Milián et al. (2017) note, nearly half (46 percent) of the 10,995 registered physicians in the country are unemployed. Unemployment, few domestic medical residency programs, as well as class status contribute to high levels of

Honduran-trained doctor (and nurse) emigration (Carmenate-Milián et al. 2017). Salaries for existing healthcare professionals have been reduced by approximately eight percent, in part due to the terms set by funding agreements the Hernandez administration signed with the

International Monetary Fund (IMF) and the World Bank (WB), further undermining health system function (Carmenate-Milián et al. 2017).

Officially, the health system is composed of two subsectors – a public health sector that includes the MOH and the IHSS, and a private sector made up of private and non-profit entities

(Carmenate-Milián et al. 2017; Johnson 2010). The private sector covers fewer than 10 percent of the population, and the majority of the people who use private sector resources pay out of

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pocket. Only three percent of the population has private insurance. The private sector has 1,131 facilities that include medical centers, clinics, laboratories, and medical offices (Carmenate-

Milián et al. 2017). The IHSS has two hospitals, one in San Pedro Sula and another in

Tegucigalpa, seven clinics, one dentistry center, as well as two physical therapy and rehabilitation centers and a geriatric center (Carmenate-Milián et al. 2017; Rivera Williams

2009).

According to the MOH, there are seven categories of medical centers divided into two levels of care based on complexity. Hospitals are in the second tier, and are classified as national, regional, or area hospitals. There are 29 MOH hospitals, most of which are in a state of disrepair due to little or poor maintenance and most of the hospitals require significant infrastructural and equipment investments to provide adequate services in safe environments (Carmenate-Milián et al. 2017). Poor infrastructure and lack of necessary or functioning equipment are among the reasons public hospitals in Honduras report high levels of iatrogenesis (Pine 2010). Public hospitals are understaffed, under-equipped, and overwhelmed with patients because of inadequate supplies at level one care facilities (Pine 2010). A joint PAHO-USAID study in 2009 reported that 87 percent of hospitals (level two care facilities) lacked sufficient daily supplies, 53 percent had inadequate facilities, and 50 percent lack the medical equipment necessary to function (PAHO 2009, 27).

In 2013, media began reporting the instances in which patients were required to purchase and bring their own surgical materials in order to receive treatment. By 2014, this was the rule rather than the exception. To get any kind of treatment or surgery in the public hospitals, patients are now routinely given a list by a physician and must first purchase all of the correct supplies, up to and including sterile gloves for the doctors and sutures. In one case a woman, despondent

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because she desperately needed to have a cancerous tumor removed, showed me the list a doctor had given her and allowed me to photograph it. (See Figure 4)

Figure 4. A Patient’s Prescription for Surgical Materials to Buy for Kidney Tumor Removal4

The items on this list would cost approximately 3000 Lempira, around US$150, an amount of money out of reach for many Hondurans, and certainly out of reach for the woman who came to a medical mission clinic seeking material assistance to acquire some or all of these items.

Ambulatory clinics make up the first tier of the public sector. These level one, type one clinics are responsible for the bulk of health maintenance and management for the majority of the population (Araujo 2013). There are 436 CESAMO, 1,078 CESAR (specifically in rural

4 The list in the image includes: 1 Surgical Kit; 6 Vicril 0.1 sutures; 2 Zada 2.0 sutures; 4 gloves size 7.5; 2 gloves size 6.5; Four 2" elastic wraps; 1 liter of formaldehyde; 1 large wide-mouth container (patient explained for the disposal of the tumor). 115

areas), 74 maternal and child health clinics, and 15 dental school centers (Carmenate-Milián et al

2017). CESAMO are often responsible for 10,000 inhabitants or more. CESAMO in rural locations are usually supplemented by a few CESARs that typically operate in the same municipality and perform necessary triage and basic care. The CESAR nurse or auxiliary staff report to the CESAMO physician, who is typically the Chief of Medicine for the municipality.

CESAR and CESAMO are required to see a maximum of 36 patients per eight-hour day

(Carmenate-Milián et al. 2017). These health centers generally open at 7 a.m. and close for seeing patients at 1 p.m. and late afternoons are dedicated to completion of required paperwork, staff meetings, clean-up, and emergencies (Carmenate-Milián et al. 2017). There are no regular consultations on weekends, only emergencies are attended.

State or municipally run clinics are critical resources and are part of the PAHO-endorsed

PHC strategies for improving universal access to adequate healthcare around the world, especially in under-resourced regions and communities. However, the CESARs and CESAMOs in the rural zones often lack supplies and sufficient personnel to be able to attend to the amount of people in their care. This forces those who need medical attention, and can afford the travel and medical fees, to seek medical attention elsewhere. Public hospitals in urban centers also have dire shortages and are thus a gamble. In rarer instances, people will turn to private healthcare facilities, often requiring them to sell belongings or go into debt with friends, family, or banks to get medical treatment.

In the communities where my research takes place, municipal clinics serve nearly 11,000 people living in ten or more nearby communities and are usually staffed by just one doctor, professional nurse (roughly equivalent to an RN), or auxiliary nurse who is permanently on call.

This reality makes auxiliary nurses (Vernon 2009), community health workers with training in

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basic first aid, traditional birth attendants and midwives (Low et al. 2006a; Ticktin and Dalle

2005), and other local healers (Chapman 1992) central to the care strategies and health of

Hondurans. Many Hondurans rely on local healers to administer medicinal plants (Ticktin and

Dalle 2005) and ritual cures (Chapman 1992) where they are still available either in place of or in addition to biomedical cures and pharmaceutical remedies. Globally, community health workers are integral resources and in Honduras this is also the case. The public health efforts undertaken by community health workers in Honduras to curb mosquito-borne diseases like malaria, dengue, and zika, carry out deworming and vaccination campaigns, and provide crucial health and environmental surveillance and oral rehydration therapies for diarrheal disease outbreaks underscore how invaluable these actors are in preventative and long-term healthcare.

A number of factors usually contribute to these actors taking on primary responsibility for care. For example, as a result of inability to pay for transportation or hospital internment

(Fiedler and Suazo 2002), or a distrust of doctors and hospitals (Pine 2010), pregnant women rely on local midwives as a source of medical care and birth attendants, who may also be able to transport women in their care to hospitals or local clinics in the case of severe complications

(Low et al. 2006b; Sacks et al. 2013). Generally, people prefer local providers, but attempts to enforce hospital births as a strategy to reduce maternal and infant mortality, compelled many

Central American countries to de-emphasize midwifery or create barriers through mandatory professionalization and de facto criminalization, requiring birth attendants to obtain official training and certificates in order to legally provide services (Jenkins 2003; Low et al. 2006b).

The irony is that in both home births and hospital births in Honduras the primary issue is inadequate resources (Sacks et al. 2013) and reducing maternal and infant mortality is contingent upon much more than where birth takes place (Berti et al. 2015).

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As a result, accepting the requests for care from community members is fraught with contradictions. At a time when midwifery is desperately needed, Central American health systems have limited its scope. Midwives are no longer paid by the Ministry of Health (MOH), but they are encouraged to attend to the perinatal needs of mothers. Ideally, according to the

MOH goals, they are discouraged from delivering babies in homes, and are supposed to convince their wards to go to the birthing centers at their nearest hospital (Jenkins 2002). But the high rates of poverty create considerable barriers to travel and the purchase of necessary materials for a hospital birth, as well as the purchase of food and accommodations for themselves or family members, make the mandate to deliver in hospitals impractical if not frequently impossible to meet. This is even more difficult for people who live in rural areas that are hours away from the nearest maternity wards. As a result, more than half of births in Honduras are necessarily attended by traditional birth attendants or midwives, if not also by preference (Low et al. 2006).

First Popular Garífuna Hospital

The majority of remote Garífuna, Miskitu, Tawahka, and mestizo mountain communities did not have reasonable access to a hospital prior to 2008. The First Popular Garifuna hospital has been an important, and politically contentious, addition to the communities. The hospital fills a vital and unmet need for healthcare in the region, but it also does so for free and under a model of social solidarity and mutual aid, based in a foundational politics that health is a human right.

The hospital attracts patients from every department in the country – despite being in a remote area – and thus poses a potential economic threat to private and public hospitals alike. The political stance of the hospital founders, the community members that built and maintain it, and the Garífuna organization that oversees it, in addition to the support and solidary aid it receives from Cuban volunteer doctors, have made it a political target in Honduras. 118

Shortly after the coup d'état in 2009, the Honduran Armed Forces attacked the First

Popular Garífuna Hospital and the Honduran state declared it an illegal entity. The hospital continued to run with support from Cuban doctors and international fundraising efforts, but without any recognition from the Ministry of Health (MoH) or any of the medications and supplies the MoH supplies to other health centers and hospitals. As of 2015, the MoH and members of Honduran Congress recognized the Hospital again (it had been inaugurated by former President Manuel Zelaya just months before the 2009 coup d'état), and one of its original founders, Dr. Castillo was negotiating with MoH and Congressional officials to implement a national healthcare model for which the First Popular Garifuna Hospital would be the exemplar.

However, this effort was fraught and the ability of Cuban doctors to work in Honduras have been jeopardized, first when they were expelled from the country, and later when political rhetoric and violence resulted in targeted assaults on Cuban doctors and nurses once they were allowed to return.

Crises by Design

To date, 17 percent of Hondurans lack access to medical services at any level of care, and only 50-60 percent of Hondurans have regular access to public health services (Carmenate-

Milián et al. 2017; PAHO 2020). A 2013 report5 from the MOH described the state of the

Honduran healthcare system as "fragmented, segmented, exclusionary, inefficient, inequitable, and incapable of satisfying the needs and demands of the national population" (Araujo 2013, iv).

There has never been coordinated policy or administrative mechanisms for the among the sectors that make up the health system (Johnson 2009; PAHO 2007). Rather than take steps to rectify

5 As of 2021, these are the most current data available from the SES, many of the more recently dated PAHO and global health agency reports rely upon these data. 119

these structural problems through coordination and investment in critical healthcare resources, the Honduran government has instead used the new health model proposal to claim that the state’s resources “will never be enough,” and has instead ramped up its efforts to fully privatize the health system.

This is not a new tactic. Indeed, it is a hallmark of disaster capitalism (Klein 2008) that the Honduran oligarchy has embraced for decades. Some believe that the destruction of the health care system in Honduran in order to privatize began in 2013, with the defrauding of the

IHSS (Spring and Ancel 2020). But the antecedents of the current health crisis are part of the well-known history of structural adjustment programs in the 1990s that generated massive debts in low-income countries on the conditions that they, among other things, reduce (already astonishingly low) expenditures on and de-nationalize, privatize, and de-regulate common goods and services, including healthcare. The terms also required countries to minimize protections and

“liberate” their economies to allow more foreign investment and speculation, hence the now ubiquitous term neoliberalism.

After the devastation of hurricane Mitch, infrastructure already weakened by the systematic defunding from structural adjustment programs, was set back further still. Swanson

(2000) argues that Mitch was a key turning point for the Honduran healthcare system that made long-term healthcare a priority and saw the agents of Honduran governance become more discerning about the conditions of foreign aid. And while the government of Carlos Flores

(nephew of Miguel Facussé and member of the Honduran oligarchy), did refuse certain personnel during the post-Mitch recovery, official humanitarian aid increased exponentially during this era and did not waver until sanctions resulting from the 2009 coup d’état. Before

Mitch, international aid to Honduras was a mere US$415 million (Swanson 2000). After Mitch,

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international aid exceeded US$2 billion (Swanson 2000). In the wake of this disaster, Honduran elites and foreign investors took advantage of the opportunity to intensify the neoliberal project using the health system and healthcare priorities as a conduit. Within two months of Hurricane

Mitch, Honduran congress passed laws to privatize key industries and utilities (Klein 2008, 500).

Congress also overturned land reform laws and enabled foreigners to buy and sell property and lowered environmental standards and eased eviction restrictions as part of an industry-drafted mining law (Klein 2008, 500). The income inequality, land disputes, and environmentally- induced health conflicts that resulted are an ongoing issue.

At the same time, the Honduran government took on loans from various international financial institutions (IFIs) promising to “reform” healthcare in exchange (Armada, Muntaner, and Navarro 2001). Armada, Muntaner, and Navarro argue that the IFIs, including the World

Bank, International Monetary Fund, and IDB ultimately dictated health and social security reforms (2001, 731). In Honduras, these reforms included dramatic changes to the social security system, which funds the IHSS and accounts for 20-25 percent of healthcare coverage in

Honduras, and also funds the pension systems – a key factor in economic security of the retiree population in Honduras. Rather than reforms focused on shifting the administration of employer- insured health care and the pension program to reduce the strain on the IHSS, they resulted in further strain on the IHSS system – and the conditions for system-wide corruption and graft that ensued until it became public in 2014.

Armada, Muntaner, and Navarro add that social security reforms across Latin America were implemented as part of broader neoliberal structural changes (2001, 730). After Mitch,

Honduras was flooded with non-governmental organizations (including missions), which was an enormous boon for the IFIs and the disaster capitalism model. One of the hallmarks of IFI (and

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USAID) influence in health care reforms in Honduras (and throughout Latin America) is the funneling of aid through NGOs. This increased the power of the IFIs to effect structural changes, and despite the stated objectives of the reforms, also weakened the role of health ministries and governments in healthcare provision (Armada, Muntaner, and Navarro 2001, 738).

Further increasing the power of IFIs over health and social security reforms was the fact that intergovernmental organization, like WHO, PAHO, and the UNDP, became intimately involved with the lenders, in part due to their own budgetary shortfalls (Armada, Muntaner, and

Navarro 2001). This made for strange bedfellows and as Armada et al. note, reinforced the power of the IFIs and jeopardize the independence of the international agencies on a variety of levels, including policy evaluation and design and assessment of the social and health effects of economic policies (2001, 744-745). It also meant that the IFI’s, could use the metrics of WHO and the UNDP, like the Millennium Development Goals, as part of its loan conditions.

The Honduran health and social security reforms were funded through the Inter-

American Development Bank (IDB) and relied on conditional cash transfers as the primary means of addressing "the failure of the health system by paying people to take their children to preventive health services and to attend schools" (Gillespie 2004, 1996). However, as Gillespie notes, people are unlikely to use inadequate health services even if they are paid to do so

(Gillespie 2004, 1996). While largely in favor of conditional cash transfers, Gillespie argues that failure to improve healthcare infrastructure and the quality of services provided dramatically limits the ostensible success of buying health (2004, 1997).

After the coup d’état conditional cash transfer (CCT) programs were subsumed into the

2010 “President’s Program for Health, Education and Nutrition,” more commonly known as the

Bono 10,000 program, as part of a $110million IDB loan. The Bono program, still underway, has

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been critiqued as an unevenly executed assistance program funded by the Inter-American

Development Bank (IDB) that often worked as a vote buying and public relations campaign for the National Party. Bono 10,000 was unironically proposed as a social safety net program intended to improve the use of health, education, and nutrition resources among pregnant women and people under the age of 18, increase consumption spending among the extremely poor through targeted CCTs, and increase middle school attendance in rural areas (IDB, n.d.). The program aimed to do so through a stipend of L.10,000 per year (roughly US$500), or about

$40/month to extremely poor families in rural areas distributed on a quarterly basis.

The irony is that the structural adjustment programs that used the United Nations

Millennium Development Goals as required (or perhaps more accurately emboldened) the

Honduran government to cut public health expenditures (Salavarria 2003; Johnson 2010), ensuring that cash incentives would eventually stall as the public health system continues to crumble, while simultaneously creating the rationale for privatization. Not only did the reforms not decrease income and health access inequality, improve efficiency, or extend access to the impoverished in Honduras (or elsewhere in Latin America), but the ultimate beneficiaries of the reforms have been the national and transnational corporations and members of the Honduran oligarchy (Armada, Muntaner, and Navarro 2001, 745).

This set-up continued unencumbered by political parties, since the Honduran oligarchy has been well-represented in all of Honduras’ major parties (even the popular LIBRE party that emerged following the coup, which backed former First Lady, Xiomara Zelaya, as its candidate in the widely disputed 2013 elections). However, potential threats began to emerge when

President Manuel Zelaya joined the Bolivarian Alternative for the Americas (ALBA) with

Venezuela in 2008, in an effort to improve trade conditions and ensure energy sources for the

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country (Reuters 2008). This rattled the United States (and the IFIs in its control). Honduras and the United States were also part of the Central American (and Dominican Republic) Free Trade

Agreement (CAFTA-DR).

While joining ALBA did not mean that Honduras was withdrawing from CAFTA-DR, it clearly signaled that one of the United States’ most enduring proxies was intentionally allying with Venezuela and Hugo Chavez in particular, adversaries if not entirely enemies in U.S.

Foreign Policy. Zelaya also began meeting with coalition groups and signaled a willingness to shift policies to reflect popular social demands and functionally address rising income and health inequality. A bright spot of hope for a beleaguered Honduran polity quickly became an untenable threat to the long-standing status quo in Honduras. Just ten months after joining ALBA, Zelaya was ousted in the first military coup in Honduras since 1975.

In the wake of the 2009 coup d’état and the twelve years since, the National Party governments, and their powerful allies in the private business and finance sectors and Honduran oligarchy (across party lines), worked even more fervently to dismantle public goods, including health care in the country. They used the intentionally manufactured crisis of the coup d’état to place people in key roles in the MOH, IHSS, the retirement arm of the IHSS social security program and push through strategic plans and policies already in process to provoke failure in order to privatize. When Porifirio Lobo Sosa assumed the presidency, Honduras launched a massive privatization campaign called “Honduras Open for Business” within the year. He replaced the executive director of the IHSS, a position traditionally held by physicians, with longtime friend and business associate Mario Zelaya (no relation to President Zelaya) and his cousin José Zelaya in charge of purchasing.

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Prior to the coup d’état, the IHSS had already been under tremendous strain and had no reviews or reforms since its inception (IHSS 2009). Funded primarily through payroll taxes, the mandatory contributions to social security had not increased since 1962. In 2001, a strike among doctors and nurses in the Association of Doctors and the College of Medicine resulted in the minimum contribution being raised from L.600 to L.2400 (IHSS 2009). Nonetheless, the IHSS was already saddled with historic debt, inability to keep up with the rising costs of medicine and general medical equipment and supplies, as well as the maintenance and improvement costs of clinics and hospitals and its mandate to expand coverage (IHSS 2009). The 2009 report states,

“all of the aforementioned adds to the current issue of financial crisis provoked by wealthy countries, the Washington Consensus, which brought us Globalization and the defects of

Neoliberalism at all costs, as well as the political crisis of the current government of Manuel

Zelaya Rosales” (IHSS 2009). For proponents of disaster capitalism, the condition of the IHSS would be ideal. Appointing an underqualified figurehead to the IHSS, already in a dire condition, is a logical step if the goal is to provoke a crisis, manipulate its directors and key decision- makers for political and financial gain, or both.

The post-coup government took a similar, approach to the MOH. Appointed at the same time as the head of the IHSS, Dr. Arturo “Tuky” Bendaña Pinel appeared to watchdog groups to have been well informed about the state of the health system and medication supplies, but intentionally waited to purchase essential medicines using the approved processes

(“Transformemos Honduras -SALUD-” 2010). In April 2010, President Lobo declared a state of emergency in the Public Health System, which allowed for the “emergency purchase of medicines,” and a way to bypass the central, transparent bidding system for medical supplies and medications (“Honduras: Revelador Informe Sobre Compras Irregulares a Farmacéutica” 2010.).

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The MOH could purchase from any company, not just those vetted through the bidding system, and at prices not approved through the bidding system as well. This would become a crucial detail when the IHSS and MOH were found to have been overstating the cost of medications and supplies or overstating expenditures on supplies in order to embezzle the overages.

One company, and the Honduran elites and political officials that owned it, Astropharma, were among the earliest beneficiaries of this declaration and irregular contract system. Between

2009 and 2010, Astropharma saw a 1000 percent increase in government contracts, authorized by Secretary Bendaña. In 2014, the public became aware that Astropharma was selling pills made of wheat and no active pharmacological ingredients as antibiotics and other medications, as well as participating in overvaluation of formulary medication sold to both state and private entity buyers (“Empresarios acusados por fraude recibieron contratos del Estado durante la pandemia en Honduras” 2020). As the scandal broke about Astropharma, however, and investigators began following the financial transactions, it soon became apparent that

Astropharma was among one of many dominos involved in the functional collapse of the IHSS and corruption within the MOH.

While the news of Astropharma created serious concerns among Hondurans about the authenticity and function of Honduran medications, the scandal at IHSS had an even more significant effect on the faith of Hondurans in their health system. The IHSS has high symbolic significance for most Hondurans given its creation was a direct result of the Great Strike of 1954.

Congealed in it are the values of security (social, financial, health) and the government fulfilling its duty to its citizens in providing healthcare as a constitutional right. Protest marches erupted upon the revelation that IHSS equipment and medications had disappeared or had never been delivered, and that prominent members of the National Party in conjunction with massive

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corporations owned by the oligarch families of Honduras, like those that owned Astropharma

(“‘Our Central American Spring’: Protesters Demand an End to Decades of Corruption” 2015).

The Indignados demonstrations were comparable to the 2009 coup d'état protests. IHSS workers estimated that 3,000 avoidable patient deaths occurred because of insufficient equipment, medication, and medical staff (allegedly due to inability/unwillingness to pay salaries) between the time the funds were siphoned off and early 2015 (“How Hitmen and High Living Lifted Lid on Looting of Honduran Healthcare System” 2015).

Discussion

The lack of funding at the IHSS was and remains a real issue, but its financial and material crisis was not provoked by the embezzling scheme. As the scandal was unfolding, the

Hernandez administration was in negotiations with the IMF for a $188 million loan that among other things, explicitly called for the privatization of the IHSS (“How Hitmen and High Living

Lifted Lid on Looting of Honduran Healthcare System” 2015). Rather, the institutional and political failure of the IHSS was provoked by political opponents of Manuel Zelaya prior to and in the aftermath of the 2009 coup d’état specifically to create opportunities for certain state actors to take over control of the public institution, in the same way that the state has imposed direct controls over other important public institutions that experienced similar scandals and were deemed failed institutions. The defrauding of the IHSS was a planned political strategy that unfolded over more than a decade. The pattern is evident, as is the unlikely coincidence that the same people are on the appointed committees for each institution, including a banking institute, a land and title institute, the pension institute (separate from IHSS) and the IHSS.

The Astropharma, IHSS, and related corruption scandals in the MOH provide context for analyzing the role that trust and faith play in everyday Honduran health assessments and health- 127

seeking strategies. The “flour pill” revelations in the Astropharma case had a particularly lasting effect on the collective imaginary. People in Playa Felumi often told me that Honduran medicine did not work, "no llega," or that it was not strong or potent enough. They often posited that the pills they received from Honduran health sources might have been the infamous "flour pills."

This mistrust has made foreign medicine, or medicines provided by foreigners (even if they are medications purchased in Honduras) implicitly more trustworthy.

The scandals and the large-scale protests that erupted in their wake also underscore that the Honduran health system is a fundamentally political institution (Smith-Nonini 2010). To engage with a health system is to engage with the politics in which it exists, despite claims

NGOs and STMMs to operate in an apolitical space (Ferguson 1994; Barnett 2011). It is tempting to see the issues in the Honduran health system, or the lived experiences of this reality, and suggest that STMMs are a logical, perhaps even necessary response to the situation.

However, this dissertation argues that the same logics that inspire such a response are faulty and, in fact, make STMMs political tools within an intentionally hobbled health system that is understaffed, undersupplied, and underfunded rather than creating long-term solutions and viable healthcare systems. Indeed, in the context of the political economic machinations of Honduran oligarchs to create the scarcity and systematic failures in the health system, STMMs become complicit in undermining those institutions further, adding to the neoliberal rationale that public health systems should be replaced by privatized healthcare – a prospect that is antithetical to the

PAHO-endorsed principles of Primary Health Care and the goals of universal access to adequate healthcare.

Currently, volunteer based STMMs attempt to alleviate the effects of systemic poverty and limited health infrastructure through services ranging from pop-up general medical clinics,

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dental clinics, specialty surgery clinics, and health education, among others. However, STMMs represent just one among many existing incomplete and inadequate sources of healthcare in

Honduras (Johnson 2010).

This chapter has provided a more in-depth view of the health system and presented the ways the crises in which it is embroiled are the function of intentional political agendas. It also highlights specific events at the national level have had lingering impacts at the everyday level.

In the next chapter I provide an in-depth look at the CESAMO and health resources in Playa

Felumi, which will provide context for the kinds of care and health choices that are available to

Playa Felumians and whether and what kinds of gaps exist that medical missions could fill.

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CHAPTER 6

THE CESAMO AND HEALTHCARE PROVISION IN PLAYA FELUMI

While the broad context of the health system and overview of the major health factors in

Honduras are important to a general understanding of how medical missions become involved in

Honduras, the goal of this study is to under the effects medical missions have in the communities they serve. This chapter offers and in-depth view of Playa Felumi, its population, and the healthcare resources in place. I begin with demographic information and population-level data provided by the Mayor’s office and health reports shared with me by the CESAMO staff. I then describe the CESAMO, its history, and its current status, staff, as well as the day-to-day functions, CESAMO responsibilities, vaccination campaigns, contact-tracing and epidemiological surveillance, house calls, its patients and its critics. The chapter presents ethnographic data about why and how Playa Felumians do or do not incorporate CESAMO services into their health-seeking activities. It precedes a detailed chapter about the HMH clinic and its staff and volunteers.

Playa Felumi by The Numbers

Although Playa Felumi is a rural town in one of the more remote and resource-deprived departments of the country, it is also the municipal center – like a county seat. It houses the

Mayor’s office, a CESAMO, a modest kind of main street where there are modest stores and a community radio station, a few pulperias (bodegas or corner grocers). There is a kindergarten, elementary, and secondary school, which although in various states of infrastructural disrepair, are resources not necessarily available in other parts of the department.

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In 2014, the population of Playa Felumi was 7,666 people living in 1,612 households.

Approximately 52 percent of the population identified as female6 and 48 percent as male

(Municipal Report 2015). The report did not differentiate households based on ethnicity, but

Garífuna account for approximately 75 percent of the town of Playa Felumi. However, Garífuna are less than half of the population for the entire municipality. Heads of major institutions, including the Mayor and the municipal Prosecutor are ladino. The director of each school is

Garífuna.

Of the total households in Playa Felumi, 100 percent reported income that equaled less than US$1.00 a day. Using an income-based approach, the World Bank and the United Nations classifies daily income below one dollar a day as extreme poverty. Impoverishment is compounded by landlessness and unemployment, or more precisely absence of economic opportunity and remunerated work where people live. In Playa Felumi, 66 percent of households do not own or rent land, which is significant for a horticulturalist society, and also means that subsistence farming and related forms of agriculture are becoming less feasible (Municipal

Report 2015). At the same time, 95 percent of households produce their own food (Municipal

Report 2015). Of the population in Playa Felumi considered working age (5,393 people), 58 percent of them (3,139) are unemployed or informally employed such that they are classified as

"economically inactive" (Municipal Report 2015). This is ten times the national unemployment rate. Indeed, for many people who want to work, the only way is to leave Playa Felumi to search for work in the cities (or other countries), often leaving children in the care of relatives for extended periods, just to be able to find paid employment. Even that is not a guaranteed strategy, since available jobs are underpaid to such an extent that just over 30 percent of the working

6 These are the categories included on the Municipal report of Base Line Indicators I acquired from the Mayor's Office in Playa Felumi. 131

population is underemployed. In 14 percent of household interviews, for example, participants explicitly noted that “work” or a “source of employment” was a critical unmet need in the community.

Seeing a statistic that purports extreme poverty across the board, misses the observed class differences that do exist in Playa Felumi. For example, while 66 percent of households do not own land, 79 percent of Playa Felumi households own their home. Approximately six percent rent their homes, and 13 percent are borrowing housing owned or ceded by someone else. The matter of remittances also complicates the idea that class is homogenous in Playa Felumi.

Approximately 23 percent of households in Playa Felumi receive remittances, most of which (51 percent) are between Lps. 1,001 and 2,000 (approximately US$40-80) per month (Municipal

Report 2015). Additionally, some older Garífuna draw pensions and even retirement funds from the IHSS or jobs they held for decades in the US or as banana workers for Dole or United Fruit.

Others receive income from piecemeal work, or from family members working in other parts of

Honduras who send funds home, but which do not necessarily count as remittances.

There are at least three mid-level drug traffickers residing in Playa Felumi, all of whom own homes and significant tracts of land, as well as corner stores, eateries, and in some cases, even gas stations. One of them was a Garífuna man, the other two were ladino and not originally from the department. They, their families, and immediate associates enjoy incomes much greater than a dollar a day but are unlikely to report those incomes and equally unlikely to be questioned about their incomes, given the palpable and justifiable fear7 that most people have of these individuals and their networks. Their wealth was on display in the size and materials of their

7 During the course of fieldwork I heard numerous personal accounts from people who had been threatened, extorted, or violently intimidated by one of the three known narcos in town. Three individuals, one a twelve-year-old boy mistaken for his older teenage brother, were assassinated by sicarios working for the local narcos, which rocked the town and left all of us shaken and many of us traumatized during my field research. 132

houses, the number of vehicles and recreational vehicles (like ATVs, jet skis, and large outboard motorboats), or in the case of the Garífuna family, the kinds of wakes and novenarios8 they could throw (to which hundreds of people came).

I observed what interlocutors told me about the changing class dynamics in Playa Felumi.

During my home interviews, some respondents signaled that STMMs should visit "the houses, so they can note the poorest" of residents, distinguishing themselves into a separate class stratum.

Some of my interlocutors, like those with whom I resided during my fieldwork, had structurally- sound homes with adequate roofing, secure walls and doors, while others lived in single room lean-tos or shanties that were often easily damaged during rains or high winds, or susceptible to the intrusion of large rodents, venomous snakes, or dangerous interlopers because there were no doors or enclosed windows to prevent the uninvited from entering.

These class dynamics are often obscured as part of the "helping" discourses that pervade voluntourism and medical missioning, as well as the other-making identity formulations medical mission volunteers circulate as part of religious doctrine about “the poor.” I discuss some examples of this in the daily interactions I observed among HMH volunteers in Chapter 6.

Chapters 7 examines the epistemology and critical assumptions that result in this kind of erasure and chapter 8 focuses specifically on language tokens used by HMH volunteers and how their common discourse operates in Playa Felumi.

Class is also significant because socio-economic status plays a part in the kinds of illnesses people experience as well as the kinds of resources people are able to call upon. Despite

8 Novenarios are post-mourning period celebrations marking the one-year anniversary of family members who have died. They include dancing (punta especially parranda), singing, and professional musicians to play the drums. They also include food, drinks, and alcohol for everyone who participates. It is a dusk to dawn celebration traditionally, culminating for some in a dive in the sea to cleanse the spirit (though this aspect is usually observed by the immediate family). 133

growing evidence that socio-economic and environmental factors are often more important than presumed genetic (a term often used euphemistically in place of race) factors, medical mission approaches to medicine erases or ignores, often willfully, this part of the illness experience.

HMH volunteers were usually unaware of broader issues affecting residents' health and rarely asked about factors other than presenting symptoms. HMH volunteers also assumed that every

Garifuna person (who volunteers often generically referred to as Black) had high blood pressure

- and would openly show surprise if their blood pressure results were within "normal" range.

Among the medical volunteers I observed, they assumed that nearly every overweight person,

Garifuna or ladino, had diabetes. In many cases it was unclear whether the organizational narratives and agendas with regards to hypertension and diabetes as intervention priorities distorted the information incoming volunteers had to work from, or the medical volunteers held

(or transferred) this bias, independent of organizational information.

I discuss these two health conditions among Playa Felumi residents and HMH volunteers and CESAMO healthcare providers' respective responses to these illnesses in greater detail in

Chapter 10. I mention it here to bring attention to the complex circumstances of health and healthcare in Honduras and encourage reflection about the ways that socio-economic and environmental factors should influence provision of health in Honduras, particularly since these social determinants of health are part of the targeted health concerns identified by the MOH and

PAHO. Given their short-term nature, medical volunteer missions are at an inherent disadvantage in providing care to residents, be they in Playa Felumi or elsewhere in the world, if they are not privy to or interested in these structural factors.

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Healthcare Infrastructure

In 1962, Dr. Alfonso Lacayo, the first Garífuna to graduate from medical school in

Honduras, established what is the Playa Felumi CESAMO today. Dr. Lacayo's goal was to address the needs of the remote community that had been (and continues to be) systematically neglected by the Honduran state. Alfonso Lacayo was the first Garífuna to graduate with a medical degree in Honduras and having lived in Garifuna communities throughout his formative years, he understood firsthand the difficulty that Garífuna face in terms of equitable access to education, healthcare, and other basic entitlements.

The Honduran state ultimately recognized the health center as an official facility in the public health system, despite Dr. Lacayo's political affiliation and the systemic racism that has characterized the State's treatment of Garífuna communities since the 1800s (Anderson 2009;

Jung [Gilchrest] 2011; Euraque 2004). His own journey to university and medical school was a long process filled with obstacles, including racism and political persecution because of his membership in the Communist Party. Indeed, his Communist Party affiliation made it difficult to get the health center recognized by the Honduran state and later made Dr. Lacayo a target of death squads in the 1970s and 80s.Thus, the health center in addition to being a functional and important part of healthcare in Playa Felumi, is also historic.

Having achieved formal recognition in the 1970s, the health center is entitled to a government-funded staff of auxiliary nurses, licensed nurses, a doctor, and regular shipments of needed medications, medical equipment, and supplies. When the health center was initially established, Dr. Lacayo was the only physician. He trained his daughter, Gloria, as a laboratory technician to conduct simple tests - like pricking fingers and reading slides for malaria. Gloria eventually became the lab technician at Clinica Blanca and moved to the United States in the mid

2000s (See Ch. 9). 135

Today the CESAMO serves 11,535 households living in the same municipality of Playa

Felumi. It is one of the health centers for the municipality. Two are smaller outposts, CESARs.

Together they reach 42 percent of the population (Annual Evaluation Report 2014). The

CESAMO is a bright blue in the large grassy area it sits on, not the deep blue of the Honduran flag, but an electric sky blue, trimmed in a bright white. It had been painted within months of my arrival in Playa Felumi and practically glowed. It is surrounded by a tall chain-link fence that sits atop a three-foot-tall concrete retaining wall. There are gates that are padlocked closed afterhours. The door is reminiscent of a glass storefront and locked with a key. It makes the gate necessary for added security since it would be easy to break the full-length glass and walk in.

However, it allows the sunlight to illuminate the centrally located waiting area. There is electricity, however, there is no generator, so if there is a scheduled blackout or an outage because of weather or other malfunction, natural light is the only backup.

The functional layout of the CESAMO makes a U-shape (see Figure5). One of the auxiliary nurses completing her training at the CESAMO shared her Social Service report with me, which featured a detailed explanation of the components of the CESAMO with my translation (unpublished document):

Layout of the CESAMO Physical Plant

- Pre-Clínica (Intake)

- Clínica de consulta externa #1 y #2 (Outpatient Consultation 1 & 2)

- Farmacia (Pharmacy)

- Sala de Vacunación (Vaccination Room)

- Sala de Curación e inyecciones (Wound Care and Injections Room)

- Sala de Esterilización (Sterilization [of tools] Room)

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- Oficina de TSA (TSA [Environmental Health Technician] Office)

- Sala de Microscopista (Microscopist [Lab Technician] Office)

- Sala de Nebulizaciones (Nebulization Room)

- Sala de Espera (Waiting Room)

- Área Rehidratación (Rehydration Area)

- Sala de Consejería (Counseling Room)

- Bodega (Storage)

- Baño Personal (Personnel Bathroom)

- Baño de Paciente M=3 H=3 (Patient Bathrooms W=3 M=3)

Gabriela listed out each of the services or functions of the space, however some of the

“offices,” like the microscopist and the TSA office, or the Rehydration Area which shares space with the Nebulization Room.

The pharmacy was a small room with a little window that served as a counter and barrier between the patients and the person working in the pharmacy. There were stacked shelves on either side of the narrow room and a small window at the back that sometimes let in a nominal breeze. Patients brought their prescription slips to the window and waited while they were filled.

Medications were organized on the shelves using small cardboard boxes and/or labeled with tape and permanent marker indicating the type of medicine (Figure 5). Next to each row of medicine, or nested in the box, was a card with the daily counts of medicine distributed. This made it easier to do the complete inventory each week and to compile the monthly reports of type and quantity of medication used. When the medicine on the shelf ran low, Selva, who was in charge of the medication store room and inventories, would count and sign out what was

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needed. If there was no more medication, they would be forced to wait until the next distribution or donation.

Figures 5. CESAMO Pharmacy Racks, Suspensions, Boxed Medicines

Distribution is supposed to happen on a quarterly basis and correspond to the monthly reports the CESEAMOs are required to produce. However, the Astropharma and IHSS scandals

(Chapter 4) revealed widespread corruption and irregularities in the distribution chains, and further inaction and disorganization at the national level delayed distribution of medication nationwide. None of the CESAMO staff remember a time when the medicine shipments they received corresponded to the needs and regular usages identified in the reports they diligently produced.

The result was careful dispensation of the available medications. If there were common medications that were especially prone to running out, like liquid acetamenophen or diphenhydramine (generic allergy medication) for children, they used baggies to distribute enough for two to five days (Figure 6).

The freshly painted building had not always been in good working condition. A casualty of the intentional neglect of the public health system, the CESAMO had fallen into disrepair.

Bonnie, an American nun that volunteered with the CESAMO for 15 years, recalled what it looked like prior to getting an overhaul in 2013. “It’s not like I’m not 67. But the old building

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that we worked in was just horrible and I went on strike. I went on strike! I told them that couldn’t work there unless the conditions improved.” She said that people, “especially people from Playa Felumi [Garífuna]” would be “nasty.” One woman allegedly told her “you people…should have a better place for us to wait.” The previous health center was very small and the waiting area was entirely outdoors. Bonnie said that an advantage of the old center was that it was quick and easy to multi-task. One person could easily do intake and work the pharmacy because of the proximity of the rooms. “But when this new Centro was built, they did not consult any of the medical staff.” To her, the spacious layout made it “very difficult and tiresome,” to get up and check on something else or try to multitask.

Figure 6. Bagged Diphenhydramine (Left); Ferrous Sulfate Tablets 10-packs (Right)

The CESAMO Staff and Volunteers

Officially, the municipality of Playa Felumi includes one permanent physician appointment, and two physicians in social service. It also includes one licenciada (professional nurse), and five others in social service. Four auxiliary nurses are permanently placed, one is staffed on contract, and there is a rotation for two auxiliary nurses in social service. There is one permanent Environmental Health Technician post, and another reserved for a student in their

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social service. The municipality had one contract microscopist, but no permanent posting. The official staffing also included twelve registered midwives, although like the thirty COLVOLs

(collaborative volunteers – community health workers) they were not officially employed by the

CESAMO or municipality. During my fieldwork I met three physicians, four auxiliary nurses, and one licenciada, or registered nurse, all of whom were Garífuna and spoke Garífuna in addition to Spanish. I met both Environmental Health Technicians (TSAs) one of whom was a permanent placement, a Miskitu man named Madal, the other was a young Garífuna man, Jeffry, from Playa Felumi, staffed there for his educational social service, and the contract microscopist,

Elerio.

The TSEs went around the municipality checking and addressing environmental vectors, like standing water and contaminated water sources. They also did malaria screenings. They collected thick smear samples in the community, after which they took them to the CESAMO for

Elerio to evaluate for malaria. If any of those cases were positive, they would then deliver primaquine (if P.Vivax) or chloroquine (if P. Falciparum) to the patient. COLVOLS throughout the municipality were trained in these malaria screening procedures as well and regularly received slides and lancets. COLVOLs also managed the oral rehydration solution (ORS) stations.

The CESAMO doctor is also the medical chief for the municipality. At the time of my fieldwork, the medical chief was a ladino woman who did not speak Garifuna. However, the current medical chief is a young Garifuna woman who studied medicine at the Latin American

School of Medicine in Havana, Cuba, and had been one of the social service physicians posted to one of the CESARs. The CESAMO chief manages the staff (and volunteers) of the CESAMO and the two CESARs located in neighboring towns. They attend regional health meetings in

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Trujillo, coordinate with the Mayor’s office, and non-governmental organizations. They oversee and deliver required epidemiological, demographic, and medical reports to the Regional Health

Office. And they see patients at least one day per week.

Dr. Muñoz was a determined and energetic force while I was in Playa Felumi. She had been the medical chief at the CESAMO for two years and had attempted to meet with the teams at the HMH clinic, but the clinic was closed both times she went. The day we met she explained that when the brigades are in town the number of patients in the health center goes down. She said that “helps a lot, because we have very little staff. I’m only one doctor for the entire municipality,” in which there are over 11,000 people. She told me there are two other health centers (CESARs) in the neighboring towns, but nurses are usually assigned those posts. In addition to all of her administrative duties, she regularly saw patients at least one day per week at the CESAMO. The other days she was either present, but obligated with paperwork or meetings, or she was in Trujillo attending Regional Health Office meetings. Occasionally, Dr. Muñoz was away for trainings.

One of the auxiliary nurses working there during my fieldwork, Gabriela, was completing her servicio social, or the practical "social service" component of her formal auxiliary nurse training. Gabriela was one of the first CESAMO staff to greet me and over the course of my time in Playa Felumi we became good friends. She would finish her auxiliary nursing degree the following August. I asked her if she would return to work at this health center and she said, 'I don’t know, we’ll see what the government says,” hoping she’ll be assigned somewhere. As my time in the country neared its end, Gabriela expressed anxiety about what would happen after she finished her term - her employment in the CESAMO was not guaranteed, and despite the great need for health professionals and the number of trained and available professionals waiting to be

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hired throughout the country, it can be very difficult for medical staff to find placements at all levels of training. Gabriela was not able to find employment as an auxiliary nurse in Playa

Felumi or in La Ceiba, the third largest city and a place where she has family. Her husband found work in Canada, where they now live.

Selva, an auxiliary nurse in her early 40s, was one of the permanent post auxiliary nurses in Playa Felumi. She usually worked in the triage area and she filed and organized patient records. She was also in charge of the medical supply inventory and kept the keys to the storage room. When she finished the triage process for patients in the morning, she usually took care of vaccinations, injections, and wound care. Selva, like Gabriela, was from Playa Felumi and had family there.

Estela was another permanent placement auxiliary nurse. She was in her 50s. A Garífuna woman, she was born and raised near La Ceiba, and like many Garífuna in the cities, she did not learn Garífuna as a child. She had lived in Playa Felumi for many years, and had recently started learning the language. Estela had a deceptively gruff demeanor that belied her thoughtful, kind, and thorough character. Estela also had diabetes and used her experience to help educated fellow

Playa Felumians about the disease, how to check blood sugar and manage personal nutrition and medication.

Eliomara was in her 50s as well and the only permanent licenciada. If Dr. Muñoz was the chief, Eliomara was second in command among the CESAMO staff. Eliomara had many duties, including the management of directly observed therapy (DOT) for individuals with tuberculosis and antiretroviral therapy for people living with HIV. She did patient consults and participated in vaccination campaigns with the auxiliary nurses. She was also from Playa Felumi.

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Unofficially, there were also two nuns that volunteered their time in the clinic. They were

American Methodist Quakers. "One is a pediatrician,” Gabriela told me, "so tons of people come to see the pediatrician!” Bonnie was a retired pediatrician and Dayspring was in her twenties.

She had studied music at a college in the Pacific Northwest of the United States before coming to

Honduras as a nun. They occasionally had other “interns” who came for trial periods to decide if they wanted to take their vows. Bonnie and Dayspring worked one day per week in the

CESAMO. Bonnie practiced as a pediatrician with the permission of the Medical Chief, Dr.

Muñoz. They wore sky blue habits without head coverings, self-made and unintentionally reminiscent of a longer version of nurses’ scrub dresses. Dayspring usually worked in the pharmacy and administered nebulization treatments. The nuns only volunteered in the CESAMO on Tuesdays, so the other days there are two fewer staff.

Epidemiological Data for Playa Felumi

Dr. Muñoz shared the Annual Evaluation Report for 2014 with me. It included comparative data about healthcare infrastructure and epidemiological information from 2011-

2014. The ten primary causes of morbidity in the municipality of Playa Felumi in 2014 were: common cold (29.6 percent), febrile illnesses (18.7 percent), intestinal parasites (12.11 percent), acute hypertension (8.95 percent), diarrhea (7.3 percent), urinary tract infections (5.8 percent), tension headaches (5.44 percent), bronchial asthma (5.19 percent), pharyngotonsillitis (strep throat) (4.14 percent), sexually transmitted infections (2.94 percent). There were 207 cases of diarrhea in children under the age of five in the town of Playa Felumi, an incidence of 23.7 percent. There were no diarrheal-related deaths in Playa Felumi in 2011, 2012, or 2014, but the

CESAMO recorded two diarrheal child deaths in 2013. The CESAMO recorded 42 cases of pneumonia in children under five in 2014, two of whom died as a result of their illness. 143

In 2014 there were ten confirmed cases of P. Vivax malaria in the entire municipality. No

Falciparum were detected. And there were no deaths (there were two malaria-related deaths in

Honduras in 2014). Only three of the cases were in the town of Playa Felumi. The low incidence in the area (less than one percent) is a result of intensive programs of environmental precautions, eliminating standing water, cleaning and treating outdoor wash basins, clearing detritus from yards and fields, and regular fumigation. There were twenty confirmed cases of Non- hemorrhagic Dengue in the municipality in 2014, nineteen of which were concentrated in Playa

Felumi. Dengue is also known as “break-bone” fever and includes symptoms common with malaria. Like malaria, it is a mosquito-borne disease.

Other major health concerns were high average incidence of HIV (7.5 percent) in Playa

Felumi, which accounted for all newly diagnosed cases in 2014 in the municipality. Tuberculosis was also a common issue. There was a 26 percent incidence in 2014 in Playa Felumi, however there was a 100 percent curation rate for all cases not associated with HIV (76 percent).

Diagnosis and treatment of HIV, tuberculosis, and malaria and dengue are all free – funded largely by the Global Fund or other international relief agencies. However, the CESAMO was only supplied with enough antiretroviral (ARV) therapy for already registered cases. In a meeting with the mayor, he explained that the CESAMO did not “always have enough of the medicines if someone isn’t already registered as HIV+, they can’t receive medicine. So, if a new case emerges, they may have to go elsewhere or go without medicine until the [CESAMO] is stocked with it.” The lag time can be a critical factor in patient health.

The CESAMO report also indicated complete vaccination coverage for all scheduled childhood vaccinations, which tracks with national vaccination rates and PAHO evaluations of vaccination coverage. Vaccination campaigns alone reached approximately 45 percent of the

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population in 2014. The remaining cases were met through regular patient visits to the CESAMO for scheduled vaccines and well child visits, or nurse visits to patient homes for follow-up on missed appointments. All vaccines are free, and the majority are provided through grant programs or international funding schemes, patients do not have to pay the Lps. 10 fee to receive scheduled vaccinations.

In addition, the CESAMO reported 83 percent coverage for prenatal care. The national goal is 95 percent coverage. Some patients received prenatal care in private clinics which compete with (rather than supplement) the CESAMO coverage totals, but they kept a running list of pregnant women receiving prenatal care in private clinics. The CESAMO in Playa Felumi also achieved a 97 percent coverage in cervical cancer screenings.

The CESAMO and its staff do an incredible amount of work despite having few supports and resources. One of the first issues raised in the Annual Evaluation was the issue of personnel.

This appeared to be a near-uniformly recognized problem among residents of Playa Felumi. The mayor commissioned an independent survey, which underscored that “the biggest issue is the need for more personnel.” I asked him whether the municipal or the central government pay the healthcare staff. “The central government pays them.” He added that they only pay out “every six months [through the municipality, which issues the checks], and if anything is overdue from the previous six months, they withhold that amount plus a fine from the current monies owed,” creating a never-ending cycle of arrears and generating income for the central government and siphoning off funds from the health centers in the process.

La Maratón

One of the first things Gabriela said when I met her was that the CESAMO doesn’t have enough medicine because the government does not send enough. She also said that medical 145

missions are helpful because they sometimes leave medicines for the health center. She told me that the nuns bring medicine, too. The Sisters buy Honduran medicines with monies donated from churchgoers, friends, and family in the United States and donate them to the health center.

Gabriela said, “If it wasn’t for the brigades and the nuns, [the CESAMO pharmacy] would be closed.” She then told me the HC staff would be mounting a door-to-door campaign in October to collect money to buy ceiling fans, chairs, and an “oasis” (water fountain).

But before that, there was another maratón scheduled to collect money for maintenance and repairs of the ambulance. At the health center meeting the day before the event, Dr. Muñoz impressed the importance of the fundraiser and convincing community members to participate,

“people have to participate because it’s [the ambulance] is for everyone.” In addition to the staff at the CESAMO in Playa Felumi, the staff of the CESAR would be going door-to-door to raise funds in their respective towns. The CESAMO and CESARs would be close, so that the staff could coordinate the fundraiser and collect funds.

The maratón was very much a community event. Gabriela, Selva, arrived first, followed by Madal the Environmental Health Technician (TSA) and the head auxiliary nurse, Estela, who was technically on vacation, but attended the fundraiser to keep track of the money raised. When she arrived, she had an unopened envelope with some writing on it in her hands and was eyeing it dubiously. She told Madal that she needed to count it. Estela announced aloud how much was supposed to be there according to the writing on the envelope and expressed concern that it was not all there. She handed some small bills to Madal to count, while she counted some of the larger denominations. Two other auxiliary nurses arrived in time to witness the counting. Estela and Madal flicked through their respective stacks and announced the results, it all added up.

Madal exclaimed, “See, it’s all there!” Estela said, matter-of-factly, “alright, my doubt has

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passed.” The rest of us chuckled. She added, "you have to count it, even better to do so in front of the person who gave it to you…It’s a responsibility. And if it’s not all there, then I’ll have to pay it back!”

Shortly after, the president of the patronato (a community council), Don Samuel arrived.

He was a tall, jovial man and was almost never without his kit hat in the colors of the Jamaican flag. Immediately, the CESAMO staff asked Don Samuel about the sound equipment and tent that was supposed to be there. They worked together to try and contact the person responsible, but he was in La Ceiba, 5 hours away, so they would have to make do without it. That question answered, they turn their attention to the ambulance. The ambulance driver arrived on foot, and after a brief conversation left to bring the ambulance so that everyone could see it. A woman who works for the municipality had come by and did not know that Playa Felumi had its own ambulance. She thought the fundraiser was for the one in a neighboring town, not their own. Don

Samuel, Estela, and Madal agreed that the ambulance should be present as a kind of proof that it exists, and that the fundraiser is for the purpose of keeping it in good repair. The driver left and promptly reappeared with the ambulance.

The ambulance, a Ford Everest SUV, pulled up alongside the park. It had been customized to be able to transport a gurney and fitted with an oxygen tank. There are red and white sirens on the roof and stickers from half a dozen groups claiming the ambulance as their project. In black letters along the passenger doors stickers said, “donated by the government and the people of Spain.” Below that was a strip in the shape of the Honduran flag and where the stars would usually go letters declared, “property of the State of Honduras.” Another sticker on the back passenger-side window claimed, “Government of National Unity - The Government of

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All.” Below that, a Secretary of Health sticker was affixed just slightly off-center. The back left tire was low on air.

Twenty or so teenagers, in their white and navy blue school uniforms, meandered through a nearby street with a box wrapped in white paper. A few students ran up to the houses as they passed by to ask for a donation. The students were recruited by the CESAMO and the patronato to help collect money. There are at least three or four groups of students that I could see from the park., Estela explained to me that each group was assigned an area of town and they would bring everything back to the park to hand to her once they had gone to each hour or filled their box.

Someone mentioned that in the neighboring town where another ambulance is stationed the youth raised around 1800 Lempiras going door to door.

The nurses then expressed their dissatisfaction with how the day’s events had panned out so far. Don Samuel and Madal walked appeared with an enormous loudspeaker in their hands to try to rig to the ambulance. One auxiliary nurse said that what Dr. Muñoz valued most was

“improvisation.” The others agreed. Yessica, another auxiliary nurse nodded her head emphatically. Selva rolled her eyes and huffed. Yessica added, “it is very disorganized.” The doctor did not attend the fundraiser. The nurses then began talking about the next campaign in

October. I asked Selva if she thought it would go more smoothly than the ambulance fundraiser.

She nodded emphatically. She was confident it would, especially because the nurses were organizing it. She and Yessica were already talking about logistics and what they needed to do.

While the nurses planned, Don Samuel and Madal and the ambulance driver finally got the car fitted with the loudspeaker. They jumped in ambulance and slowly drove around town announcing the fundraiser and asking people to make a donation. A few people, mostly young children sent by their parents, came to the park to and make their contributions. Two

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schoolteachers appeared with sacks of money to add to the count. With the lull in traffic and lunchtime approaching, Estela decided to get started on tallying up the donations. I helped count.

The ambulance circled around a couple of times to drop off manila envelopes, stapled shut once filled, with donations they were able to collect. The running total came to Lps. 9,331, around

US$467. It seemed like a lot of money, but Don Samuel said the goal was Lps. 25,000 to cover maintenance for the entire year. Estela, Don Samuel, and Madal stayed at the park for a while longer, hoping for straggler donations.

Vaccination Campaigns

In addition to raising funds for the maintenance of donated, but government-owned equipment, the CESAMO staff were also responsible for door-to-door vaccination campaigns.

There were quarterly campaigns, including a nationwide annual week-long vaccination initiative in April or May each year, during which common childhood inoculations are administered, as well as seasonal influenza vaccines for all ages.

During the quarterly campaigns, a couple of nurses would be assigned to go out, allowing for the CESAMO to remain open and see patients. Those doing vaccines would prioritize any households that had missed regularly scheduled vaccinations in addition to the municipal region specified on their schedule. Sometimes, communication faltered and during the November vaccination campaign, Gabriela ran the CESAMO alone. The nuns were scheduled to assist, but something had prevented them from showing up and they had no way to communicate their unexpected absence. I had not scheduled to work in the CESAMO that week and happened to stop by on my way to take care of other tasks. I saw her working alone and offered to help. What ensued was a two-woman show (until the microscopist arrived). And it was no ordinary health center day. Among the first few patients triaged was a child with fever and another with diarrhea 149

as well. The child’s diarrhea could not be held in his cloth diaper and leaked onto the floor, which resulted in a delay while we scrambled to find gloves, a mop, and bleach. Gabriela whipped up some litrosol (Oral Rehydration Solution) and tasked the mother with both administering the litrosol and mopping up the watery substance on the floor.

By 8am we realized the nuns were not coming, and Gabriela realized she needed to start consults if she ever hoped to get everyone seen and back home at a reasonable hour. Eliomara was not answering her phones either. She turned to me and said, “ok, what you need to do is write down name, identification number, age, weight, height, and blood pressure” and collect the

Lp.10 fee (less than one dollar) from each person getting a consult. Gabriela did not ask if I could or would, she was putting me to work! It was a rapid-fire orientation. She took the stack of files for the patients we had triaged together so far with her and went to a consultation room so she could start treating patients. There were several kids with fever, which Gabriela had me dose with acetaminophen right away. The microscopist, Elerio, showed up around 9am and jumped into the pharmacy, until I finished triage.

Eliomara and Estela returned to the CESAMO after their vaccination rounds about 11am and gave vaccinations to patients, but only to those waiting on vaccinations. They didn’t administer any antibiotic injections or otherwise see patients. They refilled their coolers with supplies and quickly left again to continue their vaccination campaign, leaving Gabriela to fend for herself. There simply were not enough staff.

During the national campaign the CESAMO was closed for regular care. If there was an emergency, patients could contact any of the CESAMO staff and someone would meet them at the clinic. The nurses and Dr. Muñoz broke up into teams. Each carried a grey and black mini- sized cooler with a neon orange handle stocked with vials flu shots and various childhood

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vaccines on the Honduran schedule of vaccines, including Diptheria, Tetanus, and Pertussis

(DTaP), Hepatitis B (infant and child doses), oral polio (OPV), measles, mumps and rubella

(MMR), and pneumococcal conjugate (PCV), and rotavirus (RV). They also carried vitamin A to administer to any newborns or infants they encountered during the campaigns.

Sometimes the mayor’s office would provide vehicles for the nurses to use during vaccination campaigns but this time everyone was on foot, except for Estela and Dr.

Montenegro, the CESAR physician completing her social service as part of her training at the

Latin American School of Medicine. They were compelled to travel on horseback into the remote mountainous areas of the municipality. I accompanied Gabriela and Selva on their rounds in half of Playa Felumi for two days. On the second day we joined forces with Eliomara and

Estela for the last half of the afternoon, after they had finished their assigned campaign area. The nurses knocked on doors and even stopped people in trucks or walking along the road to ask them if they were up to date on their vaccines or if they had already received their flu vaccinations. Children received vaccinations and vitamin A treatments at home. The nurses diligently recorded their information, and if there were newborns or new pregnancies disclosed during their vaccination campaigns, they recorded that information to keep the records at the

CESAMO updated. They were responsible for keeping accurate maternal and child health records and identifying and caring for every health need – even if people never came to the

CESAMO or disclosed their health status to the CESAMO staff.

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Figure 7. Auxiliary Nurses Give Flu Shots During “National Vaccination Days” Campaign

Even on foot they had to keep track of all of the paperwork. One older man was going to decline the “obligatory” vaccine. He seemed to be deciding, although I had already registered his initial refusal. He asked me if it was dangerous to swim in the sea after getting a vaccine. I told him I thought salt water was good for healing the body and was confident that I was not sharing anything inappropriate after Gabriela had answered numerous similar questions during the campaign. He then agreed to get the shot. Gabriela looked a little peeved when he finally agreed to the shot after I took his name down as refusing the vaccine. Messing up the paperwork! She smiled at him nonetheless and prepared the syringe. He winced dramatically as Gabriela poked him with a needle and plunged the still-cold flu serum into his deltoid muscle. He jokingly warned me that if anything happened to him that it was on me. I nodded, accepting responsibility. His wife, who had already dutifully received her obligatory shot, laughed at the spectacle and argued that he was just afraid and making excuses.

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Papeleo – Neverending Paperwork

One of the consequences of the Honduran health system being so heavily dictated by the

PAHO-IFI relationship described in Chapter 5 is an enormous amount of paperwork for staff, particularly at the CESAR and CESAMO level. There is so much mandatory paperwork, that health centers close by 1pm for seeing patients and staff remain to spend the next three hours completing patient notes and epidemiological reports. When I returned to volunteering in the

CESAMO one day after having been gone to observe medical mission teams, some of the staff were relieved. Selva finished doing triage and discovered me working in the pharmacy. She flashed a big smile and said she was going to “take advantage that [I was there] to do all this paperwork!” I nodded and smiled, “I know! Y’all have so much paperwork!” Selva lamented,

“and they say that we should not be here until one or two in the afternoon, but we have to be here to this paperwork and if we don’t, then we get in trouble!”

Most Fridays the CESAMO either closed early or was closed for all but emergency patients, so that the staff could file paperwork, finish weekly reports, and clean the entire facility

(the floors and bathrooms were cleaned and sanitized daily, as were any medical instruments used). The last Friday of the month was usually fully staffed but silent except for the scrape of rulers making straight lines along pages of handwritten reports and papers shuffling. All of the hand-written reports were then submitted to Eliomara who entered them into the computer for final submission to the Regional Health Office. Printing is expensive, so the nurses create many of the forms by hand. Only a few of the required forms are provided by the Regional Health

Office.

On other occasions, the CESAMO staff carried stacks of paperwork home with them to finish off the clock. There was simply too much paperwork to complete within the designated work hours. One Friday in March, after spending the entire day at the CESAMO completing and 153

filing paperwork, I joined Gabriela at her house to help her with maternal and child health surveillance reports, we looked through the weekly reports to identify any pregnancies, the types of family planning and contraceptives as well as their any corresponding due dates, and all vaccine appointment records. We added anyone identified as missing their appointments to another list, and Gabriela would later be responsible for calling (if possible) or visiting those families to follow-up and make sure they were on schedule. The CESAMO and CESARs have to meet a family planning quota established by the MOH in accordance with funded program guidelines dictated by PAHO-IFI program priorities. To be in compliance, they must report on the number of contraceptive methods scheduled, including how many condoms to distribute, and how close they come to reaching the planned numbers.

Consultations at the CESAMO

I was allowed to observe patient consultations at the CESAMO with the permission of the attending doctor or nurse and the patients. All of the staff spoke Spanish, and several of the

Garífuna nurses spoke Garífuna and could offer consultations to monolingual Garífuna patients as well. Dr. Muñoz was very thorough, patient, and kind to her patients. She speaks quickly, but clearly and will slow down when giving instructions or providing health education. I observed her consults with thirteen patients. Complaints ranged from gastritis, to prenatal visits, and more complicated concerns about HIV. At a physical exam the doctor discovered an inguinal hernia, caused by organ tissue breaking through a weakened abdominal wall. She scheduled a follow-up appointment for the following week because the child had diarrhea. The doctor counseled the child’s mother to boil water, even if it was bottled, especially for the children. She asked the child’s mom if she knew about the community posts with Litrosol (oral rehydration solution) in

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case the diarrhea did not improve. Dr. Muñoz did not prescribe antibiotics to everyone, only if she suspected or confirmed an infection.

She saw several pregnant women. The doorknob was missing from the door and they were waiting for a replacement, so when one expecting parent needed a pelvic exam, she put the plastic chair in front of the door and asked me to sit in it to ensure that no one entered unexpectedly and violated the woman’s privacy. Dr. Muñoz explained routine lab tests to another young woman who was pregnant for the first time. When the doctor discussed the HIV test and what would happen if the woman tested positive, Dr. Muñoz matter-of-factly explained,

“Today, HIV is like any other illness. If a mother has diabetes and develops complications, she could die. If she has hypertension and develops complications, she could die. If she had HIV and develops complications, she could die. Before, people with HIV died because there was no treatment. Now there is treatment, including here in [Playa Felumi]. Nobody dies from HIV if they follow their treatment plan.”

She did not want the young woman to worry about the test or the potential outcome. She tried to reassure her that she would be in good hands with the CESAMO.

Dr. Muñoz had notable rapport with the patients that came into the CESAMO. She also took into consideration various social and economic realities that people face in the course of trying to take care of themselves and their families. When another family came in with children who had diarrhea or vomiting, she made sure they had follow-up appointments to ensure the symptoms had resolved or decide whether hospitalization was necessary. She also made sure parents knew how to make or get oral rehydration solution. I observed as she asked one parent,

“Do you know how to make litrosol?” The woman said, “yes.” Dr. Muñoz, then asked the mother to tell her “how to do it.” The doctor listened intently while the patient explained, “boil water and let it cool. Then put a liter of water for one bag of litrosol.” The doctor smiled and praised the satisfactory answer, “Perfect!”

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There were a few instances when patients sought clarification at the CESAMO regarding experiences with medical mission treatment they had received at Clinica Blanca. One young man, in his early 20s came in very concerned that the health problems he was experiencing were related to HIV. Dr. Muñoz sent him to Elerio for a rapid HIV test, and when he returned with a negative result neither of them were satisfied. He explained that he had gone to see a medical mission team at Clinica Blanca for a malaria test. But when he read the slip of paper the mission volunteer gave him, “positive” was marked next to HIV on the form. It was unclear when he had visited Clinica Blanca, and there was conflicting information from mission volunteers about whether they had HIV tests. This caused further confusion. Dr. Muñoz wanted to be certain and alleviate the young man’s distress. She referred him for further testing in Trujillo and a follow-up in three months.

I also observed Sr. Bonnie during her CESAMO consults. She spoke Spanish well, though at a deliberate pace. In the first consultation I observed with the retired pediatrician, a mother had recently taken her son for a consultation at the medical mission clinic. She brought him to the CESAMO because he had a cough. She reported to Sr. Bonnie that the mission volunteers said her son had an infection, and that he also had malaria. She also wanted some vitamins because the volunteer at Clinica Blanca told her the child was malnourished. Sr. Bonnie scrunched her nose and scowled. This occurred on numerous occasions. Parents would come into the CESAMO after a consult at the medical mission clinic a week before, distraught because they had been told they were underfeeding their children or that their children were

“underweight.” Bonnie reassured the mother, “Nothing satisfies them!” referring to the medical missions and said, “To gringos yes, he might seem undernourished, but for a Honduran, no. He looks fine.” Sr. Bonnie asked the mother what medicines they had prescribed at Clinca Blanca.

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The mother recalled an antibiotic for the infection, amoxicillin she thought, and had given him medication for malaria as well.

Sr. Bonnie examined the child, listening to his lungs briefly and then asked him to look at her while she demonstrated a deep breath that she wanted him to mimic. It took a second, but he then took in the short inhale and made a loud breathy exhale. She checked his hands, his ears and his throat, mostly in silence. She then put a hand on his belly and looked at him and said, "I’m going to hit you, are you ready?” and with a closed fist, lightly hit the hand on his belly with the pinky side of her hand. She then sat up and told his mother that she saw no signs of infection. Sr.

Bonnie asked his mom about the last time that she treated him for parasites. The mom’s eyes widened. She pursed her lips and tried to remember. A smile broke across her face and she said,

“I don’t know, years.” Sr. Bonnie threw back her head with a smile and half-joking exclaimed

“What kind of mother [are you]?!” The mom laughed. Sr. Bonnie asked the mom if the missions gave her anti-parasitic medications for her son. “No,” she said, and Sr. Bonnie did the same thing, “What kind of brigade [were they]?!”

Sr. Bonnie spent about 15 minutes with each patient. She first gathered the reason for the visit from the patient and then repeated it back to them, sometimes telling them, “I want to make sure I really understand the story,” and then examined the patient and told the adult relative, usually the mother, but sometimes an aunt or grandmother, what she thought was going on. She then wrote out the prescriptions and explained each one and how each one should be administered. Occasionally, while writing the prescriptions out, the adult would ask them to add something to the list. “I also need Ibuprofen,” or “he also has sores! Can you give me something for his rash?” Usually, the requests were for basic things like vitamins. And Sr. Bonnie would include them on the script if they were available in the pharmacy.

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Sr. Bonnie consulted another family, a woman with 3 children in tow, all of which were very young, one child was her nephew, and the infant and 18-month-old were her children. The mother sat in a chair by the doctor’s desk with her shoulders hunched forward as she held her baby in her lap. She looked overworked and repeated that the older boy was her nephew. The mother was so soft-spoken that I struggled to hear what she was telling Sr. Bonnie. The doctor asked me to go fetch a notebook from Sr. Dayspring. I brought it back and Sr. Bonnie flipped to a back page and began writing on a slip of paper. In the notebook was a handwritten recipe for formula that called for milk, water, and sugar. I listened as Sr. Bonnie talked to the mother and asked about the children’s father. “He left,” the woman explained.

Sr. Bonnie prescribed medicine for the children and as she was doing so the woman asked if she had anything for hair that was falling out. Sr. Bonnie asked whose hair was falling out and the woman said her own. The nun sat in her chair and gently folded her hands in her lap and said, “Nooo…the cause of this is stress, and there’s nothing I can give you for that except for prayers.” She then said, “if you ever need us for anything, we’re here.” Sr. Bonnie then explained how to make the formula she had written out and the mother asked what she meant by

6oz. “I don’t understand 6oz?” Sr. Bonnie took an empty juice bottle and tore the wrapper off and found a marker and eye-balled 6oz. with the tip of her forefinger and thumb and marked the bottle with the black marker and gave it to the mom as a measure of 6 ounces of water. Sr.

Bonnie reassured the mother and said, "I have great faith in your capabilities as a mother and that your son will grow well.” She said again, perhaps trying to convince the woman. With that, the overworked single mother gathered up the two toddlers with one hand, the other still holding the infant and ushered them out the door. I asked about the improvised formula recipe and she said that her own brother had grown up on that kind of formula. She then explained that the mother

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was so overworked and had the children so close together that she can no longer produce milk.

"Her husband not only left his career but left them.”

Auxiliary nurses also did patient consultations and if there were complicated cases or attention required beyond the typical plan of care for common illness, the nurse would ask the

Licenciada or the physician for direction. If Dr. Muñoz was not available in person or by phone, the nurse would give the patient an appointment to be examined by the doctor or a referral for follow-up in Tocoa or Trujillo.

Diarrheal Epidemic

In early January 2015, there was an outbreak of diarrhea in Playa Felumi. At the beginning of the week, health center staff were concerned that they were seeing increased cases, so they called an impromptu meeting. Four CESAMO staff and I crowded in to the first consultation room and Dr. Muñoz reviewed the past few week’s reports, looking for lines highlighted with red crayon indicating diarrhea. She read the neighborhood and patient age off so that Jeffry, could note them. He would repeat after Dr. Muñoz, occasionally repeating the information incorrectly, prompting her to tell him to concentrate.

Initially the nurses had referred to it as an epidemic in passing, using gallows humor to get through what had been a rough month for a variety of reasons. Even if it was not an epidemic the point of the day’s meeting was to develop an action plan to address the root causes diarrhea and prevent it. After tallying up all of the cases it was clear that there was an actual epidemic.

They counted 27 cases of diarrhea in a three-week period, the majority concentrated in one neighborhood. The auxiliary nurses, the TSA, the registered nurse, and Dr. Muñoz all strategized, and developed an action plan. Jeffry was in charge of implementing the action plan as the health promoter and TSA. He was to report the cases to the mayor and then develop and 159

implement a plan to address health and hygiene that could be attributed to high incidences of diarrhea. They would use community radio, Radio Garinagu, to announce a new policy concerning health and hygiene and to inform people about the COLVOL posts where people could find oral rehydration solution.

The day after the meeting, I accompanied Jeffry and Gabriela as they visited houses to share the new public health policy and ensure previous environmental health campaign efforts were still being practiced. Gabriela brought a stack of blank patient forms to complete for any clinical visits stuffed in the bag she was carrying, already filled with ORS, metronidazole, and diphenhydramine. She came to do follow-ups with families that had come through the health center this week with diarrhea and/or vomiting.

Together they decided to visit the neighborhood with the highest incidence of diarrhea and that Jeffry said had been least cooperative with maintaining their yards and disposing of garbage in the way deemed appropriate by the recent ordinance. Part of the ordinance was to keep the yards around homes clean, trash was to be put in a large hole dug as a sort of garbage bin and burned, and grass chopped (work usually done with a machete). The goal was to reduce water source contamination and prepare yards for fumigation and pest control, which apparently is less effective if the grass is too tall. Most of the houses we visited were “casas de madera” were constructed of wood. These were usually more modest, the windows usually open squares without screens. In Playa Felumi wooden houses tended to mark lower income, although that was not always the case. Some of the concrete homes we visited were small, but housed several people, also marking financial scarcity.

At each house we stopped at Gabriela asked about anyone with diarrhea or vomiting while Jeffry walked around the property looking for issues and then reminded them to comply

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with the new rule or face a fine and visit from the police. He told me and Gabriela that he and

Don Samuel had already come through this neighborhood with the rule but not everyone had taken heed.

We found three more cases of diarrhea in the neighborhood. Informally, Gabriela asked how people got water. Many said they bought it. “Supposedly Superagua,” naming the company that sold five-gallon bottles of purified water. People did not trust that the purified water is properly purified, or at least not contaminated. The healthcare workers did not trust these commercial water sources either and parents were always encouraged to boil even “purified” water for their children. Other people boil the well water and/or chlorinate. People only boiling their water were also encouraged to chlorinate.

As we left one house Gabriela pointed to the puddle in the middle of the road. Jeffry noticed its improbability and I watched for a moment as they stared at it, trying to figure out what they were looking for. It should not have been there. The sand all around town was dry after the rains had passed, and the day was particularly sunny and hot. I eventually realized they were looking for evidence of a broken pipe, so I joined them to look for bubbles. I spotted some and pointed to a barely visible spot. “Ahhhh, YES!” Gabriela exclaimed. Jeffry said, “we have to report it. Gabriela, remind me to do that.” She chided him to “Make a note!” Jeffry left and

Gabriela asked the nearby resident if there was a broken tube. “Yes,” the woman answered and then slowly walked over to ask Gabriela about getting a new vaccination card for a child who will be going out of town. Gabriela told her to go to the CESAMO and someone could do it for her that day. While at the woman’s house, Gabriela treated two more teenagers for diarrhea. a

15-year-old and an 18-year-old. The older sibling was wearing a heavy felt winter cap, despite the scorching heat.

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The cases of diarrhea, in addition to being part of the mandatory surveillance and reporting sent to the Regional Health Office, were taken very seriously by all of the CESAMO staff. The Annual Evaluation noted an increase in cases of diarrhea in 2014 throughout the municipality. In response, they requested a water analysis and tested the majority of water sources. The report noted, “IT IS NOT SAFE FOR HUMAN CONSUMPTION IT IS

CONTAMINATED WITH FECAL WASTE, the TSAs met with the community water board, and they decided to chlorinate the water, the TSA chlorinated the water and taught [the water board] the process, but the water board has not done it.” After another meeting they learned that one community was buying purified water, but two others, including Playa Felumi continued to consume the contaminated water because they did not have resources to purchase purified water or sufficient supplies to continue to regularly chlorinate the water sources. This acute issue reflects the broader patterns of unreliable water sources and sewage contaminated water that the

MOH and PAHO have identified as critical social and environmental health concerns.

CESAMO Patient Perspectives

Despite the various challenges that the CESAMO staff face and the center’s infrastructural limitations, it was viewed favorably albeit critically by Playa Felumians. Of the 53 household interviews I conducted, 41 respondents (77.4 percent) said they went to the CESAMO for care. Playa Felumians sought out care at the CESAMO for routine and preventative health concerns, including vaccinations for children, well-child visits, prenatal and postpartum exams, contraceptives, preventative and routine gynecological exams, blood pressure and glucose monitoring, and DOT medication and check-ups for HIV and Tuberculosis. They also sought treatment from CESAMO staff when they or their children experienced asthma, fever, suspected malaria, had diarrhea, or were otherwise feeling unwell. 162

With few exceptions those interviewed said they believed the medical care they received were adequate and that they were treated well by the staff. There were only two respondents who said that they felt the medications they received did not work. Only one of the 53 households interviewed said the cost was an issue, “It’s always money, every time!” The Garífuna woman in her 60s also noted that the fact that medical missions “do not charge” was the reason she went to

Clinica Blanca more often than the CESAMO. Although there was a nominal fee of Lp.10 (less than one dollar) for consults, patients were rarely turned away if they could not pay it or did not have it on hand. They allowed people to register for consults and bring their fee later, or if circumstances called for it, waived the fee and noted it in their logs to account for short balances in their official reports.

Even when respondents did not get along with staff or felt particular staff were problematic, they distinguished the conflict from the treatment they received. One Garífuna woman in her 30s said, “Well, in terms of medicine, the medicine helps. There are some people of bad character there, but I don’t have any complaints about the medicine they give me.” The respondent did not name anyone specific and was among only two respondents who had specific complaints about interpersonal treatment by staff.

When asked what the CESAMO did well, respondents overwhelmingly responded that the staff “attend patients well,” “listen to what people have to say,” “they are kind and treat me well,” “they treat people well. Before, there was a doctor who yelled at people,” “they provide good exams [consultations], talk to the people, they don’t scold people when they are failing,”

“they provide good care,” “I prefer the [CESAMO].”

Young children did not view the CESAMO positively. In fact, most children were terrified of it. Part of their distaste for the CESAMO was that the primary reason children went

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there was for vaccinations. If children were especially sick, penicillin and other injectable antibiotics were frequent, efficient remedies. Another contributing factor was the general use of injections as a threat. “If you don’t eat your dinner, we’ll give you an injection!” I heard people warn children, “Better behave or you’ll get an injection.” Unsurprisingly, some children would start screaming the moment they hit the CESAMO doors. It did not win the CESAMO and its staff any favor among young children that the commonly used antibiotics (especially penicillin) burns upon injection. Even generally painless procedures, like nebulizations, could be frightening and disorienting, causing babies and toddlers to wail. Children already anxiously awaiting their turn could hear the distress of other children, adding to the generally unpleasant experience for little ones.

Playa Felumians had several suggestions for ways the CESAMO could be improved but recognized the structural constraints. Of thirty responses offered, 40 percent (12 respondents) noted that the CESAMO did not have sufficient quantities of medication or a sufficient variety of medications. Two household interview respondents said that wait times could be long, or people would be turned away and have to return the following day, but also recognized this as a symptom of too few personnel. One interviewee responded, “The only problem is it's really slow.

Waiting for a long time. Probably because they just have one doctor.” Another said, “They are not always available,” referencing the limited hours at the CESAMO. Indeed, “More personnel” was the second most frequent suggestion, accounting for 23 percent of responses. “To improve…more doctors, and a laboratory. But the nurses they have do a good job!”

The high school students that participated in my research were emphatic about the variety of medications. In their group miniplays, the students acted out treatment for serious illness or injury with a prescription of acetaminophen. In the discussion of the performance, students noted

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the frequency with which the analgesic was prescribed, especially because other medications were not available. When I asked students what they thought could be done to improve health many said, “more medicine” and “more personnel.” I asked them for their ideas about how to get more medicine and personnel. One girl quickly said, “ask the President!” Another said to ask the mayor, and another girl suggested that they have a meeting in the community. Some of the school children and youth also suggested that the CESAMO be open 24 hours a day, every day of the week. One high school student in the 13–15-year-old cohort suggested that the existing staff could work in shifts so that the CESAMO could be open all the time, while also accommodating the limited staff and their need for days off. In a different class of 17- and 18- year-olds, two young women echoed this idea. Their solution included more doctors and nurses to staff the CESAMO.

The next most frequent request was for equipment and improved facilities. Some of the respondents wanted simple comforts, like chairs and more comfortable space in which to wait for their consultations but appreciate that it was “already bigger!” The second fundraiser of 2014 raised enough funds to build benches, but they were unable to raise enough for a filtered water station. Other suggestions were more technical, like those for a laboratory and “necessary equipment.” The microscopist could do malaria tests, rapid HIV tests, and could collect BAAR sputum samples, but those samples and other tests, like pap smears and cervical swabs had to be delivered to Tocoa or Trujillo for analysis because they did not have the equipment to process the samples. Interviewees identified, “glucometers or ultrasounds…[and] exam tables,” among the items that would improve the care they could receive at the CEASMO.

Despite their frustrations, respondents believed the CESAMO and its staff “help the community” and appreciated the care and the things they thought the CESAMO did well. One

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respondent credited the CESAMO staff for “fumigating [for mosquitos], going out to vaccinate.”

Another praised Dr. Muñoz’s patience and skill at interpreting the results of diagnostic tests, and sharing the information with the patients, “She reads the results really well!” Two respondents made a note of the health education talks the CESAMO staff decided to offer to all patients while they were in the waiting room. The interviewee stated that it was an example of one of the

CESAMO’s strengths that “they gave advice; charlas - In August [2014] they talked about sexual violence, STDs, using condoms… someone from here and from Trujillo did the talks.”

Gabriela was usually responsible for giving the talks while she was there and had a notebook with hundreds of handwritten pages of script and discussion points on a variety of topics.

Discussion

This chapter presented an overview of the healthcare infrastructure, the CESAMO and its staff, their responsibilities, undertakings, and the constraints they face. It also presented data about the general perception of healthcare services and reasons that Playa Felumians seek out medical attention or resources at the CESAMO.

The next chapter examines Health Missions Honduras and the details of their goals and work in Playa Felumi. It presents details about Clinica Blanca, a typical day at the HMH clinic, perspectives from HMH volunteers, and the Playa Felumian staff that work for the medical mission organization. The chapter introduces some of the lead volunteers' espoused beliefs and their perspectives about their work and the project of short-term medical missions in general.

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CHAPTER 7

HEALTH MISSIONS HONDURAS: AN ORGANIZATION AND ITS VOLUNTEERS IN HONDURAS

In the previous chapter I introduced Playa Felumi, the CESAMO and its staff, and provided a glimpse into the healthcare realities, experiences, and practices among Playa

Felumians. In this chapter I introduce Health Missions Honduras (HMH), a cross-section of its volunteers, and provide a glimpse into experiences working in Clinica Blanca. This chapter focuses on the people of HMH, their experiences and perspectives as volunteers, and the infrastructure and operations of Clinica Blanca. The next chapter examines one of HMHs guiding texts, the discourses and narratives it influences among volunteers, and the effects that has on the work they do.

Health Missions Honduras (HMH) in Playa Felumi

Health Missions Honduras (HMH) is a volunteer-run non-profit, 501(c)3 organization based in the southeastern United States. Their mission is to provide free medical, and occasional dental and optometric services to vulnerable communities in the Department of Colón, Honduras.

HMH also attempts to offer health education regarding disease prevention, sanitation, and nutrition. HMH organizes up to twenty teams per year (but usually between 10 and 14) and occasionally allows other team-sending organizations to use Clinica Blanca as a base of operations for their own medical missions (which do not usually run clinics in Playa Felumi).

In its current form HMH is governed by a Board of Directors that consists of North

American volunteers, and as of 2019, one English-speaking Honduran who has worked with the organization for the past 10 years. The Board holds two to three meetings each year, at which members plan the volunteer schedules, discuss governance of the organization and fundraising,

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and make decisions about services and programming and collaborations with potential resource providers or local churches for space. Sometimes, the board meetings involve discussing literature, like the book When Helping Hurts, as part of planning their missions, organizational strategies for intervention, and moral or philosophical approaches to mission interactions with community members. The board meetings are closed, and the proceedings are not public, but they do invite guests or outside speakers on occasion.

Recalling the trends observed in the literature in Chapter 2, HMH determines the criteria and conducts their own evaluations of their work. Their GuideStar page indicates that:

Each meeting of the Board of Directors has [a] report from each of the Committee Chairs which outline their progress in meeting the goals set forth. In addition future retreats for the Board as a whole to evaluate progress and establish new goals and objectives are anticipated.

As of 2020, their self-reporting also indicated that they collect feedback through emails and survey, town halls and community meetings. Though unspecified, these seem to focus on volunteer input. In another statement, the HMH Board indicates that they “employ non- traditional ways of gathering feedback on programs and trainings, which may include interviews, roundtables, and external reviews with/by community stakeholders.” During my observation of

HMH in Playa Felumi between 2014 and 2015 there were no town halls or community meetings or interviews with patients attending the clinic. In that time, HMH Board members did have meetings with the Board of Directors of Casa Hogar, the children’s home the volunteers call “the orphanage,” as part of their operating responsibilities, but these were not “community” meetings or attempts to conduct “external reviews” of HMH activities.

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History

The founder of HMH, Dr. Simons, began working in Honduras in 1987, working first in church-operated clinics on the island of Utila. He made his first trip to Playa Felumi in 1995 and founded HMH the same year in order to raise funds to build a permanent clinic in the town. The clinic, which I call Clinica Blanca, is also colloquially referred to by Playa Felumians as "el hospital" (the hospital) or "donde los gringos" (literally "where the gringos are"). Eventually the organization built two satellite clinics in neighboring towns within the Playa Felumi

Municipality. Both are within a one to two-hour drive of Clinica Blanca, to allow for day trips and easy return for the volunteers to eat dinner and sleep in the living quarters on the second floor of Clinica Blanca.

One of the residents of Playa Felumi has been employed by Dr. Simons since the start of its creation. Ricardo works for HMH as a handyman, interpreter, general errands coordinator

(gofer), and bus driver. He is in his early 60s. His sister, in her 50s, and brother, in his 70s also work for HMH. He is a friendly man, short in stature, and quick with a smile. His family grew up on the Bay Islands of Honduras. They are not Garifuna, but Ricardo speaks Garifuna fluently, along with Spanish (his natal language) and English (the language most common on the Bay

Islands, and often the first tongue of people born there). He held Dr. Simons in high esteem and told me about how Clinica Blanca came to exist. Ricardo told me what had been shared in the eulogy for Dr. Simons.

The HMH founder had been an Air Force pilot, or perhaps Army, Ricardo did not recall which branch, and had been in several different battles. On his "fourth or fifth mission," Ricardo explained, "Dr. Simons was in a lot of danger and thought he might die, so he prayed to God and said if God saved him from this, he would do something to help others and bring them to God."

Ricardo punctuated the story with heavy nods and a calm, sure cadence. He paused, staring into 169

the distance wistfully. He looked up at the walls of Clinica Blanca next to us. "This clinic was that repayment." Ricardo lamented that Dr. Simon’s nephew seemed to be negatively altering that legacy, in particular, by suggesting that clinic patients might be asked to pay a fee in the future. Ricardo was adamant that the clinic being free was central to the Dr. Simons' vision and to change that would dishonor the founder's memory and betray the intended purpose, both functional and spiritual, of the clinic.

In early 2014, Dr. Simons passed away at the age of 93. The organization faced a critical turning point as new leadership took over. By the time I first encountered HMH volunteers in

August of 2014, Dr. Simons' nephew, Buck, a silver-haired septuagenarian and retired civil engineer, assumed leadership of the organization and began to make changes. Dr. Simons' nephew had been a board member with the organization prior to Dr. Simon's passing. But Buck's approach to missions differed from Dr. Simons' in ways that had begun to shape the HMH's work in Honduras almost immediately. One of the longtime Honduran logistics coordinators, Alan, described Buck's approach as "moving [game] pieces," and was not sure what his own place would be or what the future direction of the organization would be under Buck's direction. There was also tension between mourning the loss of the organization founder, who was also family and a friend to most of the veteran volunteers, and the impetus to shift the philosophical and organizational focus of HMH.

The transition did not seem to interrupt the day-to-day work of the missions during my observations, with a few exceptions. There did appear to be a divide among volunteers: those long-time volunteers who got involved with missioning through Dr. Simons and remained loyal to his ideas, and those later generations of volunteers who aligned with Buck's approach to

"charity." Dr. Simons had always intended to provide free healthcare to Hondurans - as a charity.

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Buck, however, believed that "charity" denied people dignity, and that the way to restore dignity is for people to work (as unpaid volunteers) or pay for the volunteer services that HMH provides.

He believed that people would regain dignity and "have a stake" in the organization this way and emphasized that he and volunteers in his camp saw a problem of entitlement and ingratitude among Playa Felumi visitors to Clinica Blanca. Buck’s view is not unique. It reflects a broader alignment of contemporary evangelical Christianity with neoliberal values, which reinforce well- established principles of the “Protestant Ethic” as Weber described them in the early 20th century. I discuss this perspective and its neoliberal-evangelical relationship in the next chapter.

Clinica Blanca

From the outside, the HMH clinic, Clinica Blanca, is fortress-like. It is surrounded by a twelve-foot-tall chain-link fence, that is chained and locked when teams are not in town unless one of the Honduran employees is present preparing for a team’s arrival or doing maintenance on the building, water system, or back-up generator. The building itself is a two-story rectangle. The bottom floor is the sign-in window (see Figure 8 below), a small patio, that leads to the heavy door that opens to the waiting room. To the right of the patio is an alcove that opens to a sliding window where medical mission visitors await their prescriptions, sometimes for thirty minutes, sometimes for more than an hour. There is a long bench where people can sit while they wait. All of the windows and doors have heavy cast-iron bars or gates affixed to them. The bars on the windows are permanent.

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Figure 8. Sign-in Window at Clinica Blanca

To the left of the building is a wooden staircase that leads up to the second story of

Clinica Blanca, where the dorm, kitchen, and living space are located. Gates also secure the doors in these spaces. The stairs lead to the large, covered deck that looks directly onto a small patch of coconut palms and the beach. There are several rocking chairs on the deck and ceiling fans whose blades resemble wilting flowers as a result of the humid, salty air. The windows and doors on the second floor are not gated, since the door leading to the deck from the stairs is already gated. The views of the beach are unobstructed by cast-iron security features.

There are three doors, one in the middle that leads to the common areas of the dorm, and two at either end of the wall which lead directly into (or out of) the sleeping quarters. Nested between the dorm rooms, which usually have two to four single beds, are modest bathrooms with 172

a shower, toilet, and sink, with warm water and indoor plumbing (no bucket flushing required).

This is something of a luxury compared to the average medical mission experience. In the thirteen years I traveled with mission teams, there were only a few trips in which we had beds or mattresses to sleep on – we usually slept in our sleeping bags, perhaps with thin camping mattresses between us and the concrete or earth that served as our beds. In over twenty trips, there were none in which we had hot water or flushing toilets – a reality that is much more akin to the daily reality of most Playa Felumians. In the house I stayed in during my field work, and in approximately 67 percent of Playa Felumian households (Municipal Report 2015), although there was usually running water, bucket flushing was still very much the norm. While many volunteers adapted as well as they could or begrudgingly tolerated the accommodations in the

Clinica Blanca dorms, their amenities were quite good in the context of the average Playa

Felumian experience. Journal entries, group meetings, and survey responses frequently included volunteer commentary on their temporary lodgings.

Just pulled the sink away from the wall trying to turn on the water…Thought the knob pulled up – the two 1x1 wooden sticks supporting the front of it tilted precariously but the pipes held – no water on the floor or running down the wall – right the supports + brush the teeth…time to…enjoy the sound and feel of the fan against my slightly sweaty body.

-Dr. Jackson, 27 Sept. ‘14

To assist team leaders with planning and help volunteers feel more oriented when they arrive, HMH includes the floor plan of Clinica Blanca on their website (see Figure 9). It is a large compound, and in addition to the clinic and lodging, has its own water tank and filtration system as well as a large generator that ensures the compound has electricity even when the

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Figure 9. Clinica Blanca Floor Plan town’s power goes out either as a result of damage or regularly imposed blackouts. This is partially because the pharmacy is air-conditioned year-round to keep the medications stored at the proper temperatures. The team leader of the first team I encountered, Bobbie, gave me a quick tour of the entire Clinic space, including the pharmacy. From my notes:

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Bobbie led me to the pharmacy through the unmarked door in the waiting area and said, “Close the door, please, since this room is air conditioned” There were lots of knowing smiles and vigorous head nods among the 5 or 6 people, mostly women in the pharmacy. A man was at the frosted glass window in the far corner of the room. The room was bright and very cool in the August heat. Bobbie explained that "every team brings their own medicines and then leaves them here, so we have a pretty nice pharmacy.” There were three or four rows of bookshelves stacked with medicines and more medications were on the built-in shelves along the perimeter of the two outside walls. Bobbie introduced me and told the volunteers that I would be observing and instructed folks not to mind me if I “pop in and out.” As we walked out, I noticed a bookshelf along the interior wall piled with books, various Physician’s Desk Reference and pharmacology books, all ten years old or more.

Team Leaders and In-country Staff

Teams are composed of one or two team leaders who are responsible for a number of bureaucratic and operational tasks in addition to whatever service area - physician, nurse, interpreter, preacher, pharmacist, or layperson - in which they are skilled. Most medical mission organizations that operate in Honduras are religious, and the ones I observed between 2014 and

2015 were explicit in their affiliation with the United Methodist Church, although not all of the teams were explicitly religious in their focus (and a few volunteers did not identify as religious in any way). However, some of the mission leaders told me during their trips that they had considered completing the United Methodist Volunteers in Mission (UMVIM) trainings, but for various reasons had been unable to do so. The trainings incorporate practical concerns like organizing teams, handling paperwork, and what to do in case of an emergency. However, the

UMVIM books and trainings do not address the serious ethical complexities or intrinsic cultural imperialism of Methodist missions. Although there is no corresponding training, UMVIM team leaders are expected to be "culturally sensitive." But with no explicit standards for what that constitutes, it is unclear how UMVIM trainings expect volunteers to meet that goal.

On most missions, team leaders are identified months in advance, either through self- selection or at the invitation of the mission sending organization when they are setting the 175

calendar of teams in advance of their fiscal year. Medical mission organizations live and breathe by the trip fees volunteers pay – so if they are unable to fill their rosters and calendar with a minimum number of teams per year, they are likely to run accounting deficits unless they can scrounge up enough individual donations or grant support to balance their operating costs. One of the key tasks of team leaders is to recruit volunteers for their teams. Having a known or well- liked team leader already assigned to the team is a way for the organization to attract returning or recruit new volunteers into the organization.

For HMH the team leader also has to decide what days the teams will work in Playa

Felumi, if they will work in any satellite clinics (and this is sometimes decided in conjunction with the Board of Directors in the event that satellite clinics have gone without team visits or community members have conveyed special requests through HMH employees), and the general agenda. Team leaders are also responsible for assigning roles and responsibilities to volunteers, ensuring everyone stays on tasks, resolving disputes (if any), and making key decisions on behalf of the group and the organization. They are responsible for paying the employees before they leave for the end of the week, documenting any needed supplies or repairs for Clinica Blanca, completing a pharmacy inventory the first and last day of clinic, and recording and submitting a one-page final mission report. The report documents 1) the location of the clinic, 2) aggregate number of patients seen, 3) aggregate number of prescriptions, 4) total cases of malaria (see

Chapter 10), 5) total number of dental patients if a dentist is present, 6) the total number of glasses distributed, 7) total number of referrals written, description of problems encountered during the trip, and 8) “two to three human interest stories of patients and their care and highlights of the mission trip” with names and pictures for promotion of HMHs work in

Honduras.

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While there are a few tasks or responsibilities that are common among team leaders, there also tends to be significant variation. A few of the team leaders described their roles on the anonymous team surveys:

I am the team leader so it was my job to make all the arrangements in Honduras and purchase or collect all the medications and supplies that the team would use. Also to assign the staff their jobs, where we would work, etc.

Team leader ... All advance preparations. Ensuring daily schedule went smoothly. Knowing the people of the village and their needs.

I organized the team of 13 nurses and ancillary medical personnel and did the assignments. I worked in the pharmacy during the week, as one of our pharmacists had to cancel the trip at the last minute.

Although the reports are required, one team leader and HMH Board member explained that it was often difficult to get team leaders to complete the required reports. In fact, HMH had been part of a nutrition and vitamin program supported by a grant, but Marjorie explained that they had lost the grant because they could not get the team leaders to complete the required reports.

One team leader, Phil, journaled about his work as team leader and interacting with the

Honduran coordinator, Alan, during his trip.

30 Sept The majority of the team traveled to […] an outlying clinic but [Alan] and I have chosen to travel to Tocoa in order to purchases construction supplies and some groceries. I always enjoy talking with Alan concerning the latest news about his family matter, concerning the clinic and HMH as well as the state of current affairs in Honduras. I worry about the amount of time his service in [Playa Felumi] takes him away from his wife, family, and two churches; one in La Ceiba and one in Roatan. Yet his leadership is steady, like a captain guiding a ship, and his demeanor and character are upbeat. The HMH is quite blessed to have him as a member of our team. I look forward to seeing him again in January [at the HMH Board Meeting].

-Phil

Deciding if and when to leave to get other supplies, or whether to send someone to acquire what is needed is also the purview of the team leaders. In this case, Phil opted to go 177

himself because he also wanted an opportunity to socialize with Alan, they are both Evangelical pastors, and though born and raised in Honduras, Alan’s first language is English. Phil does not speak or understand Spanish and is not medically trained, so a chance to talk to Alan and work on a task (which included driving about five hours round trip) was enjoyable.

As the in-country coordinator, Alan’s employment with HMH is constant, although as

Phil notes, Alan also runs two churches through which he also earns income. In 2014, HMH leaders invited Alan to join the Board of Directors at the HMH Board Meeting held in January of

2015. Alan did not confirm whether he had accepted the invitation during my research, but the public listing of the HMH Board of Directors now lists him. He clearly had a lot of power within

HMH, especially in comparison to other Honduran HMH employees. During a mission in late

September 2014, I had a chance to talk to Alan and learn more about his relationship to HMH.

[Alan] sort of runs back and forth, but really tries to stay behind the scenes. He seems very friendly, but he seems exasperated frequently. I asked him how long he’d been working with the organization. “11 years,” he told me. “It started as one. I told them, ok, I’ll do it for a year, until you can find someone else. And here I am. I’ve submitted a letter of resignation twice and they won’t accept it. I sent the last one just last year. But Buck called me and said, ‘we need to talk about this.’ They won’t let me go. I thought, maybe, it was just time for me to move on to something else. But now that Buck is in charge, he’s moving pieces. I don’t know. And now they want me to be on the Board. In fact, I have to go to the Board meeting in […] January.” I joked that he’s been with them for a long time and now he knows all their dirty laundry. Without missing a bit, he gave me a sideways grin, chuckled, “heh, that’s why they won’t let me go!”

He then told me that he had hoped that Claudio would be ready to take over by now. I told him I hadn’t seen him around and Alan explained that he had a conflict with some National Bible Day activities with his church in La Ceiba and had forgotten about it until the Monday before the team came. Alan seemed frustrated while he continued with the story. “I’m glad you told me, because that means I need to find somebody else. So, I called Aaron. I had worked with his mother for years. That’s how I got started here.” Alan told me one day he had received a call and the founder said that they were "trying to get this clinic started but that to do that they needed my help. I told them they didn’t even know me. How did they know I was right guy for the job? ‘Don’t worry we’ve done our research and you’re the guy we want.’ I told them I’d give them a year… And here I am. I had really thought Claudio would be ready to take over by now. He’s been working with us for about 9 years, but he just isn’t interested. And the thing is, the Board, they

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don’t trust him. I had been sort of training him, I even paid for him, out of my own pocket, to go to English school. He went for a little while, but after three months stopped and said he had other things going on.”

Alan’s relationship with HMH is complex. He tried to resign from his position twice in the eleven years he has worked for HMH but has been compelled to stay on, and currently occupies a seat on the United States-based Board of Directors.

Alan’s role as in-country coordinator was also valuable because of his connections in

Honduras. He had close relationships with powerful Honduran politicians and businessmen like

Mario Canahuati, a politician and former Foreign Minister (2010-2011). In early 2015, Alan told me that his friend in San Pedro Sula, Mario Canahuati, had just told him that [the government] was about to change all of the police “here” [in the department of Colón]. “Normally when they do that, they let us know so we can write a letter and [HMH] can tell them what we’re doing here and to….” he trailed off. “Leave you alone?” I inquired. “Well, that or to keep an eye out.” In a country where the police are widely known for their corruption, the ability to influence how they interact with individuals and groups is significant.

Although generally friendly, Alan could also be mercurial. In February 2015, I was observing the mission team and there was a commotion about patients queuing up for intake.

One of the employees that managed the door and number of people who entered, Aurelio, asked people to line up and be courteous to the intake staff. That day, Alan took a decidedly different approach. He shouted, “The line must be like this!” and motioned his arms in demonstration,

“NOT HERE!” indicating the area on the patio where people had been huddling up. He sternly delivered an ultimatum, still shouting, “If you do not make the line, we will not check you in!

And when the bus arrives from [the neighboring town], we will check them in and not anyone else!” I asked him about the line. He quietly explained to me, “well, the frustration is that these people don’t make a line and then there’s a mess at the window and these people can’t do their 179

job. Yesterday we went to [a satellite clinic] and told people to get in line. It was pouring rain and they still stayed in line!” I nodded and wondered to myself what the difference might be. He was still visibly irritated and turned to go inside.

After greeting some friends, I sat down to write some notes and saw that two young women and a little boy had been triaged, and waved back to get their consult, but I hadn’t seen the older woman who had been first in line. I saw Alan and, just like with the line, I asked him why the young girls had gone first. The response I received was unexpected. It was hostile and unlike any of our previous friendly conversations or general interactions. He looked at me and said with disgust, “because I wanted to.” The uncharacteristic exchange caught me off guard.

Perplexed, I said that this other woman had been in line since 6:00 a.m. He shouted at me, “I don’t care!! It’s a big deal?!” Rattled, and still trying to convey curiosity, I said “No, I was just curious.” I was also confused. Alan was furious. “You don’t get to question what I do!!” He was yelling loudly and clearly pissed off. I handled the escalation poorly, and instead of letting it go, said I wasn’t questioning him, that I was just curious and said I had wondered if the girls were here on Sunday. He kept on, “That’s exactly what you’re doing! Don’t question what I do! I know what I’m doing!” He walked away and I stood there bewildered and glanced around the waiting room. One of the interpreters offered a sympathetic look. Aurelio shook his head and added a disapproving, “that guy.” I later learned that Alan had lost his temper with nearly everyone that day following an interaction with an older patient who had not brought proper identification. He had scolded the patient and they exchanged words. All of which prompted his intense frustration and irritated interactions with the rest of us.

That day I learned what the other staff already knew, when Alan was irritated, everyone gave him a wide berth and avoided interaction with him as much as possible. He spoke about

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Playa Felumian patients, “these people,” as non-compliant, disorderly. Throughout my observations, the mission volunteers rarely, if ever, saw this level of frustration from him. As

Phil’s account reflects, HMH volunteers viewed Alan’s demeanor as “steady” and “upbeat,” and although it often was, mission volunteers also missed out on the full picture of social dynamics within Clinica Blanca, Playa Felumi, and Honduras more generally. Alan seemed to occupy a liminal space as an outsider to Playa Felumi, reinforced through the ways he regularly distanced himself from “these people,” and as an employee and member of the HMH organization, but also a Honduran. He did not always feel he belonged with HMH, as indicated by his attempts to leave, but he also did not identify with the Hondurans living in Playa Felumi.

The other employees, the women who worked in the file and patient registration room, the women who cooked and worked in the kitchen (often for more than 15 hours a day!), the interpreters, who were usually Ricardo, his brother, and a cousin, the groundskeeper and night watchman, and Ricardo’s sister who did housekeeping (cleaned the bathrooms, bath and bed linens, and general cleaning of the living space), all lived in Playa Felumi. And while they had relationships with HMH, they did not eat and socialize with the volunteers, with few exceptions.

The kitchen staff ate their lunch on the tiny porch outside the kitchen door because, according to one of the cooks Evelín, “most teams do not like for us to eat with them.” This may have been attributed to the fact that most team members on most of the teams I observed, did not speak

Spanish. The rationale was never one of scarce resources – there was always plenty of food to go around.

The staff were also often reluctant to ask for consultations if they needed healthcare or supplies, but they also did not go to the CESAMO for healthcare citing distrust of the CESAMO, concern about its capacity or efficacy echoing rhetoric of the medical missions, and out of a kind

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of loyalty or sense of competition between the CESAMO and Clinica Blanca. In March 2015 a woman came to Clinica Blanca with pregnancy complications, she was a relative of the head cook, Amelia. Amelia was concerned about her kin and told me that she thought the CESAMO was responsible for the woman’s complications and added that she had “not been to the

CESAMO in a very long time. I stick with the gringos.” Amelia and Evelín also valued the evangelicalism of HMH and during the spread of the Chikungunya outbreak to Central America while I was conducting research explained to me that “Chikungunya does not affect the children of God. I am well, thank God.”

Few of the teams I observed included volunteers that spoke Spanish. There were a few teams that had volunteers who came specifically to assist as “translators.” The paid “translators” were Ricardo, Samuel when available, and Celia when available. For volunteers and paid interpreters alike, there were no guidelines or evaluations, outside of self-identified skill level for volunteers. Because there were so many volunteers and so few interpreters, these staff and volunteers usually running back and forth between rooms and stations in the clinic. Those interpreting did so in the consecutive style. Patients or HMH volunteer would speak a bit, then the interpreter would relay the message. None of the interpreters were medically trained (unless they were a clinician who also happened to speak Spanish). Clinicians who spoke Spanish could usually work much faster than those working with an interpreter but were uncommon on the teams I observed. The consecutive interpreting was only a partial factor. The interpreters also frequently added their own suggestions for the patients or counseled the patients about their symptoms before repackaging the patient’s narrative in their own version, sometimes accurately and sometimes with adjustments. In my observations from 17 October 2014, I wrote:

They often omit information that the medics would probably consider important, or in the numerous side conversations, they are usually offering medical advice to the patients in

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addition to, or sometimes instead of, what the doctor is saying. There doesn’t seem to be any clear guidelines for translating or any training for the translators.

This was the case for every interpreter, whether paid “staff,” or a paying volunteer. One volunteer added their own advice to a nurse practitioner’s suggestions. He instructed the patient to “stop eating rice” because it “has carbs.” In a country where food scarcity and accessibility are daily issues, and in Playa Felumi where these trends are amplified, telling someone to cut a staple food from an already calorically and nutritionally limited diet could be dangerous and does not align with current best practices in PAHO nutritional guidelines (“Protocol for the

Nutritional Management of Obesity, Diabetes and Hypertension in the Caribbean,” 2020.). The staff interpreters’ suggestions were usually more in line with standard care plans, preempting or anticipating a medical volunteer’s prescriptions, partially because the list of symptoms from the patients and the responses from the medical volunteer were so common and repetitive. In either case, neither the patient nor the doctor was aware that the interpreter was not relaying the explicit information of the medical volunteer or patient, and the patients did not know that the interpreters (except in the case of the paid staff) were not trained medical personnel or community health workers.

HMH Volunteers

Of the volunteers I observed, 57 percent were women, while 43 percent identified as men. This follows the trend found by the few systematic studies of the gender demographics of

STMMs, which suggest that women make up a majority of participants (Campbell et al. 2009;

Howell 2012).9 Age demographic data collected in my survey revealed: 13 percent of volunteers

9 None of the volunteers I worked with openly identified as as non-binary or gender-variant, so I will refer to men and women herein. 183

were in their 20s, 23 percent were in their 30s, 21 percent were in their 40s, 23 percent were in their 50s, 15 percent were in their 60s, and 5 percent were septuagenarians.

I initially suspected that most of my observed STMMs would come from the U.S. South, as HMH is based in that region and the majority of medical mission organizations I have encountered over the years are headquartered in southern U.S. cities. And while most (n=8) teams were organized out of Southeast states, the STMM volunteers who made up those teams hailed from 14 states across the United States and from nearly every region including the West,

Southwest, Midwest, Southeast, Appalachia, Mid-Atlantic, and Northeast. The remaining three teams were organized in the Midwest, Southwest, and the Northeast (Figure 10).

Figure 10. Breakdown of Volunteers by State of Residence

In general, there are very few STMM volunteers from lower income brackets. The majority of mission volunteers are in professions or part of broader social networks that enable them to spend thousands of dollars and take a few weeks off to do this kind of work. This reflects 184

current data about mission workers and voluntourists globally. Below is a chart (Figure 11) with the breakdown of STMM volunteer participants in my study by profession (n=53).

Figure 11. Professions among STMM volunteers

It must be noted that while there is very little racial or ethnic diversity among STMM volunteers, there is often class diversity. The class and wage gap between students, wage laborers and retired primary school teachers on the one hand, and their professional healthcare provider counterparts on the other, can be quite wide. Within the STMM strata, nurses and physicians are generally economically better off than their collaborators. My observations and individual informal interviews suggest that working-class volunteers tend to be more sensitive to class differences within Honduran communities than their wealthier colleagues.

Eugene, a volunteer who raised funds among coworkers, friends and family to pay his trip fees, seemed bewildered about the ways that other volunteers described one of the first stops on the team's journey to Playa Felumi. He distinguished what he witnessed and experienced from 185

the ways the rest of the team labeled the first site "the dump." This was Eugene's third trip, but his first in which the team had included this stop. Putting "the dump" in air quotes, he described what he saw to me in an impromptu interview in the upstairs common room of Clinica Blanca:

"There's a landfill and they've filled one section of it and people have now built houses. Some of the pieces of metal and things are scraps from the dump, but people aren't eating out of the garbage. They've got little houses and they've built a church. But some folks...I was on a team with, you know, doctors and stuff and they just couldn't believe people could live like that. But I grew up in a place not much different than that. They think that if you don't have the big screen [television] and all these other things that you can't be happy. But these people were happy, smiling. And these doctors are probably more unhappy than they are because they're stressed out because they have to work all the time to get even more stuff!"

While his wording here appears to romanticize poverty in reaction to what he saw as a more hostile discourse, Eugene was not oblivious to the difficulties the people at “the dump” faced. He distinguished again between the kinds of stress he attributed to the physicians he worked with and the people they visited. "They [the residents of this community] have real stress," he told me, like trying to figure out when the next full meal would be or how to get safe drinking water.

Eugene's ability and willingness to discern between a common disparaging medical mission narrative about impoverished people in Honduras and recognize the variation in class positions that is typically flattened by humanitarian discourse (see Chapter 7; cf. Jung [Gilchrest]

2014) among STMMs is an important departure. Eugene was the only volunteer among over 100

I encountered who self-identified to me as working class. But, while working-class volunteers are sometimes represented on STMM teams, insights like Eugene’s are generally overwhelmed by the dominant discourse. In some ways, they are seen as dissenting opinions, questioning the

"sacred cow" (Fassin 2011) that is volunteer-based humanitarian aid. While Eugene spoke to me about his observations, his devotional, addressed to the entire team, took the form of a

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personalized, abstract starfish metaphor, underscoring the value of saving one life and reinforcing dominant humanitarian narratives.

Given that participation in medical missions, or any voluntourism, has a minimum average cost of US$1500, it is unsurprising that individuals with more disposable income make up the majority of participation demographics. These data also underscore that STMMs—like other forms of voluntourism—provide opportunities for symbolic capital accumulation to individuals with the economic capital to acquire it, consistent with the observations of Vrasti

(2013, 2014) and Mostafanazehad (2014a, 2014b).

I found a diversity in political perspectives among STMM members. Like-minded individuals usually found one another and formed small cliques in order to discuss broader social issues (most often about "home" rather than about Honduras), but avoided conflict or heated debates – if there were dissenting opinions among volunteers, especially newcomers, they usually shared them privately if at all. I mention political diversity and ideologies here, first, to provide an accurate panorama of STMM teams’ heterogeneity, and second, to provide the foundational context for understanding the ways that entrenched political ideologies travel with volunteers, affecting the practices and outcomes of STMMs in the countries and communities where they work.

Of particular note were numerous volunteers’ concerns about "charity," "welfare," and

"poverty," some of which seemed to be informed specifically by the book When Helping Hurts, a

"guide" written for mission and development aid workers that relies heavily on dependency theory and culture of poverty tropes, as well as cultural imperialism and hierarchies of civilization (see Chapter 7). Dr. Barrister described some of her work in the United States and her thoughts on U.S. healthcare policies in a journal entry.

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Back home – I am semi retired, but work in two different free clinics that serve the homeless and uninsured. As of now – I have never met anyone who has successfully signed up for and /or have been able to benefit from “Obama-Care.”…As Christ says – the poor will always be with us.

Dr. Barrister, 27 Sept. ‘14

During a day of observing HMH volunteers at Clinica Blanca in March 2015 I encountered another discussion about U.S. healthcare and social welfare policies and recorded it in my fieldnotes.

Over cake volunteers bemoan “Obamacare.” One volunteer explains that her husband is financially better off paying the fines for not offering care than providing his employees with the mandated insurance. She said she could also get cheaper insurance for her and her children if she filed taxes as separated but living in the same household. Another volunteer added that it was “all bull crap anyway,” and the group of volunteers signaled their agreement with one another and continued to enjoy the cake.

A bit later, while divvying out donated toys and lollipops for kids in the main room, some donated sunglasses catch a volunteer’s eye. “Where were these donated from?” Marjorie, the team leader responds, “Don’t Ask, Don’t Tell!” She then tells everyone that an employee of a local donation center [in the U.S.] is a personal friend and when the center receives certain items her friend will send them to her. “Formula comes to me because they can’t give it out because the druggies use it to cut their drugs with. Sunglasses come to me and, I don’t care, the people who come in there, the people on welfare, they don’t want second-hand stuff, they don’t want somebody’s hand-me-downs!” Marjorie says her friend tells her, “if they go to a good cause….” leaving it at that for the group to fill in the blanks.

These narratives highlight some of the common paradoxes I have observed over more than a decade of work with medical missions. The volunteers in these passages are actively engaged in efforts to provide free healthcare to Hondurans, who they characterize as among the most vulnerable. They also classify “the poor” as permanent features of society or characterize the same people as “druggies” or undeserving of the “hand-me-down” items that they intend to distribute to Hondurans. As I show in Chapter 8, many HMH volunteers also criticize the

“government” healthcare available to Hondurans, and their criticisms about a for-profit health system like the one in the United States is not based in a belief that healthcare should be free and

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readily available to everyone, since the organization and many volunteers and the HMH board argued for a fee for service at Clinica Blanca. The narratives about the deserving or undeserving poor also appeared in volunteer and staff interactions with Playa Felumians.

HMH Missions: A Typical Day with a Volunteer

I have been on more than a dozen STMM trips as a volunteer interpreter and observed another dozen during my fieldwork period. In many ways, every team is different. Volunteers participating in my study would often point this out. "Have you been on trips like this before?" one volunteer asked me. Upon affirming, he said with a knowing smile, "then you know they are all different." But there are also many ways in which the volunteer experience follows familiar patterns. An excerpt from Dr. Porter’s journal entry provides a succinct overview of the typical day on an October team’s trip.

Today is day 3 in the clinic in [Playa Felumi]. Yesterday we were in [a satellite clinic] the whole day. Our typical day goes from 8-5 or 8:30-5:30, with a break for lunch. It is a very busy day. Most providers see 30-50 patients/day. We see patients in ones and multiplies, typically families stick together. We have a nurse that checks patients in (taking BP/temp/O2 sat/pulse), a lab where we do tests for malaria/UAs [urinalysis]/Blood sugar and a pharmacy where we keep our medication. One thing that is really nice here is that each patient has a folder. I think this improves continuity of care. This is one obvious difficulty with medical mission work, - typically in the US in the outpatient setting you would enact a treatment and then be able to reassess if the treatment worked or make any necessary changes. It is difficult to do that here, but at least we can look back and see what the last provider did. I think because of the lack of follow up we rend to treat infections a little more aggressively than we do in the US, because we worry that if we miss something the patient will be in trouble. There is a medical clinic in town that I don’t know that much about, and there is also a hospital somewhere nearby, but these can be more expensive for them. For example, there won’t be a trip for four months after this one.

-Dr. Porter, 15 October ‘14

Another team’s volunteer described seeing nearly 50 percent more patients than the number Dr.

Porter described as typical.

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Very busy clinic day @ [Playa Felumi]. One MD and I saw 140 patients – many of them mothers with children. Lots of HA’s [headaches], runny noses, cough with children – also requests for vitamins – for everyone – parasite med – lot of intestinal worms, head lice. (Had to take a shower and wash my hair) – nothing special about these people or children, I just always start having an itchy scalp when I see any pt. with lice. – Many cute kids – almost all very trusting and well behaved in spite of long waits in the heat.

-J. Barrister, 29 September ‘14

Between this entry and one two days later, this nurse practitioner and another volunteer saw 450 patients.

A typical day in the pharmacy involved sorting, cutting, bagging and labeling pills, as well as making suspensions (if patients do not have access to safe drinking water). Volunteers who did not speak Spanish and were not “medical” were often assigned to pharmacy tasks. It was also usually the space where the largest percentage of volunteers were needed because it takes and incredible amount of time to sort, label, and dole out the prescriptions. At Clinica

Blanca, a bonus of working in the pharmacy for most volunteers was that it was air-conditioned in order to prevent medications from spoiling. At the end of the mission season in October any leftover medications that would expire before the next team arrived in February were destroyed.

I had an opportunity to spend more time in the pharmacy with later teams. I joined an

October team one afternoon to help them catch up.

As we worked in the pharmacy, Marjorie sat across from me. She complained to another volunteer sitting with us that the pre-bagged pills she kept finding were sorted strangely. "Another team did this!" I asked her, while I cut and counted 480 metformin pills, if there was a standardized list of procedures that each team is supposed to follow. "Yes, but they're all volunteers. They're volunteers...they're supposedly medical, supposedly," suggesting that they should know to do things differently and more in compliance with the established procedures. Among the four teams I have encountered to date, none have done the same things in the pharmacy each time.

All of the teams did pharmacy set up and inventory before clinic started each time. The distribution of medications and vitamins is one of the primary outputs and evaluation metrics

(particularly the number of prescriptions and pills) of medical mission activities. 190

As a counter to the pace (or monotony) of clinic, volunteers often got to know each other, supported each other, and refilled their proverbial tanks during downtime. During my research

STMM volunteers ate lunch and dinner together, played games together, drank and told ribald stories or reminisced together. As part of my participant observation, I joined volunteers for morning coffee, devotionals and team meetings, lunch, and dinner, card and board games. One team thoroughly enjoyed drinking spiked soda from red plastic cups. They brought several crates of liquor with them as part of their kitchen supplies – an unusual practice. They intended to revel as much as they intended to work, and upon invitation I reveled with them.

Dr. Porter’s description of the daily clinic routine left out these non-work times and the scheduled visits to Casa Hogar as part of the typical mission experience in Playa Felumi.

Volunteers wake up for breakfast and pre-clinic meetings between 6:00 and 7:00am, most have coffee. A few early risers walked out to the beach to watch the sunrise, while others were in their pajamas and struggled to keep their eyes open. Others sat on the porch and stared wistfully at the horizon while they waited for breakfast to be served. Most teams opted for devotionals in the mornings, expecting to be too tired at the end of the workday. However, a few teams preferred evening meetings to reflect on the events of the day in the context of the religious texts and teachings they planned to discuss together. Two of the eleven teams I observed had no form of devotional or group reflection meeting as part of their experience. By 8:30am everyone descended to the clinic to get their workstations ready and begin taking patients. After clinic ended, between 4:30 and 5:30 each day (depending on the demand and preference of the team leaders), volunteers usually changed out of their clinic clothes, many went to swim in the surf if the water was not too rough and the weather was good.

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At least one day of each mission trip was dedicated to spending time at Casa Hogar, which volunteers colloquially called “the orphanage.” I discuss the activities and relationship of

HMH and its volunteers with Casa Hogar in more detail in Chapter 11. For the purposes of establishing the typical schedule of activities for HMH volunteers, I note here that trips to Casa

Hogar were usually at the beginning of the week or the end of the week and entailed an hour or two of programmed activity, like a “birthday” party or general celebration where volunteers handed out toys to the children there. It was also common for a few volunteers to get together during team “downtimes” to go to the home and spend time playing with the children once or twice as time allowed.

Evangelical Circulations: Self-Making, Escape, and Sacrifice in Volunteer Motivations

In their own words, which I gathered through informal interviews and journal entries, volunteers went to Playa Felumi to "make a difference," because "they were called by God," or because they felt they had "been blessed and want[ed] to give back." Volunteers also derived spiritual and emotional benefits from the experiences, that helped give their work or their daily lives back home more meaning or context.

For a Sabbath day, it’s sure seemed like a busy day. The day began with sermon preparation. Then at 8:30 in the morning, a group of six of us went to the Catholic Mass. The entire group had a devotion, song, and prayer at 10:30. At noon, we gave the orphan’s a party and lunch. Following the orphanage party, I had to preach before a sizeable crowd at the City Park. The day is a special day of the year in Honduras called “Bible Day.” What a busy day! I might have to go back to work in order to slow down.

-Phil, 28 Sept. ‘14

Others were unsure how they fit in but craved the change in scenery and a reprieve from the everyday paperwork and demands of their roles in the U.S.

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Ah the work left undone. Charts – the schedule to make – the papers to the new advisor… But the ocean breeze is primal, soft sounds of the surf, even though I have yet to see the water. After dark arrival on forever bumpy road – teeth shattering. AND no beer at the end of the trail. Kept questioning how I ended up here – Today with the folks I barely relate to – Not the patients – they are the same everywhere – Me fellow “servants.” Good people all – surely…

-Dr. Jackson, 27 Sept. ‘14

Spouses, parents with their teenage or twenty-something children, and life-long friends traveled together on STMMs to strengthen their relationships and share a significant life experience. Some travelled with STMMs as a way to see what a life as dedicated missionaries might be like. Nearly all left friends and family, work, bills, and other quotidian obligations behind in their respective towns and states in the United States - everything on pause for the duration of their trip since most did not have phone or internet access, "sacrificing" these luxuries to make the trip. One of the first devotionals I attended took the idea of personal sacrifice as its focus. A volunteer named Fran was that meeting's leader and asked each person in the room "What did you sacrifice to be here?"

Fran started by listing her own sacrifices and nearly everyone mentioned that they'd given up "family" in some form or another. One volunteer said her husband had recently had a heart attack and that she "hated to leave him and he kind of hated for me to leave," but she came anyway. Others talked about missing out on visiting with their grandchildren, and some said that there were important business things back home that needed attention, but that they would

"rather be here" in Playa Felumi.

One STMM volunteer's survey response underscores the sense of sacrifice and commitment that many of her co-volunteers share:

“I know the people know that our clinic is staffed by people who truly care about them and aren't going on a medical mission just to prove they are ‘good people’ to put it on a resume. Most of us return over and over again. I have been going two weeks a year and up until this past fall I only earned three weeks of vacation a year••, it has impacted my 193

family and the families of other team members who do the same. The community knows most of us and they know they can trust us and that we respect and care for them. I'm sure there are other short-term mission trips that do not have the years of long standing relationship with the people they serve like we do.”

Medical mission volunteers are part of a larger political-economic system that has helped to shape their actions and engagements, their understandings of who they are and what they are responsible to do. In no way do I consider their entanglement in the neoliberal humanitarian project an excuse for harmful interactions. As many authors since Illich have demonstrated, good intentions do not mitigate the consequences of well-intentioned but ultimately damaging interventions (Benton 2016a; Berry 2014; McLennan 2005). But an understanding of who

STMM volunteers are, who they perceive themselves to be, and the multiple subjectivities they embody, does help make sense of the decisions they make, the rationales and frequent cognitive dissonance (Allen 2015) they share, and why changing a medical mission model many of them openly recognize as broken is difficult.

In the next chapter I provide a detailed review and analysis of When Helping Hurts, the text many of my interlocutors implored me to read and told me is a guiding text for their thinking on short term mission work.

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CHAPTER 8

WHEN HELPING HURTS: AN ANALYSIS OF CONTEMPORARY MEDICAL MISSION PRAXIS

In October 2014, I met some of the leadership of the organization that HMH coordinates and sends medical missions. During this encounter and on several that followed, board member volunteers repeatedly mentioned the book When Helping Hurts: How to Alleviate Poverty

Without Hurting the Poor...and Yourself, by Steve Corbett and Brian Fikkert. I learned from the volunteers that this text plays a prominent role in the organizational planning and mission of

HMH. At the time of my fieldwork, all of the members of the Board of Directors had read it as a requirement of participation on the Board and several repeat volunteers had read it as well either out of interest, or aspirations to join the Board. Because it forms a theoretical foundation for the teams, it merits a close review that will facilitate a better understanding of the assumptions and methods the teams rely on and believe are essential to performing "good" mission work.

In addition to this main title, the authors also provide two supplementary titles. The first is Helping Without Hurting in Short-Term Missions: Leader’s Guide. Corbett and Fikkert assert that their book "will guide you through the process of designing a healthy, more effective trip."

The second, for volunteers, is the companion book, Helping Without Hurting in Short-Term

Missions: Participant's Guide. Corbett and Fikkert wrote the books in response to "the countless church and ministry leaders" that approached them for more resources after publishing the original book.

In this chapter I review these titles and reveal the ways that HMH volunteers seek to deploy the theories and theology advanced in the texts. I begin by providing a brief background of the authors to help elucidate how their positions in the world inflect upon their actions and influence their epistemologies. Next, I review the book, providing a chapter-by-chapter

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summary, highlighting the book's arguments and prescriptions. I analyze the underlying premise of the book and situate the methods and implications of the authors' work in the context of current research on volunteer tourism, short term missions, and critical development studies.

Finally, in the next chapter, I examine how this text was called upon by the short-term mission organization and teams I observed in Playa Felumi, Honduras.

Positionality: The Authors

Steve Corbett is an associate professor of Community Development at Covenant College, a small private Christian institution. He holds an MEd from the University of Georgia and has a background in non-profit aid work with Hungry International. Brian Fikkert is a Yale-trained economist and former World Bank consultant. Fikkert is Professor of Economics also at

Covenant College. Their co-authored guidebook, When Helping Hurts, is a product they offer through Covenant College's Chalmers Center, founded by Fikkert. The Chalmers Center mission is to equip churches and nonprofits to "help the poor in effective, biblical ways" (Chalmers

Center, "About," n.d.). According to the preface, Fikkert is the book's primary author and calls on his own experiences as the case studies and points of reference for their "biblically based" model for short-term mission interventions.

When Helping Hurts: A Review

Corbett and Fikkert (2014)have written a guidebook for faith-based short-term mission organizers and volunteers that aims to generate a reflexive, theory-informed practice among them. The book is explicitly meant for Christian volunteers and is premised on Christian biblical teachings and clear that its intended audience is people who identify as evangelical Christians.

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In the introduction Fikkert describes an encounter with a "rugged lady" identified as a local witch doctor "deep in a slum" in Kampala, Uganda (2014, 22). The local pastor, with whom

Corbett and Fikkert partnered to "test" their "biblically-based small business training curriculum"

(2014, 21), excitedly agreed to help the woman renounce her practice and urged her to bring all of her herbs and implements to burn them in a spectacle on the church floor. After the woman's bag of herbs were burned and the director of women's ministries, Elizabeth, commanded the demons to "leave the witch doctor alone," she announced that the woman would now be called

Grace. Fikkert recalls that few people remembered to call her by her new name and continued to refer to her as "the witch doctor" (2014, 23). We never learn the woman's given name.

The story continues when Fikkert and Elizabeth notice that their new convert was absent one week, after several days (or weeks - it is unclear) of attendance. They learned that "Grace" became ill with tonsillitis and since she had renounced her only form of income, she was unable to pay for treatment and, we learn, because she was HIV positive, was refused treatment at the local hospital. Fikkert was horrified to learn that, "desperate for relief," Grace paid a neighbor to cut her tonsils out with a kitchen knife. The pastor asked him to pray, so he "led [them] in whatever a conservative Presbyterian prays for ex-witch doctors with HIV who live in crowded slums and who get their neighbors to cut out their tonsils with kitchen knives" (2014, 23).

Skeptical of the immediate effect of prayer on Grace's condition, and feeling helpless, Fikkert asked if they could get Grace some penicillin (not medical attention, just penicillin). Elizabeth said it was expensive, about US$8.00. Fikkert gave her the money and then went straight to his waiting taxi because he "wanted to get out of there before the sun went down" (2014, 24).

Elizabeth gave Grace the penicillin.

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Fikkert attests that he "could hardly believe [his] eyes" when he saw Grace at the small- business training class a week later. But Fikkert also believed "[he and Elizabeth] probably saved

Grace's life with the penicillin that day" (2014, 24). I note the irony. Fikkert seemed unsure that

Grace would survive the condition they found (and left) her in and, without any medical expertise, decided that penicillin was the best cure not only for Grace but also for his sense of helplessness. And when Grace survived, and returned looking "better than ever," Fikkert easily accepted responsibility for her recovery.

The introduction chapter then turns to Fikkert's quick reflection on his close encounter "in the very bowels of hell" (2014, 23). Fikkert reaffirms that he and Elizabeth saved Grace's life, but also states that he may have "done an enormous amount of harm in the process" (2014, 25).

He does not explain the harm he believes has been caused or his reflection on the experience in the remainder of the chapter. Instead, Fikkert returns to his reflections on the Ugandan encounter one hundred pages later after Part 1, three chapters in which Corbett and Fikkert (2014) lay out the "Foundational Concepts for Helping Without Hurting," and a theory of poverty in chapter 4.

If the evangelical orientation of the book was unclear to readers in the Introduction, chapter 1, entitled "Why Did Jesus Come to Earth," makes it obvious. Each chapter begins with three or four reflection questions, the topics of which are visited in the chapter, and the reflection questions are revisited at the end of each chapter. The questions for Chapter 1 alert the reader that they will be exploring the topics of the biblical role of Jesus Christ, the cause and function of punishment in the Bible's Old Testament, and the primary role of the [Christian, Protestant] church. While there is little indication of its relevance to mission activity, the first paragraph suggests this chapter will be a philosophical interpretation of Christian theology as it relates to the poor. Corbett and Fikkert assert that nuanced differences in the interpretation of the reason

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for the prophet Christ's role on Earth "can have dramatic consequences for all endeavors, including how the church responds to the plight of the poor" (2014, 31). Corbett and Fikkert suggest that they know how "Jesus Himself understood His mission" (2014, 31), taking care to emphasize those biblical passages in which Christ healed various ailments as evidence of the role that Christian mission volunteers should emulate.

The next section shifts to an example of a church in Jim Crow era Mississippi. This is one of the first instances where the authors equate poverty or "the poor" as a marker of blackness.

The section is entitled "What Would Jesus Do?" but uses the Southern Baptist Church's dismissal of ongoing civil rights abuses against African Americans as its teaching example. Corbett and

Fikkert, note that the pastor-representative in their example acknowledged the overt form of Ku

Klux Klan terrorism of Black Americans (2014, 35), and held the position that "slavery was a sin, and racisms like Germany's or South Africa's an offense to the faith," (2014, 36). Reverend

Marsh believed this was a problem of personal piety but noted that the issues of "the crushing poverty of the town's Negro (sic) inhabitants, rituals of white supremacy, the smell of terror pervading the streets like Masonite's stench (sic)" were not incorporated into sermons or even mealtime conversation (2014, 36). Corbett and Fikkert note that Reverend Marsh was right to emphasize personal piety, but "failed to embrace the social concern that should emanate from a kingdom perspective" (2014, 36). In short, the Corbett and Fikkert model argues that saving souls is insufficient to help the poor. I will return to the contents of this section later in this chapter to discuss the epistemological assumptions and their implications for missioning work as observed in this study.

The authors continue. They note the "pervasive... social, political, and economic system designed to keep African Americans in their place" (2014, 36), but are more focused on the

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actions of the religious leader. Reverend Marsh, "rightly" according to the authors, feared retribution from the KKK if he spoke out against them directly. So instead of denouncing the white supremacists, Rev. Marsh targeted Civil Rights activists in his speeches as "hypocrites for not believing in God" (2014, 36). Corbett and Fikkert claim that the activists sought "the peace, justice, and righteousness of the kingdom," but did not want to "bend the knee to the King

Himself [Jesus]" (2014, 36). Corbett and Fikkert conclude the section by noting that Rev. Marsh was wrong in his attempts to help the poor by focusing solely on personal piety while dismissing the social, political, and economic realities (what they refer to as "the kingdom") that Civil

Rights activists were addressing. At the same time, they note that Civil Rights activists were wrong in their attempts by focusing solely on "the kingdom without the King" (2014, 36), and in their presumed lack of personal piety.

The section is brief, but Corbett and Fikkert hope to underscore that their approach to helping the poor without causing harm requires belief in God, and intervention at the local level with awareness and commitment to changing the social, economic, and political conditions. In the following section, they go into more detail about the "task of the church" and its followers as an institution. Corbett and Fikkert declare that God wanted people to "'spend themselves on behalf of the hungry,' not just sing praise music" (2014, 39). In other words, people's piety should be buttressed by action that reflects that piety. The authors note that God, as quoted in the

Old Testament and the New, said "there should be no poor among you," (Deuteronomy 15:4) and added in other passages that the role of the righteous is to "loose the chains of injustice...to set the oppressed free and break every yoke" (Isaiah 58:5-10). The instructions seem fairly straightforward.

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Corbett and Fikkert then situate these Old Testament directives in the context of North

American Christians (2014, 40). As the richest people on Earth, at a time of the highest levels of economic disparity in the world, Corbett and Fikkert argue that it is the responsibility of North

American Christians, specifically, to intervene in the plight of the poor. While they assert that biblical scripture affirms a strong preference for the poor over the powerful, they finesse the implications and reassure the North American Christians who have material wealth that the poor

"are not inherently more righteous or sanctified than the rich" (2014, 41). This orientation is important to their argument, but also reflects the authors' own positionality.

Their analysis and discussion not only reveal their perspectives about material wealth, but also poverty and immigrants. The authors assert that "wealth is viewed as a gift from God"

(2014, 41). Corbett and Fikkert tell readers that "the poor are at the center of a strategy for expanding the kingdom" (2014, 41). The authors find this "strange indeed," but note that the

"early church's engagement with suffering people was crucial to its explosive growth" (2014,

41). They describe cities of the Roman Empire as a "filthy," collapsing, illness and plague- ridden, "urban cesspools," (2014, 41-42). Paradoxically, although they had "high population densities," the "only way for cities to avoid complete depopulation" from crime and disease was

"for there to be a constant influx of immigrants" (2014, 41). The authors call this influx "a very fluid situation that contributed to urban chaos, deviant behavior, and social instability" (2014,

41). This analysis reflects conservative U.S. political perspectives that simultaneously need immigrants for the functioning of society, but also attributes "urban chaos, deviant behavior, and social instability" to them (2014, 41-42).

Corbett and Fikkert argue that attention to and care for the poor was ostensibly beneficial to those marked as poor, but the evidence they present suggests that the "success" of the church

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was more about statecraft and the supremacy of Christian charities over other forms of support than about reducing suffering and increasing equality. Corbett and Fikkert relate this to the

"explosive growth" of Christianity in Africa, Latin America, and parts of Asia. The authors assert that by 2025 Africa will replace Europe and the United States as the "center of

Christianity," if it ever was (2014, 43). Colonial and contemporary (or neocolonial) missioning has no doubt contributed to this trend. Citing historian Phillip Jenkins, Corbett and Fikkert identify the entire regions of Africa, Latin American, (and parts of) Asia as the "have-nots" and

"have nothings" (2014, 43) without addressing the colonial (and Christian) origins of this lack.

Next, Corbett and Fikkert discuss the "Great Reversal," a period between 1900-1930 in which "evangelicals battled theological liberals over the fundamental tenets of Christianity"

(2014, 43). During this period, evangelicals retreated from front-line poverty alleviation efforts because they disagreed with the rising popularity of the idea that "equate[d] all humanitarian efforts with bringing in Christ's kingdom" (2014, 43). The authors suggest that the evangelical church has not fully recovered from this retreat and should "rediscover" their roles. Making space for short-term missions, Corbett and Fikkert note that these activities are not exclusive to the institution of the church, and that "parachurch" groups can and should minister to the poor, though they must "always partner with the local church, which has God-given authority over people's spiritual lives" (2014, 44).

The chapter wraps up by tying together the case studies of Kigali, Rwanda and Laurel,

Mississippi, concluding that missing from evangelical missions' efforts and near exclusive focus on "saving souls" meant they were missing a critical "all of life" perspective and approach in their work (2014, 45). Based on their arguments in this chapter this "all of life" perspective indexes social, economic, and political factors. Citing missiologists James Engle and William

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Dyrness, Corbett and Fikkert (2014, 45) add that the efforts of mission volunteers had only superimposed a "'superficial, privatized veneer on a secular lifestyle [sic] characterized by animistic values and longstanding tribal hatred and warfare.'" The authors also highlight "dignity and worth of each individual" as part of the "all of life" approach. Dignity is a key concept for these authors and a frequent token of discourse among the mission volunteers with whom I interacted. As such, I will return to a more thorough discussion of the term and its implications.

In the second chapter the authors identify what they believe is the root problem: poverty.

The chapter begins with perspectives from the World Bank (recall that Fikkert is a former World

Bank economist). Corbett and Fikkert suggest that the World Bank was able to resolve poverty in countries like France, following World War II, but using the same techniques of pouring capital into low-income countries did not work to alleviate poverty (2014, 49). Corbett and Fikkert assert that one of the issues causing this misalignment is a fundamental difference in the ways that primarily "Caucasian North Americans" view poverty and the ways that non-white poor describe their own impoverishment. The primary difference, they claim, is that the non-white poor emphasize the psychological and social effects in addition to the material aspects of poverty. Corbett and Fikkert further argue that the experience of poverty in "the African-

American ghettos" [sic] is similar to the experience of poverty in the Majority World (2014, 51).

For the authors, North American poverty is explicitly equated to African American identity.

The authors argue that this mismatch can have dramatic consequences for efforts to alleviate poverty. They use a medical analogy about the misdiagnosis of illness to drive home a message that treating only the symptoms or misdiagnosing the underlying cause of poverty could result in making the lives of the impoverished worse and could result in "hurting [the mission volunteers] in the process" (2014, 51). They identify potential misdiagnoses of poverty and the

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corresponding treatments in a chart. "Lack of knowledge" would call for "educating the poor," a problem of "oppression by powerful people," has a prescription of working for social justice, the

"personal sins of the poor" can be resolved with evangelizing and discipline, and finally the "lack of material resources," is treated simply with giving material resources to the poor (2014, 52).

The authors suggest that at face value these might seem like simple solutions. But, they add, what if the "fundamental problem" of a person who cannot pay their electric bill "is not having the self-discipline to keep a stable job" (2014, 52)? Corbett and Fikkert tell the reader that the symptoms of poverty are often similar around the world, but the "underlying diseases behind those symptoms," are not as obvious and differ with each person (2014, 52). In addition, they say, the poor are not "fully aware of all that is happening in their lives," nor are they

"completely honest with themselves or with others" about the causes of their poverty. Corbett and Fikkert go on to note that poverty alleviation is "all very time consuming," and that

"spending yourself," to alleviate hunger and satisfy the needs of the oppressed involves more than giving a poor person a "handout," which they maintain may do more harm to the person than good.

The authors summarize four main points from the perspective of the doctrine of creation that they argue is essential to the applied aspects of their book that follows. The first is that human beings are multifaceted physical, psychological, spiritual, and social beings, and thus poverty-alleviation efforts should be equally multifaceted and holistic in design (Corbett and

Fikkert 2014, 56). Second, volunteers must engage with all of creation, including dirt and culture. Third, "our basic predisposition toward poor communities," should include that they are

"not just filth and rubble," but are also part of the "good world that God created" (2014, 57 italics

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in original). Finally, they say, volunteers are not "bringing Christ to poor communities," and "the residents of these communities may not recognize that God has been at work" (2014, 57).

Poverty, the authors assert, is the result of broken relationships. The authors do note that everyone, themselves included have these broken relationships. The authors offer the example of a Kenyan woman named Mary, who has "poverty of being" that manifests as low self-esteem, shame, poor money management, and bad decision-making skills. But, says Fikkert, poverty can also manifest as "poverty of stewardship," and uses himself as an example whose symptoms of poverty manifest as "workaholic tendencies." He notes that this form of poverty is unlikely to result in material poverty but can affect interpersonal relationships.

If the poor, who suffer from such a "poverty of being" feel that they are inferior to others,

"the economically rich often have 'god-complexes,'" which they believe authorizes them to

"decide what is best for low-income people" (Corbett and Fikkert 2014, 61). Fikkert offers himself as a case for reflection, and merits quoting at length:

"I confess to you that part of what motivates me to help the poor is my felt need to accomplish something worthwhile with my life, to be a person of significance, to feel like I have pursued a noble cause...to be a bit like God. It makes me feel good to use my training in economics to 'save' poor people. And in the process, I sometimes unintentionally reduce poor people to objects that I use to fulfill my own need to accomplish something. It is a very ugly truth, and it pains me to admit it..." (Fickert and Corbett (2014, 61).

Following this telling passage, the authors explain that one of the biggest problems with poverty- alleviation efforts is that the interventions exacerbate the god-complexes of the economically rich and communicates their supposed superiority and the supposed inferiority of the economically poor (2014, 61). They add that, "this dynamic is likely to be particularly strong whenever [white] middle-to-upper-class North American Christians try to help the poor" (2014,

61).

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They use the case study of a church group that "decided to reach out to African American residents of a nearby housing project" (2014, 61). Some of the volunteers "expressed some disdain for the project residents, and all of the members" were afraid to go inside the residences

(2014, 61). Their plan was to deliver Christmas presents to the residents, and they were moved by the children's smiles and the warm welcome from their mothers, so continued to bring gifts at different holidays. However, after doing so for several years, the volunteers began to dwindle because they reported being "tired of trying to help these people out," noting that despite

"bringing them things," for several years, "their situation never improves... They are all unwed mothers who just keep having babies in order to collect bigger and bigger welfare checks. They don't deserve our help" (2014, 62).

The authors argue that, in fact, the fathers would often hide when the volunteers arrived out of shame and embarrassment that they were unable to provide gifts and material items to their families. Further, they argue that this very activity and the effects it had on the men in the homes, "likely made the fathers even less able to apply for a job [because of the lack of self- esteem caused by their shame and embarrassment], thereby exacerbating [their] material poverty," rather than alleviating it (2014, 63). In addition, the authors suggest that the volunteers developed "compassion fatigue," and that the "poverty of community," increased as the experience widened the "gulf between the church members and the housing project residents"

(2014, 63). Although the authors misuse the concept of compassion fatigue, this example invokes some of the common perspectives and concepts that mission volunteers express.

In the final "foundational concepts" chapter, the authors argue that volunteers should focus on processes rather than "products" and people and relationships over "projects" (2014,

76). In so doing volunteers embedded in this kind of work can reconcile the foundational

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relationships the authors contend are damaged among all of us in previous chapters. Corbett and

Fikkert give the example of a Baltimore-based organization that began its poverty alleviation work by simply building genuine relationships with people in the community they lived and worked in, through "hanging out," going to picnics in local parks together, traveling to nearby cities together, and listening to the needs and desires of the community members in order to "live on the terms set by [their] neighbors" (2014, 77). Corbett and Fikkert highlight the success of a people-centered, process-oriented relationships. I will return to this approach later in analyzing very idea of short-term mission efforts.

Next, Corbett and Fikkert explain that the biblical view of poverty blends the politically conservative view that "people are materially poor due to their personal failures," and the politically liberal stance that they are poor due to "the effects of broken systems on their lives"

(2014, 79). They attribute these personal failures and broken systems to distorted worldviews and provide a number of examples of "faulty worldviews" (2014, 79) that contribute to the relative poverty of (Black and Indigenous) people around the world. A faulty worldview concerning God, they argue, contributes to poverty among Bolivian farmers in the Alto Plano. A

Christian aid agency (the reader might wonder if this was one of the organizations that Steve

Corbett worked at prior to writing this) attempted to help the farmers increase crop yields. The crop yields increased, but the organization was disappointed that that farmers' incomes did not increase proportional to the crop yields. The authors argue the Bolivian farmer's use of money to purchase symbolic tributes to Pachamama at harvest festivals was a poor decision, a personal failure, that contributed to their poverty and is a result of their "distorted" worldview (Corbett and Fikkert 2014, 80). The authors argue that instead of increasing the farmers' material wealth,

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the aid agency was "adding to these farmers' idolatry," who responded to the increased crop yields with "increasing levels of praise to Pachamama for her benevolence" (2014, 80).

In the next example, they return to the "inner-city ghetto" to discuss the "distorted worldview concerning self" (2014, 80). They explain that a young (Black) woman's "feelings of inferiority" prevented her "from looking for work," and led to her teenage pregnancy. They cite an "inner-city medical doctor," who claims that “’For many young women (young girls, really), having a child may be the only way of finding someone to love and be loved by. Sex and childbirth among teenagers in the ghetto...[are] about personal affirmation'" (Corbett and Fikkert

2014, 80). Her personal failings "led to economic ruin for her and her family" (2014, 80).

Corbett and Fikkert then proceed to their example, also from within an "inner-city ghetto," of the "distorted worldview concerning others" (2014, 81). The story focuses on young

(Black) boys and the idea of "ghetto nihilism," and "predatory gratification" (2014, 81). They describe the death of a young boy at the hands of two pre-teen boys in a housing project in

Chicago. Corbett and Fikkert attribute their actions to the "'predatory gratification' that is embraced by some members of the criminal subset of ghetto populations," (2014, 81). These violent crimes impact the material poverty of the victims, they say, but also makes people living among such violence "present-oriented and give them little incentive to invest in their futures through such things as being diligent in school. And of course, a failure to get a good education contributes to their long-run material poverty" (2014, 81).

The authors contend that each of these examples of faulty worldview are evidence that poverty-alleviation efforts must include "worldview transformation," and therefore need to construct programs and seek out funding that supports "biblical worldview transformation"

(2014, 82). They assert that "governments are not usually good donors" for this type of change.

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Keen to bring it back to the reader, the authors explain that it is not only the worldviews of the materially poor that need a paradigm shift, but also those of North American Christians. Corbett and Fikkert lament that, "modernist" and "postmodernist worldviews," have resulted in:

"secularism, materialism, and relativism, all of which have contributed to addictions, mental illness, and broken families... For example, in pursuit of more material possessions...many

[white] American couples are running themselves ragged, with both parents working long hours in high-stress jobs. In the process, children and marriages are often neglected, tearing families apart and leading to a host of long-range psychological and social problems" (2014, 83). The authors acknowledge, somewhat paradoxically, that transforming the worldviews of individuals will not transform the systems that contribute to the poverty of the materially poor.

The authors attempt to explain how broken systems impact the examples that they attribute to personal failings in the previous section. They return to the Bolivian Alto Plano, but this time argue that the effects of petrodollars flooding the economies of Majority World countries, like Bolivia, resulted in rampant inflation, a decrease in the dollar value, and increase in interest rates. These events meant that loans extended to these Majority World countries now became impossible to pay back, without "rescheduling" by the International Monetary Fund, which required borrowers, "to cut federal expenditures, devalue their currencies, slash trade barriers, abolish inflation indexing for wages, and move toward free market economies," (2014,

84 emphasis added). For the authors, the infusion of a domestic source of national income, petrodollars, is destabilizing and counterproductive. The only solution, they argue, is to impose the structural adjustment policies and predatory privatization characteristic of disaster capitalism that are root causes of Bolivia’s position as a low to middle income country. Neoliberal

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economic policies are deeply intertwined with the author’s particular (and popular) brand of evangelical Christianity.

The authors suggest that the farmers in Bolivia "did not understand these events," and although they did not cause them, this economic restructuring "had a tremendous impact on their entire economic situation" (2014, 84). While the authors admit that these systems often develop and are perpetuated outside of the control of the individuals they affect, they also assert that these structural issues do not excuse personal and spiritual moral failings (Corbett and Fikkert

2014, 86). Ultimately, it seems, it is still the poor who are responsible for their poverty.

In the remainder of the book, Corbett and Fikkert elaborate their "general principles for helping without hurting" (2014, 97), followed by their recommended strategies for putting those principles into practice. The first principles prompt readers to consider anyone who has asked them for "money or things" in both the United States and other countries, and then reflect on whether it would be appropriate for volunteers or their churches "to give money or things to these people," (Corbett and Fikkert 2014, 98). The authors suggest that missioners must determine "whether the situation calls for relief, rehabilitation, or development," adding that failure to make such a distinction is the most common cause of harm in poverty-alleviation efforts (Corbett and Fikkert 2014, 99).

Corbett and Fikkert define relief as the "urgent and temporary provision of emergency aid to reduce immediate suffering," (Corbett and Fikkert 2014, 99) in which a giver provides assistance that the receivers are incapable of providing for themselves. Rehabilitation, by contrast, should "restore people and their communities to the positive elements of their pre-crisis conditions" (2014, 100). Corbett and Fikkert quickly mention that the dynamic should include community members participating in their own recovery and abruptly move on to the process of

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development. Development, they explain, is a process that should benefit both the "helpers" and the "helped," and is not done "to" or "for," but with people (2014, 100). The authors maintain that each of these approaches are mutually exclusive, and that providing material "relief" in the rehabilitation or development stages is "likely to do harm" to the recipient and the provider

(Corbett and Fikkert 2014, 100).

In order to determine when intervention is appropriate, the authors instruct readers to reflect on whether there is "really a crisis" and to what extent the individual asking for or receiving assistance is responsible for the crisis (Corbett and Fikkert 2014, 101). Helpers are also instructed to ask whether the person can help themselves and whether the person has already received relief. The latter is not necessarily concerned with duplication of services in the view of the authors, but with preventing the requestor from taking advantage of assistance in lieu of long- term solutions (2014, 102).

The authors observe that North American volunteers "often project [their] own ideas of what is an acceptable standard of living onto [others] and are quick to take a relief approach"

(Corbett and Fikkert 2014, 103) The authors express concern that in addition to being potentially considered "unwise" by local community members, this misguided relief attempt creates dependency and "undermines local judgment, discipline, accountability, stewardship, [monetary] savings, and institutions" (2014, 103). The correct recipe for "effective relief" is "seldom, immediate, and temporary," according to Corbett and Fikkert (2014, 104). The authors also draw from The Sphere Project's Minimum Standards of Disaster and Rehabilitation Assistance, a set of widely regarded benchmarks developed as a guidepost for humanitarian intervention.

Corbett and Fikkert annotate five key guidelines from the Sphere's Minimum Standards.

First, affected populations must be included in the assessment, design, implementation,

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monitoring, and evaluation of any assistance. Corbett and Fikkert add a significant caveat that would-be helpers must determine "the capacity of the target population to make wise decisions and shoulder responsibilities," but otherwise agree that people should be treated "as the responsible stewards... even asking their opinions once in a while!" (Corbett and Fikkert 2014,

106). Second, would-be helpers should conduct assessments to understand "the disaster situation and determine the nature of the response" (2014, 106). The authors remark that this "requires

[volunteers] to know the local context and situation or to be working under the auspices or coordination of those who do" (2014, 106). The next Sphere guideline urges volunteers to respond only when needs are unmet by a local people or organizations because of inability or unwillingness to help. At face value, there is significant flexibility within this guideline, and

Corbett and Fikkert sum it up succinctly: "If local people and organizations are able and willing to help those in crisis, then stay away!" (2014, 106).

The fourth Sphere guideline the authors draw on concerns equitably and impartially providing target assistance based on need and vulnerability. Corbett and Fikkert simply interpret this recommendation as "making sure the people who get the assistance are truly vulnerable and needy" (Corbett and Fikkert 2014, 107). Finally, the Sphere Project maintains that aid workers must have the "appropriate qualifications, attitudes, and experience to plan and effectively implement appropriate assistance programs" (Corbett and Fikkert 2014, 107). The authors also note that "jumping in" during a major disaster or taking a top-down, savior approach in post- crisis conditions can "do more harm than good" (2014, 107).

The authors emphasize that "bad relief" can "cripple local initiative" and "undermine local people's stewardship of their own lives and communities" (Corbett and Fikkert 2014, 108 &

109). Corbett and Fikkert also assert that chronic problems resulting from and in impoverished

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communities can only be solved with long-term solutions. They add that in planning and carrying out relief work would-be volunteers should "avoid paternalism" (2014, 109). In particular, Corbett and Fikkert urge readers to avoid five types of paternalism: resource, spiritual, knowledge, labor, and managerial.

By this point in the text, the authors have cautioned against infusing communities with money or material items. Here, they reiterate their stance that providing people with money and material goods during non-crisis periods is detrimental to the individuals receiving "hand-outs," and add that a material response in impoverished communities often undermines local businesses

(Corbett and Fikkert 2014, 109). They move quickly on to spiritual paternalism, which they also mention in passing to remind the reader that although they are planning to do mission work, the materially poor they seek to help often have a deeper Christian faith than mission volunteers from North America (Corbett and Fikkert 2014, 110).

Next, the authors discuss "knowledge paternalism," or the assumption that mission volunteers (in this case) know best "how to do things" (Corbett and Fikkert 2014, 110).

However, the authors' analysis and cautions about knowledge paternalism are equivocal. On one hand they note that "the failure of experts to understand the realities of life on the ground," may lead "them to give life-threatening advice to the materially poor" (2014, 110). They add that by not knowing the local context the "experts" may also conclude that the poor are "irrational and culturally backward," because they refuse supposedly "expert" advice (2014, 110). First, they caution readers against believing that the materially poor need mission volunteers to think for them (2014, 110). Yet in the next sentence Corbett and Fikkert state that avoiding this form of paternalism is "tricky...because the truth is that [North American Christian volunteers] often do have knowledge that can help the materially poor" (2014, 110). The authors tell readers that the

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materially poor know their situation and are able to think and understand the world around them.

But "like all of us, the materially poor are often wrong about how the world works and can benefit from the knowledge of others," (2014, 110). While cautioning the readers against knowledge paternalism, the authors themselves participate in it.

The section on labor paternalism is very brief but includes a telling anecdote. Fikkert recalls his own college mission trip to Mississippi:

"I will never forget the sick feeling I had as I stood on a ladder painting a house while the young, able-bodied men living in the house sat on their front porch and watched. I did so much harm that day. Yes, the house got painted, but in the process I undermined those people's calling to be stewards of their own time and talents." (Corbett and Fikkert 2014, 112).

Corbett and Fikkert argue against doing labor for anyone who could do it themselves. Yet the narratives that Corbett and Fikkert employ to support their claims evidence their culture-of- poverty prejudice with clearly racist overtones.

Finally, the authors address managerial paternalism, which they believe to be a result of middle- and upper- class North American cultural practices. The issue, they argue, is that North

Americans are "prone to take charge, particularly when it appears that nobody else is moving fast enough" (Corbett and Fikkert 2014, 112). Corbett and Fikkert suggest that some common reasons that people, communities, and churches in low-income communities might not take charge are that: they lack confidence (returning to the theory of sweeping inferiority complexes among the impoverished); the poor do not need to take charge, since someone else will do it if they wait long enough; "they, like we, have internalized the messages of centuries of colonialism, slavery, and racism: Caucasians run things and everyone else follows"; they do not believe the project will address the pressing needs, but fear the consequences of telling volunteers; and finally, the outsiders will bring money and resources with them if they are allowed to "run the show" (2014, 113). 214

Only after a discussion about the dangers of blueprint development and participatory learning and action, the authors finally discuss short-term missions (STMs). Surprisingly,

Corbett and Fikkert point to numerous ways that STMs fail to meet not only the criterion they believe necessary to "helping without hurting," but also fail to meet the needs of communities and stated intentions of the STMs themselves. This is a warning to the target audience for their book—recall that the mission volunteers directed me to this text as a resource they were using to shape their efforts in Honduras. The authors identify a number of ways STMs fall short, then offer suggestions for ways STMs should modify their approach to poverty alleviation efforts.

The authors suggest that many STMs do harm because they lack sound cross-cultural perspective (Corbett and Fikkert 2014, 151). This is due to differing concepts of time and self, they believe. North Americans are monochronic, with a view of time as finite, while “Majority

Countries” (their euphemism for countries where the majority of the world’s population live) are polychronic, with varying conception and relationships with time (2014, 152). In addition, North

Americans have a highly individualistic view of the world and relationships in it, while many in the “Majority World” have a much more collective view (2014, 152). They admonish STMs to

"move beyond an ethnocentric thinking that either minimizes these cultural differences or immediately assumes that middle-to-upper class North American cultural norms are always superior" (2014, 154), while repeatedly rejecting relativism, suggesting that the only truth is biblical truth (which, in this case, is not subject to contextual interpretation).

The authors take interest in the impacts of STMs on "recipient, materially poor communities" (Corbett and Fikkert 2014, 155). As Corbett and Fikkert note, most research on medical missions focuses on the benefit to volunteers and the churches (or organizations) that send them (2014, 155). According to Corbett and Fikkert, "the core problem with STMs to poor

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communities...[is] the idea that poverty is due to the poor lacking something" (2014, 155). This is a welcome observation of a practice among volunteers that I discuss in-depth in Chapter 8. Yet the preceding chapters outlined numerous deficits of the poor that presumably explain their condition as such.

Even if their underlying assumptions and rationale are inconsistent, the authors do identify significant problems with STM interventions. They note that the abbreviated time these teams spend in distant locations limits their work and precludes them from doing long-term work to address chronic issues (Corbett and Fikkert 2014, 155). STMs, they assert, should be "seen as an extension of local organizations rather than as independent, outside agents" (2014, 156).

Finally, Corbett and Fikkert point out that STM expectations of what is possible in one or two weeks is generally unrealistic and emphasize that STM focus is on a product rather than a life- long, relationship-centered process (2014, 157). Moreover, volunteers tend to overstate the quality and durability of the "friendships" they develop with their foreign counterparts in just one or two weeks (2014, 157).

Ultimately, the authors assert that STMs are usually not an appropriate response or the most appropriate way to provide relief or development assistance. In their view, STMs are paternalistic and undermine local knowledge, especially when superimposing individualist approaches on collectivist contexts (Corbett and Fikkert 2014, 158). Corbett and Fikkert also highlight the astounding financial implications of STMs, noting that it is not uncommon for teams to spend US$20,000 to $40,000 to stay onsite for one to two weeks, money that often could fund long-term salaries or locally led and managed infrastructure projects (2014, 161).

Despite stating that "the returns do not seem to justify the investment," the authors make suggestions for "improving the impact of STMs" (2014, 163).

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They suggest that groups make sure the agency or organization receiving them

"understands the nature of poverty" and the "basic principles of poverty alleviation" as the authors have presented them (Corbett and Fikkert 2014, 163). This recommendation rests on the assumptions that Corbett and Fikkert's principles of poverty alleviation are accurate and that the teams are in a position to know for themselves the nature of poverty and whether their host organizations "understand" it in the same way. As such, the teams retain a position of superiority and power vis-à-vis their host counterparts.

The next recommendation is to ensure that not only the host organization but also the community has actively requested the presence of the STMs and are the lead decision-makers about what, if anything, an STM will do if invited to visit. Corbett and Fikkert (2014, 163) caution those who would send STMs to "be sincerely open to not sending a team." The authors also add that the teams should not duplicate services or take on work that people can do for themselves. People are not necessarily able to be their own physicians, but this would seem to suggest that if there are medical professionals available, teams should organize in a capacity of assistance to the existing resources, not to replace or duplicate them. Finally, they recommend that the number (not the size) of teams should be small and "promote interaction with the host environment" and lessen the impact of unintentional harm to the community (Corbett and Fikkert

2014, 163). At face value these recommendations have utility but are not the standard by which most mission teams operate – even one’s whose volunteers have read their book.

Corbett and Fikkert's recommendations about the language used in recruiting and advertising these teams are illuminating. They take issue with language that overemphasizes the

"sacrifice" that the mission volunteers are making in their one or two-week trip. The authors assert that such a sacrifice is unrealistic in such a short time and creates an image of "how

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helpless the poor people are without the team's help" (Corbett and Fikkert 2014, 164). The authors also feel strongly that a focus on tourism or promises of fun and adventure in the marketing literature for STMs, and that asking people to fund such vacations with tithes and offerings "is an outrageous insult" (2014, 164). Corbett and Fikkert also argue for mandatory pre-trip training. This training should include their poverty alleviation principles, but also "team- building, spiritual preparation, country-specific information, including some basic language training" (2014, 165).

The authors consistently undermine many of their main points with contradictory arguments buttressing their prescriptions for successful missions. The authors' positions on "the poor," poverty, and the assumptions they reveal within their example cases and discussions inform problematic epistemologies and rationales commonly invoked by STM leaders, their faithful readers.

Critical Assumptions

There are several critical assumptions upon which Corbett and Fikkert build their guidelines for "helping without hurting." The most explicit within their text is the supremacy of

North American (white) Christian (Protestant) worldview. Other key assumptions draw on antiquated, yet persistent ideas about poverty and “the poor.” While many of their recommendations for medical missions are not intrinsically harmful taken alone, their overall ideology reinforces and legitimates many of the key harms perpetuated by mission volunteers to

"the poor" as Corbett and Fikkert refer to them.

Using intertwined religious and neoliberal capitalist logics legible to most white North

American Protestants, Corbett and Fikkert's arguments reinforce and justify racial superiority and ethnocentrism. The authors seem to be aware of the racial power dynamics involved in 218

discussions of poverty alleviation, even noting that they "have internalized the messages of centuries of colonialism, slavery, and racism: Caucasians run things and everyone else follows"

(2014, 113). However, they stop short of recognizing how their recommendations, and even the examples they have chosen to use as guideposts to readers, reinforce these centuries-old colonial relationships. In each discussion of non-U.S. case studies, the authors highlight ways that the lifeways and worldviews of Others make their knowledge suspect and mark them as inferior.

For example, in their first case study the authors admonish witches in Uganda.

Anthropological studies have demonstrated the adaptive qualities of witchcraft in cultures around the world (cf. Evans-Pritchard 1937). Obvious ethnocentrism notwithstanding, the story also erases the Ugandan identity of the woman who was renamed Grace. Corbett and Fikkert also use

Conradian language to describe Kampala, Uganda as "the very bowels of hell" (2014, 24). In another case study, Corbett and Fikkert describe indigenous Bolivians as ignorant, and because of their belief and ritual celebration of Pachamama, as victims of a "faulty worldview," (2014, 84

& 86). The farmers "do not understand" complex events like macroeconomic systems and

"waste" their wages on harvest festivals and rites (2014, 84)—a view once promoted but long rejected within anthropology. While the authors suggest that mission volunteers should look for existing resources and recognize what "the poor" do have, their focus on what the impoverished lack in supposed intelligence, material resources, spiritual resources, and cultural resources, dominates the text. That discourse overshadows the practice suggestions they make. The effects of this become evident as medical mission volunteers invoke the former and struggle to implement the latter.

This Othering tendency is not reserved for distant peoples. The authors frequently Other

African Americans, claiming that experiences of impoverishment among African Americans are

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a result of "feelings of inferiority," ostensibly to white Americans, and "behavioral" problems

(2014, 85, 87, 102). The authors refer to "the poor," as a single homogenous group, flattening the ways that class, gender, and race complicate who is considered poor and under what circumstances. Indeed, one of the most significant assumptions is that blackness is equivalent to poverty. Every example the authors use when discussing the impoverished refers to African

Americans, indigenous Latin Americans or Black Africans. Although the authors try to convince the readers that the white mission volunteers and the authors themselves are "poor" in other ways, they continually distinguish the materially (and presumably morally inferior) poor as

Black and/or indigenous. North American poor people are always indexed as African American, giving the false impression that to be poor is to be African American and to be African American is to be poor. Corbett and Fikkert make clear that people in the Global South—the poor they are referring to—are Other. This reinforces the White Savior narrative (Pierre 2013; Benton 2016a,

2016b); the authors' observation that they have internalized colonial white superiority and assume that the targets of mission interventions have internalized it as well entirely fails to disrupt this process, instead becoming merely another mechanism to justify it.

These deeply embedded ideas studied and shared by medical mission volunteers about who and what the (non-white) poor are with relation to their (white) counterparts affect the ways volunteers interact with the people they come to Honduras to “help.” They provide justification for how the volunteers decide what kinds of interventions are needed or do not merit their efforts, and who is worthy of their efforts. The assumptions of the authors of When Helping

Hurts permeate the ideologies and practices of mission volunteers, defining commonly used concepts like "dignity" in moralized and racialized terms often not shared by the subjects of their volunteer work. Volunteers determine need and extend or dramatically restrict their interactions

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based on how they define this concept. Mission volunteers do not trust members of the community who seek out missions' resources to "behave" responsibly, to be intelligent enough to understand their own health, how to make decisions, how to manage their own care, or how to manage their own community.

Corbett and Fikkert make suggestions, including calling for short term missions to reconsider going on these kinds of jaunts at all. They accurately reclassify their trips as voluntourism and instruct groups considering such activities to rename them if they insist on continuing to conduct them. However, their suggestions are inconsistent as they assert that

Christians are duty-bound to assist the poor and further empower would-be volunteer groups with moralistic discourse that justifies intervention and reinforces colonial white savior tropes.

The next chapters show how frequently volunteers' language, decisions, and interactions with recipient communities reproduce Corbett and Fikkert’s harmful contradictions in critiquing and guiding short term missions. Volunteers repeat and take up the very critical assumptions that

Corbett and Fikkert claim to avoid, but in fact reproduce. The data presented highlight the actions and attitudes Corbett and Fikkert instruct mission volunteers— who have adopted this text as a guidebook for their actions in Honduras—to avoid.

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CHAPTER 9

THE LANGUAGE OF LACK: INFLECTIONS OF CONTEMPORARY MISSIONARY DISCOURSE

“…for the bearers of each culture came to objectify the other, they invented for themselves a novel self- conscious, even as they accommodated to the relationship that enclosed them.” -Jean Comaroff

Introduction

Medical mission volunteers have a particular way of speaking about their work when describing it to others, writing about it on blogs, and narrating their experiences for funders and auditors in newsletters, fundraising appeals, and other announcements. This is not unique to the medical mission volunteers I encountered during my year of fieldwork. Medical mission volunteers largely employ the same linguistic markers that volunteers and professional humanitarians have used for more than two decades while engaging in related activities (like building houses or schools, teaching, or food aid) all over the world.

In the previous chapter I analyzed a text that HMH board members and volunteers identified as instructive to their developing goals as a mission organization. When Helping Hurts offered suggestions for how short-term medical missions should organize their efforts. However, the pervasiveness of underlying assumptions, and neoliberal and anti-poor ideologies that are enmeshed in contemporary evangelical Christianity throughout the text overshadowed those suggestions.

In this chapter, I demonstrate the ways that HMH volunteers reproduce the problematic white savior tropes and moralistic discourses I identified in the previous chapter, while ignoring or failing to meet the broader practice suggestions. I build on previous corpus analysis (L. S.

Jung [Gilchrest] 2014) to examine the way STMM volunteers talk about their activities and the

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people they purport to help. The time I spent conducting participant-observation among STMM volunteers was often done on the backstage, where performers can speak candidly, without subverting the performance, during volunteers’ break and leisure times (Wodak, Johnstone, and

Kerswill 2010). These were moments when STMM volunteers could talk among themselves or speak openly with me about being a volunteer or about the work of missions in general.

Understanding how these ideas circulate (Handman 2018) among medical mission volunteers as part of the self- and Other-making inherent in the medical mission encounter

(Comaroff 1991) makes it easier to understand how the practices, behaviors, and activities of

STMMs constitute different forms of iatrogenic violence (Daniel 2018, McFalls 2010). Further, the data presented in this chapter demonstrate the ways that medical missions use discursive formations to create the “gaps” they purport and are purported to fill.

Discourses Observed in Volunteer Language

Divine Intervention and “Giving Back”

Many volunteers used language of religious purpose, that they had been “called” to

Honduras, to Playa Felumi, to “give back.” Some identified the calling in the abstract, as a feeling of duty or obligation to “use [their] talents” to respond to human suffering. Others identified theirs as a calling from God, an obligation borne in their religious beliefs and spiritual practices. Recall that the founder of Health Missions Honduras described his motivation to begin the organization and medical missions to Honduras as a gesture of gratitude and obligation to

God in exchange for surviving as a fighter pilot in an active war zone (which war was unclear in the retelling).

During an early morning devotional, a February team leader, Dr. Collin, posed the question to his team, “Why are we here?” He said that his colleagues (physicians), “back home

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ask me: Why do you go? Isn’t there enough to do here? Are you really making a difference?” Dr.

Collin continued, “Medical professionals say: ‘It’s only a week, are you really making a difference?’ But we saw 100 patients yesterday.” He smiled, leaning forward on his knees in his chair, shook his head from side to side for a brief pause then decidedly said, “I think we made a difference!” He said it as though he was convincing himself and the others, while also wrestling with the questions from his colleagues back home. He also added that he and his fellow volunteers did this work by “using talents God gave” them and “going where [they] are called.”

Another veteran team volunteer began a March team devotional with a reflexive question.

“Why do I do this? God, I want to do this for you and not me. [Quoting] Isaiah 45, ‘you make the crooked places straight.’ You see the poverty, the beautiful people, do you think they know how we live? No, and thank God, because this is their home.” For this nurse, participating in this medical mission was a way for God to straighten out the crookedness of Playa Felumi through her and her fellow volunteers. She also suggested that if “they” (Playa Felumians) knew how the volunteers lived, “they would not want to stay in their home.” I will return to the implications of this sentiment below, but it indexes assumed knowledge, positionality, hierarchies of power, and the relational geographies that are typical of temporary medical mission interactions.

On the same team, another veteran volunteer affirmed that not only were the volunteers there doing God’s work, but according to her, Numbers 20:24-26 suggests, “We have the authority because we believe in Christ.” This volunteer uses her own interpretation of this passage in the Bible to imbue herself and her fellow volunteers with moral authority. To go with her ministrations, the pharmacist had collected pumice stones from the beach to give to her fellow volunteers as a symbolic gesture that they were “rubbing off the rough edges,” both on themselves and the people and community around them.

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In addition to the everyday conversations and the context of devotionals, a few survey respondents explicitly listed a duty to God as their primary reason for volunteering on short-term missions. Table 1 below includes the entries submitted by respondents. For some this religious context is understated, or part of a personal ethic not necessarily tied to evangelism. For others, like team leader Marjorie, “ministry” is an explicit part of their intentions.

Table 1. Selected Survey Responses: Why do You Volunteer on Short-term Medical Missions?

Age, Gender Volunteer Response

As a Christian I feel a calling to help those in 55-60 years, woman, medical need. As a [medical professional] I know I have years of education and experience to benefit the people in countries where there is an extreme lack of health care. It "fills my tank" in ways that I do not receive fulfillment in my suburban practice. 70+ years, man, non-medical To do god's work in other countries

I feel called by God and by my faith community to 55–60years, woman, non-medical do so. And, I love it; these are the happiest weeks of my life. 70+ years, woman, non-medical God calls me ... And the rewards are immeasurable. 40+ years, woman, medical As a Christian I feel a calling to help those in need. Because Jesus said to help others. To love others 55–60 years, medical as yourself. To make the world a little better place. To witness to the truth.

In these examples, the respondents are invested in the evangelical effort to bring “Christ’s kingdom” into existence through their “service” (Corbett and Fikkert 2014, 43). All invoke a direct relationship with God, and like the volunteer who ran the aforementioned devotional, invoked a sense of authority. Three of the five exemplars also explicitly note the benefits to themselves – some in terms of feeling gratified or replenished as a result of their efforts. The 225

benefit of personal salvation is implied herein as well. In answering the call from God, they are not only ensuring their place with the evangelical community, but in Heaven as well (Bialecki

2017; Handman 2018; Luhrmann 2012).

Volunteers also articulate a desire to “try and give back.” Though, as Sullivan (2017) has noted, to whom they are giving and what this performative reciprocity is connected to is not typically articulated. One volunteer said they were motivated by “[t]he experience of giving back and helping others.” Another said they wanted to “[g]ive back to those less fortunate and gain perspective to countries outside the US.” For some volunteers, the reward for giving back was directly tied to their identity and sense of satisfaction. Volunteers said, “I enjoy giving back in a capacity that I am trained in,” and “it feels good to do good.” Another explained that “You help so many people and in the process it always makes me feel sooo good and appreciate what I am blessed with.”

In addition to noting the positive emotional benefit she received, the nurse also referenced what she was “blessed with.” This aspect of “giving back” reinforces the idea that

“wealth is a gift from God,” or that specific skills are a direct result and evidence of divine blessings in their lives (Corbett and Fikkert 2014; Handman 2018). A retired nurse volunteer said, “I like to remind myself of how blessed I am and how the rest of the world lives.” Others did not use the explicit language of “blessings” but referenced it implicitly in terms of how

“fortunate” they are. One volunteer described their reason for joining missions as “an opportunity to share my skills and knowledge with those less fortunate than I.” Others said, “to help others less fortunate than us,” and “[t]o help people that do not have the same opportunity that I am fortunate enough to have.” Another volunteer explained, “I enjoy using my skills as a

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pharmacist to benefit the less fortunate who may not otherwise be able to receive medical attention.”

Still other volunteers articulated “giving back” as a form of reciprocity to God and their obligation to make a return gift (Bornstein 2012; Mauss 1990). One mission doctor wrote, “I have been given the gift/talent of being a physician, and I have the means to go to remote places where there is a need.” Another was explicit in their sense of duty, “I feel I have been given much and obligated to share with those who have less.” A nurse and veteran volunteer put the desire to give back in a different context during a pre-clinic morning devotional. She began with a parable about spotted and speckled sheep from Genesis 30 and 31, biblical scripture that described divine intervention and miracle. She then related the parable to her understanding of the work of the mission volunteers, “These people have deep sadness that’s way beyond their medical need. A lot of us have a lot of deep personal stuff that we have gone through and that’s why we come to give back.” Implied in her reflection is that God healed the “deep personal stuff,” evidence of God’s existence and divine intervention, and those blessings and experiences are the gift that requires the reciprocal action of giving back.

This is a specific characteristic of what critics of temporary and wide-scale humanitarianism identify as white saviorism (Cole 2012). Cole (2012) notes that the White

Savior Industrial Complex “is not about justice. It is about having a big emotional experience that validates privilege.” Giving back is less about helping resolve injustice that leads to the kinds of disproportionate scarcity in Playa Felumi, but about the anticipated rewards to the giver

(see Table 1 above). Other scholars interpret the impetus to give back as part of individuals performing their role as a cosmopolitan, moral subjects - a way to affirm their sense of self as a good, neoliberal subjects (Vrasti 2013; Crossley 2012; Frazer and Waitt 2012).

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Lack of Knowing: Knowledge as Primary Determinant of Health

In the previous chapter I discussed Corbett and Fikkert’s (2014) guidebook to medical mission groups. In it, they identify a basic set of four “easily” identifiable problems and the logical solutions for each, summarized in Table 2. HMH volunteers did not use the terms oppression or social justice during any of my observations or in their survey responses.

Although no volunteers explicitly mentioned “sin” as problems to be solved in Playa Felumi, they did reiterate the language that Corbett and Fikkert used to connect “poverty” with personal failings and poor discipline. I will return to that discourse after presenting examples of the ways that “lack of knowledge” and “lack of resources” are part of discursive processes by which medical mission volunteers establish authoritative knowledge and their own subject position vis-

à-vis Playa Felumians.

Table 2. When Helping Hurts Simplified Problem/Solution Chart (see Ch. 8)

Problem Solution Lack of knowledge Educate the poor Oppression Address social justice Personal Sins Evangelizing and discipline Lack of material resources Handing out material goods

Of the 53 surveys completed by STMM volunteers, 46 percent of respondents said they believed that lack of knowledge or education are the most common causes of poor health. Table

2.1 contains 24 volunteer responses (46 percent) to the question about the most common causes of poor health. This represents the majority of volunteer responses. Though nearly half of respondents explicitly mention a lack of information or knowledge on the part of the patient, 74 percent of volunteer responses state or imply that patients are responsible for their health concerns or are non-compliant in some way.

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The idea that patient ignorance - lack of knowledge or education - is at the root of illness or patient “deviance” is an example of the ways that hegemonic medical ideology becomes part of the colonial relationships STMMs have with the places and peoples they visit. It also reinforces Corbett and Fikkert’s (2014) persistent assertion that “the poor” do not understand what is happening, that they do not know what their own experiences mean or “are not honest with themselves.”

The positioning of the Other as ignorant, or untrustworthy is not limited to the patient encounter. Indeed, it is a fundamental characteristic of the self-making process for the (white) medical mission volunteer. It therefore extends to all Hondurans and further established the superior, authoritative knowledge of the medical missionary. HMH volunteers reproduced the same sorts of infantilization and stereotypes woven throughout Corbett and Fikkert’s handbook.

One medical school instructor, who taught laboratory science and epidemiology, was surprised when I mentioned that several glucometers, provided to the CESAMO by the Honduran government and donated by previous mission team volunteers, did not work.

The volunteer raised her eyebrows and pursed her lips. “Maybe they just need batteries,” she said. “Those are so simple. Maybe they [the CESAMO staff] don’t know that the strips have to match,” she added. She was perplexed. “They’re so simple, even a child could do it!” She added flatly, “It’s a shame they got all of that and it doesn’t work.”

CESAMO staff and STMM volunteers independently told me that the two groups did not communicate or collaborate with one another. In other instances, volunteers denied the existence of the CESAMO, discursively creating more scarcity than genuinely exists, or attempted to discredit the CESAMO staff as incompetent. One volunteer responded to a survey question about challenges they faced during their trip by stating that their “team was not aware of local health clinic.” In extreme cases, some medical mission volunteers refused to believe the CESAMO existed, and, in the face of irrefutable proof of its presence and function, dismissed the center as

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insignificant and incompetent. For example, when I asked one team leader at the outset of my research if they worked with local health resources, she exclaimed, “There are no other resources!” Even when I insisted that just a few hundred yards up the road was a fully functioning health center, she could not reconcile the empirically true information with the dominant narrative of HMH.

Part of the denial of the CESAMO stems from HMH’s founder Dr. Simons’ long-held rhetoric that insisted to donors and potential volunteers that Clinica Blanca was the only healthcare option available for miles around. Sr. Bonnie, a former HMH volunteer, elaborated one day while telling me about her history with HMH, “I met the founder. And when I met him, he told me there were no other health centers for miles around. He gave me a form letter [that said as much] and said ‘here, use this!’” The form letter used for fundraising said that Clinica

Blanca was the only resource available to the residents of Playa Felumi—despite the fact that it is a mere ten-minute walk from the CESAMO and within a bus ride in either direction of the

First Popular Garífuna Hospital or the Salvador Paredes Public Hospital in Tocoa.

Many volunteers indicated in survey responses that they did not know about the

CESAMO or the services it provided. Some volunteers acknowledged a health center or

“government clinic” did exist but produced or reproduced discrediting narratives about it. During a lunch break at Clinica Blanca one afternoon, Misty, a nurse volunteer, asked, “So is the health center…do people just not go there, because the people there aren’t properly trained?” Misty’s question assumed that Playa Felumians did not seek care at the CESAMO or CESARs in the area and that the reason they avoided them was because doctors, nurses, and staff were poorly trained.

Medical mission volunteers on most of the teams that I observed, composed of predominately white volunteers, suggested that Honduran medical professionals were incompetent, and a few

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generalized that all Honduran medical staff were egregiously unqualified. These assumptions were sometimes based on the accounts of a few patients who came in to Clinica Blanca for second opinions or follow-up care after negative experiences with hospital-level care in the cities. Few of those reported experiences were the result of care at the CESAMO and none of the volunteers considered the significant role that discrimination against Garífuna Hondurans plays in their maltreatment in Trujillo, Tocoa, and La Ceiba (the nearest public hospitals).

Table 2.1 Survey Responses Indicating Lack of Education or Knowledge Deficits as Causes of Poor Health in Playa Felumi

Survey Question: “Based on your experiences, what are the most common causes of poor health where your mission team worked?” (Italics added for clarity) "lacking good education and resources" "I would love to have someone teach these people how to grow a vegetable garden to put better foods on their tables" "Lack of education and lack of non processed food sources" "Lack of healthcare and finances and mostly education" "Lack of knowledge and lack of access to healthcare, poverty" "Lack of knowledge on pts [patients’] part Lack of availability Lack of funds Transportation" "Lack of resources and education" "Poor hygiene, poor diets, poverty, lack of education/understanding" "Poverty [and] Unawareness" "Poverty, poor hand washing, limited access to clean water, low education." "people (pts) not taking responsibility for their health. education to out lying areas" "Lack of oral hygiene education contributes to the problem. Proper care was not a priority." "Lack of regular access to medical help, funding, and knowledge of health conditions, prevention, and treatment." "Lack of knowledge - unprotected sex, delayed prenatal care. Financial - cost of meds, glucometer strips, surgeries" “Lack of clean water. Lack of proper nutrition. Lack of clean living conditions. Personal hygiene issues. Perhaps a knowledge deficit as well.”

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"POOR DAILY HYGEINE LACK OF EDUCATION LACK OF RESOURCES TO HAVE GOOD DAILY HYGEINE" "Overall, most people either don't understand the connection between their health behaviors and their wellness. The concept of preventing disease and staying healthy is minimal" "knowledge deficit regarding what good health really means & involves" "Successful efforts to educate patients in healthy eating and lifestyle changes has limited value because other needs take precedence." "Poverty (bar none!), ignorance, lack of education, social stigmatizations, lack of transportation," "Being a woman, because women are not valued as men are. They are prone to STD's and unwanted pregnancies due to the machismo attitude, they are expected to care for children and the household without resources to do so. Their education is not prioritized." "poverty limiting food variety and sources smoke and dust exposure from indoor cooking/ burning trash/dusty roads poor water supply exposure to parasites lack of knowledge about general health principles" "-they need to be educated about the disease and the meds and when they need to seek help-- with proper education it is safer for these families to have the meds at home rather than rely on the govt clinic or [HMH] clinic being open for business." “lack of government interest in investing in healthcare poverty lack of information sanitary conditions”

In nearly every example listed, the volunteers assert that individuals have little or no knowledge about personal hygiene, food and nutrition, or “basic healthcare principles.” And it is not just that they lack knowledge, but that they lack understanding, a linguistic coding that suggests cognitive deficiency. It also echoes Corbett and Fikkert’s assertion in When Helping

Hurts, that “the poor” do not know what is happening to themselves. The significance of this coding reinforces a hierarchy of knowledge and power and supports implicit assumptions of superiority of the volunteers. As noted in the table above, one volunteer wants to “teach these people how to grow a vegetable garden.” The suggestion assumes that people do not already know how to grow a garden, and implicitly attributes health issues to personal failings – not

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knowing how to grow food, not eating “better foods.” The assumption reinforces the volunteer’s authoritative knowledge and obscures the fact that Playa Felumi had historically been a subsistence community that grew and harvested its own vegetables and fruits and has a rich, culturally embedded, horticultural background. It also fails to recognize the structural issues that already prevent people from accessing “better foods.”

This sort of distrust and infantilization are frequent among STMM volunteers and are part of the discursive technologies of power that justify and guide their interventions in communities like Playa Felumi. The assumptions and ideologies underlying this discourse also severely limit the interactions that volunteers are able and willing to have with their Honduran counterparts - meaningful, mutual aid is stopped short because of these fundamentally diminishing narratives.

Only 36 percent of volunteer responses indicated direct vectors of illness, e.g., “water and mosquitos,” or posited that structural issues such as insufficient infrastructure, environmental concerns, or inequality were involved in the overall health and susceptibility to illness of Playa

Felumi residents. One respondent wrote, “I think lack of appropriate medical care. Individuals who could not afford medical care do not receive it. It is a shame that Honduras does not have some form of medical coverage for the needy and poverty-stricken individuals and families.”

Even here, “appropriate medical care” suggests that there may be care available but that it is substandard. While there are certainly cases of malpractice and negligence within the Honduran health system at large, this blanket statement erases the valued work of the CESAMO and its staff despite the significant resource limitations it faces. In this example, as in the majority of medical mission language the volunteer is referencing acute or emergency care, she is not referencing primary or preventative care, which exist but not in the missionary imaginary or lexicon.

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The Discourse of Perceived “Needs”

Similar to the use of “lack,” STMM volunteers established their position, or stance, vis-à- vis their patients and Hondurans more generally through the discursive production of need. In the same STMM survey there were 38 invocations of “need,” both identifying a perceived benefit to the community and establishing the rationale for STMM intervention. In some examples, the term “need” is a synonym for lack and corresponds to the “lack of material resources” category.

The “need” or “needs” identified in Table 2.2 and Table 2.3 are based on perception, but also part of the circulation of discourses of need that are critical to the self- and Other-making process in the medical mission encounter. Some of the terms are used as characteristics of Playa

Felumians, establishing their subjectivities as “needy,” while others are other ways of distinguishing deservingness.

Table 2.2 Volunteer References of “Need” as Marker of Playa Felumian Subjectivity

Examples of Discursive Markers of Subjectivity (Italics added for clarity) I wanted a chance to provide orthopedic surgical care to the needy people of Honduras To help provide some sense of hope and at least short term comfort to the needy. is a shame that Honduras does not have some form of medical coverage for the needy and poverty stricken individuals and families helping a lot of sick kids in need

Implicit in these examples, and the ones in Table 2.3, is the suggestion that the care the volunteers provided is reserved for those deemed “needy.” Care is not guaranteed for everyone and as some of the examples in Table 2.3 demonstrate, volunteers are dissatisfied when they perceive the recipients of HMH care to be undeserving. For example, one of the respondents below notes “I felt as though we handed out Meds to people at that point in time didn’t necessarily need them,” and another adds that “only a small percentage of the patients we see have acute and serious medical need.”

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Table 2.3: Volunteer References to “Need” in Playa Felumi as Markers of Deservingness

Distinguishing Among Deserving and Underserving (Italics added for clarity) wanted to help people in an area of need be helpful and serve those who are in desperate need of basic health needs. As a Christian I feel a calling to help those in need good quality healthcare to patients that needed it. Only a small percentage of the patients we see have acute and serious medical need I felt as though we handed out Meds to people that at that point in time didn't necessarily need them

Providing reading glasses to some folks who really needed them. Sharing food with some folks who really needed food. Maybe some will even want to help others in need more

Any person that was truly in need of help And received it is a success to me. On the surgical side of things I felt there was a great need! We saw so many people with fractures, deformities, and club feet. The surgeries, on the other hand, I felt were all great and the patients and families were in great need and I think will be life changing for some

Patient deservingness was among some of the challenges that volunteers identified in their surveys as well. One physician volunteer said, “The patients presented with similar complaints to obtain medications/supplies for eventual use… not necessarily treating an acute issue. The [patients] were not entirely truthful in their presentations or responses to questions.” A nurse practitioner expressed a similar frustration, “many patients we see are not ill. Still, if the only service we provide them is a supply of free over the counter drugs, I suppose that is ok.”

Another physician was more direct in their judgement. “Patients in the [Playa Felumi] area seem to think they are "entitled" and my teams do not enjoy working [Playa Felumi] as much as they did in the past. This is something our board is looking into closely. By trying to help these people we have caused this problem.”

In Table 2.4 the samples articulate “need” as an assessment. Usually these were perceived although sometimes were articulated as a result of individual’s direct observations

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during their medical mission trip. In a few examples, “need” was used as an indication of “lack” that work the same way as the exemplars identified in Table 1 above.

Table 2.4 Volunteer References of “Need” as a Measurement or Indication of “Lack”

I have been given the gift/talent of being a physician, and I have the means to go to remote places where there is a need. Providing primary care and administering needed medications To serve the medical needs of the local community Fulfilled a high pharmacy need in all 3 places we served TRANSPORT THOSE OF SURROUNDING COMMUNITIES TO AND FROM THE CLINIC. MEET THEIR PHYSICAL NEEDS WITH ACCURATE DIAGNOSIS AND CORRECT MEDICATION TO TREAT THEM. In a more tangible mode we wanted to […] assess their needs in person and reestablish our personal ties with those who assist us in our mission in Honduras To serve and meet the medical needs of patients we met at our clinics Understanding the needs of the patients. We frequently did not have enough of the medications needed, there was no way of tracking previous treatments identifying patients that were in need of higher level of care and helping them meet their needs either during the encounter or by referring them to other resources provided needed medications to patients lack of follow•up meeting needs of the community we found people in need of life changing orthopedic surgery, we provided people including young children with asthma medications to enable easier breathing. I do believe the families with children with asthma need to have medication at home•• when asthma flares they will need around the clock albuterol••most asthma is not associated with pneumonia but people need to be able to care for their children who cannot breathe in their own homes at 2am Also dental and vision care is needed If they could afford electric the open fires would not be needed and the smoke would be gone. Successful efforts to educate patients in healthy eating and lifestyle changes has limited value because other needs take precedence they need to be educated about the disease and the meds and when they need to seek help

The concerns in Table 2.4 are also based primarily on assumption rather than on a systematic needs assessment or other method to determine what Playa Felumians identify as their most salient needs. For example, among an October mission team, I observed an exchange between a team leader and a woman who had come to the brigade clinic with her children. Clinic was coming to a close, and the team leader, Marjorie, was sitting on the now-empty waiting

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room benches facing the woman and explaining to her how the packets of food she was giving to her worked. The woman was giggling nervously, as Marjorie spoke. Marjorie speaks Spanish adequately, though with a heavy North American accent.

Marjorie was becoming visibly frustrated at the woman’s laughter and thought it was due to her language skills or accent, so she asked me to interpret since I was standing nearby. The woman explained that she didn’t understand why Marjorie was trying to give her bags of dried lentils and rice, when what she was asking for was money to get some food for her and her children now before their long trip home. These bags of food would not be edible until after they arrived home and cooked it for an additional hour, plus she added, the rations tasted awful. Her children were hungry right then. Marjorie became more aggravated and said bluntly that the woman could take these bags of food or go without them. The woman took the rations but left without the means to procure a meal for her and her children before leaving Playa Felumi.

Discursively, when STMM volunteers use the term need, they are taking a linguistic stance of power, positioning themselves as the solution or remedy to those needs, or justifying their actions as necessary. As Cole (2012) remarks about the typical White Savior, “All he sees is need, and he sees no need to reason out the need for the need,” that is, they do not search out the root causes of poor health access or impoverishment. This is in part due to the ideological stance that individuals are responsible for their circumstances, that their impoverishment or status as “less fortunate” are the result of personal failings, poor discipline, or “sin,” and not the result of structural violence.

Similarly, the exchange between Marjorie and the mother above, demonstrate what

Benton (2016a) has called this the supremacy of the humanitarian rationale. The (white) volunteer decides what issue is most pressing and what form of assistance is most appropriate,

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regardless or in spite of the needs and assistance aid recipients and local aid workers explicitly request. At the same time STMM volunteers’ positions those about whom they are talking, patients and residents of Playa Felumi, as “needy,” insufficient, and less powerful or intelligent than medical mission volunteers. STMM volunteers are also making evaluative claims about their patients, categorizing them as entitled or ungrateful when instead of accepting the

(misguided) assistance offered, they ask for what they actually need.

This is also the work of therapeutic domination. The donor-recipient relationship mirrors the doctor-patient power dynamic wherein the doctor has the authority. Therapeutic domination expects the compliant subject to accept the advice and prescription (of aid in any form) without question. If they do question it, or do not perform gratitude as expected, their protests or demands are labelled “irrational outbursts” (Daniel 2014), and dismissed. The mother’s protest for timely aid and complaint about the aid offered instead was treated as an “irrational outburst” and met with an ultimatum, forcing her into compliance rather than responded to her clearly articulated needs.

Discourses of Distrust

The discourses of “lack” and “need” overlay the explicit assertion of Corbett and Fikkert

(2014) that the “poor” do not know what they really need or want, or that they are “not honest with themselves,” and as a result of their “poverty of being,” they cannot be trusted to make their own assessments of their needs. This ideological stance reinforces the authority of medical missionaries to make decisions on behalf of the people with whom they interact, for even when someone seeking resources directly states what they need, like the mother asking Marjorie for money to pay for a prepared meal in the immediate term, they are already considered untrustworthy or incapable of knowing their own needs. 238

In March 2015, a woman brought her family to Clinica Blanca and retrieved a bottle of amoxicillin from the canvas bag she carried. She had received it from a brigade the previous month. She administered it to her child once, but before administering it a second time noticed that the liquid suspension, dated 06/2014, was expired. She held onto the bottle and waited until the next brigade arrived to raise the issue. The STMM volunteer I was translating for at the triage station frowned and quietly told me in English that “the meds [antibiotic] are ok to give past their expiration date,” while she wrote out a triage card for the family that had been to the CESAMO less than two weeks earlier.

The day before, another woman had brought in an expired bottle of amoxicillin and would not give it to her child because when she opened the suspension it was smelly and curdled and didn’t look or smell like Amoxicillin that she had given her daughter in the past. The child’s mother explained that, “this is not the first time I have given amoxicillin,” anticipating the deflection of her complaint. The nurse to whom the concerned mother had presented the rancid bottle of antibiotic suspension suggested to me in English that the patient had handled the medicine incorrectly, “maybe she kept it in a hot place,” rather than acknowledge the STMMs error and the often intentional, albeit unethical practice of “donating” and prescribing expired medication.

In both of these cases, expired medication and the circumstances of its souring are laid at the feet of the patient (or patient’s parent). The patient is labeled non-compliant (not administering it or storing it improperly), ignorant (i.e., expecting the patient to “know” which medicines are safe to take past their expiration - liquid antibiotic suspensions are not one of them), and thus deemed a bad biological and therapeutic citizen (Nguyen et al. 2007; Whyte et al. 2013). Further, patients are expected to be deferent and grateful, even if the medications are

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soured and unusable, any complaints are dismissed as “irrational outbursts,” and challenge to the expected hierarchy of power typical of therapeutic domination (McFalls 2010; Daniel 2014).

Patients of the HMH clinics are not the only people who cannot be trusted. The assumption that those intervening, especially those who believe they are intervening on behalf of

God, know better than those they encounter leaks out of the missionary-patient encounter, revealing the more nefarious white supremacy and iatrogenic violence that pervades the mission encounter. So, all local knowledge, no matter how dynamic becomes inferior to the authoritative knowledge of the foreign interveners. As such, local health staff and community health workers, and caregivers are subsumed into the undifferentiated category of Corbett and Fikkert’s (2014) poor, who cannot be trusted because they are too ignorant to know what they need and how things work, or they are dishonest with themselves about their own failings and sin.

Misty, a nurse volunteer, asked me a question that was typical of the entrenched bias against Honduran healthcare: “So is the health center…do people just not go there, because the people there aren’t properly trained?” Medical mission volunteers on most of the teams that I observed, composed of predominately white volunteers, suggested that Honduran medical professionals were incompetent, or generalized that all Honduran medical staff were egregiously unqualified based on the accounts of a few patients who came in to Clinica Blanca for second opinions or follow-up care after negative experiences. Few of those reported experiences were the result of care at the CESAMO and none of the volunteers considered the significant role that discrimination against Garífuna Hondurans plays in their maltreatment in Trujillo, Tocoa, and La

Ceiba (the nearest public hospitals).

In a conversation with Buck, one of the organizational leaders and a team leader, he described his ambitions for the HMH clinic. He was interested in hiring a social worker to

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coordinate from Playa Felumi on a regular basis. I asked him if one of the social worker volunteers from Playa Felumi assisting at the HMH clinic that week were what he had in mind.

He quickly said, “I would prefer if it was someone not from Playa Felumi.” I asked why. He explained, “because everyone who works here is a Barra, and the Barras have money and no one else except drug runners do. I don’t mind paying translators, but I want more volunteers.” The

Barras that Buck is referring to are some of the related paid staff at the HMH clinic, Ricardo and his siblings. One of the half dozen social workers volunteering at the clinic that week was

Ricardo’s son, but the others were unrelated to any of the staff. Even if they were, Buck’s response suggests that he does not trust the staff or their families, despite their years-long relationships and employment with HMH. Buck compared the Barras relatively stable income and wealth to “drug runners,” despite most of their income coming directly from their employment with HMH. Buck’s explanation indirectly asserts that he did not trust Playa

Felumians with the role of social worker or local coordinator.

Indeed, another place where authoritative knowledge and trustworthiness appeared were in the dynamics between HMH volunteers and Sor Inez, the woman who founded and ran the children’s home, Casa Hogar, in Playa Felumi. Individual volunteers and HMH were heavily invested in Casa Hogar, both emotionally and financially. In Chapter 6, I described visits to

Casa Hogar as part of the typical medical mission experience. Volunteers brought gifts and organized building projects for the home. During my research, one of the teams was very vocal in their frustration about the state of the swing set, built a year before by some of the volunteers who had come on another team. They were also concerned about the seeming lack of toys or remnants of donated gifts from their visit a year prior. Around the common room table, Jason demanded to know, “Why is the swing set no longer in use?” One volunteer, Joan, told me she

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believed Sor Inez took the toys from the children, either withholding them, or dishonestly “given to another orphanage” in Tegucigalpa. Others echoed these concerns. Lynn, visibly frustrated, almost shouted, “I’m so mad that the toys we brought aren’t here. We bring toys every year and I never see them!” Shannon added anecdotes about Sor’s methods, “I know Sister Inez is a control freak. So maybe it’s a control thing. She’s told me that the kids take the toys and hide them in their rooms, which may be true…” Two other volunteers chimed in with their concerns about

“never” seeing kids with toys that have been donated, one started, “We never see them playing with toys…” and the other filled in, “Any daycare you see always has toys! But we’ve brought them!” Within these discourses are implications that Sor Inez is neglectful, if not abusive, dishonest or unethical (taking donations intended for the home to give to another children’s home), and that what she reports is suspect or intentionally deceptive.

The concerns resulted in a stern meeting, late (after dark) one evening after clinic had ended and after a meeting with the entire board of the fledgling school that Sor Inez and HMH were trying to establish for the orphanage. I interpreted for that meeting and then I was asked to stay, which put me in the very uncomfortable position of interpreting for the team leader, Dr.

Clarkson, during her meeting with Sor Inez. On one hand, I was glad I had the opportunity to witness the exchange, and on the other hand I felt (as I later commented in my fieldnotes) that the position Dr. Clarkson was taking was abusive.

Dr. Clarkson sat to my left on the long bench against the wall of the waiting room at

Clinica Blanca. Her right arm was draped over the back of the bench and she leaned forward as she spoke. Sor Inez sat across from her in a chair, her ankles crossed beneath her long skirt. She sat upright, poised, with her hands gently clasped and resting in her lap. Dr. Clarkson began, asking Sor Inez what happened to the swing set that had been built and installed the year prior.

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Sor listened intently, with the calm smile that she often wore. She first expressed gratitude for the wooden play set and said, “the children play on it every day, and just love it.” Sor Inez then tried to delicately explain that the children are very energetic and sometimes play too rough with the things they have, and inevitably those items break. She added that some of the children “son especial,” have special needs, (a fact well-known by Dr. Clarkson and the volunteers), and when they play, they are not always careful with toys or the play set.

Dr. Clarkson nodded and moved on to the next issue, explaining that the volunteers are concerned that they do not see the toys they have donated at the orphanage. “Why are there no toys?” Her tone belied the implication that Sor Inez was depriving the children in her care of playthings. Sor Inez calmly and respectfully answered, smiling and nodding her head slightly in a deferential gesture, despite the accusation. Sor Inez explained that the children “have a destructive tendency,” so when the toys break, as they eventually do, they get thrown away. Dr.

Clarkson shifted and said, “I remember what is was like having three small kids, and I know they can be destructive.” They both chuckled briefly, relieving the mounting tension in the room. Dr.

Clarkson seemed to find the responses plausible, if less than ideal. Sor Inez added calmly but firmly, “Everything that is given, I give to the children.” Dr. Clarkson placed her hands on her knees, nodded slightly, and thanked Sor Inez. The interrogation ended unceremoniously and one of the chauffeurs for the team drove Sor Inez back to Casa Hogar.

Sor Inez’s motivations and actions were constantly called into question by STMM volunteers and leaders. In addition to their speculations about Sor Inez withholding toys or limiting play and recreation, volunteers also spoke critically when Sor Inez brought new children to the home. On a spring team in 2015, Marjorie was openly frustrated that there were “new children” at the home “that Sor Inez didn’t bother to tell [her] about.” Marjorie raised her arms in

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the air, expressing greater frustration and concern because, she said, “we gave her a computer!”

Marjorie’s statements implied that Sor Inez should have used the generously donated equipment to immediately relay (and approve) the addition of new children to the home, expecting that Sor

Inez should be using it to communicate in a manner consistent with her and Buck’s expectations.

Although the foundation was established to raise funds to build a renovated home for the children, the financial support associated with it was often used as a motivator (or threat). The support, like so much aid, also made the givers feel entitled to decision-making and direction of the home and the children.

Ruby told me how she remembered children’s experiences at the home before the

STMMs intervened. She recalled that when Keylor was in the home, before the new space was built, Sor Inez “let the children run amok. And she had locked Keylor and two other boys in a room. She had them locked in this room because they had done something wrong. And she’s

Catholic, that’s just her way, but that affects a kid. We told her that if it was like this when we came back, we would pull funding. She was always traveling to do stuff and the kids would be alone. It was just…” she trailed off and fixed her eyes on the waves of the incoming tide as she rocked in the chair on the Clinica Blanca balcony.

There is a lot going on in Ruby’s recollection, but I want to first draw attention to the exertion of power via money. The organization’s representatives disagreed with something, and the first response was to threaten to “pull funding.” This is a common practice in the world of grants, donor-supported projects, and within the neoliberal marketplace at large. Neoliberal governments (including Honduras and the United States) consistently employ punitive, or divestment funding strategies. Foundations, donor-funded volunteer organizations like HMH, and other non-profit service organizations function within neoliberal logics, so it makes sense

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that HMH and its volunteers, who are embedded in, subjects of, and constituted within that system, default to such mechanisms. Rather than recognizing that less funding would exacerbate any identified concerns or shortcomings, HMH’s (or any funding entity) response is to punish

“bad behavior” as an incentive to change it. Sin and personal failings require discipline interventions.

Also evident in these interactions is the dismissal of Sor Inez’s knowledge and capacity.

When Ruby recognizes that Sor Inez has some knowledge, it is “Catholic” knowledge, invoking common stereotypes about harsh nuns, and relegating her knowledge to a lesser position in an imagined hierarchy of Christian knowledges and practices.

Manifestations of Self and Other through Medical Mission Discourse

The language of lack and need are not neutral observations about missing resources.

Certainly, as Playa Felumians indicated in previous chapter, there are tangible resources that would improve the capacity of the CESAMO and ease individual lives and health concerns. But medical mission volunteers frame what is missing in terms of personal, intellectual, even moral deficiency among Playa Felumians. Using the framework of “blessings,” and divine fortune, medical mission volunteers also depoliticize and decontextualize the structural obstacles, such as systemic political economic failures and the legacies of colonialism and extractive capitalism, from the reasons that need exists in Playa Felumi in the first place.

Critically, medical mission volunteers also produce hierarchized identities for themselves and Playa Felumians. Needy, ignorant, spiritually impoverished or corrupt, Playa Felumians are shunted into the category of “the poor,” despite acknowledgement of seemingly exceptional class and power dynamics and are deemed too incapable or too irresponsible to make decisions for

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themselves. A related consequence results in medical mission volunteers dismissing or denying the integrity of the stated needs and desires of Playa Felumians.

Having fully established the other, these discourses simultaneously establish the subject position of medical mission volunteers. These discourses allow contemporary medical missionaries to assume the position of superiority within the medical mission encounter. Doing the divine work of God, they have religious authority. Their religious authority and identity as

North Americans solidify their claim to authoritative knowledge. Their relative wealth and comfort are divine rewards for their personal decisions and acceptable discipline.

These might be best considered archetypes, as they are ways that Playa Felumians and medical mission volunteers defy or otherwise disidentify with these subject positions. However, they are archetypes created via the very language of the medical mission volunteers in my study.

Referring back to Corbett and Fikkert (2014), for example, there are instances in which the authors try to distinguish their actions and their intentions from the discourses they simultaneously reproduce. But this is also part of the nefariousness of subjectification, the very process of defining oneself and others in terms of how one becomes what the other is not, or does not have, or does not do reinforces existing hierarchies of power. So, while volunteers might not embody this discursive medical mission subjectivity in its entirety, or push back on this subjectivity in some ways, they are very much engaged in this discursive process.

Furthermore, these discourses directly impact the ways mission volunteers engage in the medical mission encounter.

In the category of social and structural iatrogenesis, these discursive practices fit into the definitions of equity harms, particularly within the context of their “responsibilizing” ideology.

They also meet the criteria for group and social harms, using stereotypes and reinforcing

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problematic colonial (and necessarily racialized) hierarchies. These discourses are also examples of therapeutic domination, a foundational element of iatrogenic violence in medical aid encounters, that reflect the uneven power dynamics of the doctor-patient encounter at broader levels.

This chapter has named specific discourses that HMH volunteers fall upon and circulate as a way to establish their personal identities, their authority to intervene, and the necessity of their presence. I have argued that these constitute forms of social and cultural violence within the iatrogenic violence framework. The next chapter presents the perspectives of Playa Felumians about their health and needs, providing a counter-discourse to the dominant medical mission narrative and demonstrating the ways that Playa Felumians inhabit and push back against the subjectivities generated in the medical mission encounter.

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CHAPTER 10

DISSONANCE: PLAYA FELUMIAN’S KNOWLEDGE, DEFINITIONS OF HEALTH, AND ILLNESS NARRATIVES

The illness narratives of Playa Felumians, how they talk about their illness experiences, connect their relative health or wellness to their broader socio-economic and political contexts.

Their ideas about health and what constitutes wellness and the physical impacts that rapid ecological and political economic shifts have had on their bodies and the collective body of

Playa Felumians are also reflected in their ecological worldview. The patterns that emerge suggest that Playa Felumians have adapted semantic illness networks (Good 1977) and idioms of distress (Nichter 2008; 2010) to index broader causes of physical and metaphysical distress.

In the previous chapter I presented the discourses of HMH mission volunteers, including their perspectives on the underlying causes of disease and their perceptions of Playa Felumians’ understandings of health and illness. I identified a few ways that STMM volunteers discursively construct the patients they encounter in Playa Felumi as “lacking.” The volunteers simultaneously reinforce their own ideas of superiority while transforming Playa Felumians into inferior subjects through linguistic markers that portray them as ignorant, incapable of deciding on or managing their own healthcare, or in the case of medical personnel at the CESAMO, ignorant and insufficiently trained or incapable of properly using medical technology.

This chapter presents the perspectives of Playa Felumians, complicating the discourses presented in Chapter 9, and contextualizing the meaning and the potential effects medical mission interventions have on health. Included here are the observations and evaluations of everyday Playa Felumians, including children and youth, who were managing their health and seeking care when they (or someone in their families) felt unwell. Examples of common illness narratives also demonstrate how Playa Felumians encode their broader socio-economic and

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political experiences into their physiological experience of health, using idioms of distress

(Nichter 2008) and establishing semantic illness networks (Good 1977). I also discuss the perspectives of Playa Felumian biomedical healers, including physicians and midwives, as well as spiritual healers called buyeis and the tensions they reveal.

“Estoy poco bien”: Illness Narratives, Idioms of Distress and Semantic Illness Networks

In addition to the 53 completed surveys from STMM volunteers, I conducted semi- structured interviews with 51 heads of household in Playa Felumi. I visited homes in each of the eight neighborhood of Playa Felumi and went house-by-house to recruit participants. Whenever I asked people how they were feeling, regardless of their gender or age, the most common response I received was “not that great.” Participants in the household interviews I conducted were often experiencing pain or other symptoms of a specific illness like diabetes or hypertension. Sometimes, their somatic experience of pain was tied more to social and economic problems – the pains of constant stress and structural violence.

When I asked individuals what they did to stay healthy and prevent illness or what causes illness, 54 percent of respondents named sanitation, hygiene, and/or good nutrition and healthy eating habits as key factors. This suggests that a majority of patients have the knowledge that medical mission volunteers believed they lack. Of the 51 interview respondents, fewer than 10 percent did not or could not answer, or explicitly responded, “I don’t know.” However, I do not attribute this to ignorance or “knowledge deficit” as many of the brigade volunteers did. Instead,

I attribute the dissonance to the way I asked the question in an admittedly biomedical way.

Tellingly, when I asked the same participants what they did to stay healthy or to feel better when they became ill, participants answered in ways that upend the HMH mission

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volunteers’ typical characterizations. The remaining respondents answered with specific vectors of illness, such as mosquitos, contaminated water supply, failure to seek medical attention at first signs of illness, failure to take prescribed medications, or chronic disease as the cause of illness, often addressing the same issues that STMM volunteers identified as areas of patient failure or ignorance. One woman, speaking of her hypertension, said “It’s congenital,” a hereditary disease that runs in her family. A different woman, speaking specifically about diabetes, told me that “it isn’t curable,” and added that the medications she receives from the HMH mission clinic “don’t help” her, but the ones she purchases from a pharmacy in Tocoa or La Ceiba did.

In some ways, Playa Felumi residents have internalized the biomedical discourses and negative stereotypes and perceptions that HMH mission volunteers (and Honduran biomedical doctors) circulate about herbal, traditional, or indigenous medicine. I frequently listened as Playa

Felumians distanced themselves from the use of caseras - non-pharmacological, plant-based, or homemade remedies. Sometimes the rejection of traditional medicines was emphatic, accompanied by equally vigorous body language, such as waving arms, leaning back and away from me, or shaking their head no. Often younger respondents would say, “I don’t use them, but my mom and my sister do,” although this response was usually less emphatic and permitted respondents to distance themselves from the question without having to expressly reject traditional medicines (that many people still use, even if they prefer not to talk about them with outsiders).

Several respondents, however, like the exemplars below and patients I observed at

Clinica Blanca, identified named herbal and homemade remedies as a regular part of the ways they stay healthy or heal themselves when feeling ill. I observed a woman in her late 50s being triaged at Clinica Blanca. While her blood pressure was being taken by the paramedic volunteer,

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she showed me the medicines she used to manage her blood pressure and azúcar (sugar). She used allspice, garlic, and coriander seed. The garlic she gets from a relative in New York, where a large Garífuna diaspora resides and uses that and coriander seed to help manage her blood sugar. Allspice is widely used for gastrointestinal discomfort and is also used for reducing water retention. Garlic is eaten whole or swallowed like a large pill. While coriander and allspice are made into a strong infused tea.

Still other respondents spoke about complex matrices that contribute to a decline in overall health. Another woman, Gemma, linked the shift to changes in land ownership and use

(see HH3 below), which in turn has dramatically affected the daily physical activity of most

Playa Felumi residents and resulted in the near elimination of subsistence farming.

HH2: Hygiene because here, heh! [Everything is] Totally covered [with dirt], you have to wash everything, we are dependent on medicines daily…

HH3: To be healthy is [difficult] because the food…is no longer natural like before. You know, they put chemicals. They used to go to the mountain, but now they buy everything. There was more movement, and they were mentally [healthier], too, for waking up early [to work the land]. But everything has changed. It's a drastic change. We have to feed ourselves…but with natural things… but with chemicals [chemical fertilizers]. But… you can still find natural food here.

HH6: Take care of myself well, eat well, eat healthy…healthy food, not too much fat, salt. [When you get sick] Depends on the illness - acetaminophen, chamomile, honey.

HH8: I go to the doctor [at the CESAMO], take medicines, sometimes I go to La Ceiba, I have a doctor here, and there too.

HH12: Take medicines; maintaining diet, go to health center or private clinic. Go to health center. Boil water before drinking. Keeping house clean to avoid mosquitos and avoid Dengue; follow doctor's directions - go to health center, eat well.

HH15: Take pills, eat fruits and vegetables, exercise, go to the doctor, [use] anise, rosemary, chamomile.

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HH30: [Go to] health center, get medicine, cinnamon tea, oral rehydration solution [litrosol], clean, burn trash10

HH35: Purify water by adding 2-3 drops of bleach, wash hands, keep clean; get pills [medicine], home remedies… chamomile, rosemary, garlic, lemon. Acetaminophen [for] more serious [things].

These responses from community members and would-be medical mission patients complicates the overwhelming perspective of HMH volunteers that the targets of their commentary and aid have “knowledge deficits” or “need education.”

Additionally, comments and drawings from interactive workshops with school-aged children similarly suggest knowledge and understanding of personal and environmental hygiene and the correlation between environment and health. In separate workshops with 10–13-year- olds, 14-year-olds, and 15–17-year-olds,11 I asked students to draw something that was related to health. Students could also opt to write a poem if they did not want to draw. Many students opted to draw an image and then write a poem to accompany it. Of the n=60 drawings I collected, n=21 students made an explicit connection to nature or an element of the natural environment. Of this third of youth participants, 29 percent (n=6) explicitly mentioned the importance of disposing of trash appropriately, not burning it near the home or schools or health facilities, putting refuse in its designated locations, and the effect pollution has on health (see Appendix B). Many of the youngest age group (n=40) drew images and diagrams indicating specific diseases and illnesses.

There were n=17 drawings that include a rendering of an individual with a specific illness. Some are covered in speckles (Figure 12.1) identified by the artist as either varicela

10 The issue of solid waste management is one of the MOH and PAHO identified challenges. There is no other way to eliminate garbage in Play Felumi, controlled burn of trash prevents it from accumulating, attracting pests (which are common disease vectors), and from [further] polluting waterways and arable land. There are also local ordinances that require trash to be burned in a hole, so that it can be controlled and help reduce air pollution from smoke (see Ch. 6). 11 These age divisions are a result of the predetermined division of students in classes approved for participation by school administrators (refer to methods section in Chapter 1). 14-year-olds were not singled out as a group, instead the workshop with the approved class was coincidentally only 14-year-olds on the day of that particular workshop. 252

(chicken pox, “varicella”), manchas (skin discoloration, common symptom of niacin and other vitamin deficiencies), granos (usually raised skin irritations, sometimes a rash, sometimes dermatitis), or coliches (worms, a slang term for intestinal parasites). Still others’ drawings indicated cáncer, or someone who “fainted because he didn’t eat.”

Figure 12.1. Manchas

In revisiting these drawings, I was struck by the number of specific illnesses and maladies the youngest of the youth I worked with highlighted, especially the ways that their

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observations and connections echoed the concerns expressed by (unrelated) adult participants with whom I conducted interviews. Both youth and adults describe their community as having more illness, with cancer and chronic diseases being the greatest specter.

One youth captured this subtle anxiety in a brief poem she wrote next to an image on her drawing (Figure 12.2): “we have to take care of the environment because there are many illnesses and the people are dying.” Three interviewees named climate change explicitly as causes of specific illnesses, especially asthma and other respiratory illnesses, but also as a general cause of a decline in health or access to good quality air, water, and food. Other interviewees named specific environmental factors as vectors or causes of poor health, and contaminated or suspect-quality air, water, or food as reasons people in Playa Felumi become sick.

Figure 12.2. Hay que quidar el ambiente

HH23: “Because of the climate. The weather now is really terrible.”

HH25: “Climate change”

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HH35: “I suppose it’s the rain, the air, and the water that comes to us already contaminated.”

HH36: “…the rain, pests, the air, contaminated water…”

HH40: “many chemicals in the food”

HH49: “Climate change”

In addition to indicating a general perception that people are unwell in Playa Felumi, these drawings indicate that there is a broad understanding and, rather than a “deficit,” a surplus of knowledge about health, the environment, and food. One student drew a pineapple (Figure

12.3), a common export crop grown in the country, but a hardy fruit that can be grown (slowly) or purchased from one of the several vegetable trucks that come through town a couple of times a week. Beneath the pineapple is a description of the fruit that tells the viewer that if the pineapple is bitter, it can be made into a juice to fortalecer, or strengthen, the body (usually nutritionally).

Moreover, the schools had specific public health literature, posters, and information in every classroom, further challenging the notion that “these people,” and Hondurans in general, lack education or understanding. Education, information about public health strategies, diseases and their causes and prevention are not missing in Playa Felumi. Nor is the intellectual capacity to understand this information. As the Playa Felumians of all ages deftly indicate, structural violence is their key obstacle in maintaining good health.

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Figure 12.3 La piña es dulce

Bodyscapes – Linking Bodily Wellness to Land Loss and Ecological Destruction

The Garífuna (and mestizo) population in Playa Felumi often link diabetes and hypertension to dramatic changes in the physical, emotional, and social landscapes of their community. Many attributed the appearance of these illnesses to “la carretera,” the road carved out only about forty years ago, and with it the entrance of outsiders into their rural town. Most

Playa Felumians I spoke with attributed the prevalence of these diseases to changes in physical landscape and a decline in traditional foodways. Still others attributed the diseases to trauma of various kinds, both direct and indirect.

Playa Felumi was once a more abundant wilderness, rich with flora and fauna that distinguished Garífuna territories from less ecologically diverse parts of Honduras. The stories I heard from participants about Malaguas, “bad waters,” the paradoxically named ecological treasure that once fed, taught, and entertained the Garífuna of Playa Felumi, seemed to inhabit

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their memories like a fairytale or parable of yore. While we stood waiting on the environmental health technician before visiting homes around town, Don Samuel, who is in his 40s, described the “paradise” he had visited many times as a child and youth. His eyes glimmered and he spoke with a wide smile as if vividly experiencing the memory. He told me that when he was young his parents would go to “el monte,” just like everyone else’s parents.

From Playa Felumi, it is a 2-hour walk along the beach to Malaguas. “The water is green, green, green!” Every Friday, after school, children would trail behind their parents to this luscious green lagoon. Families would spend Saturday fishing, cultivating, hunting, and then

Sunday bring back food and supplies (like wood and medicinal herbs) for the week. It was also an opportunity to learn about their ancestry, their territory, Garífuna heritage, and the importance of ecological balance. As quickly as his joy from the memory came, it disappeared. He lamented that no one goes to “el monte” anymore. Youth “ni sabe,” he says. They “do not even know” the place exists, and it has largely been encroached upon and turned into pasture for cows and horses. “Ya lo perdió.” It is lost now, Don Samuel says.

The loss of this once verdant patch (Gandy 2012) to cattle ranching and horse-rearing is not the result of a sudden shift in Garífuna priorities or cosmovision. Instead, African palm plantations and commercial cattle ranching have rapidly enclosed this territory in order to bring it into line with capitalist logics (Brondo 2013), according to which land left fallow (even or especially intentionally) is wasteful or unproductive. Fallow land is misinterpreted as a profit loss, despite being better for long-term health and productivity of arable land. This violent process of capitalist enclosure has left local Garífuna feeling vulnerable and dispossessed, and as Moran-Thomas (2019) notes, is just the most recent iteration of a violence process of

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dispossession that began with over 200 years prior with the violent removal and expulsion of

Garífuna from their crops, lands, and lifeways in St. Vincent.

On an especially hot day, I walked to one of the furthest points of Playa Felumi to follow up with some of the people who had participated in household interviews. The neighborhood was relatively “new” to Playa Felumi. Although the land has always been there, it had not always been residential. Most families who lived there were given permission to build homes on the land that is held under ancestral title as communal Garífuna property. The coconut palms, citrus, and other trees and vegetation common in the more central and western-most parts of town, are noticeably absent there, making the heat from the looming sun that much more abusive. At a brisk and steady pace, it took about 45-60 minutes for me to walk – without stopping – to that part of town from the other side of town.

While telling me about her concerns for covering the costs associated with her daughters’ primary education and the daily struggle to keep food on the table, Carlotta explained how enclosures continued to aggressively affect Garífuna communities. “Before, you could go to the fields and harvest cassava, plantains, malanga, but not anymore” I asked Carlotta why. “People don’t go. They don’t want to go.” She also added that it was becoming more difficult to go and work the cultivable land. “There’s no land.” Cattle invade yucca fields and eat the plants, trampling and destroying the crops. “Indio” cattle ranchers are also illegally encroaching on the land. She explained that if you don’t have barbed-wire fencing, or if you couldn’t afford it, like her, then your crops would be damaged. “One time, we went to harvest and when we got there, there was nothing left.” The cattle of an encroaching rancher had eaten or destroyed most of the crops. “It wasn’t worth the effort to go anymore,” Carlotta said.

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She added, “[The Indios] come with their barbed wire here and there, and then there’s no land to cultivate. We had about twelve manzanas of land, but now there is only seven or eight manzanas.” I asked her if she could go to the mayor or if she had other recourse. She laughed.

“Heh!” Protesting to or about the cattle ranchers is a life-threatening option. Just one month earlier, a man was gunned down and killed in the mid-morning on the main drive into town because he had allegedly stolen cattle. Lack of political and legal recourse and the high likelihood of violence have led many people to throw in the towel. “My brother says it’s best to just sell it.” She paused to consider the weight of her statement. “It was my great grandparents’ land.” The weight of making a decision to sell and the sentimental and spiritual value of the ancestral lands of her great grandparents seemed to loom over her. “But it’s better to sell it,” she said after a long, heavy silence. “No hay de otro.” There’s no other way.

This loss of territory and subsistence space to the disruptive logic of capitalist development is deeply gendered. While Don Samuel lamented the loss of an Eden, Carlotta described a palpable loss tied directly to economic stability and survival. Garífuna women in

Playa Felumi, and throughout Honduras, are historically the cultivators—and defenders—of land

(Brondo 2013; OFRANEH). Young boys work the land occasionally or are tasked with helping in the preparation of yucca or other foods, but by the time they are adolescents, their land- working roles are generally limited to chopeando, cutting grass with machetes, maintaining common spaces (like cemeteries), or processing oils from palm fruits and other cultivated plants.

Men primarily work in the seascape, making, repairing, and casting nets; fishing and selling their catches; and making and maintaining dugout boats, though now many have converted to fiberglass boats with outboard motors due to deforestation and convenience. Men also leave the communities to work elsewhere and send home income and remittances in a

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tradition institutionalized at the turn of the 20th century, but that extends to the very origins of the

Garífuna over 200 years ago (Gonzalez 1989).

While ecological changes to the sea—due to commercial fishing, polluting run-off from

African palm plantations, and other aggravators—have affected fishing patterns and men’s livelihoods, women experience territorial loss most acutely. As the matrifocal title holders, cultivators, and historic defenders of land, women are the hardest hit by the siege of violent encroachment and the global man-made disaster of climate change that has accompanied capitalist development. Cultivation of Garífuna lands and community plots in the area used to be a way of life. But “blancos” or “indios,” Ladino cattle ranchers and Facusse’s palm empire have encroached on those lands, making it dangerous or impossible to cultivate and forcing people out, leaving them without an affordable source of food and with a decline in physical activity, which are compounded by dramatic upticks in experienced stress—all of which contributes to various forms of illness.

This ecological and socioeconomic context is largely ignored within the discourses used by medical mission volunteer doctors describing the causes of illness in Playa Felumi, and

Honduras more generally. These experiences of land loss, either through ecological destruction, enclosure, or the simultaneous occurrence of both is necessary context for understanding why

Playa Felumians have to buy food, often processed, or commercially grown fruits and vegetables that are frequently exposed to dangerous pesticides (a common source of high annual rates of poisoning in Honduras).

Healers and Healing

Among the options for healthcare and healing that Playa Felumians may seek at the

CESAMO or outlying CESARs, they also have midwives, spiritual healers, and there are 260

unemployed, but certified doctors who either live in town or come (infrequently) as nominally paid medical contractors for Clinica Blanca.

Though midwives are counted among the health personnel available to the municipality and are required to report health information and check in with the CESAMO regularly, they are not paid by the CESAMO or the municipality. Noemi had been a midwife since she was 15, initially learning from an elderly midwife who had passed away before our meeting in 2015. She received training in 2003 from “Medicos del Mundo,” a Spanish organization, in collaboration with the Secretary of Health. She also received training from a medical provider who had come with a brigade to Clinica Blanca more than ten years prior and offered a training for Birth

Attendants. She had not been back since. She also shared that Paciencia, the previous lab technician for Clinica Blanca, had been an important community organizer and ally to the midwives in particular, using her experience and social capital with the missions to bring trainings and material resources to them. Noemi said Paci left Playa Felumi three years earlier

(around 2012) because she had started receiving threats and demands for “war taxes,” a common extortion practice of organized crime in Honduras. Paci not only left Playa Felumi, but the country in fear for her life.

Noemi showed me her training certificates, beaming with pride. I asked her about her work as a midwife. Her husband interjected, “Oh yeah, midwives do everything, everything!”

Deliver, cook herbs, everything!” “Yes,” she agreed. I asked about the herbs midwives use and she told her enthusiastic husband to bring the bags out so she could show me. “Bring the bags!”

While he retrieved the large bags from the kitchen area immediately behind where I sat, she explained that she did not receive a salary from the government, “only payment, L.1000,” that the family she is attending pays.

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She opened the sack and showed me a variety of things inside the bag. “This is chamomile. This is pericón. This is encino tree bark.” I asked her if we could lay them all out on a table so I could take a photo of them. She moved a number of things off the large wooden plank cutting board and got a clean piece of fabric to lay over the board. We then pulled each sample out. Chamomile, Pericón (a species of marigold), valerian root, Encino bark, cinchona bark (also known as Jesuit’s bark or Peruvian bark), allspice, rosemary, anise, cloves, all of which is used to make a single tea that a new mother drinks “to cleanse the uterus.” The mixture helps to heal the maternal body and to purify blood and “wash” or cleanse the uterus. The midwife then removes the placenta and bury it outside, but “there are some families that want to bury it inside, but these days it is normally buried outside.”

Noemi told me she liked being a midwife. She just wished she could receive a salary from the Secretary of Health. As a registered midwife, she is required to report all deliveries to the health center and there were rumors, she told me, of the municipality imposing a tax on all the midwives, “a fee.” Free labor for the state, from which they would also extort a fee.

I asked her if there were differences in the way young midwives and the earlier

“ancianas” had done things. She thought about it. “Well, today we use the suction bulb for the nose, but before we used our mouths.” She demonstrated making an unsettling sucking noise, mouth opened over an imaginary newborn’s nose and mouth. I cringed when she did it, imagining sucking blood, mucus, fecal matter, and other birthing fluids from the nose and mouth of an infant. She seemed uncomfortable with the ideas as well and said, “the suction bulb is better, because you always swallow some,” sliding a finger down her body from throat to esophagus to stomach. I nodded, making a sour face. I asked if she could think of other things that were different between then and now. “The instruments used to cut the umbilical cord,” she

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said. Now they used scissors cleaned with alcohol and sterilized with flame (usually from matches). Before, they used “Gillette” razor blades, “for single use only and then threw them away,” she added.

There were several young Garífuna doctors, most within five years of completing medical school, that lived in Playa Felumi but were unemployed or “waiting for placement.”

Some lived in Playa Felumi or visited family there, but they were unable to practice medicine outside of a placement with a CESAMO or CESAR or establishing a private practice. None of these underemployed doctors were interested in private practice and did not have the economic capital it would require. Sometimes they volunteered their service with HMH, but sometimes they were invited to work for pay if the organization had not recruited a sufficient number of physicians, nurse practitioners, or physician assistants. This practice varied widely among the teams, there were only three of the eleven I observed that allowed Honduran doctors to work as part of their teams. Drs. Arranda and Soriano were two Garífuna doctors, both of whom had family in Playa Felumi, that I observed on mission teams at Clinica Blanca.

Dr. Arranda was trained at the Latin American School of Medicine (ELAM) in Cuba in the bio-psycho-social tradition, which compels healers to consider more than just the molecular body in their assessment and treatment of patients. Physicians are taught to widen their gaze to consider the socio-economic realties of their patients and the inseparable relationship of mind and body. Western biomedical traditions are only recently attempting to move away from the model of Cartesian duality that artificially separates mind from body and narrows the medical gaze (Foucault 2003). Despite the attempts to bring social determinants of health into the mainstream, most of biomedicine still ignores social factors that contribute to (or cause) illness and disease.

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Dr. Soriano was another ELAM-trained Garifuna doctor who volunteered with the brigade teams on occasion. A thoughtful and accomplished young physician, he was skeptical about the utility of STMMs. His first day working with this particular STMM team, he told me

“I’m happy to give out (gift) prescriptions, but that’s not what I studied [medicine] for. I studied

[medicine] to save lives, you know?” He was concerned with preventative care and what is colloquially referred to in the US as holistic healing. Dr. Soriano was dubious about the capacity or will of STMMs to practice that kind of medicine. Nonetheless, he collaborated with them and used the opportunity to support Garifuna communities and educate - not just patients, but STMM volunteers as well.

One February day there was an exchange at the lunch table between Dr. Soriano and two

U.S. volunteers, Trina and Amber. Dr. Soriano asked Amber what she thought of herbal and traditional medicine. Amber hesitated for a minute, looking down at her fingers. She took a deep breath and then said, “I don’t like it. There is no data, no clinical data to support it. The FDA hasn’t approved it and [the Department of Health] recently did a study and pulled vitamins and supplements from a bunch of major pharmacies and stores and found that the primary active ingredients weren’t even in them and that some of the fillers could cause allergies.”

Dr. Soriano listened intently and said that as a doctor he agreed, then added, “but if a patient says, ‘Doctor can I take this [garlic supplement] for my blood pressure,’ I tell them that as a doctor I advise you to take this medicine because [the garlic] doesn’t have a dosage, but if it makes you feel better, go ahead and take it. But don’t stop taking the ‘real’ medicine for this other thing” [don’t replace the prescribed remedy with the herbal remedy]. Dr. Soriano added that he had to “respect the culture and the traditions of the patient.”

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Both Drs. Arranda and Soriano reveal a double bind (Foucault 2003; James 2010), or competing tensions, of their own. While wanting to “respect” Garífuna ancestral knowledge about medicinal herbs and healing techniques, they also casually dismiss them. On numerous occasions both Dr. Arranda and Dr. Soriano would use the phrase, “la gente tiene muchas creencias [(Garífuna) people have many beliefs],” as a euphemistic way to express frustration with “beliefs” that biomedical ideologies discredit as outmoded (Adams 2005; Lock and Nguyen

2018; Singer and Baer 1995). When Dr. Soriano and Amber talked about herbal and traditional medicine, Soriano agreed with Amber’s stance that because a remedy is not “clinically proven” it is suspect and assumed to be ineffective. At odds with his desire to respect culture and traditions is the seeming imperative of biomedical hegemony.

Though a common trope of biomedical discourse, their assessments did not take into account the bias in clinical studies, which privilege pharmacological medications and drugs manufactured by large companies hoping to push profitable drugs through the testing and approval process. Nor does it consider the fact that many of those drugs originate, and are in many cases stolen, from the botanical knowledge and natural resources of indigenous communities in the Global South (Oguamanam 2006; Posey 1990). It is entirely possible that there are “clinically significant” effects of herbal remedies, but little to no clinical research is done on those, unless there are considerable profits at stake for large companies.

There is significant medical anthropological and ethnobotanical research that suggests that botanical remedies have measurable healing properties (Moerman and Jonas 2002), in addition to their importance as tangible connectors of ancestral knowledge and the significance of local flora, fauna, and the land on which it grows to the well-being, identity, and power of various peoples throughout the world (Reyes-García 2010). In La Ceiba, Honduras, Ticktin and

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Dalle (2005) conducted ethnographic research among midwives and found consensus knowledge

(Moerman 2007; Ankli, Sticher, and Heinrich 1999) of 79 local plant species used to treat 15 different conditions. Ticktin and Dalle note that use of medicinal plants has declined due to official Ministry of Health “retraining” programs - which dismiss the midwives’ traditional knowledge and make most midwives believe they are not allowed to use medicinal plants (2005).

Deforestation, which has resulted in the extinction or near extinction of certain medicinal plant species (Ticktin and Dalle 2005, 240) has also played a role. Ticktin and Dalle conclude that if some of the widely available medicinal plants used are effective, they would be highly beneficial to the improvement of maternal-child health, but underscore that a shift in priorities and a valuation of traditional knowledge are needed to conduct clinical research and take the necessary first steps (2005, 240–41).

And while the medical mission volunteers’ superiority and authority must be reinforced through a rigid dismissal of local knowledgeways, it is well documented within anthropological studies that biomedicine is not incompatible with ancestral or traditional knowledge (Calvet-Mir,

Reyes-García, and Tanner 2008; Giovannini and Heinrich 2009; Reyes-García 2010), but rather one of a variety of options available. There are, however, important social aspects of illness and threats to well-being that biomedicine, and thus biomedical practitioners, Honduran and medical mission alike, do not and cannot address.

Garifuna healers also talked about these phenomena. In March of 2015 I spoke with a

Garífuna healer, known as a Buyei in Garífuna, in Playa Felumi who explained this phenomenon.

Just shy of 24 years old, Satuye (Satu), was well-respected in Playa Felumi. Satu, clearly articulated how STMM and other biomedical practitioners dismiss or miss these expressions - like Dr. Farnham who heard a “healthy” heart.

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I interviewed him in the modest house where he worked. The doorway was shrouded in a plume of smoke from a bowl of herbs and fragrant plants that served a dual purpose of keeping evil spirits and (evil) pests away. We sat in a simple, small room in two blue plastic lawn chairs.

There were two five-gallon buckets filled nearly to the rims with a steaming dark liquid. My eyes stayed fixed on the steaming tubs. The liquid was fragrant and smelled lightly of caramel. There were about 20 empty bottles still wearing their Tatascan labels [a local aguaardiente], but these bottles had been collected to portion the medicine that was still steaming in the buckets so the young Buyei could distribute them to those that needed them. In the corner of the room there was a wooden table stacked with stones atop which sat candles, an image of the Virgin Mary, and two maracas, each marked with black paint in the shape of a cross. A large cross on a long strand of rosary beads hung from the center of the table.

Over the course of our interview, Satu talked about several topics. I include excerpts of our interview (see Spanish transcription of full interview in Appendix) in which he touched on biomedicine, healing and the limitations of biomedical doctors, as well as deforestation and loss of indigenous language and knowledge about medicinal plants.

Satu: Many people have come [to me] that suddenly [experience] a swollen leg or a swollen foot or a swollen hand, or who was cutting [vegetation] with a machete and suddenly realized, bum!, they had been marked. So they turn to the doctor. They go to the doctor. There are things that the doctor can attend to and there are things for which the doctor has no solutions. Additionally, [inaudible] when there is, when it has to do with, how do I say it, what is, is a spiritualist matter, when it has to do with witchcraft. When it has to do with harm, when it has to do with worldly illnesses, the doctor cannot [treat these]. Because the doctor will only say, “there is nothing wrong with you.” But, if it is a common malady, that one always has, such as diabetes, such as anemia, such as prostate [illness], such as liver infections, such as…okay. These, sure, for this the doctor can treat these [diseases].

Laura: Like things of the body.

Satu: Of the body.

Laura: What they can see, such as symptoms… 267

Satu: Yes, what they can see in all of their machines. But there are things that they cannot see. That they cannot resolve, which are the things that we Buyeis treat. For which only we have the cures. And only we can overcome these, you understand. Because the buyei, are sent buy God to cure, not to harm.

[…]

Satu: There are things that, there are people, there are youth that forget. What a buyei is, is from here onward, they [buyei] have always been amongst us. And there will never be anyone who can overcome us. Because it is in our blood. And there are things that here in [Playa Felumi], including one’s language, that they are forgetting. And these people [buyeis] serve as protectors, because they protect us from all that is bad, from all danger.

[…]

So. I was just now making this, it’s hot. [Gesturing to a large pot and dozens of bottles, some still empty and some filled with steaming hot liquid].

Laura: Yes, it’s hot!

Satu: I have some clients there who, well, they have asked me to make these for them. And I have to travel all this week. I have other work that I must do away from outside of [Playa Felumi]. So I want to dispense this medicine today, God willing.

Laura: What is it?

Satu: Mm?

Laura: This medicine, what is it?

Satu: This medicine is purely herbal. Yes. Purely herbal.

Laura: Which herbs? And what is the medicine called?

Satu: The medicine is for harm and for luck.

Laura: Okay.

Satu: Yes, for harm and for luck. There are various types of herbs, the herbs tell me what they are called and what their uses are. They are very good.

Laura: Yes, I am currently learning the different herbs that people use for cures, like caseras [home remedies], but their other uses as well.

Buyei: Yes, exactly. For infection, for example, if you have a tumor starting [to grow], or something for which you need an operation, if you start with all of this, it is indeed treatable. There are various herbs [plants] in the world for which the people do not know the uses. Perhaps there is a plant that heals some illness or heals some, how do you say it, some disease that I cannot remember the name of. Colon. [Pause] Mm.. so the people go 268

and - bum! bum! bum! - with the machete and cut down the plants. And they don’t know that these plants can be used to heal people. There are things that we - we do not have to deforest the whole world, cutting down plants constantly. That [inaudible], at least. Mm- hm. Such that [hand gesture indicating finality]. That’s how things are.

[…]

Whoever wants protection from anything bad, it is here. Whoever wants an ablution [lit. translation: bath] for luck, too. Whoever wants and ablution for harms, for work [employment], for bad dreams, it is here. Stomachaches, infections, also. Exactly.

Okay, there is another point that I have not explained, that I am going to tell you about. It is about our ancestors, our common ancestors, our Garífuna ancestors, which we are accustomed to calling “Gubida.” Gubida appears in various forms, has various ways it affects someone. They are good people. Gubida are people, beings, that have gone on, like our mothers, our fathers, brothers, that have been dead for five or six years. We call them Gubida. So, people who are family [of Gubida] who forget to give them a celebration, a mass, a wake, or a chugu, or a dugu…

So, when these beings see that we are not doing these things, that we do not remember, they become angry and afflict us. And how do they afflict us? Such as suddenly, you are in the fields, you are [working with] the machete, and bum!, suddenly you’re on a stick, you fall, you break a bone and can’t walk. You go to the doctor, but the doctor says, “there’s nothing wrong with you.” But if you go to the buyei, the buyei tells you, “it was your grandmother. She did this to you, because you didn’t give her a [ceremony], because you didn’t perform a chugu for her, or because you did not give her a religious mass. But if you accept [your responsibility], you will be cured. If you do not accept it, this same person will continue to plague you. It will complicate [your health] and you will [eventually] die.” I always stress and say that they are alive, because they are, they live. And they live to protect us, not to harm us. That’s all I can tell you.

Laura: That makes sense. I have seen a dugu once, but yes, it’s…It makes sense because you have to let the dead rest.

Buyei: Rest.

Laura: You have to put them, you have to arrange everything so that…

Buyei: Exactly. So that they are well, so that they are happy where they are. There are people that always…it has also happened, not that I am criticizing Christian people, the Evangelical, but that they, because they do not believe, because of that, they say that this does not exist. That it does not happen. That it is this or that. But they are also victims of this [phenomenon]. There have been many [Evangelicals] that have been victims of this [Gubida illness], upon whom [the Gubida] have caused injuries, have caused poor health. And they [the Evangelicals] turned to a doctor, and the doctor wasn’t able to cure them. And the same pastors there like fools, if you’ll excuse the term. [Changes register of voice to higher pitch to portray an ecstatic Evangelical invocation] “Oh Lord! It is the Father that is the cure you seek! It is this over here or that over there, in the name of 269

God!” They always say the same things, you understand? Until, when there are no [religious] signs, until they are resigned to go in search of a cure. Because I have seen many people like that, who are Evangelical who have turned to a buyei for a cure, and [a buyei] cures them. So, we don’t have to criticize. We have to tie our tongues so that we do not criticize. Sure, it is good to have religion, but it is the same God. It is the same God. But this [Garífuna spiritual practice], is something that is, that has been here a long time. I don’t even think my that my grandmother was born yet, when this started. So, there is no one that can take it [from us], only God. Only God.

Within this conversation, Satu highlighted the difference between disease and illness

(Kleinman 2010; Nichter 2008; Singer and Baer 2005), situating both in a broader context. He acknowledged the diseases that present with specific symptoms legible in biomedicine, and that they are left to the care of biomedical doctors. Later in the interview, when telling me about some of the botanical remedies he has used, Satu also noted the well-documented practice of medical pluralism, wherein traditional or ancestral medicines are used in conjunction with biomedical pharmaceutical remedies (Calvet-Mir et al. 2008; Giovannini and Heinrich 2009;

Reyes-Garcia 2010; Singer and Baer 2005; Vandebroek and Balik 2012).

“But there are things the doctors cannot see,” he says, noting the limitations of a narrow biomedical view when the very bodies they encounter are enmeshed in complex social, economic, and political contexts that have significant bearing on their their physical, mental, emotional, and spiritual well-being. Buyeis are spiritual and emotional healers, ready to attend to the complex metaphysical concerns that manifest as inexplicable (to biomedicine) physical maladies, like a swollen hand or foot, or as spiritual and emotional plagues.

Narrating (Illegible) Illness: Semantics and Idioms of Distress in Playa Felumi

Health, like so many other things, is culturally mediated. What it means to be healthy, to experience illness, and to be well are all determined by a complex web of social relations in addition to physiological markers (Kleinman 2010). Patterns emerged in Playa Felumian’s illness

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narratives that suggest that they have adapted biomedical terms to reference broader social problems. During the same visit with Carlotta mentioned above, she told me her mother’s recent health had been very bad. “Ever since the death of her son, my mother’s health has been really bad.” Carlotta chewed on the last words, squinting her eyes and shaking her head for emphasis.

Her mother had hypertension and diabetes, but she had been taking her medication as instructed and still felt terrible. Her blood pressure had been high despite her medications and “she has tremors,” Carlotta told me, shaking her hands to demonstrate. Carlotta said a sister lived with her mother in another neighborhood where Carlotta used to live, too, but she worried that the extra attention her sister could provide did not seem to be helping her mom through this spate of poor health. The unresolved issue of her brother’s unexpected death both marked her mother’s decline and was read by those caring for her as a contributing cause to symptoms that might have been attributed to hypertension or uncontrolled blood sugar in biomedical contexts. Instead, or in addition, tremors and uncontrolled symptoms despite compliance with prescribed care plans, became the semantic index for endemic violence, grief, and lack of political recourse in the killing of her brother.

Many respondents who had diabetes or hypertension (or both) spoke specifically about stress, anger, worry, or “problems at home” as causes or aggravators or their diabetic or hypertensive symptoms or conditions. One respondent (HH18) named “worry and fear” as factors that would raise one’s blood pressure.

For example, Marta went to Clinica Blanca multiple times because she was concerned about her heart. Her chart noted that she had hypertension. “Me hace POM!” Flexing her fingers in a rapid explosive motion. “Me palpita.” She had brought with her an x-ray and EKG of her heart that she obtained from a doctor in Tocoa. Dr. Farnham looked at her x-ray and EKG strip.

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He told me in English that he thought it was “just an effect of persistent hypertension,” but wanted to listen to her heart first before ruling anything out. He listened then lifted his head and rolled his chair back over to the desk with a quick push off the ground with his toes. “Her heart sounds perfectly normal today!” He said to her in a cheerful tone. I interpreted. He then told her that he thought it was just an effect of prolonged hypertension. Her eyes and tightened lips showed her concern. There was no relief in her expression.

While the doctor jotted down notes I asked her if she was worried about anything. “Well, yes.” I asked her what she was worried about and she hesitated. Then she began her illness narrative with the death of her three-year-old, three years ago. But, she added, she had only had these heart problems for the past four months, shaping her narrative to the encounter at hand. She continued her story. Another son had recently left to go to the US, but he did not call, and he did not help them financially because he could not find work despite making the dangerous journey for better economic opportunity. She had a brother that was helping her son when he still lived in

Playa Felumi, but he had stopped helping him. “And I don’t like that, because when he was here, he helped,” signaling her distress that her brother was failing in his familial obligations to his nephew because the young man had moved away. In the four months she referenced there were also three murders in this small town, the third happened only a couple of days before I observed this consultation, when a 12-year-old boy was killed by a hired gunman - and for which there was no recourse.

Marta’s vivid description of her distress is one example of the ways that symptoms of hypertension become part of semantic illness networks to describe other stressors (Good 1977;

Kleinman 1989). The distress Marta is describing is not caused by her hypertension, as far as the physician and the diagnostic tests she had underwent were concerned. Her symptoms were not

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legible biomedically. In her illness narrative, Marta explains the correlation between her chest pain and heart health and the economic concerns, grief, and chronic insecurity she had and was enduring at the time.

Her use of diagnostic tests and seeking out STMMs for relief are both ways of communicating that distress (Nichter 2010). Her use of biomedical language and symptoms to call attention to it, are part of a semantic illness network. While the issues manifest in her body, they are illegible (or irrelevant) to the biomedical physicians - STMM and Honduran alike - to whom she goes to seek help. Using the language and diagnostic tools of biomedicine she attempts to render her suffering more legible in search of a resolution, and at the very least to communicate her suffering as a way to alleviate it.

Playa Felumian’s Perceptions of Medical Brigades

Playa Felumians also shared their insights about the medical missions as an additional option for healthcare. In addition to general praise interviewees made critiques, offered suggestions, and identified the most pressing needs in the community. Praise primarily focused on children and toys and material items they bring for their children. A few respondents emphasized medication, but the majority were non-medical resources or emphasized the kindness and demeanor during consultations, particularly with children. Many articulated the importance of free consultations and medications.

Approximately half of respondents did not include a response to questions about what missions could do better. Of those that responded, their critiques included concerns about expired medication, interpreters, poor communication, and insufficient medications, especially for chronic diseases.

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HH1: Sometimes [they bring] expired medicines, sometimes [expired by] as much as a year, and we can’t take them like that.

HH2: Sometimes they only speak English and I don’t understand what they are saying, but they care for me well.…The days [they work/for clinic]. For example, sometimes people come to see them, but they are not there [as advertised].

HH3: For example, they sometimes give expired medicine and that's a concern in the community.

HH4: When I show them my medicines, they don't have it and they change it.

HH10: Sometimes they bring expired medicine.

HH11: Health is the same when there are no brigades. They help in material ways - money, items, but health doesn't change.

HH14: It’s a question of volume. Material they don't have to do things here, equipment. They need more equipment and technology.

HH21: Sometimes when they come, they bring expired medicines and this can harm people. So I don't look for doctors there, these pills harm people and don't work.

HH23: They ask me if I have a “dollar” [dólar] instead of “pain” [dolor], but they care for me well.

HH24: They do not give food [they should].

HH29: … they don’t respect us. Illnesses come, there is hunger – it’s not that we don’t want to work.

HH43: sometimes give expired medicine – in the little bag you can’t see the expiration date. One has to take care [to check]. Some [mission] doctors don't have experience, come as residents, only some doctors with experience.

Contrary to mission discourses that Playa Felumian’s do not know what they need or do not understand what is happening, my research participants from the youngest to the oldest were acutely aware of their situations and experiences. They offered suggestions that reflected the structural problems that affected their reliable and equitable access to healthcare and medications and causes of illness. Their responses also underscore the ways that Clinica Blanca provided the same services as the CESAMO – and with the exception of the rare dentist or occasional

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surgeon, they did not provide specialized care or contribute to skill sharing with local healthcare providers.

HH4: There are times when there are no medicines here, they should always send medicines. There are never medicines [at the CESAMO].

HH7: They need more instruments to detect [illnesses] - [they don't provide] advanced care, just check your blood pressure and then give you pills, that’s it.

HH8: They should visit the poor families in their communities [within Playa Felumi] where there is still poverty.

HH15: Visit homes - people who can't leave. They can't go anywhere, and the HC also doesn't visit [incapacitated patients].

HH16: if they were permanent it might improve - maybe the HC would learn something - what if they worked together?

HH18: Visit the houses so they can note the poorest… There is nothing here, what we need is food. They should help us with food. They should help with this. Sometimes they send help.

HH19: Sometimes they write prescriptions for medicine for people to buy. Try to have all the medicine. Every brigade is different.

HH22: Things seem ok. Do ultrasounds here, they only lack a few resources to be able to do that. Helping poor people, sometimes give money, food, clothing.

HH23: Road [improvements], help poorest people, food, nutrition.

HH25: More doctors in the clinic, so that they clinic can be open 24 hours…installing a water pump.

HH34: Someone permanently there [at Clinica Blanca].

HH39: An operating room or a maternity room.

And when asked what the most pressing needs were, those that chose to respond focused on a number of structural and infrastructural concerns. The greatest demands were for sources of remunerated employment, permanent medical staff, specifically physicians, and improved water sources.

HH23: What are the needs – there is no [remunerated] work. Work is hope.

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HH24: Source of work. Families have to leave [the country] to go North [to the U.S. or Canada], and this journey is horrible, dangerous. A factory, for seafood, clothes, plastics.

HH26: A center to attend pregnancies, so people don’t have to leave the community or the country to have their babies. They only attend births as emergencies at [Clinica Blanca].

HH27: Come together to demand more. Improve the roads, a bank of cash machine, stores. Maybe a permanent doctor, 2 even 3 permanent doctors.

HH28: Doctor here, always. There is hardly enough medicine, and more people. Construction [for work], there’s hardly any work.

HH40: Doctor for children, pediatrician for children. Change the roads; let people who have training treat patients; somewhere for water so it doesn’t have so many microbes.

HH41: Source of work, some [financial] institution so [people can] pay interests- Microfinance so we can borrow without high interest rates.

HH42: Source of recreation; source of work.

Conclusion

The perspectives of the Playa Felumians presented here counter the medical mission volunteer discourses outlined in Chapter 9. From the youngest to the most senior, Playa

Felumians know what makes them sick, know where to go and what to do to find remedies, while also articulating the structural factors and violence that constrain their capacity to act.

Playa Felumians also use the physiological markers and biomedical terminology associated with diabetes and hypertension to reference acute social, economic, and political distress. Their illness narratives reveal the experiences and symbols that on one hand give meaning to their biomedical diagnoses, but also how they use medical discourse to “articulate distinctive configurations of social stress and to negotiate relief” for themselves (Good 1977, 25). Use of diagnostic tests to confirm physiological manifestations, the “felt symptoms” of broader social issues, and the ways they use a biomedical lexicon to index past traumas, current stressors, feelings of powerlessness, or insecurity constitute an “idiom of distress” (Nicther 2008).

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Biomedical doctors in Playa Felumi invoke the hegemonic discourses typical of biomedicine, while also maintaining space, even if diminished, for “creencias” (beliefs) and ancestral knowledgeways. Drs. Arranda and Soriano also reflect the broader trends and noted concerns about un- and underemployed healthcare workers that contribute to the gaps in the

Honduran health system. HMH gives them a brief and temporary place to practice for a few days, and to earn a few days of income, but this opportunity is in no way systematic.

Their participation with HMH mission teams also reveals the ways that some HMH missions recognize the existence of healthcare options outside themselves and adequacy of the care they can provide. This relationship also reveals the unequal dynamic between HMH and the

Honduran healthcare system, HMH will accept assistance from local healthcare providers and collaborate when it benefits them, but are generally reluctant, and sometimes hostile, to providing the same level of assistance to the CESAMO.

At a superficial level HMH provides supplement healthcare personnel, but reluctance to coordinate with local healthcare providers, follow local best practices, and the extremely limited and inconsistent manner in which they hire underemployed Honduran physicians (and no other health personnel) limits the efficacy, significance, and quality of their intervention into the identified needs of improving personnel support, specialists, and capacity.

The perspectives included in this chapter further demonstrate the resources available to

Playa Felumians, that there are resources, even if limited. And medical missions are viewed as a sometimes helpful, but also limited resources, along with the CESAMO, midwives, caseras, and spiritual healers. The majority of Playa Felumians understand their health and its relationship to their rapidly changing environment, the quality of the food and water to which they have access, and the structural barriers that limit them.

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The next chapter presents ethnographic data that demonstrates the consequences of the problematic discourses of medical mission volunteers presented in Chapter 9 and the resulting dismissal of the illness narratives, local expertise, and ancestral knowledge presented in this chapter. Chapter 11 and subsequent chapter present data that reveal a pattern of iatrogenic violence.

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CHAPTER 11

A BUG OR A FEATURE? MEDICAL MISSIONS, ANTIMICROBIALS, AND IATROGENESIS

In the previous chapter I discussed the illness narratives of Playa Felumians and their understandings of and strategies for maintaining health. I also presented perspectives of Playa

Felumian healers, including biomedical doctors, spiritual healers, and midwives who combine ancestral midwifery practices with biomedical trainings and technologies think about health, illness, structural violence, and their roles in the lives of their fellow Playa Felumians.

Chapter 11 returns to medical missions and asks whether HMH was providing critical services and filling in gaps or providing service based on presumed needs Playa Felumi. HMH volunteers’ discourses about disease, their own authority, and roles in Playa Felumi inform their decisions and become evident in their actions. I demonstrate the various ways that disregard for local healthcare infrastructure and staff expertise, local and national protocols for care, and global best practices in malaria and intestinal parasites (commonly referred to as deworming) treatment constitute iatrogenic violence. General distrust and poor compliance with national and global health best practices regarding collection and reporting of epidemiological data about malaria and intestinal parasites, as well as treatment protocols, not only constitute malpractice and negligence, but threaten the stability, credibility, and long-term access to available local healthcare resources at the CESAMO.

Among the most pressing concerns in the provision of healthcare and the most threatening diseases in Honduras, malaria and intestinal parasites do not rank in the top ten.

While diarrheal diseases continue to be a concern primarily in children, and may be the result of parasitemia, unimproved and contaminated water sources are the root causes of diarrheal outbreaks. The health care and access needs identified by the MOH and PAHO include structural

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improvements and access to adequately purified water sources, but do not include malaria or deworming.

Anti-malarial and deworming campaigns in Honduras have been very successful, and garnered international recognition from PAHO as exemplars in the region (Mitchell 2013). The

World Health Organization used the successful deworming treatment and prophylaxis campaigns in Honduras served as evidence for global recommendations for locally managed and administered deworming programs (“UN Health Agency Recommends Large-Scale Deworming to Improve Children’s Health” 2017). Despite these successes and established protocols for prevention and treatment of malaria and parasitemia, medical missions operated as though both were areas of dire medical need.

Deworming is a ubiquitous practice among medical missions, not only within HMH, but among mission generally making the implications of overtreatment significant. HMH was also particularly dedicated to “diagnosing” and treating malaria in Playa Felumi. However, important factors in their practice cast doubt on the accuracy of their diagnoses and irrational use of antimalarial medications. Medical mission volunteers’ frequent use of antimicrobials without confirmation of bacteria with available diagnostics did not follow best practices and may be contributing to already growing antimicrobial resistance in the country and region more broadly.

Missions in The Time of Malaria

When Health Missions Honduras (HMH) began working in Honduras in 1998, malaria was still a considerable problem in the country. In 1998 the Pan American Health Organization

(PAHO) considered roughly 80 percent of the country’s population “at risk” for contracting malaria. Local health officials, NGOs, and health promoters implemented an effective large-scale public health campaign to help prevent malaria and increase response times between diagnosis 280

and treatment. By the time I began working with the First Popular Garífuna Hospital of

Honduras in Ciriboya on the northern coast, close to Playa Felumi, in 2009, there were very few cases of malaria reported, with the annual numbers dropping to 9,300 cases from over 14,000 in

1998 (“WHO World Malaria Statistics” 2015). In 2012, I was traveling as an interpreter for an

STMM and had casually asked our hosting doctor about malaria in the area, since every mission volunteer insisted on taking and trying to convince others to take malarial prophylaxis. My affiliate and co-founder of the First Popular Garífuna Hospital, Dr. Luther Castillo, gave me an emphatic “Nah!” and said that, “There aren’t many cases of malaria, now.”

Epidemiological data showed that in 2014, there were fewer than 3,500 confirmed cases of malaria in the entire country, annually, and incidence lower than one percent. In 2018, there were 653 reported cases of malaria in the entire country, and fewer still in 2019, with just over

250 confirmed cases of malaria in all of Honduras. In fact, Honduras had been consistently reducing cases of malaria by 75 percent or greater each year until Hurricanes Eta and Iota struck in rapid succession during the COVID-19 epidemic in 2020, increasing mosquito vectors, damaging infrastructure, slowing distribution pipelines of essential personnel, supplies, and medications, and ability to conduct mass screenings (“World Malaria Report 2020: 20 Years of

Global Progress and Challenges” 2020). Before 2020 the country appeared to be on track to eliminate malaria by 2020, although that timeline has now been pushed back (Rodriguez 2020).

In 2014, the CESAMO in Playa Felumi, confirmed just ten cases of P. Vivax malaria in the entire municipality. There were no cases of P. Falciparum that year. And there were no deaths (there were two malaria-related deaths in Honduras in 2014). Only three of the cases were in the town of Playa Felumi. The majority of cases originated in hamlets closer to the African

Palm plantations. The fronds of the large palm leaves create a deep well in the 40- to 60-foot-tall

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canopy of the tree. Deforestation due to the rapid expansion of African Palm monoculture simultaneously drives mosquitoes into new habitats, like livestock enclosures (Zahouli et al.

2017). People who live near or work in the palm plantations are much more likely to be exposed to malaria, dengue, and other serious mosquito-borne illnesses (L. Jung [Gilchrest] 2011).

Dengue has been a much greater concern than malaria throughout Honduras. There were twenty confirmed cases of Non-hemorrhagic Dengue in the municipality in 2014, nineteen of which were concentrated in Playa Felumi. Dengue is also known as “break-bone” fever and includes symptoms common with malaria and Severe Dengue is also known as hemorrhagic dengue. Use of antibiotics and non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and aspirin are contraindicated for patients with suspected dengue (Secretaria de Salud 2019).

Antibiotics are ineffective and increase the risk of viral resistance, and NSAIDs increase the risk of hemorrhaging, which could be deadly.

Low incidence of malaria in Playa Felumi and the country at large (less than one percent) is a result of intensive prevention and prophylaxis programs, including environmental precautions, eliminating standing water, cleaning and treating outdoor wash basins with larvicide, clearing detritus from yards and fields, and regular fumigation. WHO and PAHO have consistently recognized near-total coverage of malaria prevention in Honduras (“WHO World

Malaria Statistics, 2015” n.d.; Reyes 2019). In Playa Felumi two TSAs, Madal and Jeffry, regularly walk or ride around the municipality to identify and eliminate vectors, apply larvicide to community water sources, fumigate, and provide training and education to COLVOLs and residents. Larvicide is distributed to each household free of charge and children and adults are trained and proficient in regular application and mosquito prevention. Local policies for keeping yards clear of tall grass, leaves, and general debris through burying or pit-burning are also part of

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vector-borne disease prevention, and the TSAs, as well as the Patronato (the town council) ensure that residents are in compliance.

Although rapid diagnostic tests (RDTs) are popular around the world and approved by the WHO and PAHO, the global health organizations still consider microscopy the “gold standard” for malaria diagnosis (World Health Organization 2015; 2016). There are P. Vivax and

P. Falciparum specific RDTs used in Honduras, but they are prioritized in areas that do not have trained microscopists. Neither the CESAMO nor Clinica Blanca used RDTs. Both clinics used

Giemsa and Wright’s stain methods for rapid analysis of “thick smear” blood samples for malaria. The WHO best practice recommendation declares that:

Prompt, accurate diagnosis of malaria is part of effective disease management. All patients with suspected malaria should be treated on the basis of a confirmed diagnosis by microscopy examination or RDT testing of a blood sample. Correct diagnosis in malaria- endemic areas is particularly important for the most vulnerable population groups, such as young children and non-immune populations, in whom falciparum malaria can be rapidly fatal. High specificity will reduce unnecessary treatment with antimalarial drugs and improve the diagnosis of other febrile illnesses in all settings.

WHO strongly advocates a policy of “test, treat and track” to improve the quality of care and surveillance (World Health Organization 2015).

As part of mass screening for malaria, CESAMOs around the country trained COLVOLs and volunteer health promotors (usually women, but also a few men) to take thick smear blood samples for malaria screening as well. Once they have collected a sample, the COLVOLs either deliver it to the CESAMO within the appropriate timeframe (24 hours) or call Madal or Jeffry to retrieve it and take it to the CESAMO for analysis by their formally trained and MOH-certified microscopist, Elerio. Health promoters cannot diagnose patients and they are not allowed to deliver the prescribed medications until a trained lab technician (laboratorista or microscopista) has analyzed the sample and verified a positive result, (and confirmation that the patient is not pregnant or breastfeeding).

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The medication for malaria is carefully controlled by CESAMOs and regional health offices, first because current best practices dictate that treatment should only be provided upon diagnostic confirmation. Although the WHO and PAHO endorse the use of artemisinin-based combination therapies (ACTs), and they are widely preferred because of lower rates of resistance, few side effects, and safety in pregnancy and breastfeeding, chloroquine with primaquine combinations are still among official recommendations for treatment plans where resistance is not yet a problem (“Malaria Consortium - Artemisinin-Based Combination Therapy

(ACT)” 2021). ACTs are the recommended first line treatment for P. Falciparum and for confirmed malaria for which species cannot be determined (World Health Organization 2015).

Prescription of choloroquine as a monotherapy not in conjunction with another recommended antimalarial is never recommended (World Health Organization 2015).

Accordingly, Honduras still uses a chloroquine + primaquine combination as first line treatment for uncomplicated P. Vivax and as radical cure (World Health Organization 2015), except in cases of pregnancy. These drugs are much more cost-effective, but they have drawbacks compared to ACTs. Several studies suggest that in areas with chloroquine resistance, the continued use of chloroquine can exacerbate anemia by promoting viral replication (Bönsch et al. 2010; Braga et al. 2015; Ekvall, Premji, and Björkman 1998; Marques et al. 2014).

However, Honduras remains one of the few countries in the region for which chloroquine is still an effective treatment for P. Vivax (Marques et al. 2014). In addition, if the powerful drug is given when there is no malaria present, aside from having negative side effects, it may also contribute to antibody resistance to malarial drugs (Marques et al. 2014; Price, Douglas, and

Anstey 2009; Street 2018b; 2018a). ACTs are readily available, but are reserved for confirmed

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cases of P. falciparum, pregnant and lactating patients, and any indeterminate species of malaria in keeping with national protocols and global best practices.

Primaquine is contraindicated during pregnancy due to increased risk of complications, including severe haemolysis, and potential for fetal harm, and miscarriage (Arrow, Panosian, and

Gelband 2004; Rogerson 2017; World Health Organization 2015). The risk of miscarriage and rumors among Hondurans that young women seek out malaria medication to provoke miscarriage is a serious concern in a country where abortion is treated as a crime and punishment is strictly enforced.12 While malaria medications are free to average Hondurans, the global costs of financing malaria treatment are significant and medical resistance to chloroquine could be dangerous and extremely costly in Honduras (as it has been in India and other countries where resistance to chloroquine is already common) and would threaten the progress towards eradicating the disease already made in the country (Arrow, Panosian, and Gelband 2004;

Marques et al. 2014; Price, Douglas, and Anstey 2009).

HMH missions did not use any type of ACTs. Their formularies included only chloroquine and primaquine at the time of research (and on a 2020 version of the listed medications available at Clinica Blanca), which would limit their ability to effectively treat pregnant or breastfeeding patients without coordination with the CESAMO, or confirmed cases of P. Falciparum in accordance with global best practices and national malaria treatment protocols. Chloroquine can be used as a suppressant during pregnancy but must be maintained and regularly monitored (Rogerson 2017; World Health Organization 2015). The standard of care in Honduras follows WHO guidelines and prescribes ACTs for patients past their first trimester with confirmed malaria.

12 There is a minimum penalty of five years in prison for the woman who takes an abortifacient (knowingly or unwittingly) and for the person who administers it to her as an accomplice in homicide. 285

Malaria is a carefully monitored disease, in part because of the millions of dollars in external funding that support public health education and treatment efforts, but also because best practices require track and trace disease surveillance. Like other serious and potentially deadly diseases, public health officials monitor malaria for any sharp increases or outbreaks, so that public and preventative health professionals can respond if a need arises. The CESAMO tracks all malaria cases on charts by week and month and keeps the figures in a yearly calendar.

CESAMO staff document the name, neighborhood, and symptomology of the affected persons, and then compile them in a report that is sent to the municipal government (mayor’s) office, the regional health office, and ultimately the appropriate department of the MOH.

According to Honduran law and regulations established by the College of Doctors in

1992, medical missions are required to report epidemiological data. Medical missions must report data about specific pathologies diagnosed and data about certain diseases, especially malaria and diarrheal diseases. These pathologies are tracked, not only so local and regional health centers can provide appropriate, adequate care to patients and manage limited resources, but also because results-based funding from global health agencies, like PAHO, the World Bank, and the UN Development Program (UNDP), is contingent on this information. However, most medical missions do not submit pathology or epidemiological reports to the CESAMO or regional health authorities, if they collect the appropriate information at all.

While HMH provided the aggregate number of “positive” malaria tests to an unaffiliated doctor in Trujillo, they did not collect any of the appropriate corresponding surveillance information. Rather than comply with global and national best practices (and laws), HMH missions simply counted the number of patients tabulated as a gross number (rather than a count divided by age, sex and pathology), the number of pills distributed, (only sometimes divided by

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class such as, vitamin, pain reliever, antibiotic, anti-fungal, etc.), and, if working with a dentist, the number of teeth pulled.13 HMH missions would not report (at the time of my research) the malaria cases to the CESAMO under whose jurisdiction it functions, nor to the corresponding regional health office.

Throughout the last decade working with medical missions in Honduras, teams would often claim that they did not know that there is a law that dictates which epidemiological data must be systematically collected and to which public health authority it must be sent. Often, teams would claim ignorance, and presume it excused any mistakes or oversights. But global best practices clearly emphasize the importance of epidemiological monitoring and surveillance.

Many STMM volunteers believed that because “there are no rules,” they have license to act without accountability or to engage in ethically questionable activity. The mantra of one volunteer working in the pharmacy on a team summed up the prevailing attitude he observed among his co-volunteers, “if there's no law, there's no problem!" Yet even when presented with the law specifically written to regulate foreign medical missions—a document generated by the

College of Doctors in 1992—teams often dismissed or ignored it.

When I presented the HMH leadership with the law (and a translation), the board members waved a hand to signal their disregard and stated that they report their activity to the legal entity that maintains their NGO status in the country. When I informed them that this was a separate protocol, one team leader I spoke to, Marjorie, tightened her lips and shrugged. She told me that the volunteers would not do “extra paperwork.” As an example, she explained that HMH had received a grant and donation of vitamins to Clinica Blanca and the only requirement was for mission teams to report who received the vitamins. But they lost the grant and had to discontinue

13 Teams rarely do cleanings or restorative dental work because it would mean fewer patients seen and results in lower numbers reported to their funders. 287

the program because “none of the team leaders would complete and submit the appropriate reports.”

Despite new information, the teams made no systematic changes in their data collection or reporting practices. If the teams reported information, it was incomplete, inaccurate, ignored best practices, and deviated from proper communication channels. Furthermore, the unorthodox practices, rooted in distrust and presumed authority, posed substantial risk to long-term health infrastructure and national efforts to eradicate malaria.

HMH did report the “confirmed” malaria cases it diagnosed, but not to the appropriate health clinics or medical authorities. Instead HMH reported their “positive malaria cases” to a

Honduran doctor that the current board president, Buck, met on a previous trip. While Buck believed the doctor worked for the Regional Health Office in Trujillo, Dr. Cruz actually worked at the public hospital in Trujillo and operated a private health clinic in the same town. The

Trujillo physician that HMH entrusted did, apparently, report the malarial cases to the Regional

Office in Trujillo via an unclear procedure. And the CESAMO staff became aware of the reporting because the Regional office contacted the CESAMO of Playa Felumi to inquire about the unusually high rates of malaria in the municipality. The Regional office wanted to determine why the CESAMO had failed to report these additional cases and why they had not seen the positive slides or test results Global best practice and standard protocol within the Honduran healthcare system for positive malaria cases diagnosed by microscopy require quality assurance, so all positive slides are prepared and delivered to the Regional Health Office for review (World

Health Organization 2015; 2016). This inquiry and circuitous reporting of dubious results put the

CESAMO in danger of failing their mandates—through no fault of their own.

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The relationship the HMH president established with Dr. Cruz is significant for two reasons. First, Dr. Cruz has no relationship to Playa Felumi and has a private clinic while holding a public health position. It is a widespread practice among physicians who simultaneously work in public positions and run private clinics to take donated medicines and sell them at premium costs or to take medical supplies from public clinics and hospitals where they work to treat paying patients at their private clinics. It is also a common practice to refer public hospital patients to their private practices in order to increase paying clientele. Not only does this pose a considerable conflict of interest, but it is a despised practice among many Hondurans who view it as a form of rampant corruption that steals from the impoverished body politic.

This was an especially sensitive topic during my fieldwork period because of the

Astropharma scandal that broke the year before. The Gutierrez family’s pharmaceutical business was contracted by the Honduran government to manufacture and supply formulary medications to the Honduran Social Security Institute (IHSS), and they engaged in over $100 million of fraud, including providing inert tablets rather than pharmaceuticals with active medicinal ingredients. This was one of the first dominos to fall in a government-wide, co-institutional scandal that ultimately cost the lives of an estimated 3,000 people (see Ch. 5). Thus, as a result of rampant corruption, the average Honduran is especially skeptical of doctors with private businesses and hypervigilant of corruption and any suspicion that they are being cheated. The fact that HMH refused to leave medications and supplies for the CESAMO, and preferred instead to leave them for this doctor, with no ties to the community and no accountability measures, is indicative of the persistent distrust in local CESAMO staff and undermined local health infrastructure as well.

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Second, and perhaps most importantly, refusal to coordinate with the CESAMO on epidemiological surveillance or to share pertinent information about monitored diseases represents a significant threat to the stability, availability, and credibility of local healthcare in

Playa Felumi. Failure (or refusal) to report these pathologies locally means that local health providers, in this case the CESAMOs, are unable to track and develop interventions when there is a malarial or diarrheal outbreak or other potentially dangerous epidemiological phenomena. If there is a malarial (or any other type of) outbreak, the CESAMO staff are responsible for identifying and addressing it – regardless of the role medical missions play.

When there was an outbreak of diarrheal illnesses in Playa Felumi in January of 2015, the

CESAMO organized nursing and environmental health staff to identify the site of the outbreak and determine the causes. They also set up community health outposts and supplied them with

Oral Rehydration Solution (ORS) packets so that parents could keep their children hydrated – dehydration being the greatest health risk posed by diarrheal diseases. I accompanied nurses who went door to door in one of the neighborhoods that had the highest rates of diarrhea. They asked families about their water sources and if they had any symptoms, reminded people of safe water protocols, especially if the family didn’t have funds to buy their own water, and advised them about the health posts for ORSs and when to call one of the nurses or the doctor. When medical missions fail to share basic epidemiological information or to report to local and regional health bodies, they impede prompt public health responses and may, in fact, be endangering lives because of their inaction and prejudice.

Another major concern about HMH’s unorthodox and uneven reporting of malaria was the accuracy of the malaria screenings conducted at Clinica Blanca. Recall in 2014 that the total number of annual cases for Playa Felumi was just 10, and the total confirmed cases for the entire

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country was 253. In March of 2015 alone, Clinica Blanca reported six times the annual numbers for the region as “confirmed” cases, and 25 percent of the national total of confirmed cases.

While the lab set up at Clinica Blanca was similar to the CESAMO and both used Giemsa or

Wright’s stain methods for thick smear diagnosis of malaria, they do not have a quality assurance protocol, and the qualifications of the young woman HMH employed to read the slides frequently came into question.

Between 1998 and 2012, HMH had worked with a local nurse, Paciencia (or “Paci” for short), who had been trained by her father, a prominent physician in Honduras during his lifetime, to read blood smears for the malaria parasite. The HMH founder had befriended Paci and she worked at Clinica Blanca until abruptly leaving the country for South Carolina in 2012.

Rumors suggested that she fled after having received death threats from organized crime syndicates in Tocoa. Before she left, I was told that Paci trained a young, local teenager,

Esmerelda, to do the laboratory work in her stead. The type and duration of training Esmerelda received was unclear. Esmerelda came to be employed at HMH in 2012.

The “confirmed” cases of malaria that HMH reported were read by Esmerelda, who conducts all laboratory tests, including analyzing blood smears, at Clinica Blanca. She was paid a modest amount by each medical mission that required her assistance in the lab at Clinica

Blanca. She was about 20 years old at the time of my study and worked in the preschool library.

Esmerelda had no medical background or training and aside from informal and occasional training given by an HMH volunteer once or twice per year, did not receive any continuing education. Esmerelda was also not a COLVOL or community health promotor, so did not attend any of the monthly meetings or regular malaria trainings provided by CESAMO staff.

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Esmerelda was beloved by many of the volunteers who remembered her as a patient at

Clinica Blanca. Thus, when questions arose about her qualifications or about the potential ramifications of her misreading and misdiagnosing malaria, a palpable tension arose between volunteers who wanted to defend and protect their friend and those volunteers and CESAMO staff whose concerns for ethical and adequate healthcare superseded their personal relationships with Esmerelda. From my fieldnotes:

Buck [HMH board president] told me that Dr. Cruz told him that their brigade found more cases of malaria in the month of March (reportedly 63 cases) than were found in the whole department of Colón. I told him that they do malaria tests at the health center, but Buck said that he didn’t think they [the CESAMO] were “doing the slides right.” I told him that their reports indicate that there haven’t been many cases of malaria in the town of Playa Felumi, but in other parts of the municipality there have been documented and reported cases. “Well, if they’re getting cases then how does that work with what Dr. Cruz told us? Everyone in [the department] reports to him.” He seemed irritated by my questions. He believes Dr. Cruz from Trujillo. He also believes that Esmerelda has never been wrong (and is “doing the slides right”), but several interviewees reported that Esmerelda has misread labs or says a test is positive when it is not. This afternoon, I observed as an STMM volunteer, Trina, trained Esmerelda to more accurately read slides [Esmerelda was having difficulty identifying the appropriate field of vision through which to determine the presence of the parasite through the microscope]. (October 14, 2015).

Esmerelda’s employment would perhaps be less controversial if she was not known, by patients, the CESAMO, and even members of the HMH board of directors to be confirming blood samples negative for malaria as positive. One household interviewee added this critique in addition to her praise of Clinica Blanca efforts, “Sometimes the person who does labs [at Clinica

Blanca] says they have malaria, and it's not true, and [Clinica Blanca doctors] give malaria meds, but the person gets worse.” This was not merely a matter of a few false positives. One team leader had expressed concern with the other board members of HMH about the employment of

Esmerelda in Clinica Blanca and was suspicious of the high rate of malaria being diagnosed.

While I was observing their team, the team leader, a physician, along with a third-year osteopathic resident took 19 slides to the trained lab technician at the CESAMO. All of the slides 292

were ones that Esmerelda had reviewed for malaria earlier that day at Clinica Blanca and had interpreted as positive for malaria. Elerio, the lab technician prepared his workstation. He carefully examined each slide visually, holding them up to the light and confirmed they had been adequately prepared. One by one he viewed each slide under the microscope. He removed the first slide, his fingers gliding the thin piece of glass off the stand, his eyes pegged to the eyepieces as he placed the next slide. I asked him if it was positive. “No. Negativo.” He said, in his stern voice. He read the second, then the third. All 19 slides, 100 percent, were negative for malaria.

That day, the team had prescribed 19 doses of malarial drugs for individuals who did not have malaria in direct contravention of established best practices. The medical resident, Garrett, and Elerio speculated about why the readings might be so off. Elerio explained that the malaria parasite very closely resembles the normal leukocytes found in red blood cells and that it could be an easy mistake to make if the person reading slides was not familiar with the peculiarities of the malaria parasite forms that distinguish it from those leukocytes. Human error, malpractice, and negligence all contributed to misdiagnosis, unnecessary treatment, increased risk of antimicrobial resistance, and potential inaccurate diagnosis and treatment of other febrile diseases. Those patients may have also endured the other unpleasant side effects of chloroquine

(including nightmares, dizziness, blurred vision, nausea, vomiting, and diarrhea) unnecessarily

(and without follow-up may have stopped taken the course of medication early, further increasing the risk of resistance). On that day alone, at least 19 patients were victims of direct harms, and potentially psychological harms associated with false positive diagnosis and associated stressors.

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Upon learning that the samples were actually negative, this particular team leader and board member, Dr. Collin, decided that the team under his direction would stop testing for malaria at Clinica Blanca and would not employ Esmerelda for the remainder of the week. Any suspected cases of malaria would be sent to Clinica Blanca for testing. Dr. Collin also sent an email to the board of directors, the team leaders coming for the rest of 2015 and included Dr.

Muñoz on the email, detailing the findings and requesting that teams cease testing for malaria, and/or send suspected malaria to the CESAMO for follow-up, until the issue of Esmerelda’s training could be properly addressed. Dr. Collin’s request was met with conflict and hostility by a majority of the board. Some teams continued to employ Esmerelda anyway, willfully posing a threat to patient health, sound diagnostic and surveillance practices, and threatening local and national efforts to effectively combat malaria, and ultimately the ability of the CESAMO to meet its mandates because of willful obstruction.

A little over a month and three medical mission teams later, the board president returned with another team. Due to the controversy over Esmerelda’s expertise and the malaria false positives, the president decided to call a meeting with the medical director for the CESAMO. I was invited to attend and asked to take notes. Dr. Muñoz and Eliomara represented the

CESAMO. Srs. Bonnie and Dayspring were invited as friends of Buck and Marjorie to act as interpreters (though in a meeting at the CESAMO ahead of time, she declared her intention to back the position of the CESAMO if the opportunity arose). Dr. Arranda was invited as well as a physician and veteran HMH volunteer, Dr. Farnham. We all sat around the two plastic foldable tables that were pushed together to make a long meeting table. This was the first meeting of its kind in at least three years, despite numerous attempts of Dr. Muñoz to establish a relationship with Clinica Blanca since her tenure at the CESAMO began two years earlier.

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Malaria came up in the middle of the conversation, after a discussion about trying to get the teams to go to communities that “really need” medical coverage. Dr. Muñoz asked if the teams would be willing to bring a nurse from the CESAMO to work in the clinic and when teams go to outlying communities.

Dr. Muñoz: We would like to join your team for pap smears, immunizations, family planning, because we have a special program.

Buck: And for malaria?

Dr. Muñoz: Yes, of course!

Buck: [The CESAMO] lab tech could train someone?

Dr. Muñoz: Yes, Elerio is willing and has offered, but the person has to be dedicated. It would probably take 3 months if she works hard, possibly less.

In my notes, I wrote:

Esmerelda (HMH lab tech) - has committed to going to Centro de Salud every day to get trained by Elerio – will start Monday 16 March 2015 (after the mission has left) – Elerio will come to Clinica Blanca Wednesday 11 March 2015 to work and train Esmerelda there.

After the meeting, that week’s team made adjustments in keeping with the agreement reached with the CESAMO doctor and nurses. The decision angered other members of the team who viewed it as an attack on Esmerelda, which resulted in strong reactions and worry about the young woman’s future with the clinic. On Tuesday March 10, 2015, my notes included this excerpt:

They have stopped doing malaria tests because they are trying to figure out what to do about Esmerelda. Yesterday she did malaria tests, but today they’ve stopped. They are sending the suspected patients to the “government clinic.” There are musings among veteran volunteers. E.g., Ruby talked to me in the hallway, she is wondering how to say, “we think you’re reading them wrong.”

Not all of the teams kept to the agreement. Some teams hired Esmerelda in protest.

Esmerelda went to the CESAMO to train with Elerio one day but did not finish a full week of

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training. When asked why, she said that she did not like working with Elerio. Dr. Muñoz was desperate for a solution to the untenable situation. She suggested that Esmerelda attend a training in Tegucigalpa and emailed the information to the board president. Esmerelda agreed to go, and

HMH agreed to pay for it, but it is unclear whether she attended or that she received the necessary minimum training in a three-day course intended for current medical students.

As of 2020, HMH promotional materials indicated that Ruby had received training to conduct malaria screenings. However, it is unclear whether Ruby currently travels with every team (at the time of this research she only went on one or two teams per year), and whether

Esmerelda also received additional training, is still employed by HMH, or what teams now do, if anything, to comply with quality assurance best practices and reduce false positives and reading errors in accordance with global best practices.

Just in Case: Troubling Trends in Medical Mission Antimicrobial Use

Unfortunately, HMH missions’ approach to malaria was not the only example of malpractice I observed. Over the past decade, there have been growing concerns in the global health community about the creation of “superbugs,” a colloquial term for viruses and bacterial infections that are resistant to common, readily available antimicrobials and antimicrobial combinations. The medical literature suggests that antimicrobial resistance (AMR) is a predictable result of over-prescription or “irrational” use of antimicrobial drugs.

It is now common knowledge that antibiotics are not medically effective against viral infections and may, in fact, contribute to medically resistant strains of bacterial infections as a result of overuse of antibiotics (Kirby 2011; Mendelson et al. 2016; Vento et al. 2010). Until very recently, most studies concerning AMR focused on countries outside Latin America. But

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recent scholarship attends to the AMR crisis in the region (Munita and Arias 2016). One study specifically noted alarming incidence of AMR among the group of bacteria referred to as

ESKAPE pathogens in Honduran hospitals and the threat antimicrobial resistance poses to broader public health (Zuniga-Moya et al. 2020). These studies indicate that AMR is already a serious problem in the country, and complicated by the fact that antimicrobials are frequently used in agriculture, and are widely available over the counter.

Global health authorities, including the World Health Organizations have called for increased attention to the issue of AMR because of what they see as a real potential for the “end of the antibiotic era,” wherein lack of effective antibiotics will result in a return to high rates of mortality because of common diseases, in the near future (“Global Shortage of Innovative

Antibiotics Fuels Emergence and Spread of Drug-Resistance” 2021; “High Levels of Antibiotic

Resistance Found Worldwide, New Data Shows” 2018). Indeed, recent studies show that 30 percent of neonatal sepsis fatalities worldwide are the result of antibiotic-resistant strains

(Laxminarayan et al. 2016).

In 2015, the World Health Organization issued a “Global Action Plan” for antimicrobial resistance in light of these concerns. The primary objectives of the Plan included 1) Public health awareness campaigns about antimicrobial resistance; 2) epidemiological surveillance and vigilance concerning the incidence, prevalence, different types of pathogens and geographic patterns (i.e., who is sick and where they live); 3) prevention as the first line of defense. Current best practices in AMR strategies emphasize prevention through improved sanitation, hygiene, and safe drinking water – all of which are structural and infrastructurally-dependent; and 4) optimized use of antimicrobials in humans (and animals).

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In this context, widespread practices among HMH volunteers to prescribe antibiotics without confirmed diagnoses with available resources are especially concerning. The discourses of “lack,” and distrust of or competition with local health resources (rather than cooperation), and assumption of intellectual and moral authority, create the conditions in which HMH volunteers and medical missions deviate from global and national best practices and protocols and contribute to over-prescription and increase the likelihood of AMR. The CESAMO seemed to be keenly aware of the threat that antimicrobial resistant infections pose and thus are much more conservative in their prescription of antibiotics. The CESAMO staff were also concerned about the unclear protocols for prescribing antimicrobials without diagnostic confirmation.

Patients do not go to Clinica Blanca less frequently; in fact, the same patients go every time the brigades are in town “a ver qué hay” (to see what there is), while others go between two and six times a year. The vast majority of patients do not come for simple check-ups or well- child visits. (In fact, they go to the CESAMO for that kind of care because it is perfunctory as part of the country-wide initiatives to reduce infant and child mortality rates that, according to

PAHO, have successfully decreased over the past decade as a result of the efforts).

Instead, Playa Felumi residents come in complaining of cough (tos), runny nose (gripe), fever (calentura), conjunctivitis (mal de ojo), urinary tract infections (mal de orina), and headaches (dolores de cabeza). Some come in with concerns about malaria (and Chikungunya while it was part of a media frenzy, which Hondurans and STMM volunteers alike eventually just called “Chik” because of its unfamiliar pronunciation). The HMH medical volunteers who assessed and treated Playa Felumi residents at Clinica Blanca, almost always diagnosed them with primarily viral infections, yet very commonly prescribed antibiotics regardless of available diagnostic tests and ultimate diagnosis.

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Clinica Blanca and the CESAMO treated the impulse to not let patients leave empty- handed differently. Honduran doctors will openly joke about the phenomenon of “por si acaso” or “just in case” scenarios, but they do make sure patients leave with vitamins or other innocuous but helpful medicine (like acetaminophen). STMM volunteers, however, react to the “just in case” imperative aggressively, as if there are no additional resources available, and in contravention of established best practices.

There are two factors that figure into this difference in practice. First, STMM volunteers want to ensure that every patient walks away with something. In so doing they provide evidence that the patients were cared for and their long wait resulted in a tangible benefit, and that the mission’s distribution counts look good for donor reports. HMH emphasis on aggregate data for their weekly reports encourages pill distribution and the culture of quantity over quantity in medical mission encounters contributes to this imperative (cf. Biruk 2018 for discussion about the common and widespread practice of “cooking data” in medical mission and humanitarian interventions.) No one walks away empty-handed and Playa Felumians are discursively constructed as so impoverished and “needy,” that inappropriate antibiotics or donated toys are

“better than nothing” (Sullivan 2018). The second factor in this equation is that medical mission volunteers uniformly prescribe antibiotics without diagnostics — lab work, cultures, blood tests

— to confirm that a bacterial infection exists (with the exception of UTIs and malaria), even when these tools were consistently available both at Clinica Blanca and the CESAMO.

The Giemsa and Wright’s stain methods the CESAMO and Clinica Blanca use to diagnose malaria can also be used to determine a number of bacterial infections. The trained microscopist at the CESAMO can confirm pneumonia, upper respiratory infections, and because of the incidence of Tuberculosis in the region, he is also trained for BAAR sputum tests.

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Anything they are not able to confirm, but require diagnostics for, they regularly refer to the public hospital at Tocoa or Trujillo. Diagnostic tools are available at the CESAMO and even at

Clinica Blanca, which has a “lab in a box” set up similar to the simple but effective microscropy available in CESAMOs, in addition to a centrifuge and other equipment useful for diagnosis of simple, common bacterial infections. And even when mission teams left Clinica Blanca and worked at outposts, they would take the microscope and “lab in a box” along with Esmerelda with them.

Because of the temporal peculiarities of the STMM experience and volunteers' pervasive, though erroneous discourse (and in some cases belief) that no other (adequate) care is readily available for infections or typical medical complaints, medical mission volunteers attending patients prescribe antibiotics—"just in case” it does turn out to be a bacterial infection and they are not there anymore. In this brief moment, they comprehend their temporary nature, but the effects of the discourses of lack are powerful and compel volunteers to prescribe— even if some medical mission volunteers ultimately question this practice.

In one instance, I asked about a patient who had severe febrile symptoms, who in any other circumstance would have meant an immediate trip to a hospital. From my field notes on

October 15, 2014 in the post-clinic hours at Clinica Blanca:

[I’m talking to] a young Nurse Practitioner, in her late twenties. She saw a patient [a young man] in Tecasio yesterday with a fever of 106, she said they got it down to 103 before he left. I wonder why they didn’t send him to the hospital. She said his malaria test was negative, but that “they” said it could be because the parasite is active at night, so it might not have shown up in the test. I suggested it could be Dengue or Chikunguya, which are viral and hard to treat.

Another medical volunteer, a Physician Assistant, pops his head in and I ask him about the guy in Tecasio. “Why didn’t y’all send him to the hospital?” He made a face and said, “I don’t know if anyone thought about it. We got him on fluids and Tylenol and his fever came down. We gave him treatment for malaria and an antibiotic, which should cover just about everything.” He laughed and exclaimed, “Shotgun medicine in Honduras!”

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High fever might have been a sign of infection, but many mosquito-borne viruses and parasites, including dengue and chikungunya, are often characterized by high fevers. An acute symptomology, such as an extremely high fever of 106 degrees Fahrenheit, would suggest that the parasite was active if it was present and would have shown up in any tests. A troubling possibility is that there may have been malaria but the young layperson reading the slides has insufficient skills to accurately interpret the samples. Current best practices also indicate that in the absence of confirmed malaria, no antimalarials should be given and other common causes of fever should be considered and patients treated accordingly (World Health Organization 2015).

There was no evidence of malaria, and yet malaria medication was prescribed. The argument that the P. vivax malaria parasite is more “active” at night, makes little sense given that the patient was highly symptomatic at the time of clinic intake. WHO guidelines indicate that “In nearly all cases of symptomatic malaria, examination of thick and thin blood films by a competent microscopist will reveal malaria parasites.” Someone recently treated for malaria with chloroquine or an artemisinin derivative may have a negative smear, in which case an RDT should be used to confirm negative diagnosis. That process would require medical mission practitioners to review patient medical history and ask if and when the patient had last been treated for malaria. The guidance also states that RDTs should be used if quality-assured malaria microscopy is not readily available.

HMH volunteers followed none of these best practices. And despite the availability of quality-assured microscropy at the CESAMO, and track and trace best practices, they did not refer the young man for local treatment or follow-up. Nor did they collect vital statistics and share them with the CESAMO staff so that they could follow-up and ensure the young man improved or got the appropriate care. And if the patient had Dengue, statistically more likely in

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Playa Felumi, prescription of antimicrobials is not recommended and it is critical not to give acetylsalicylic acid (aspirin) or ibuprofen, which are commonly given to reduce pain and fever.

In dengue patients, this increases risk of hemorrhaging which could be fatal if the patient has severe dengue (Secretaria de Salud 2019). But as the Physician Assistant in the excerpt above mentioned, sending the sick young man to the hospital or referring him to the CESAMO for follow-up did not cross anyone’s mind and even prompted him to joke about “shotgun medicine,” in Honduras. None of the symptoms or potential or suspected diagnoses explained the prescription of an antibiotic. They reduced the young man’s fever to 103 degrees and sent him on his way without instructions in case his symptoms persisted or any way for local health providers to contact him to follow up, especially since that was the last team before the rainy season.

Irrational antimicrobial use also occurs as a result of persistent prescription for a chronic or unresponsive infection over a long period of time (Vento et al. 2010). The ultimate result is that the antibiotic no longer has an effect on the bacteria in question, and, if prescribed for viral infections, may make the viruses more virulent and harder for the body’s immune system to overcome (Vento et al. 2010). One nurse practitioner, Valerie, was dubious that HMH teams could be increasing risk of superbugs. She recalled an experience in a survey response:

We have treated many bacterial infections...are we risking development of "super bugs" by our antibiotic use? I am not really thinking we do as I have seen very severe bacterial infections in very remote areas (the cloud village for example) where there has been no healthcare for years and years and obviously no antibiotic usage...the bad infections are there. People need to be reassured that they don't always need a pill to treat something just like we have to educate people here in the states there is a need for continued health education…”

Her comment indicates a community outside of Playa Felumi, which was visited by only one of the eleven teams I observed over the course of a year. She assumed that there was no antibiotic use in the village to which she refers, and generalizes that example into a much broader context, which suggests that the same is true for Playa Felumi. Importantly, antibiotics 302

are widely available at local pulperías (independent corner stores that can be run out of a home or as an independent shop) and are functionally unregulated by the Ministry of Health or other kinds of regulatory bodies in Honduras.14 Anyone can get antibiotics in any amount (so long as they can afford it) for any reason, even in secluded areas. And her response does not indicate any method for confirming infections or any way of tracking healthcare. The assumption that there

“has been no healthcare for years,” is also hard to reconcile given that she and several other volunteers describe Playa Felumi as “having no healthcare”

Deworming

Honduras is considered a regional and global exemplar in their deworming prevention and treatment protocols. However, HMH approaches to deworming are informed by the presumption that intestinal parasites are untreated and ubiquitous and that there are no prophylactic measures in place. As a result of these assumptions medical missions in Playa

Felumi (and potentially throughout Honduras) are likely contributing to over-prescription of anti- parasite medications, anthelmintics especially, which is also a growing concern in Honduras, if not also the global health community (Mendelson et al. 2016; WHO 2016). Moreover, despite clear best practices and protocols, HMH operates according to their own logics, in a clear case of therapeutic domination and malpractice.

Anthelmintics are medicines like piperazine, albendazole, and mebendazole that are commonly used to treat roundworms, hookworms, and tapeworms in children and adults

(Montresor et al. 2002). The medicines serve to paralyze or kill the parasite, which is then passed

14 As of May 2015, the Ministry of Health was working on regulations to be enforced through the

Regional health departments, but the details and implementation had not been settled.

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through the digestive system (Montresor et al. 2002). Over-prescription of anthelmintics may occur when volunteer or sanctioned health professionals prescribe medications without confirmation that parasites are indeed present, a process that usually requires laboratory diagnosis of both blood and fecal samples (Mendelson et al. 2016). Without these tests, the prescribing individual risks treating the patient for parasites they do not actually have (and possibly missing a diagnosis of another pathology in the process). It is also possible that the parasites present are not the types most effectively treated with the STMM go-to drugs

(piperazine and albendazole), in which case they have not only not treated the parasite but may be building resistance in other parasites (Hu et al. 2010). Amoebas, for example, commonly associated with contaminated water sources are an intestinal parasite, but do not respond to piperazine or albendazole.

Because diarrheal disease (often a result of intestinal parasites) continues to be a leading pathology and cause of infant and child mortality in Honduras, various state and non-state entities have made concerted efforts to implement wide-reaching preventive parasite treatments.

All school-aged children attending pre-kindergarten through high school are supposed to receive free preventive treatment for parasites in accordance with Pan American Health Organization recommendations. It is a multi-functional prevention plan that is designed to improve education by enhancing nutrition (parasites deplete the body of vital nutrients, as does persistent diarrhea) and by reducing infant and child mortality and morbidity as a result of diarrheal diseases.

Children should receive treatment at school every six months according to recommended dosages. In most cases this program, implemented by the Ministry of Health and nutrition- and children-focused NGOs, was working as designed (Director of Feed the Children Honduras, interview, August 12, 2015).

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For children not in school, anthelmintics and parasite treatments are one of the few medications that rarely run short in the nurse stations and CESAMOs. When children go to health centers for routine care and have not received or have a confirmed case of “worms,” the protocol in the nurse stations (clinic outposts) and CESAMOs is to administer the medication on the spot in accordance with global best practices. Direct observation guarantees that children will take the treatment properly. No follow-up is required upon administration of the medication, however the CESAMO is available if parents have concerns or questions after their children have been treated or if complications arise, unlike with the STMMs. And even if children do not make it to the CESAMO, for example for obligatory well-child visits and vaccinations, the nurses working under the direction of the CESAMO compile lists of those families with children missing vaccinations and make house calls, providing the vaccinations at home and any other care, including parasite treatment, on the spot. Deworming is also a standard part of the several vaccination campaigns health care providers carry out in Honduras each year. PAHO lists

Honduras as a successful example in their operational guidelines for deworming in the region

(PAHO 2015). Honduran doctors and nurses routinely ask patient families when their last treatment for parasites occurred. Each of the CESAMO staff and Honduran and Cuban doctors with whom I interacted asked patients about the last time they had received treatment. If it was fewer than three months (the strict minimum indicated for use of the medications), they informed the patient that they would have to wait to take another treatment.

Overdose of anthelmintics like albendazole is toxic to the body and in rare cases can be fatal, although development of antimicrobial resistance is the most pressing global concern

(Mendelson et al. 2016; WHO 2016). This fact presents a critical concern with the common anthelmintic prescription practices among STMMs. The majority of STMMs that practice

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general medicine, including the thousands that operate in the country annually (and not just those

I observed during my field research), do not ask individuals when they or their children received their last parasite treatment.

Because brigades operate in a decontextualized space and time—not in conjunction with local healthcare providers or with research and current information on health practice in the country—they operate under the assumption that they are each patient’s only option, even after the STMMs pack up and leave. Among the STMMs volunteers I observed, who came as frequently as every fourteen days (but fewer than three months apart), none asked their patients if they had already received treatment for parasites. In the unusual circumstance of the teams in my study, HMH kept patient records going back approximately nine years. However, a frequent complaint among volunteers and in my own observations, records were not uniformly completed, did not include critical information, and often did not include the prescriptions given, which were filled out on a separate piece of paper and given to the pharmacy, and did not usually make it back to the patient record. Despite keeping such records, I did not observe a single doctor reviewing the patient file to confirm last known antimicrobial treatment.

Further review of the records showed that patients often received deworming treatment regardless of a positive diagnosis for worms, patients were sometimes not prescribed an anthelmintic despite a positive diagnosis, and children, especially those that visited the clinic often, were prone to over-prescription (in this case characterized by receiving treatment within three months or less of a previous treatment). In many cases, volunteers gave out albendazole or mebendazole, without systematic prophylaxis in mind, contributing to over-prescription. Instead, they gave these treatments out as a matter of course along with thirty-day packets of vitamins and acetaminophen or ibuprofen.

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Table 3 shows a cross-section of patients who received parasite treatment at Clinica

Blanca. Each entry includes the ages of the patient at the time they visited the clinic. Some visited multiple times a year, or over several years. Ages at each visit and diagnosis are noted as they are especially pertinent to diagnoses and dosages given to children. The entries exclude any visits where parasites were not a patient complaint and visits where parasite treatment was not prescribed. The continuous rows highlighted in the same color represent a single patient that visited the brigade clinic multiple times. Of the 30 visits included in the table, there were 24 instances of over-prescription. The table also reveals generally inconsistent protocols in administering deworming medications, including instances where the chart indicated a positive diagnosis but no corresponding treatment, or prescriptions given in close succession without diagnosis (or diagnostic confirmation).

Table 3. Trends in Anthelmintic Treatments among STMMs

Patient Patient Complaint Parasite “Worm” Patient Age/Gender # Rx Given Diagnosis 1 Pain in bones Yes No 67/F Pain in bones Yes No 66/F 2 Diarrhea Yes No 2y/F Parasites Yes No 18m/F Parasites Yes No 12m/F 3 Parasites No No 10y/F Cough, cold, vitamins Yes No 8y/F Cough, cold, vitamins Yes No 6y/F ** Within 2 months of previous treatment Parasites Yes Yes 6y/F 4 None listed Yes No 17y/M Parasites No No 14y/M Headache Yes No 13y/M Parasites Yes No 11y/M ** within 1 month of previous treatment “Wants worm medicine” Yes No 11y/M 5 Headache, cough, ear Yes No 8y/F ache Parasites/vitamins Yes Yes 8y/F

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6 Fever, cough, Yes No 4y/F congestion 7 Parasites, vitamins No Yes 3y/M Cough, diarrhea, No No 3y/M congestion, fever, parasites, vitamins Cough, parasites, No No 3y/M diarrhea Parasites, vitamins Yes No 3y/M **within 5 months of previous treatment Wheezing, abdominal No No 3y/M **malaria treatment pain, cough, fever (malaria) within 2 months of previous treatment Fever, runny nose, Yes No 3y/M **within 3 months of wheezing previous treatment Cough, fever, diarrhea No No 2y/M (malaria) Rash, parasites, vitamins Yes Yes 2y/M**within 3 months of previous treatment 8 Headache, back pain, Yes No 24y/F chest pain, pain in heart Shoulder pain, asthma Yes No 23y/F Asthma, back pain, No Yes 23y/F cough, headache 9 Vitamins Yes No 58y/M 10 Chest pain, cough, Yes Yes 54y/M swelling, stomach unease As my household interviews and participant observation confirm, many patients are what

STMM volunteers called “frequent flyers,” or patients who come several times a year, whether they have an immediate medical need or not. In Table 3, for example, patient “7,” marked in red, is the same young boy who came with his family to nearly every brigade each year. In his case, he received at least three anthelmintic treatments within a twelve-month period, despite not having a parasite diagnosis, and in one case where there was a positive diagnosis of parasites did not received treatment. He was also treated for suspected malaria twice within a two-month period. Many of those individuals and their children also seek treatment at the health center, and their children attend school. All of this means children in Playa Felumi have little if any need for

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anthelmintic intervention and are at higher risk of overuse as a result of medical mission malpractice. And once again, HMH’s refusal to cooperate with the CESAMO to provide appropriate surveillance obstructs efforts to monitor and control diarrheal and intestinal parasite outbreaks.

In a meeting with Honduran zoonosis officials working in the Ministry of Health in

Tegucigalpa on August 2, 2015, the Director of Zoonosis informed me that her unit is currently investigating the incidence of antimicrobial resistant parasite infections. According to local

Garífuna doctors working at the hospital in Trujillo, patients are now appearing in hospitals with chronic parasitosis and resistance to piperazine and albendazole, the two most common and cost- effective treatments for intestinal parasites, particularly roundworms, in both children and adults.

There is a high likelihood that medical missions, and any foreign mission team including non- medical missions, that hand out anthelmintics are contributing to a growing public health problem in the country.

The Consequences of Anti-Cooperation and Cures in Search of Diseases

Medical missions in Playa Felumi do not intentionally complement or supplement the

CESAMO or local healthcare resources – negating a core claim about the key benefits of medical missions in general. While they did represent more medical personnel on the ground, and Playa

Felumians recognized the ways their presence alleviated certain pressures on local health resources, HMH missions did meet any of the stated personnel needs identified by the MOH and

PAHO nor did they respond to identified health needs. Instead, they responded to needs conjured through discourses about perceived lack and need and inaccurate assessment of disease prevalence, resulting in overtreatment and opportunity cost harms.

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In many ways, HMH behaviors not only reflected mission discourses of lack and need, but also suggest they viewed the CESAMO as competition. Volunteers frequently discredited the

“government clinic” to ensure patients would continue to visit Clinica Blanca, ignoring at worst and misunderstanding at best, the reality of medical pluralism in Playa Felumi (and throughout

Honduras), ultimately undermining Playa Felumians’ equitable and universal access to healthcare. This pattern is especially apparent in the treatment of chronic diseases like diabetes and hypertension that I discuss in the next chapter.

Moreover, medical missions duplicated, often unnecessarily, the services available in

Playa Felumi. For example, malaria is well-controlled in Honduras, and prevention and treatment are efficient, effective, and compliant with local norms and global best practices. There is a large network of trained community health workers in addition to formally trained staff at the

CESAMO, all of whom received regular ongoing training to stay abreast of best practices. While a few volunteers found value in the work of the CESAMO and tried to enforce norms within

HMH regarding malaria diagnosis, treatment, and reporting, the majority refused to collaborate and comply. Despite concerted efforts of local health care workers and staff at the CESAMO to establish a relationship with Clinica Blanca missions, inconsistency, indifference, and competitive ideology and presumed moral authority on the part of HMH volunteers, teams, and organizational leadership, resulted in short-lived cooperation.

HMH disregard for global and national best practices concerning diagnosis, treatment, and surveillance, were also damaging to the progress made towards malaria eradication because of negligence and malpractice. The practice of reporting inaccurately high rates of “confirmed” malaria cases through inappropriate channels threatens the CESAMOs existing resources which could be diminished if the Regional or National Health authorities believed the CESAMO was

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failing its monitoring, surveillance, and treatment mandates for malaria. A far-reaching implication of this issue is that it contributes to the political narratives of failure and the provoked crises in the public health system that are invoked to justify privatization of healthcare in the country, further reducing equitable, affordable access to healthcare for Playa Felumians

(and all Hondurans).

Furthermore, refusal to collect and report appropriate epidemiological data to the

CESAMO about relevant illnesses, not just malaria, threatens the health of Playa Felumians because it limits the ability of the CESAMO to respond to outbreaks. For some volunteers, it also seems that the specter of accountability wherein HMH’s teams could be compelled to change their practices and comply with surveillance best practices might also have discouraged cooperation and actively contributed to the antagonisms between the two groups. All of which ultimately weakens existing healthcare infrastructure – rather than bolstering it.

These practices were justified through the circulation of discourses of moral and intellectual authority and are indicative of therapeutic domination and iatrogenic violence – which characterize the exertion of power in medical encounters, resulting in social disruptions at the individual and institutional levels which outweigh the benefits of aid (Daniel 2014; McFalls

2010). Despite the availability of diagnostic testing for common bacterial infections, and quality- assured microscopy at the CESAMO, as well as exemplary antimalarial and deworming prophylaxis, HMH missions based their diagnoses and treatment protocols on presumed lack of resources and incidence of disease. The discourses of lack and need were ultimately more powerful drivers of action than global and national best practices and treatment protocols.

Furthermore, discourses of distrust that malign and discredit local healthcare workers and

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simultaneously served to reinforce the intellectual and moral authority of HMH volunteers, render available data, protocols, laws, and expertise irrelevant.

These examples of malpractice, negligence, and ineffective and inefficient programs constitute clinical iatrogenesis in the form of direct harms and social-structural iatrogenesis in the form of opportunity cost harms. Rather than collaborate with local healthcare workers in

Playa Felumi, share medications locally, or focus their efforts on structural improvements or genuinely unmet medical needs in conjunction with the CESAMO, HMH consistently wasted resources on cures in search of diseases. Contravening globally recognized best practices and irrational use of antimicrobials as result of those actions also constitute public health iatrogenesis, threatening not only the health of Playa Felumians, but the overall susceptibility of

Hondurans to effective treatments for potentially deadly diseases.

The next chapter considers the influence of these discourses and themes on medical mission approaches to chronic diseases. Presumed moral and intellectual authority meant that medical mission volunteers and board members dictated the terms of local cooperation attempts, engaging in further therapeutic domination and using the impossible terms as justification to halt cooperation and of their distrust and dismissal of the CESAMO and its staff. These discourses also reflected the rationales medical missions used to justify ongoing treatment of chronic diseases, despite their own acknowledgements that it was ineffective and ultimately damaging to local health in the long-term.

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CHAPTER 12

PRESIÓN Y AZÚCAR: MEDICAL MISSION APPROACHES TO CHRONIC DISEASE IN PLAYA FELUMI

When I arrived in Playa Felumi, I was surprised at the frequency with which I encountered diabetes, hypertension, and stroke among the relatively small population of just over

3,000. It almost seemed that everyone over the age of forty suffered from diabetes or hypertension. In my many years traveling to Honduras, rates of diabetes and hypertension had not seemed to be so prevalent. As I visited homes, getting to know the town, its neighborhoods, and its residents, I observed a number of elderly women and men who were confined to a bed (or a wheelchair if available), had lost use of their eyes, or had lost fingers, toes, or entire limbs due to complications from diabetes or the effects of stroke (a common comorbidity of chronic hypertension).

Critical medical anthropologists, global health practitioners from across disciplines, and vast global institutions like the World Health Organization consider these conditions be among the most pressing, and least-attended-to concerns to human health (Allen 2017; Allen and Feigl

2017; Arredondo et al 2018; Hossain et al, 2007; Reubi et al 2016; Whyte 2012). Incidence of

Type 2 diabetes and hypertension are fastest growing in “developing” or formerly colonized places in the world. Anthropologists also recognize diabetes and hypertension as diseases of development or modernity, reflecting rapid global shifts in how bodies move and what foods and nutrients are available for consumption (cf. Baglar 2013; Manderson and Smith-Morris 2010;

Mendenhall 2012; Smith-Morris 2006; Whitmarsh, Ian 2013; Wiedman 2012).

The previous chapter focused on the clinical and social iatrogenesis that resulted from the failure or refusal of HMH medical missions to cooperate with the CESAMO and comply with global best practices in diagnosis and treatment of malaria and more common illnesses. This

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chapter expands on those findings to consider the implications for chronic diseases, particularly diabetes and hypertension. I put medical mission approaches to Type 2 diabetes and hypertension in context of identified health concerns and local efforts to identify and care for patients with chronic disease. MOH and PAHO identify chronic conditions, specifically Type 2 diabetes and hypertension as primary health concerns to be addressed in improving access to, equity, and quality of healthcare in Honduras. The prevalence of Type 2 diabetes among adults is 7.4 percent

(and growing) and 22.6 percent for hypertension (and occurs at near-equivalent rates in women and men) (“Honduras” 2017; International Diabetes Federation 2019). In Playa Felumi, incidence of hypertension (24 percent) and diabetes (10 percent) recorded in my household interviews corresponded to the national rates, with incidences being slightly higher than the national average. Approximately 10 percent of interviewees experienced both hypertension and diabetes. Cardiovascular disease (which includes congestive heart failure, hypertension, heart attack, stroke, coronary artery disease, among others) and diabetes are in the top ten causes of morbidity in Honduras, but account for 18 and 6 percent of all Honduran deaths respectively (all ages, all sexes) (“Mortalidad por causa de muerte: nivel por país | OPS/OMS” 2020).

While HMH has the potential to improve personnel and equitable long-term access to chronic disease management in Playa Felumi, they ultimately knowingly misdirect resources to ineffective and inefficient solutions and directly impede the capacity of CESAMO staff and community health workers to manage diabetes and hypertension in Playa Felumi. Inconsistent and ineffectual treatment of chronic (and complicated) illnesses like hypertension and diabetes not only constitute opportunity cost harms but result in direct and psychological harms as well.

Entrenched biases that inform mission volunteers’ beliefs about disease causation and responsibilizing narratives about disease and compliance, as well patient care plans, also

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constitute equity and group and social harms by reinforcing racialized disease stereotypes and social hierarchies. The attempts of short-term medical missions to intervene in these disease processes on an irregular and unmonitored basis, may, in fact, be making treatment and patient compliance with a life-long health management regimen (for chronic illnesses like diabetes and hypertension) more difficult.

Diabetes

Individuals who have diabetes experience chronic high blood sugar when the pancreas is unable to properly regulate insulin production. It is a serious disease that can result in premature death if untreated. Type I diabetes is usually present at birth or diagnosed in childhood. In

Honduras, Type I diabetes is typically an early childhood or early adulthood death sentence. The likelihood of survival increases dramatically if someone with Type I diabetes lives in an urban area near a well-stocked hospital and has the means to pay for insulin and regular healthcare visits, and eventually dialysis.

Type 2 diabetes, also called diabetes mellitus, is typically diagnosed later in life, but there is a raging ideological and epistemological debate concerning the cause of late-onset diabetes.

One of the most popular and persistent theories of the last century was the “thrifty genotype,” proposed by James Neel in the early 1960s (Neel 1962). The theory posited that unequal diabetes risk in nonwhite populations was presumably the result of frequent famines prior to

European contact (Moran-Thomas 2019). A lingering consequence has been biomedical canonization of the myth that Afro-descendant, Latin American, and Indigenous peoples are inherently predisposed to diabetes, despite the fact that Neel and numerous others have since concluded that no such gene exists (McDermott 1998; Moran-Thomas 2019). And although medical mission volunteers often noted structural factors that contributed to the challenges of 315

managing chronic diseases, they also invoked “genetic” predisposition in relation to racial category and responsibilizing narratives about diet and lifestyle that reinforced discourses of ignorance.

While current global best practices and national guidelines for the management of diabetes mellitus in Honduras do emphasize nutrition as an important part of care plans, they also include as best practice that dietary advice must be based on a variety of social and structural factors and should be specific to each individual (Pan American Health Organization 2004;

Secretaria de Salud 2015). There are also established diagnosis and treatment protocols for Type

2 Diabetes. Type 2 diabetes should be confirmed using HbA1C tests, so long as there are no mitigating factors that might affect accuracy, or with a Fasting Glucose Plasma test (Secretaria de Salud 2015). In primary care centers, including nurse outposts and health centers like the

CESAMO, the protocol is either metformin or glipizide or a combination of the two, as first line treatment for confirmed Type 2 diabetes (Secretaria de Salud 2015). Metformin is typically available and is included in the Honduran formulary in a dose of 850mg. Glibenclamide is also typically available and is provided in 25 or 50mg dosages according to the Honduran formulary.

The formulary is a list of all the medications that the national health system has approved and that should be available in the pharmacies of the health posts, health centers, and hospitals.

Nurses’ stations report cases of diabetes to their municipal health center (CESAMO), and each

CESAMO keeps track of diabetic patients and their frequency of visits to the health center for treatment and medications. If the CESAMO has the equipment, healthcare workers can check the blood sugar of the patients and monitor their blood-glucose levels. If not, they take the patient narrative and the other vitals and administer their prescriptions in 30-day supplies, so that patients must return for follow-up care and make sure that their dosages are effectively managing

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blood sugar levels. If the nurses or doctor suspect that the patient’s blood sugar is not well- regulated and they cannot perform a test, they will write a referral for the patient to go to the hospital in Tocoa or Trujillo for follow-up and testing before changing their medication dosages.

Insulin, a drug widely used and taken for granted by US health practitioners, is unavailable in health centers and nurse outposts. Individuals can purchase injectable insulin, but at very high cost, between US$25 and $50 depending on brand and dosage, and are often unable to buy sufficient amounts to regularly administer and maintain the kind of regimen necessary for insulin-dependent conditions. Insulin is available “al nivel hospitalaria,” at the hospital level, treated in a similar way as a controlled substance. The kinds of insulin available are for responses to medical crises, e.g., patients who arrive with acute blood sugar levels in ketoacidosis (a build-up of acids [ketones] in the blood) or coma. The insulin is usually short- acting, since there are no expectations that the patient will begin a regimen of injectable insulin upon discharge from the hospital, unless necessary for non-crisis management of their illness per recommended practice. Short-acting, as the name suggests, is a fast-acting, but quickly absorbed medicine, which requires multiple, scheduled administrations over a short period of time and monitoring in those individuals who need it. Insulin, as a particular pharmaceutical remedy, is expensive, even in bulk, and is therefore only supplied by the Ministry of Health to hospitals in conservative quantities.

When STMMs land in a given location and treat individuals with diabetes in the ways US medical practitioners are accustomed, there is risk of clinical iatrogenesis to the patient. Among the medical brigades that come to Playa Felumi on a yearly schedule, there is a specific group that attempts to address diabetes in particular. Of the eleven brigades I observed in Honduras, one team was particularly concerned about the treatment of diabetes. Dr. Clarkson led the team

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and most of its volunteers had been coming to the town for many years. They kept separate patient charts in locked bins and returned just one or two times annually in an attempt to provide follow-up and care for the “known” diabetics in the community. They usually arrived in the middle of the brigade season. While other teams saw diabetic and hypertensive patients, it was not their primary focus.

On their first workday in Playa Felumi, Dr. Clarkson’s team only saw patients with diabetes. The medical residents, doctors, and nurses on the team made a concerted effort to persuade every patient with “uncontrolled” blood sugar not already using injectable insulin to begin doing so. In no uncertain terms, the diabetic specialist, Dr. Clarkson, insisted several times that week that without insulin these patients would die. She believed that the combination of metformin and glipizide they were taking was simply not enough and that most patients did not have their blood sugar “under control,” in the way that US practitioners codify that phrase.

Prescribing insulin to patients who have no way to maintain that form of treatment is dangerous for at least two reasons. First, as previously mentioned, insulin is costly and especially difficult to access in rural areas. Insulin also requires refrigeration, adding additional complications for areas without access to electricity or with extremely limited or unreliable access to it, like Playa Felumi. Towns east of Playa Felumi do not have electricity at all. So as a method of treatment, insulin is extremely impractical, as it cannot be safely or reliably stored.

This is also why management of Type 2 diabetes with combination metformin and glipizide is the recommended protocol in Honduras (and throughout Latin America and the Caribbean) and insulin is only recommended after every attempt to manage blood sugar has been made without it

(Pan American Health Organization 2004; Secretaria de Salud 2015).

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More critical than impracticality, however, is that sporadic access to insulin can provoke diabetic crises in patients. Physiologically, when a patient takes insulin, it helps to regulate their blood sugar, since the pancreas of a diabetic patient does not adequately regulate this critical hormone (Montoya 2011). When patients take injectable insulin, they must take it continuously because their body becomes accustomed to it and ceases to compensate because a synthetic hormone has replaced the need for the pancreas to produce its own insulin. In fact, the opposite often occurs, so that if an insulin-dependent diabetic patient suddenly runs out of the medication or abruptly ceases administering it, their blood sugar is more likely to spike. If this happens regularly it could result in permanent damage to the endocrine system, lead to acute diabetic ketoacidosis, diabetic coma, stroke, or heart attack.

My neighbor, the matriarch of the family that I rented a house from, had Type 2 diabetes.

She had been convinced to take insulin, and worse still, to use insulin pens, like Levemir or

Lantus—which are name brand drugs originally designed for the convenience and compliance of

North American insulin-dependent people with diabetes who didn’t like carrying syringes or wanted a less painful option for injectable insulin. The problem with these pens is that they can cost up to US$50 each, in addition to the fact that one pen does not contain sufficient doses of insulin for an entire week of treatment (much less a month), making it necessary to purchase several pens at a time for a full month of treatment.

Pearl, like many of the diabetic patients I interviewed in Playa Felumi, was often forced to ration her medication, using less insulin than prescribed in an effort to stretch the duration of the treatment. Several teams often brought too few insulin medications to give to patients or brought different brands or only injectable forms. If my neighbor ran out of her insulin, she was

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not always guaranteed more with the next medical mission, and no teams visited between the months of late October and early February.

Indeed, my neighbor had been hospitalized six months prior to the start of my fieldwork in Playa Felumi while on a visit to see family in New York City. Eight months after my fieldwork ended, she was hospitalized again for complications related to her diabetes. Pearl was frequently out of insulin. At one point, her daughter, granddaughter, and I shared concern for her health as she was beginning to ration her insulin and was showing symptoms of high blood sugar, including disorientation, irritability, and blurred vision. I agreed to purchase three additional insulin pens for her while replenishing supplies in La Ceiba. I tried to find strips for her glucometer as well, but like most glucometers, the strips are rarely available or the technology is so quickly rendered obsolete by newer models (that require non-universalized strips), and I was unable to find them.

These pens are neither affordable or tenable for the vast majority of patients who are persuaded (or ordered) by North American medical mission doctors to use them. Difficulty refilling prescriptions because of high cost or findings the appropriate medicine and dosage in private pharmacies – because they are not on the public formulary and available in the public health facilities – often leaves patients in worse medical conditions. This medical treatment also constitutes a form of social iatrogenesis by imposing a form of “disabling dependence” and

“generating new painful needs,” in addition to transforming the socio-economic dynamics for individuals and the community at large (Illich 2013, 97).

At a very basic level, insulin injections are painful, even with the smaller needles and the intended purpose of the pens (comfort and convenience). Patients often complained about taking the shots, and the unconverted would often cite fear of injections and the corresponding pain as a

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reason they were not interested in the alternate medication. If patients used syringes and vials, the cost was similar, and patients considered the pain and inconvenience associated with injections worse, not to mention the difficulty of keeping insulin vials refrigerated. But, many medical mission doctors insist that the individuals need them, even if global best practices and national protocols do not recommend insulin for regular management and first line treatment

(Secretaria de Salud 2015), and deny the patients the right to have a say in their treatment. As

Illich (2013, 97) predicts, “the right of the patient to withhold consent to [their] own treatment vanishes as the doctor argues [they] must submit to diagnosis.”

After hearing about Pearl’s situation, Dr. Clarkson exclaimed, “that’s why everyone’s

A1Cs are all still 14!” Dr. Clarkson also told me that many years ago, the team had invested in and attempted to conduct HbA1C tests, which measure the stability of a diabetic condition, but they stopped after a couple of years when the tests consistently showed no change in elevated

A1C levels. The test, Dr. Clarkson explained, kept showing “fourteen, which is unheard of in the

US, anything over eight you get into really bad complications, but we brought them back the next year and they showed the same thing, so we stopped bringing them because they’re expensive.” Not only are the tests expensive, but they provided evidence that the interventions in diabetic treatments were not working. But rather than change their intervention model, the teams, led by Dr. Clarkson, continued to provide sporadic diabetic care for the complicated chronic condition in the same way. As another doctor on the team who has come as many years as Dr.

Clarkson said, “if you look at the medical records going back ten years, we haven’t helped the diabetic patients.”

The local health center tried to treat these chronic conditions among the patients of which it is aware, but this was made difficult by the fact that Clinica Blanca has not historically shared

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the pertinent medical information about diabetic and hypertensive patients with local healthcare professionals. Dr. Muñoz was determined to shift the dynamic in Playa Felumi. Despite acknowledgement from Dr. Clarkson and several volunteers that their approaches to treating diabetes and hypertension were not filling gaps and did not adequately meet standards of care for the management of diabetes, efforts to cooperate with the CESAMO were tenuous and short- lived. The emphasis on insulin also seemed to be a crucial criterion in Clinica Blanca volunteers’ efforts and willingness to collaborate with the CESAMO, as well as the long-term presence of the same physician.

Dr. Clarkson explained that she had attempted to work with the “government clinic” in years past. “We talked to them before about getting insulin down here, but they were very uncooperative! They didn’t want the insulin needing a refrigerator…just very uncooperative.” I suggested that they weren’t being uncooperative by refusing insulin requiring refrigeration because it is true that they are not allowed to store anything but vaccines in the refrigerators they have in the HC. The regulations are very strict and very clear. She replied, “We offered to buy them a refrigerator, but they just weren’t interested! I’m hoping this doctor will be.”

The CESAMO had only recently received an infrastructural upgrade, so reliability of electricity, along with space for a refrigerator, no matter how free, may have been among practical reasons for declining, in addition to the national protocol for diabetes management which stipulate insulin as a last resort or only when “intensive” treatment is medically indicated

(Secretaria de Salud 2015). Dr. Clarkson was generally distrustful of the CESAMO and the expertise of its staff, which became apparent when Dr. Muñoz came to Clinica Blanca to meet with Dr. Clarkson. The power dynamics between Dr. Clarkson, Clinica Blanca, Dr. Muñoz, and the CESAMO were also apparent.

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Dr. Muñoz had hoped to be included in the mission’s first day of activities with diabetic patients in order to learn about treatment plans, the educational information being shared, and identify patients. Miscommunication had prevented that from happening, but Dr. Muñoz persisted and asked if she could participate in the team’s activities later that afternoon. She offered to give an educational talk about diabetic nutrition, appropriate exercise, which would also give her a chance to get to know the patients frequenting Clinica Blanca. Dr. Clarkson and a few other volunteers listened (as I interpreted) and nodded along. Dr. Muñoz explained that

“there are diabetic and hypertensive patients that only come [to Clinica Blanca], so we do not have the opportunity to manage their care, and since we are not managing their care and they only come here, we would like to learn who they are and make use of (aprovechar) the time to give an educational talk.” Implicit in Dr. Muñoz’s request was the CESAMO’s responsibility to patients, known or not, and the quotas and benchmarks for care of diabetic and hypertensive patients and in meeting national health priorities.

Dr. Clarkson asked me if Dr. Muñoz was asking to “work together on managing the diabetic and hypertensives.” I confirmed, “this is the goal.” Speaking to me rather than Dr.

Muñoz directly, Dr. Clarkson responded.

Dr. Clarkson: Tell her, we would love to do that.

Laura: [interprets]

Dr. Muñoz: [nods]

Dr. Clarkson: Tell her that for many years, we have recognized the fact that these chronic diseases need to be managed by a doctor who’s there all the time.

Laura: [interprets]

Dr. Clarkson: [now speaking to Dr. Muñoz] So, I understand that you’ve been here for two years. Is that correct?

Laura: [interprets]

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Dr. Muñoz: Yes.

Dr. Clarkson: And what are your plans, for you? Are you planning on staying here longer?

Dr. Muñoz: Yes.

Only after this brief exchange, which felt very much like a job interview, Dr. Clarkson introduced two of the physician volunteers with her who had been present throughout the conversation, and then resumed the conversation.

Dr. Clarkson: So, what we’ve done in the past, we wanted to work with the government clinic, but the people were coming and going so much, that we couldn’t get a long-term established relationship with someone at the government clinic. So, we had the idea that we would try to work with the government clinic, to the point where we would send medications down here for the diabetics. Even insulin.

Dr. Muñoz: Mm-hm.

Dr. Clarkson: Um, that, that’s very difficult to do, but we still would like to try something like that if she’s interested in doing that with us.

Dr. Muñoz: Of course, that’s why I’m here!

Dr. Clarkson: So, it’s very easy to send blood pressure pills and pills for the diabetics. And we can start to try to educate the patients that they can get some of their medications at the government clinic, they don’t always have to come to this clinic. So, what we need to do is share our names between who she sees for diabetes and who we see for diabetes. We need to share those names. And then I don’t know if she could come to the diabetic class this afternoon, but we could teach together, and that would give the diabetics more confidence.

Dr. Muñoz: Ok

Dr. Clarkson: And she could meet some of the diabetics that come to the clinic. So that they could get to know her…

Throughout the conversation Dr. Clarkson’s assumptions about the CESAMO and the relationship Playa Felumians have with it and Dr. Muñoz were evident. Dr. Clarkson suggested that Playa Felumians would not or did not have confidence in Dr. Muñoz, and that they did not know her or have a relationship with her (despite the fact that she lived and worked in Playa

Felumi and was well-liked and respected). After Dr. Muñoz gave an interactive and lively talk to 324

diabetic patients during the afternoon class, Dr. Clarkson listened and offered a, “pretty good,” seemingly surprised that Dr. Muñoz would be sufficiently versed in diabetic education or so well-received by the patients (many of whom she already knew and with whom she had good relationships).

Dr. Clarkson’s statements also revealed that they did not currently or had not encouraged people in their care to follow-up with the CESAMO, and that by default patients believed they could only go to Clinica Blanca for treatment of diabetes and hypertension. Dr. Clarkson also insisted that the reason they could not establish relationships with the CESAMO in the past was because there was too much turnover (though she did not mention any uncooperativeness to Dr.

Muñoz). While Dr. Muñoz answered honestly when she said she planned to stay, it is unreasonable to expect that circumstances of people’s lives might change. Furthermore, while the position of Medical Director was something of a revolving door at the CESAMO every few years, Eliomara and two of the auxiliary nurses had been employed at the CESAMO for several years.

In addition to the distrust and discrediting of the CESAMO, the conversation also openly recognized that the care of diabetic and hypertensive patients by medical missions was inadequate and created barriers to continuous care for patients. The mission doctors asked Dr.

Muñoz several questions about the availability of medications and the feasibility of insulin- dependent patients to get insulin from the nearest hospitals if needed. Dr. Muñoz explained that the CESAMO received enough medications to treat identified cases of diabetes and hypertension. Any patients requiring insulin would travel to Tocoa or Trujillo to receive insulin from an internist at the hospitals for the cost of travel and the Lp.5 hospital fee.

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Dr. Franklin asked about the feasibility for patients to accomplish a trip in a day and if patients had any barriers preventing them from traveling to Tocoa or Trujillo to get the needed insulin. Dr. Muñoz explained that for the patients that were managing their healthcare, there were few issues. She said that most of the patients she knew about could afford the cost of a once-monthly round trip to the city and acquire their medication. Other barriers included structural issues. Medication shortage and distribution problems were rampant in the public health system and one of the contributing factors to medicine shortages at the CESAMO, but also part of the intentionally provoked crisis in the public system intended to create the justification for privatization (see Chapter 5). Sometimes the hospitals were out of medications, so patients would “make the trip for nothing,” and that contributed to non-compliance because people would have no way of ensuring that the medicines would be there the next time. Patients would then either try their luck at Clinica Blanca, or they would just stop regularly managing their diabetes with medication. Dr. Muñoz explained that another problem was that the patients who came to

Clinica Blanca “preferred to wait.” So even if they could go to the CESAMO or had the means to go to the hospitals or buy their refills, when they ran out of medications, they would wait. Upon hearing Dr. Muñoz’s explanation, Dr. Clarkson said she “could see how that might create a problem.”

Dr. Clarkson managed to send at least one shipment of pill-based treatments for diabetes and hypertension after the meeting with Dr. Muñoz. Whether the teams shared patient names and charts with the CESAMO remained unclear. However, a few months after the meeting Dr.

Muñoz was offered and accepted a promotion to work in the Regional Health Office in Trujillo.

And medical mission efforts to cooperate with the CESAMO stopped almost as soon as they began. The mission organization and its volunteers’ insistence on establishing a relationship with

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a person, rather than the institution of the CESAMO that could outlast any turnover, made it easy to claim the CESAMO was “uncooperative” or confirm already entrenched biases about the reliability, trustworthiness, and capacity of the CESAMO staff. HMH board members and volunteers decided it was too difficult to collaborate, despite the fact that Eliomara was still there

(and had been for years) and Dr. Montenegro a young Garífuna woman who had spent the past two years working for the municipality at a CESAR under the direction of Dr. Muñoz, was promoted to the post of Medical Director.

Hypertension

Individuals with hypertension have chronic high blood pressure. Untreated, hypertension may lead to ischemic attacks (stroke) or myocardial infarctions (heart attacks) and increase risk of vascular and chronic kidney diseases (Koma and Lebelo 2017). While hypertension is often linked to weight (Hossain, Kawar, El Nahas 2007), many people in Playa Felumi suffer from hypertension despite being within medically desirable weight measurements. In biomedical literature the causes of hypertension, like diabetes, are frequently attributed to genetics, (poor) diet, stress, and less frequently to poverty and early childhood malnutrition (Furmaga-Jablonska

2014).

Honduran medical protocol for individuals with chronic high blood pressure is similar to those for individuals with diabetes, in that they are monitored as a special health population for follow-up and regular treatment. Medicines for hypertension typically include enalapril or atenolol and hydrochlorothiazide (HCTZ) to control the swelling that often results from congestive heart failure, a comorbidity (or accompanying complication) of high blood pressure.

Patients are supposed to be given a single thirty-day supply of the appropriate medications so

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that they can return the following month to have their blood pressure checked and receive a refill of their prescriptions.

If an individual’s blood pressure continues to be high despite taking their medicine, then the attending nurse or doctor can increase their dosage accordingly and/or refer them to the hospitals in Tocoa or Trujillo for follow-up tests and treatment as necessary. Medical mission approaches to the treatment of hypertension are not quite as intensive as with diabetes, but they do differ from CESAMO protocol. Patients with established hypertension, previously diagnosed either at the CESAMO or by a medical professional outside Playa Felumi (whether a private doctor, a doctor at one of the public hospitals, or a doctor in a US clinic or hospitals, for those who travel or have residence in the United States), get a perfunctory check-up and a refill on their pills. They are considered “easy” patients because they are there for one specific thing and the volunteers can check them off quickly and move on to their next patient.

Volunteers in the triage area at Clinica Blanca, usually a nurse or a paramedic, would take the patient’s blood pressure and note whether it is normal, low, or high. Once the individual got to the nurse, doctor, or nurse practitioner that was going to consult with them, the nurse or nurse practitioner would review the chart—if there was anything to review as charts were often incomplete or blank. Usually, if there was no change in the patient’s blood pressure, the volunteers would simply refill the existing medications, unless the patient could not remember the name or dosage, had not brought the medication packaging, or their chart was incomplete.

Medical mission doctors often decided that the Honduran formulary medication the patients were taking previously, or that the prescription given by a previous brigade physician was undesirable and prescribed them another type of medication. Household interviewees living with hypertension complained about this practice. The patient was not usually given an option.

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Rather, the STMM physician would tell them that the newly prescribed medicine does the same thing, often adding that it “is better.” One physician volunteer was outspoken about her preference for a different anti-hypertensive, in place of the commonly prescribed medication many of the patients she saw were already taking. She swapped out their medication for one that her team had brought to Clinica Blanca, which is not widely available or affordable in Honduras otherwise.

When medical mission doctors change the medication, the individual seeking treatment usually acquiesces, sometimes eagerly, because who can argue with “better” medicine? As a result, hypertensive patients often end up taking a cocktail of different hypertensive medications over the course of a year. In some cases, they only take the medications the mission doctors prescribed and gave them until it ran out. Having been told the STMM prescription is “better” medicine, they do not return to the CESAMO for regular follow-up or to get refills—even if of a different medication—to help manage their chronic high blood pressure. Other times, the

STMMs simply did not have the same medications because the pharmaceutical formulary is not standardized among medical missions, nor is it coordinated with the Honduran formulary.

Playa Felumians with hypertension often complained in interviews that they did not like when STMM doctors changed their medications. Sometimes they said they did not like the effects of the new medicine, or how it made them feel physically (sometimes dizzy, nauseous, or shaky). Sometimes they did not like that that the new medicine was more expensive to replace or difficult to find. This class of medications can cause patients to feel dizzy, or experience acute high or low blood pressure, but, unlike in the United States, when medical mission doctor’s swap a patient’s hypertensive medications, there is no monitoring and follow-up protocol because mission teams leave and do not communicate patient information with the CESAMO.

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Patient Subjectivity: Compliance, Agency, and the Deviance of Self-Care

Biomedical practitioners, professionals, and paraprofessionals often talk about “patient compliance,” that is, whether a patient adheres to the specific treatment plan chosen for them by a doctor, especially in the context of chronic disease management. Someone who is not compliant is considered deviant. Through this language of deviance and compliance, biomedical standardization narrows the possibilities for an autonomous experience of health. Indeed, these descriptors and this practice also strip individuals of their agency (Singer and Baer 1995) and their right to self-directed care (Illich 2013).

When individuals are transformed into patients or pre-patients, their agency, the choices they have to determine what kinds and frequencies of therapies to receive, the right to refuse certain biomedical treatments, or to choose non-biomedical treatments become an “intolerable form of deviance” (Illich 2013, 96). Biomedicine has monopolized authority over the body, while also ensuring compliance by removing access to other forms of healing and treatment available to patients, such as plant-based medicine, spiritual medicine, or alternative healing techniques. Despite being a kind of ethnomedicine itself, biomedical practitioners have worked to distinguish biomedicine as oppositional to ethnomedicine, divorcing it from its culturally specific contexts (Singer and Baer 1995) and underscoring the significance of its relationship to settler-colonialism and global white supremacy (McLean 2020) in the process.

One volunteer, a pharmacist on a midsummer team, was chatting with me after I introduced my research to his group. Like many volunteers, he had his curiosities about the efficacy of interventions and whether the current practices of “just handing out medicines” were working. “I’ve often wondered, you know… we come down and give this medicine and that medicine. And, what’s the compliance? Are they [patients] taking them [the medicines]?”

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Compliance, it should be noted, is always the responsibility of the patient. Regardless of the necessity of treatment, the structural barriers, or simply the individual’s own autonomy over their own body, “compliance” comes down to adherence to the norms and regulations that determine what it means to be a good therapeutic citizen (Nguyen 2005; Nguyen et al. 2007; Petryna 2004;

Whyte et al. 2013).

On one occasion, a woman came to Clinica Blanca seeking information and possible treatment for symptoms related to diabetes. The woman was in her 40s, short with a slight build.

She clasped her hands together tightly as she sat in the chair, her shoulders rounded forward and head down. Her body language and eye movement suggested she was nervous. Lisette had been diagnosed with diabetes in 2013 but had consistently declined to accept insulin-based treatment for her condition. It was unclear whether she was taking Metformin and Glibizide, though it had been prescribed in the past. She opted instead to use plant-based medicine, like sugarcane leaves, to manage her symptoms. On this March day in 2015, however, her blood glucose level was at

480 and she was not feeling well. Lisette seemed to be considering additional options.

As Dr. Arranda had asked me to, I began chatting with Lisette. I asked her why she didn’t want to take the medicines that had been prescribed. She lifted her shoulders and shrugged. Dr.

Arranda discreetly slid Lisette’s open chart toward me on the little wooden table between the three of us. The chart noted that Lisette had refused insulin and medications in 2013 and every visit since. “Refuses to take medication,” the form noted. One note said in large red, underlined, capital letters “TAKING BUSH MEDICINE,” as a scrawled condemnation of the woman’s use of plant-based remedies. I eventually learned that Lisette, like so many others living with diabetes in Playa Felumi, was anxious about taking painful medications, and justifiably

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concerned about undesirable qualities of the medications or adverse/iatrogenic effects such medications, especially injectable insulin, could entail.

Ultimately, STMM volunteers doubted Lisette’s compliance with prescribed treatment, and thus deemed the responsibility for her illness her own. Lisette received no praise or reassurance for managing to stay alive, “untreated” in the eyes of her biomedical interlocutors, or for using a plant-based treatment that gave her some degree of power and autonomy over her own body, regardless of whether it was a “clinically proven” drug. While I was in the room, Dr.

Arranda did not ask her what steps she took to feel well and stay healthy, what kinds of foods she ate, or what she did when she started to feel unwell and whether those actions or treatments had desired or undesired results for her. Rather than treating Lisette like a woman in control of her own body, one who is capable of reason and self-care, doctors, particularly medical mission doctors labelled her deviant and responsible for her own suffering.

Through her protests about taking insulin, Lissette refused to normalize a daily, painful pharmacological ritual as part of her everyday life. It is too simplistic to argue that Lissette was

“non-compliant” or “deviant.” Some of the examples Illich describes relate to an individual’s ability to suffer, cope with, tolerate, heal, or mourn within the context of their illness experience.

Specifically, Illich writes that social iatrogenesis occurs when people cannot have those experiences on their own terms — that is, when the illness experience becomes standardized or

“hospitalized” (Illich 2013, 40). Attempting to standardize the illness experience through biomedicalization could prevent residents of Playa Felumi, like Lisette, from experiencing their illness in culturally-specific ways.

It is racist and ethnocentric to dismiss her own knowledge of her body and her use of

Garífuna healing wisdom through euphemisms like “bush medicine” meant to connote

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“backwardness.” Biomedical prejudice against the sensorial (Nichter 2008), the sensory lived experience of the ill, may also explain why STMM volunteers are so quick to dismiss indigenous and plant-based medicinal practices as “bush medicine,” or as an errant “belief” (Good 1994).

The instances of thinly-veiled ethnocentrism, biological racism, and presumed biomedical superiority underlying such STMM volunteer characterizations constitutes another example of social iatrogenesis, via the erasure of indigenous medicine and use of plant-based remedies through dismissal, mockery, and stigma.

In asserting her voice during the process of seeking remedy for the illness she was experiencing, Lissette exercised her agency, refused to be passive patient (or aid recipient), and also revealed the strangeness of the Western biomedical approach to treating illness, and diabetes in particular (Etkin 1992; Nicther 2008). Insulin might help reduce the symptoms of dizziness, blurred vision, and exhaustion that Lissette experienced when her blood sugar reached high levels. But that did not make her concerns about the “side effects” of a painfully administered substance any less valid (Etkin 1992). Moreover, it does not address any of the other concerns

Lissette had when seeking help from the STMMs (or the CESAMO) when the methods she had used to survive so long were seemingly less effective than usual. No one was paying attention to

Lissette’s illness narrative (Hardin 2017; Kleinman 1989; Mattingly and Garro 2000; Smith-

Morris 2006) or attending to the array of structural concerns that, although outside the body, directly contributed to her illness and sense of well-being.

Among the North American physicians and nurses that volunteer at Clinica Blanca, the common thinking about the prevalence of diabetes and hypertension in particular was: 1) that the incidence is “normal” because this is a population of African descendants—and diabetes and hypertension are “just” more common among certain “races;” and/or 2) that the incidence was a

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result of failures of individual responsibility to maintain an “ideal weight” and eat “properly,” or

“deviance” in being non-compliant with their healthcare. Medical mission volunteers’ survey responses tended to characterize diabetes as a problem with the person—either biological or behavioral. The volunteers invoke common “culture of poverty” and “lifestyle paradigms” that ultimately inform the way they medically (mis)treat people of color (Mullings 2002) and that align with guiding discourse about lack, need, and their own intellectual authority. Most of the medical mission volunteers that specifically discussed diabetes or hypertension, in their conversations with me or their survey responses, believed that the eating habits of persons affected by this illness are to blame.

For example, to a question about what people thought the causes of illness might be, one survey respondent stated, “Diet is a major issue, patients eat a lot of carbohydrates which can lead to diabetes and hypertension.” Another wrote, “Bad diet: high carbohydrate, eating spicy foods, low fruit and vegetable intake, high amounts of pop (coke). Lack of access to clean water or patient preference to buy coke over water.” A different respondent blamed poverty but linked it to diet. She wrote “Poverty! If roads were paved, you wouldn't have all the dust. If they could afford electric the open fires would not be needed and the smoke would be gone. They could grow or purchase nice fresh veggies so their diet would not be all carbs • bread, rice, casaba

[sic].” Another said the causes of poor health are “Dietary. Lack of fresh vegetables and not a wide choice of dried beans for protein. Perhaps use of quinoa could be started.” Yet another blamed it on diet and lack of knowledge: “Lack of clean water. Lack of proper nutrition. Lack of clean living conditions. Personal hygiene issues. Perhaps a knowledge deficit as well.” Another blames “Poor diet choices/food availability/malnutrition.”

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All of these examples in some way acknowledge structural issues, but ultimately put the onus on residents. Some fall back on the critical assumption that the poor “do not understand what is happening.” While others suggest introducing different crops. Ironically, these responses also support the insistence of Playa Flumians that medical missions should provide nutritional and food assistance to meet the most pressing health needs of the community. Numerous household interviewees and patients who appeared at Clinica Blanca and explicitly asked for food aid recognized and articulated these issues, explicitly identifying hunger and having enough quality food to eat as primary concerns. Among their suggestions for medical missions were to include direct food assistance (or remunerated work, or money to acquire it themselves):

HH18: [Missionaries should] Visit the houses so they can note the poorest… There is nothing here, what we need is food. They should help us with food. They should help with this. Sometimes they send help.

HH23: Road [improvements], help poorest people, food, nutrition.

HH24: They do not give food [they should].

HH29: … they don’t respect us. Illnesses come, there is hunger – it’s not that we don’t want to work.

But discourses of “lack” and “need” that cast Playa Felumians as ignorant or irresponsible tended to override the structural (and resolvable) nature of these issues as intractable, inherent characteristics of Playa Felumian (and Honduran) reality, thus reinforcing

“culture of poverty” stereotypes. Despite acknowledging at least some of the structural barriers to adequate nutrition, mission volunteers fell back on “knowledge deficits,” and moral superiority, using moralized language about food and “diet” advice centered on U.S. popular cultural norms – rather than individualized nutritional advice that follows regional and national best practices.

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I witnessed firsthand the insistence on normative exercise and diet during my observations of brigade clinic patient consultations. The following is an excerpt from my field notes:

The patient family came in, trying to decide where they were supposed to sit. They were a family from Flor del Monte, a nearby community in the municipality. The grandmother in the group was tall and stoutly built, with broad shoulders and a distinctive nose, small close-set eyes, and a broad smile to accompany her friendly face.

When the Nurse Practitioner got to the grandma, she took the woman’s blood pressure, which was a little high, borderline. The woman also complained that she often had pain in her knees. The Nurse Practitioner looked to the interpreter and said, as if explaining to the patient herself, “she needs to lose some weight.” The Nurse Practitioner slapped her knees with both hands and continued, “Her knees will hurt because she has to carry all that weight.” Without asking about the woman’s day-to-day activities or diet, they told her she needed to eat more fruits and vegetables. The woman replied that she eats lots of bananas. “I love bananas!” she said. “How many bananas does she eat?” inquired the Nurse Practitioner to the young interpreter. The grandmother thought for a moment and then said, “mmmm, como siete al dia.” [like, 7 a day…] Aghast, the Nurse Practitioner and interpreter shouted, “that’s too many! Menos bananas!” They did not explain why she shouldn’t eat so many bananas or what she could eat instead of the things they told her to cut out of her diet.

The Nurse Practitioner also told her to eat less salt and drink fewer sodas, without asking her how much she typically ate and drank. While the Nurse Practitioner turned to write down her notes and fill in the prescription sheet with orders for vitamins, worm medicine and over-the-counter pain killers, the interpreter gave the patient the Nurse Practitioner’s instructions but added some instructions of his own.

The interpreter added that the woman needed to eat less rice, “arroz tiene mucho carbohidratos” [rice has too many carbs] and eat more fruits – but apparently not bananas. As I observed, I felt my jaw and grip on my pen tighten. He also told her to exercise. He asked if she like to dance and started to swish his hips as if dancing to silent Cumbia in his head. She said she loved to dance, and he told her to put on some music and dance for 30 minutes every day.

Secretaria de Salud 2015). In this encounter, none of the advice followed best practices. The pain

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she felt in her knees was automatically attributed to her weight and assumptions about how she moves and feeds her body, rather than any assessment of her overall diet or the daily activities she undertook. The fact that she was wearing heeled sandals and had walked a considerable distance over rough terrain and lived in a mountainous part of the municipality, or that she stood on her feet most of the day while cooking, handwashing laundry, lifting and carrying water were just as likely contributors to knee pain or arthritis, but none of those came up during her consultation.

Some volunteers were on the fence and not quite sure to what the disease should be attributed. Another respondent claimed, “Diabetes is quite prevalent, I'm not sure if it is genetic or diet• related, but it’s not due to the obesity factor like in the U.S.” This respondent qualified their statement to say that obesity was not a factor in the prevalence of diabetes, acknowledging that there are several men, women, and youth in Playa Felumi who are not considered overweight. However, the statement perpetuates the notion that diabetes and hypertension are

“fat” diseases and thus diseases grounded in the morally accountable behaviors of those experiencing them.

Each of these vignettes includes a moral judgment about the way the patients behave.

Diet, in particular, is an action—it depends on the person to engage in an activity that eventually leads to an ostensibly measurable level of nutrition or visibly identifiable level of health. Failure to diet “correctly,” to eat “nice fresh veggies,” is viewed as undesirable and deviant behavior.

Using diet as a marker also allows the medical mission volunteer to pass blame onto the person who fails, or more importantly is perceived to fail to eat the prescribed portions and kinds of foods deemed morally acceptable and directly linked to “good” health. As the narratives from the residents of Playa Felumi demonstrate, many of them ate and/or expressed a desire to eat these

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morally acceptable foods. Those narratives demonstrate not only a knowledge of those comestibles, but also trouble the simplistic notion that diet is the most logical explanation for poor health.

Pernicious Theories: Race, Genetics and Chronic Disease

Dr. Clarkson did not believe that diet has much to do with the high incidence of diabetes.

She believed it was genetic. “Of course it’s genetic!! It’s definitely genetic. The incidence of diabetes is much more common in the Black and Latino populations.” As if to explain her claim she added, “There was a 14-year-old with Type I diabetes, insulin-dependent. He was working in the fields with a blood sugar over 600. That’s not related to diet. I don’t know how he wasn’t already dead.” Dr. Clarkson’s summation much more clearly suggests inherent biological difference was the causal factor in the prevalence of diabetes and hypertension within this community. It also parrots the same kinds of observations Moran-Thomas (2019) made in her ethnographic research among Garífuna with diabetes in Belize. Healthcare providers were routinely “shocked” that the Garífuna patients they saw with blood sugars well over the established “normal” (80-120) were not experiencing severe complications or, as Dr. Clarkson put it, “already dead” (Moran-Thomas 2019, 90). Dr. Clarkson’s comment also elides Type 1 and

Type 2 diabetes, which are distinct. Type 1 is much less common and believed to be irreversible.

There is considerable research that suggests that Type 2 diabetes is not only reversible, but preventable, all of which provide a powerful counterclaim to the pernicious idea that it is

“genetic.” The elision here is not careless but further evidence of Dr. Clarkson’s position that diabetes, regardless of type, is a genetic disease, inherent in the body – and some bodies more than others.

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The racialized biomedicine that enables Dr. Clarkson or other volunteers to assert that the cause of this particular illness, Type 2 diabetes might be “genetic” is rooted in the scientifically disproven notion that people with phenotypically black or brown skin are biologically different from people with phenotypically white skin. The “thrifty gene” or biological predisposition theory is easy to fall back on, and it is dangerously common in American biomedical practice

(Moran-Thomas 2019; Roberts 2012), despite having been thoroughly disproven (Allen and

Cheer 1996; McDermott 1998). Recent scholarship has also emphasized high correlation between early childhood and maternal nutrition on the likelihood of developing Type 2 diabetes later in life (Furmaga-Jablonska 2014; Schulz 2010; Smith-Morris 2006). While problems like wasting and starvation were not common in Playa Felumi, general malnutrition caused by either not having enough food or sufficient required nutrients in the foods available was common across age groups.

Medical mission volunteers’ emphasis on “genetics” and “diet” shifts the responsibility of the illness entirely to the individual experience the illness, faulting individuals for not eating

“properly” or valuing “good” and “healthy” food, while their land is actively stolen from them

(Brondo 2013) or they are forced to sell it off to pay for their medications, hospitalizations, or the everyday costs of living (Moran-Thomas 2019). The biological determinism that comes with the oversimplified declaration of “genetics” as the causal factor of hypertension and diabetes crowds out the considerable amount of research that suggests that structural violence and intergenerational trauma are much more likely culprits of higher disease burden among nonwhite individuals (Moran-Thomas 2019; Smith-Morris 2006). Including the ecological and recent dramatic environmental disruptions in Playa Felumi (and much of the Global South) that have

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reordered lifestyles and resulted in what researchers around the world now commonly recognize as diseases of development (Brondo 2013; Moran-Thomas 2019; Weidman 2012).

Conclusions

Using the MOH and PAHO-identified priorities, it is evident that HMH missions did not fill critical gaps in management of chronic non-communicable diseases. As previously noted, they do bring personnel, though on a temporary and sporadic schedule, but they do not coordinate with local staff or provide critical missing expertise, share epidemiological information, and most often duplicate rather than supplement existing efforts. Although HMH provided free diabetes and hypertension treatment and medication, they only did so sporadically.

Supplying the CESAMO with pill-based treatments was reportedly “easy,” and would have actively improved healthcare access and the ability of local healthcare providers to respond to existing and new cases of diabetes and hypertension, but these efforts were predicated on untenable and unnecessary conditions.

Sporadic treatment, insistence on insulin even against best practices, and poor coordination ultimately contributed to the already established concerns of poor health care response and increasing the costs for patient care in the long run. Neither Clinica Blanca nor the

CESAMO regularly had enough insulin or pill-based treatments for diabetic patients to not be forced to seek out hundreds of dollars of monthly medications, self-adjust, or simply skip or stop treatment altogether when they eventually ran out. Medical mission volunteers with HMH readily acknowledged that their attempts to treat diabetes and hypertension were ineffective (and had been for years) and potentially added barriers to long-term access to equitable and adequate treatment for Playa Felumians. However, their continued behavior implied that malpractice and iatrogenic violence were “better than nothing” (Sullivan 2018). 340

The tendency to therapeutic domination is evident in HMH approaches to chronic diseases and their failed efforts to coordinate with the CESAMO. While there were some nominal attempts to coordinate with the CESAMO, rigid expectations on the part of HMH board members and volunteers hobbled any real chance of cooperation. In establishing terms of cooperation that emphasized convenience for the medical mission organization rather than working with the infrastructural and staffing realities of the CESAMO ensured the ultimate failure of relationships. The situation served to further undermine the CESAMO, its staff, and their concerted efforts to identify and treat patients with chronic disease in Playa Felumi and reinforced discourses of distrust and beliefs that the CESAMO staff were untrustworthy, unreliable, or incompetent. And again, failure or refusal to cooperate with the CESAMO, even in coordinating care or follow up for individuals with chronic diseases, undermines local healthcare infrastructure and threatens ongoing access to equitable health in Playa Felumi. Further feeding neoliberal political narratives in Honduras that seek to use provoked crises in public health infrastructure as justification for privatization – which would ultimately reduce access to healthcare in general and increase health and financial inequality, exacerbating many of the structural problems that contribute to higher chronic disease burdens in the first place.

As seen in the previous chapter, HMH volunteer protocols, practices, and discourses have several iatrogenic effects. Ignoring regional and national best practices for the treatment of diabetes and hypertension and insisting on treatment regimens that increase costs and decrease adherence for patients is malpractice, a form of clinical iatrogenesis, but also contributes to forms of social-structural iatrogenesis. Reliance on culture of poverty tropes, racialized and ethnocentric stereotypes, and the use of “responsibilizing” approaches and biological determinism to inform care plans, treatment, and advice of patients reinforce problematic social

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hierarchies and constitute psychological, equity, and group and social harms. These social hierarchies are part of the self-Other dialectic, establishing HMH volunteers as intellectual and moral authorities, more knowledgeable, responsible, and more trustworthy than their Honduran counterparts.

The next chapter considers the disparate ways efficacy and fairness are determined. It circles back to the medical mission discourses and ideologies presented in Chapters 8 and 9 to show how they influence the process of self- and Other-making in the mission encounter and why “success” is inevitable.

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CHAPTER 13

“BETTER” MEDICINE?

Chapters 11 and 12 presented examples of the ways medical mission discourses inform their decisions, care plans, and ability to respond and incorporate new information related to the medical mission encounter. I identified examples of direct harms (clinical iatrogenesis) and potential and actual psychological harms (for example the stress and distress that some individuals experience as a result of medical mission imposing injectable insulin), as well as consistent patterns of public health iatrogenesis realized when missions deviate from established best practices, both in patient care, as well as in epidemiological monitoring and surveillance. I established that in refusing to cooperate with local healthcare they further threaten the public health system and contribute to the provoked crises already present. And rather than filling identified gaps, or supplementing local healthcare resources in intentional ways, HMH missions most often duplicated (or imperiled) existing services and behaved as though in competition with the CESAMO.

This chapter returns to the themes of self- and Other-making inherent in the medical mission encounter and the ways that the ideas circulated by mission volunteers are internalized, refused, or complicated in conversations about fairness, “success,” and efficacy. The chapter considers the role of therapeutic domination and the virulence of mission discourses on the perceptions of medical mission in Playa Felumi.

Having Faith in Medicine – Meaning Response and The Social Contours of Healing

Faith in medicine is an important concept in critical medical anthropology but under- appreciated in biomedical understandings of the efficacy of medicinal and behavioral therapies to

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patients. There is substantial critical medical anthropological research on placebos and meaning responses (Moerman and Jonas 2002) that demonstrates the importance of one’s belief in the medication, therapy, and healer on the healing process. Byron J. Good (1994) argues that only when one’s issues have been shared and socially recognized can medicine be considered effective. Curative medicine and healing, regardless of biomedical discourse, are not simply a pill-for-symptom transaction, but a social process influenced by multiple factors in a culturally specific context. This is the relationship Moerman and Jonas (2002) capture in focusing on the

“meaning response” to understand how treatment works and how medicines affect illness and healing.

I also use the term faith in the spiritual sense as a belief in things unseen. This is both a nod to the fact that medical missions (whether purportedly secular or explicitly religious) often invoke religious faith and the very practice of missions are ways to seek out evidence of God’s presence and miracles, and the origins of biomedicine in colonial missioning. It is a hallmark of biomedicine, and a factor in its global hegemony, that it works - that is, cures, heals, treats effectively - because it is scientific and technological and involves expertise in the form of a specialized knowledge of the body (Good 1994). As one volunteer explained “…what we do in the US depends on technology and infrastructure that does not exist outside of the ‘first world.’”

Biomedicine, like other forms of medicine, relies on the trust or faith of its adherents – and its practitioners. It has achieved this through modifying people’s relationships with their bodies, changing the meanings of our bodies, and their functions (Foucault 2003; Haraway 1985;

Rose 2007; Lock 1993, 2017; Scheper-Hughes and Lock 1987). And, it has also achieved it through the discrediting of other forms of healing and treatment as inferior, primitive, and by

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extricating agency from individuals to prevent them from playing a central role in determining their own care.

One of the processes by which this standardization takes place is through the erosion of faith (or trust) in other doctors and healers (Good 2010; Michael Jackson 2010; Arthur Kleinman

2010). Put another way, the standardization of biomedicine entails the erasure and discrediting of non-“Western” (including the CESAMO) and non-biomedical forms of healing and curing through corresponding discourses of distrust and need/lack. The discourses not only form the subjectivity of the medical mission volunteer, solidifying their identity as moral and intellectual authorities, but also get taken up in the subjectivities of Playa Felumians who internalize the messages circulated in the medical mission encounter.

In patient consultation rooms, I often heard STMM care providers say, “I don’t trust the government clinic,” or would switch a patient’s medications and say, “this one is better.” When medical mission volunteers told individuals that something was “better,” there was often little understanding on the part of the volunteers of the context and meaning that better can have in

Playa Felumi. Not only did it mean that a medication was good as in effective, but also that what the patient was taking before was therefore not good, or ineffective and undesirable. During home interviews, I discovered that some patients would not return to the other, sufficient, and available medications when they ran out of the prescriptions they had received from the medical mission, because they had been told, perhaps unintentionally, that their previously functional medicine was no good. Even those patients taking the common Metformin and Glipizide medications did not seek out refills at the CESAMO because STMM volunteers often told patients, incorrectly, that the CESAMO did not have medication for diabetes or hypertension.

When I spoke with them, or accompanied Gabriela on house visits, patients were often surprised

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to learn that the CESAMO indeed had the medications, as well as blood pressure cuffs (and eventually glucometers), they needed. This misinformation typified the day-to-day practice of medical mission teams, how they prescribed medications, and “educated” patients.

When I asked individuals that identified as wanting to go exclusively “donde los gringos” why they preferred Clinica Blanca, respondents stated that, “they always bring good medicine,” “it’s better,” “they have better medicine,” or that there were “too many people [at the

CESAMO].” When I asked them why the medicine was better the answers included, because it is

“American” medicine, or that it “worked,” compared to Honduran or medicines labeled in non-

English languages that “no llega,” don’t work.15

When I followed up to ask why they believed care was better at Clinica Blanca, individuals would most often respond by saying that “good doctors come,” that the nurses and doctors were better because they are [North] American. Some believed they had better or more training or experience. Patient responses included, “they know how to give medicine,” and

“when they give consults, they know how to give consults” or “they do everything well, because they have studied.” Others said Clinica Blanca was “better” because it had more equipment than the CESAMO or because some volunteers would attend births and the CESAMO would not

(because they are forbidden from doing so by national policies). During my research only two teams attempted to assist during childbirth and both families were ultimately sent to the nearest hospital by the local ambulance because of complications, one woman miscarried and the other safely gave birth at the public hospital in Tocoa.

Lock and Nguyen (2018, 120) note similar tensions among North American and Tibetan biomedical health workers in their attempts to develop a midwifery program to promote “safe

15 Literal translation: “don’t arrive” 346

motherhood.” An epistemic imperative based in the assumption of the supremacy of Western ideologies of biomedicine creates “facts out of context” (Lock and Nguyen 2018, 120).

“Instruments of modernity” are designed to force the unconverted to abandon “outmoded beliefs” (Lock and Nguyen 2018, 120) in lieu of “better” medicine. Lock and Nguyen conclude that the critical issues are what counts as truth and the epistemological violence entailed in erasing other ways of knowing.

The destruction of faith in medicine can therefore be understood in the context therapeutic domination, and more specifically as a form of social iatrogenesis (Illich 2013) inflicted on the communities where STMMs work, as is the erasure of the CESAMO, and the discrediting of the broader health system, whether intentional or not. This process relies on racialized and ethnocentric hierarchies, harmful stereotypes, and thus contribute to equity and group and social harms. These overlap with psychological harms that are made apparent through internalization of negative stereotypes and shame or embarrassment concerning ancestral and indigenous knowledgeways and healing. The consequences of this disruption are not limited to the realm of ideas but were also material. There were families in Playa Felumi that refused to visit or be attended at the CESAMO because they had accepted and internalized a discourse that undermined the local (in every way), drawing on colonial notions and ethnocentric hierarchies of superiority and inferiority.

Fairness and Efficacy

Many STMM volunteers are unaware that their actions and language create harm, partially because the discourses they circulate to establish their spiritual and biomedical authority serves to insulate and absolve them of well-intentioned errors or wrongdoing. However, there were dissenting voices, that recognized pitfalls and expressed concern about HMH practices 347

models, even if they were unsure of how to enact changes or felt limited by the structure, organization, and temporariness of STMMs. Those structural limitations, too, are part of the

“dark logics” that Bonell, et al. (2015) identify as critical to evaluating potential harms and underlying structures in public health projects.

In our conversations and in surveys, physicians and non-medical personnel alike expressed their concerns about the efficacy of the teams and about the expectations of volunteers. As the vignette about malaria showed in Chapter 11, there are also diverging opinions within the STMM organization regarding medical best-practices and how to accurately and fairly provide safe, reliable healthcare to the residents of Playa Felumi. Garífuna medical students, and a mix of local and regional medical professionals, also weighed in on their concerns about medical brigades and ideas for how best to improve healthcare for Hondurans.

There were two primary areas of critique that I identified. The first was the issue of fairness—who had access to the mission teams and volunteers, whether and how that access was impartial or affected by real or perceived favoritism, keeping promises, and remuneration (for local people HMH employed). The second critique made by both medical mission insiders and outsiders concerned efficacy and organization – consistency in protocols and following them, adequate preparation and appropriate supplies, and both intra- and inter-clinic communication.

The discourses of need and lack, and the casual language of “better medicine” influenced how medical mission volunteers determined successes or qualified success in the context of their own critiques.

Fairness

HMH volunteers did not usually raise the issue of fairness. Rather, fairness was a regularly expressed concern of Honduran medical professionals, individuals employed by the 348

STMMs during the brigade season, and Playa Felumians in general. In April 2015, one young

Garífuna doctor, Dr. Soriano, who volunteered with three other young Honduran doctors had been instructed to triage and turn away any patients that weren’t emergency cases. There were about 20 people crowding the cast-iron gate that secured the waiting room area anxiously awaiting consultation. The team leader, Marjorie, was flustered because a group of children from

Casa Hogar (the “orphanage”) were supposed to arrive soon and they were to be given priority care. This, however, had not been communicated to waiting patients and those who had been there since the morning but were not able to see a doctor before the team took their lunch break.

Rather than turn the patients away, Dr. Soriano calmly assessed each patient’s concern and one-by-one they all entered for consultation. It was only later, over dinner at one of the local homes that operated as a restaurant with his Honduran colleagues and me, that he expressed his frustration at the scenario. “Disorganization,” he lamented. “It is not the patients’ fault.” Teams must be organized and stick to their plans, he insisted. Dr. Soriano said, “how am I, the doctor in uniform, going to tell patients no,” referring to earlier events in the day. “They’ll then say that the brigade did nothing, or didn’t help me, or mistreated me.” The others agreed, “Exactly.”

Within this single scenario two important issues of fairness emerge. First, Dr. Soriano, the Cuban-trained Honduran Garífuna doctor, suggests that STMM volunteers’ frustrations with anxiously waiting patients is misplaced. This frustration, and the related expectation of gratitude and “good” (grateful) patient behavior, has been a recurring theme throughout these chapters. In a relationship of therapeutic domination, deviance from the grateful patient subject-position, are disregarded or could even result in being denied resources. Rather than shifting responsibility onto the patients, Dr. Soriano insisted that poor planning and communication on the part of

HMH organizers was the source of both volunteer and patient frustration. Triage is a

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quintessential conundrum of humanitarian interventions, usually rationalized by limited time and resources (Redfield 2012; Fassin 2011). Inherent in triage is the question of deservingness—how does one decide who gets care and who does not, who needs care and who can go without

(Redfield 2012)?

Second, there was the case of the “orphanage,” which had a special, if complicated, relationship with HMH. Casa Hogar and the children who lived there routinely received a higher level of attention and care from the medical mission teams, including special house calls to provide medical consultation and treatment at the home, and/or blocking off time for the children

(there are about fifty children living at Casa Hogar at any given time) to come to Clinica Blanca

– no lines, no waiting – to receive care. It was rare that the home’s director would take the children to the CESAMO for check-ups and care. The medical director of the CESAMO, Dr.

Muñoz told me that she worried about missing the children of Casa Hogar in their coverage of

Playa Felumi, but that Sor Inez would not bring the children unless it was an emergency.

At lunch one day in March 2015, Dr. Muñoz said the Casa Hogar director would not come to the health center, or if she did “she expects the children to be seen immediately and gets mad if they are not skipped ahead [of other patients] and leaves.” Dr. Muñoz attributed this expectation to Sor16 becoming accustomed to the special treatment she (or more precisely the children) received at Clinica Blanca. Dr. Muñoz said she “just can’t do that. If there are people waiting, it isn’t fair, and there is a system in place, and I am obligated by that system.” Dr.

Muñoz worried about the kids at the home because the health center missed them for so much healthcare. She tried to send outreach nurses to Casa Hogar whenever she could to ensure children had their vaccinations and got regular check-ups. Dr. Muñoz was concerned about

16 It is not common for the honorific to be used in this way, as a name or nickname, but in Playa Felumi, this is how nearly everyone, including STMM volunteers refer to Sor Inez. 350

fairness and continuity and quality of care for the people included in the population that the

CESAMO is responsible to treat. Her account also reflects the favoritism that contributed to Dr.

Soriano’s awkward position.

Another woman, Ginny, whom I interviewed in her home, suggested that favoritism appears at Clinica Blanca in other ways. Ginny expressed concern that the poorest in Playa

Felumi did not have access to the same kinds of assistance and aid as she recalled having in previous years. “I’ll repeat that they have always helped me and my daughter. But there is a problem, there, at the brigade [clinic]. There are some employees there, that…that talk about us, about us from here in [Playa Felumi], so that now they don’t help.” She tried to explain the economic disparities, “There are some of us, friend, that have family in the [United] States, there are those of us that do not have family in the States. Those people that were there [at Clinica

Blanca] from the brigades, are scoundrels [tajos de sinverguenza], they’re sly! [Son sapos!].”

She told me that help was no longer available like it was when her daughter was still in grade school, underlining a trend in medical mission differential treatment of young children to the exclusion of older youth and adults. “When my daughter was in school, we got…how do I put it? We received some assistance, but friend, that doesn’t happen anymore. Why? Hm? Why?

I’ll tell you again, these people that were there, they want [resources] for themselves. They work like cotton, like this [holding a sponge], for themselves. It isn’t like it was before. For support to come to us, the poor, it doesn’t happen anymore. It’s the leaders there in the hospital [Clinica

Blanca].” I asked her what could be done to rectify the problem she had identified. “The same people, the same leaders are still there. We can’t do anything. If I have a child in the States…[the same employees] are there.” Ginny was not the only resident who expressed concern for reaching “los pobres” or that had observed a decrease in the kinds and amounts of assistance that

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brigades provide. Household interviewees also suggested that medical missions could improve by getting out of Clinca Blanca and into the community.

HH8: They should visit the poor families in their communities [within Playa Felumi] where there is still poverty.

HH15: Visit homes - people who can't leave. They can't go anywhere, and the HC also doesn't visit [incapacitated patients].

HH18: Visit the houses so they can note the poorest…

CESAMO staff and community health workers frequently raised the same point.

Ginny’s account requires some additional context. Clinica Blanca employed close to twenty people, almost all of whom lived in Playa Felumi though only a few of whom were from

Playa Felumi. Nearly all of the people employed there are not Garífuna. Some are Bay

Islanders—and are valuable to the STMM organizers because they speak English and Spanish, and at least one of them speaks Garífuna. Almost all of those employed were related or were related to someone who worked there in the past. Ginny’s concern was that the kinds of assistance offered to her and other people she would identify as poor has changed as a result of these employees talking negatively about Garífuna families or reporting when someone has a child or family member living in the Unites States. This last detail matters because of the assumption that having a relative in the US automatically means that those families have access to remittances or a better standard of living than those who do not. Later in the interview, Ginny, who does not have children or family living abroad, exclaims, “It doesn’t matter if someone has family in the US!” And as Playa Felumian illness narratives indicated in Chapter 10, many with family in the U.S. experience distressed because, despite the dangerous process of relocating for work and the hope of remuneration, their relatives struggled to find employment or send financial support back home.

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Ginny’s narrative implicitly suggests that the employment of ostensibly “local”

Hondurans acted as a kind of Panopticon (Foucault 2007). Employees’ proximity to Playa

Felumians, in conjunction with their positions within HMH, created a kind of web of surveillance, giving the employees power to influence the STMM organization’s leadership and volunteers’ perceptions of community members. She also believed that the power and influence of the employees put them in a position to unfairly benefit from their proximity to material resources and the social capital they have acquired through perceived (and real) nepotism.

Like Ginny, the employees at Clinica Blanca were merely trying to eke out a living and were also concerned with the value of fairness. While Ginny and others in the community argued that there was unfairness regarding who was employed, Ricardo and other employees were concerned with how that employment played out. This became evident on a mild January day in

2015.

On my way to restock on groceries at the corner stand, I saw Ricardo, one of the veteran

HMH employees leaning against the Clinica Blanca fence, gazing pensively at the building. I asked him how the work was going. He chewed his lips a moment then pointed to the new lumber on the back deck. “We already finished this.” I admired the fresh, clean lumber. There seemed to be several projects going on at Clinica Blanca all of a sudden. The warehouse/storage space doors were wide open, materials strewn about the floor. There was also a bunch of wood, concrete, and metal debris in the pharmacy waiting area. Ricardo told me they had emptied and were cleaning the water tanks. I asked if they cleaned them every year. He nodded, scrunching his face into an expression that expressed certitude. He then complained about the mess of the work around back where there were workers reinforcing the beams and rebuilding much of the back supports of the two-story building. Curious, I asked if the foundation was paying for the

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repairs and labor. He gave me a sharp look that clearly expressed his aggravation. “Heh! No, they haven’t paid me anything! I painted all of this by myself, and this,” pointing to more of his manual labor outputs. “Buck is very cheap!” Ricardo was noticeably irritated.

I had more questions. “And is he paying the guys that are working [around back]?”

Ricardo told me that HMH had contracted with an engineer in Tocoa. “All these men are from

Tocoa.” His tone was dismissive, distrustful of outsiders. HMH had brought in outside labor to do the work on the building. I wondered aloud why they did not hire local people to do the work.

He shrugged and said “Before, when this place was founded, Dr. Simons worked with a man here, called Melvin, but not anymore [Dr. Simons died in the Spring of 2014]… And [the

Tocoan men] stole two pairs of tennis shoes and one pair from [someone else].” Ricardo suggested that the outsiders hired to work on Clinica Blanca were untrustworthy and that it was only when HMH started using outside labor that things started to go missing.

Ricardo told me that he was going to have to talk with Buck when he would be there on a team in a few weeks. Ricardo said he had tried to talk to Buck before about his pay. “They only pay me $200 a month. I told Buck, that’s starvation wages!” He continued, “When I started here, with Dr. Simons, I started under these conditions [referring to pay], and if it doesn’t…if it continues like this, I won’t come back here. Nah!” It seemed that Ricardo expected to have to fight to be reimbursed for his work after painting the entire very large building himself and paying for the supplies out-of-pocket.

He continued to point out concerns he had about the current HMH leadership. “I don’t have any problem with any brigades, just with this guy, Buck. You know Aurelio?” I nodded. “In the past, he brought his cooler with a few refreshments for the people [to buy], but they forbade him to bring it.” Confused, I asked why. Ricardo declared emphatically, waving a hand, “They

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didn’t accept it!” Aurelio would bring bottles of water, sodas, and small snacks that people could buy at normal prices while waiting in the long lines, so they would not lose their place and could satisfy their thirst and hunger (and more often that of their children). Aurelio supplemented his income and provided a convenience to his fellow Playa Felumians.

Ricardo’s narrative traverses a few aspects of fairness, paramount of which is remuneration for work and fair treatment, not just for himself, but for his coworkers. The employees who work there, like Ricardo, have been there for nearly 20 years, since Dr. Simons founded Clinica Blanca. But their pay has not changed over time or with costs of basic goods.

Ricardo, his sister Luz, his brother Hugo, and a Garífuna man called Jeicob are the only employees that receive regular monthly pay. And it is the same as it was when they all began working for HMH as groundskeepers, maintenance, overnight security, and housekeeping twenty years ago. Ricardo received $200/month, though I did not learn what his siblings or Jeicob are paid. The remaining employees are paid by each brigade and therefore only receive pay when there are brigades operating in Playa Felumi. If for any reason brigades are cancelled, those employees lose that potential income. Ricardo and Hugo also receive additional pay from each brigade for working as interpreters along with another relative. One of the team leaders, Dr.

Milton shared his “payroll” list with me after I bumped into him in the Clinica Blanca hallway.

Dr. Milton had a sheet of paper in his hand and said they pay all the Honduran staff. He paused and then said, “well, here,” and showed me the piece of paper with handwriting that showed what each person was paid per day. He went line by line. Esmerelda, the young woman who worked in the laboratory (Chapter 9), received the lowest amount $11/day. The male interpreters (Ricardo and Hugo) received the highest amount at $18/day. Their female relative received $13/day for the same role. The staff that washed laundry and cooked meals for the team

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(also women) received $13/day. Dr. Milton, did a double-take, and remarked that the woman who washed their clothes were “worth more than that!” He explained that the foundation sets the rates of pay, but each team is responsible for paying the staff. Their pay is part of the volunteers’ fundraising efforts before coming down. Dr. Milton added, “So, I guess we contribute to the local economy some!” I smiled and nodded and asked him if the amounts had changed over the years. He said, "not really… maybe a dollar here or there, but nothing significant.”

On another occasion, I walked into the STMM common area on the second floor of

Clinica Blanca where the women that did housekeeping and kitchen labor were speculating in hushed voices about proposed changes they had heard about from the in-country coordinator for

HMH, a temperamental man called Alan, and whether they would still have paid jobs. They also worried about whether they would see improved working conditions, especially for the older employees, because the housekeepers and cooks often worked fifteen-hour shifts. These women arrived early in the morning between 5 and 6 am and stayed until 8 or 9 pm each day of the brigade. Two of the women are in their 50s, but their primary concern was having to work long hours and walk home in the dark, especially given the increase in drug-trafficking and other gun-related violence that had recently rocked Playa Felumi and heightened general levels of insecurity among residents (and anthropologists, too).

While Ricardo made more than any other employee at the HMH clinic, he is justified in his concerns that wages have not increased for anyone. Ricardo believed this to be related to

Buck’s direction of the foundation and reiterated that Buck was no Dr. Simons. To explain,

Ricardo recounted Dr. Simons eulogy in order to explain the core differences between Buck and the previous HMH president. Ricardo heard about Buck’s intentions from another local resident who attended a service for Dr. Simons after his death in March of 2014. The story went that Dr.

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Simons had been an Air Force pilot or perhaps Army and had been in several battles. On his fifth mission Dr. Simons was in a lot of danger and thought that he might die, so he prayed to God and said if God saved him from the danger, he would do something to help others and bring them to God. Ricardo nodded toward the building and said the clinic was that repayment. Ricardo lamented that Dr. Simons’ successor seemed to be dishonoring that history and negatively altering the clinic’s model. I asked Ricardo what he thought about some of the proposed changes that some board members had suggested; namely that people would have to pay a “nominal” fee for consults and that some board members wanted to transition from paid staff to unpaid volunteers. Ricardo seemed surprised and amused that they were considering charging patients.

He smirked and chuckled wryly, then asked, “You know Sr. Bonnie,” pointing towards the health center and the direction of Flor del Monte where they lived. “She wanted to charge like

L.5 for consults and Dr. Simons said no, he got angry! He said that she would no longer work with them.”

For Ricardo, the idea of charging patients for consults ran contrary to the intended purpose of Clinica Blanca and its founder’s ideals. That Dr. Simons made a bargain with God makes the proposed changes that much more inscrutable. His narrative also revealed the tensions within STMM organizations and the competing ideas about charity, gifts, dependency, and rights. For the residents of Playa Felumi, the services that Clinica Blanca provided are an obligation and a right. The fact that they are free is one of the most important reasons valued

HMH missions. For some STMM volunteers it was a duty to charity, for others it was a gift (but not an altruistic gift, since they demand the return-gift of gratitude and the comportment of a

“good” beneficiary), and for still others it was a toxic form of charity that generated dependency

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(rather than a relationship of mutual care and reciprocity) and threatened, in the minds of the volunteers, the dignity of Playa Felumians.

Distrust and Envy

The issue of fairness was not confined to the context of the brigades. It is an everyday issue in Playa Felumi. There are several reasons that may explain why fairness is such an important issue. Playa Felumi is first and foremost a Garífuna community and was thus founded according to Garífuna rules of social organization. Garífuna communities are communal. Land titles are held in common, and resources are shared. Sharing is a paramount value and practice.

Reciprocity is key to sharing. And reciprocity, by definition, demands fairness.

Playa Felumians revealed patterns of distrust that centered on perceived (and real) imbalances in the relationships HMH had with individuals and “organizations,” like Casa Hogar, and that STMM volunteers had with individual people through the use of “envy” as an idiom of distress. My observations and interviews revealed STMM activities fostered feelings of distrust and envy among and between Playa Felumians, which influenced social alliances, interpersonal relationships, fueled misinformation about availability and appropriateness of resources, and sometimes affected people’s decisions to seek care.

Envy is a powerful phenomenon in Playa Felumi. Unexplained injustices are often blamed on envidia, envy, and are evidence of a perceived decline in morality and human decency among Hondurans more broadly. At the funeral of a 12-year-old boy that I attended, the priest mentioned envy numerous times during the sermon. Envy did not kill the boy, and everyone in town knew that. He had been murdered by a sicario, a paid assassin, sent to kill his older brother

(just 18). The boy was sleeping in his older brother’s room while he was out of town, and the assassin made a deadly mistake. It rocked all of us. It further rocked some of us when the 358

supposed assassin was tortured and killed by a different group of vigilante assassins sent to find him and punish the mistake. The graphic photos were sent out over text and WhatsApp and social media for everyone to see and share.

The whole town knew what happened, but to say it aloud or to name names was so dangerous that no one dared. In general, the police also fear the narcos, however in Playa Felumi the local police are largely suspected to be on the payroll of the local narcos. In situations like this, when there is no recourse, and the truth is too dangerous to utter, envy is an easy and acceptable scapegoat.

Envy was not reserved only for the most extreme circumstances. Envy is a social mechanism, a linguistic mechanism, that (among other things) marks unequal access to resources. Envy is the consequence of unequal distribution of resources, but also failure to properly maintain reciprocal relationships. In this way it fits the criteria of an idiom of distress

(Nichter 2008). People who have more were once expected to help those that have less in Playa

Felumi. Garífuna communities have historically been collectivist, but systematic disenfranchisement and dispossession from land as well as concerted efforts to strip communal titles to sell land to foreign tourism and agricultural conglomerates have negatively impacted collectivism. In part, this structural violence has forced more youth to try and leave the community or country to find paid work and be able to maintain their families’ homes in Playa

Felumi.

Don Samuel explained to me that things changed in the community when younger generations started traveling to the U.S. to live and work. Those family members began sending remittances back home and suddenly stark class divisions emerged. Using an embodied example to illustrate, Don Samuel said, “Before, I would go to my neighbor’s house to visit, socialize. But

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now, I have my little house, my television, and now I don’t want to visit. I can see her wooden house and that she doesn’t have these things, and now I don’t want to visit her.”

Limited or no access to renumerated work, systemic racism, and uneven access and opportunity for remittances has resulted in rising income inequality. Don Samuel also described how an uneven influx of dollars and material resources have not only created stark class divisions but has also changed the meaning of poverty. “Before, we didn’t have ‘poverty.’ I mean, there was poorness because there was no money, but there wasn’t impoverishment.”

People had food, were self-sufficient, and there was not differential suffering from lack of resources. “And now there is a deep, DEEP, poverty! There are people here that did not have breakfast this morning and don’t know whether they will get lunch or if they will only eat a tortilla with a bit of beans or something…Money changes everything,” he said, and “it changes people.” He reflected on his own experiences traveling to a resource-poor area of Bolivia as part of work he did while in Belize with a development organization there. The experience, not unlike that of North American medical missions, taught him what it meant for people to live in poverty and to live only on a few corn tortillas a day, maybe with, but probably without beans. He says it makes him appreciate every meal he has. He said he was “blessed,” thanking God for his relative class position and invoking similar subject-making discourses circulated by medical mission volunteers.

Unequal access to public services based on political party affiliation, like the controversial and corrupted Bono de Diez Mil political program (refer to Ch. 6), and other factors, such as individualized aid programs that promote competition rather than cooperation have also contributed to more class conflict and inequality. Playa Felumians note this inequality

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through the concept of envy, although it is used by even the most impoverished as an explanation for mistreatment, unfairness, or injustice.

As it concerns the Casa Hogar, Playa Felumians often express envy and distrust conjointly. Pearl, an octogenarian with whom I spent many afternoons conversing, flatly told me that she did not trust Sor Inez. Pearl’s daughter, Durina, a lifelong resident of Playa Felumi and a teacher at the high school, is a member of Casa Hogar’s governing board and often invites the children to come by her home and pick fruit from the many trees growing in her yard that produce oranges, limes, lemons, grapefruit, avocados and coconuts. While Durina did not express any complaints to me about Sor Inez, Pearl believed that Sor Inez was dishonest about the position of need she claims on behalf of the home and the children. Pearl disliked that there were children who lived at Casa Hogar “that are not orphans.” She also registered her dislike that Sor “sends the children to [Durina’s] house to take fruit, coconuts, and other fresh things” when “[Sor] has a huge compound and receives money from brigades.” Pearl did not believe that

Sor Inez used that money for the children, but that she “takes it for herself.” She added that she did not like that Sor “asks for things” from Durina or anyone else in town.

Fairness and the ways that STMMs disrupt or amplify social dynamics in the community are the undercurrent in Pearl’s grievances. They also reflect the tensions Daniel (2014) has noted in the tendency of international aid to be highly individualized, rather than oriented around community. HMH operates on a scarcity model, using discourses of deservingness disguised as triage to decide who gets material aid, which often results in the uneven distribution of aid to a select few, while others are left out. Similar to Daniel’s (2014) observations in Tanzania, individualized aid may create the appearance of favoritism, or result unnecessary divisions in the

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broader community (even sometimes within family units), resulting in negative gossip, accusations, and conflicts between those who benefit by those who are left out.

Efficacy

The second critique that my interlocutors had of medical missions focused on organization and efficacy. Honduran health workers, Playa Felumians, and HMH volunteers all weighed in on whether and how teams were effective – that they were providing adequate, efficient care or generally contributing to improving health or health infrastructure. Several participants noted issues with best practice compliance, efficiency, and organization and communication were stand-out concerns.

In August 2014, I attended a three-day conference and workshop about healthcare among aspiring young Garífuna medical students and local Garífuna doctors organized by Dr. Castillo,

OFRANEH, and the First Garífuna Hospital in the municipality of Iriona. Dr. Castillo invited me to share my research goals with the group and I asked for their experiences and observations about medical missions in Honduras.

A Garífuna doctor in the audience suggested that, “It would be better if medical brigades were led by local doctors who know which patients need to be seen rather than brigades seeing an enormous quantity of patients who may not need medical attention or who come just to hoard medication [he mimed holding an armload of medicine] until it expires.” He continued, “this method also allows for the local doctor to make notes and maintain records so that he or she can follow up and provide continuous care. As it stands now, brigades come and doctors provide diagnosis and medicine, but don’t leave notes or records so that patients can get adequate follow- up treatment.”

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Like Dr. Muñoz at the CESAMO in Playa Felumi, the audience member emphasized continuity of care and addressed current trends in medical mission practices throughout the country that impede it or make it impossible. He also pointed out other potentially concerning practices, like hoarding medication or missing key patient populations, such as the disabled, elderly, and people with severe or debilitating chronic diseases. The critiques from Honduran research participants focused on ways to improve healthcare delivery and information flows.

HMH volunteers sometimes acknowledged the same problems. In their survey responses, some volunteers stated that, the “Team was not aware of local clinic,” or noted a general “lack of information on local healthcare resources.” Others talked about having met CESAMO personnel or a desire to work more collaboratively with the CESAMO, while also potentially addressing the “lack of familiarity” their co-volunteers identified. For instance, one survey response suggested that, “Working with the local clinic would have been far more efficient. The

[CESAMO] has a better understanding of the needs of the local population. [Would] minimize duplication of services. If there were good coordination the teams that visit could better support the clinic. They could bring supplies that the clinic needs and uses. They could bring the medical specialists that are most needed.”

Only a few HMH volunteers and their corresponding teams took an interest in establishing and maintaining relationships with CESAMO staff, although those relations cooled considerably after the CESAMO director was promoted to a regional position. Indeed, collaboration with local doctors and healthcare facilities was a common suggestion and request of Honduran medical professionals. At an annual Garífuna community health conference held in the municipality of Iriona, a Cuban-trained doctor in the audience expressed the common opinion that, “brigades need to work more closely with local doctors to better understand the data

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available about local causes of morbidity and the most common illnesses so that they can bring appropriate medications and prepare appropriate treatments.” Some STMM leaders seemed interested in learning how to collaborate, even if the logistics of doing so and intent to follow through were not clear.

Dr. Milton, for example, appreciated the perspectives of, Dr. Soriano, the Cuban-trained

Garífuna doctor who had joined the team as a volunteer between assignments at the public hospital in Trujillo. While observing Dr. Milton during clinic one day, I also interpreted for him.

He was sharing a consultation room with Dr. Soriano, and both were seeing patients simultaneously. Just after they saw their respective last patients before lunch, Dr. Milton wanted to talk to Dr. Soriano about healthcare for diabetes in Playa Felumi. Dr. Milton asked Dr.

Soriano about medicines, which ones they use at the CESAMO, and what the teams should bring. Dr. Soriano confirmed that the diabetes medications the teams brought this time are usually what the CESAMO stocks. The only difference is the doses. The CESAMO usually only receives 850 mg metformin from the Ministry of Health, despite often needing the 1000mg dose, which is more common in STMM supplies. Dr. Soriano added that it would be better not to prescribe combination drugs, formulations that have two active ingredients in one, because they are hard to find in Honduras, they are expensive, and they are not stocked by the CESAMO.

Dr. Milton also wanted to know Dr. Soriano’s ideas on the best way to treat the two most pervasive chronic illnesses in Playa Felumi (diabetes and hypertension). Dr. Soriano happily obliged and told Dr. Milton that he thought education was the most important thing that could be done, because it constitutes preventive healthcare. Dr. Soriano suggested education could be done through the community radio, instructive talks (charlas), and a diabetes and

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hypertension support group. Dr. Soriano even offered to help with these components because, he said, he “knows local idiosyncrasies.”

The efforts of individual leaders like Dr. Milton or Dr. Collin, who attempted to normalize malaria treatment and cooperative relationships with the CESAMO, were met with resistance and frustration. And although they both sought and collected important information that could be easily incorporated into HMH practice, nothing changed. The current formulary still lists the 500 and 1000mg versions of diabetes medications, for example, and there is no relationship with the CESAMO, and based on the current team report documents, required epidemiological surveillance and pertinent patient data is still not shared with the CESAMO.

Like Dr. Milton, many other volunteers, especially physicians, expressed interest in

“local” ideas or concerns about the current STMM practices. Some recognized their limitations and highlighted the value of knowing “local idiosyncrasies.” In response to a survey question about the challenges STMMs faced on their most recent trip, one respondent wrote: “We are also limited by our lack of familiarity/understanding of the medical/political situation in Honduras and cultural barriers.”

Other responses further supported Dr. Soriano’s observations about organization and communication. For examples, survey responses suggested that STMM volunteers did not have the same information, or that information-sharing and general communication between teams was very limited. At an intra-clinic level, STMM volunteers noted eight major challenges they faced on their respective teams: (1) “disorganized role distribution” among volunteers, (2) “team organization,” (3) lack of or running out of medications and supplies, (4) insufficient numbers of medical volunteers, (5) “Lack of strong leadership in [one] group [and] lack of training new

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participants from experienced participants,” (6) “too few translators,” (7) “too large of a group, issues within the group,” and (8) underutilization or misuse of volunteers’ skills.

Medical mission teams frequently made (or changed) plans on the fly, without consulting

Playa Felumians or simply informing them of scheduled or unscheduled changes. Ricardo or his sister would sometimes write the dates and which communities would be served on each day of an approaching brigade on a dry-erase board zip-tied to the chain-link gate that enclosed Clinica

Blanca. However, they could only do so if they had been informed ahead of time, and accurately, and that was not common. Furthermore, there was little communication about the brigade outside of the little dry-erase board; the brigade leaders and the local staff did not routinely make use of community radio stations to more uniformly disseminate brigade-related announcements. The

CESAMO almost never knew when a brigade would be in town, unless a mutual patient had informed one of the staff.

Poor communication had real effects on outcomes and translated into direct harms for patients, as Filemon’s story demonstrates. Nearly two years before his leg was amputated by a surgical team in 2015, Filemon presented at Clinica Blanca with a severely broken leg, just above the ankle. He had been struck by a vehicle and was unable to get osteopathic surgery at a public hospital in Honduras. When the accident happened, his family helped him get to the public Hospital Atlántida in La Ceiba. Because the break was complex, a complete separation of both the tibia and fibula above the ankle, it required surgery (see Figure 13). Filemon could not afford or marshal the necessary funds to pay for surgical supplies unavailable at the hospital. So, he returned to his home, with a still broken leg, a single crutch, and walked on the injured limb.

He lived in chronic pain. Due to the location of the break, it was prone to ulceration resulting from pressure of the misplaced bones and necessary use of his dangling foot to get around.

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Figure 13. Filemon’s Injury During a Visit to Clinca Blanca (Sept. 2014)

In late 2013, Filemon went to Clinica Blanca in hopes of a resolution. Marjorie, one of the board members and regular team leader, was with the initial team that saw Filemon and put him on a referral list for their surgical team. At the time of this research, HMH organized a team of orthopedic surgeons that traveled to Playa Felumi to conduct consultations and surgeries (in a local public hospital’s surgical theater) twice each year, usually once in the spring and again at the end of the mission season. If needed, they could also refer to other volunteer organizations that held surgical missions in other areas of the country with which they had working relationships. Patients would be required to travel, but the care would be free. However, the

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referral process was marked by poor communication within and across teams and with Filemon as well.

Initially, medical mission doctors told Filemon that they could perform surgery to reset his misaligned bones and restore his mangled limb. Filemon came to every brigade clinic the entire year I was there to find out when he would get surgery and to have them clean the wounds on his misshapen leg. But because there was poor communication, Filemon retold his story to medical mission doctors every time he came - many of whom had no idea that he was on the organization’s referral list. Each team treated Filemon as a new – and urgent – case. The condition of his leg and the scale of pain he experienced on a daily basis were recognized as emergencies. But Filemon’s case was not a priority despite the severity of his injury and the corresponding health risks (like septic infection and ulceration) that accompanied it. Children were always prioritized, even if their conditions were not painful or potentially life-threatening.

Finally, in October 2014, a year after his initial referral, Marjorie gave Filemon a date for surgery in April 2015. Many of the STMM volunteers assumed that Filemon had intellectual deficits, but in none of my observations did anyone ask him whether he understood or if he had family who could join him during consultations. Without consulting Filemon (or his family), and operating under these unverified assumptions, Marjorie decided that Filemon did not have the capacity to make an earlier date in February 2015 that would have required him to travel to one of the cities. Filemon accepted the April appointment, without having been given the option to choose an earlier date, and dutifully waited.

Filemon was the picture of compliance and continued to take care of his leg as well as he could over the subsequent six months. He had visited nearly every brigade I observed over the course of this research and had been to several more brigade clinics prior to that, seeking

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treatment, wound-cleaning and pain relief. Nurses at the CESAMO cleaned his wounds when brigades were not present, sometimes at the health center and other times at his home during a health campaign day. A wound like his, through no fault of his own, is difficult to care for and highly prone to infection, not only because both his tibia and fibula were completely broken above the ankle, but also because the nature of the break meant constant aggravation of the lesions and ulcerations that resulted from the protruding bones just beneath the skin and the pressure he was forced to put on the foot for mobility.

When April arrived, Filemon’s leg had become badly infected despite the efforts of his family and friends (including me) to check on him and make sure his injury stayed clean and uninfected. He was excited when he arrived to get his pre-operative consultation and finally get his leg treated. More animated than I had ever seen him, he had a wide smile on his face and his eyes were bright. The orthopedic surgeon and nurse called him for his consultation, but he when he emerged from the room down the hall, the smile and sparkle in his eyes had disappeared. He seemed in shock and was somewhat despondent. When I asked what happened, Filemon told me that the orthopedist had determined that the infection in his leg had spread to the bone and that unless they amputated it would eventually kill him. The surgeon and nurses ultimately blamed him for “not keeping it clean” and “letting” his leg get infected, resulting in the abrupt decision to amputate rather than repair. Instead of missions prioritizing his care and treating his condition with urgency, Filemon languished unnecessarily, until he was ultimately blamed for the fetid condition of his leg and forced to make a terrible choice - lose a limb or die.

The surgical team “successfully” amputated Filemon’s leg below the knee that week.

Some of the volunteers were emotional in response to Filemon’s reaction to the diagnosis and about an undesirable outcome (an amputation rather than a restoration). Ultimately, they

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shrugged and said, “what a shame,” or diminished the preventable tragedy by saying, “we’ve done all we can do,” (sometimes adding the line “the rest is up to God”). None, however, assigned responsibility to the organization for failing Filemon and his family through inconsistent follow-up and delaying care until the only outcome available was an undesirable one.

Adia Benton (2016a) explains this as part of the endemic white supremacy that pervades humanitarian intervention. She refers to it as humanitarian exceptionalism (2016a, 199). The volunteers are the experts, and they decide what is urgent, what is not, and what action to take.

“But doing anything at all is better than doing nothing,” even if something goes wrong, as in

Filemon’s case (Benton 2016a, 199). Benton explains when humanitarians, or mission volunteers in this case, fail to resolve a need or their actions do not go as planned: “It is not simply because things are more difficult and complicated…it is also because they could have intervened better with the proper support and [intentional cooperation with] the people they mean to help” (2016a,

199). In this case, doing nothing in April 2015 would have meant a slow, painful death for

Filemon, but this circumstance would have been avoided had the STMMs done “better” months earlier, communicated with him and each team, and prioritized his timely care.

“We All Want to Feel that We're Making a Big Difference”

How volunteers measured “success” reflect trends noted in existing literature. Because there are no standards for monitoring and evaluation and teams did not systematically follow global or national best practices for care, they tended to evaluate themselves based on personal experiences and in ways that supported continued activities (Berry 2014; S. S. Green et al. 2011).

Despite acknowledgment from some HMH board members and several mission volunteers that their efforts were not effective and could be increasing problems for patients and in the 370

community, mission volunteers invariably believed that the missions were “successful,” or that the teams met their goals, or that the “good…far, far outweighs the negatives.”

Some volunteers measured success in terms of the number of patients seen, reflecting

Playa Felumian observations and the general perspectives of Hondurans who noted “quantity” as a key concern of medical missions. One volunteer wrote, “We managed to see over 1200 people in approximately 5.5 days. It was one of the most incredible teams I've been a part of.” Another said, “over 500 patients in 4 days of work.” Others claimed success at over 600 patients, “close to 700” patients and “successful treatment of about 1000 people.” Some were less specific in their counts, “we saw a lot of patients, and treated some people that were very sick,” or “Being able to treat many people. Giving out at least 60 pairs of glasses. Unique experience with team.”

While some focused on the numbers of patients seen or prescriptions fills, or efficiency in

“processing” patients, measures of success varied significantly. Some volunteers emphasized an event at Casa Hogar as their measure of success, like “the orphans had a happy day,” “supported the orphanage with a birthday event,” “The orphanage party was a success!” or “One big success was just spending time at the orphanage loving on all of the children.”

Others from the surgical team stated that the surgeries were successes and “life- changing,” but doubted the utility of general medicine. One volunteer replied, “The surgeries is where I think we made the biggest impact. Now a couple kids with club foot will be able to walk/play normally. Also, some people would have died if they did not get different appendages amputated.” Another simply said, “The kids we fixed.”

Other volunteers found success in terms of the volunteer experience, “Our team worked really well together,” “good team dynamics,” “we were a well-oiled machine.” One volunteer hoped the experience would have long-term effects on the younger volunteers in her group,

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“Having some young well to do folks on the team see how other people live and hopefully don't take for granted what they do have. Maybe some will even want to help others in need more.”

But these measures of success demonstrate how varied the rubrics were from volunteer to volunteer, as well as the anecdotal nature of contemporary medical mission evaluation. However, volunteers’ discussions about the long-term effects complicated these notions of success and reveal the role that dominate discourses of medical missioning play in these assessments and the process of self- and Other-making.

I asked HMH volunteers what they believed the long-term effects of their work were in the communities they served. Some volunteers strongly asserted that HMH missions had a significant positive effect. While other volunteers expressed concerns. Their responses reveal paradoxes within the medical mission encounter, not only among volunteers, but within the

HMH organization, and key differences in the volunteer and Playa Felumian experiences of the same encounters.

Sally, a nurse practitioner and veteran volunteer, was dedicated to the work of medical missions and although she noted results could be varied, she wholeheartedly believed in their potential and realized effectiveness. She responded at length:

“I believe they can be quite varied. I think the [HMH] clinic has had an amazing effect on the people of rural [Playa Felumi], lives have been changed for the better and lives have been saved… We have saved lives literally on some of our trips—there were asthmatic children with no medicine and no way to get to the hospital who may not have lived had we not been there—there were babies with congenital heart defects who may not have survived the next 24 hours had we not been there—the list goes on—for those individuals the effects of our short term trips has been unquestionable. Have we somehow made people dependent upon us—maybe—I think it can be hard for consistency when so many teams work out of the same facility—for instance some teams bring insulin and believe in the locals using it and other teams do not—the overall health of a diabetic may not be improved by this. But I do know we have done a lot of education in the 11 [non- consecutive] weeks I have spent in Honduras [over the course of three years] and I believe this health education will trickle down and hopefully gradually help to make a

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healthier community… there is a need for continued health education certainly but the good that has come of our trips far, far, far outweighs the negatives.”

Her response suggested that she recognized areas of concern, such as diabetic treatment and consistency of care in general. But as she concluded, any shortfalls were far outbalanced by

“the good that has come” of their trips. Her response is also laden with the medical mission ideologies and discourses. Playa Felumians are reproduced as under/uneducated. The CESAMO is erased. The language of passive “dependency” and neoliberal invocations of “trickle down” benefits underscore the subject position of Playa Felumians. But, “lives have been saved,” evidence of the presence of God in their lives and their mission work, and justification for continued practice, even though consistency and chronic disease care are noted problems. Her narratives also suggested that the lives saved by the teams could not have been saved by the

CESAMO, which had nebulizers and resources for asthmatics and during my observations regularly sent families for follow-up for suspected heart murmurs.

Medical mission volunteers believed that because CESAMO was not open 24/7 that its staff would not take care of patients in off hours. Many community members believed this as well. However, patients who visited the CESAMO or listened to community radio knew that they could call the nurses or the doctor in an emergency, and the nurse or doctor would either come to their home or could arrange to meet the patient at the CESAMO to administer necessary care

(whether a breathing treatment, wound care and stitches, or emergency care for acute high blood pressure).

Sally was one of many volunteers that was reticent to work with the CESAMO and preferred to distribute nebulizers to individuals directly, but not the CESAMO. She was adamant that asthmatics needed the equipment at home, which is certainly true. However, as with medication and equipment for diabetes or hypertension, misinformation and medical mission

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volunteers’ distrust and disinformation about the CESAMO meant that some people believed they could not get treatment for asthma in an emergency or replace their supplies there, ultimately creating risky situations if there was a crises when medical missions were absent. This

(sometimes intentional) misinformation that some STMM volunteers used to validate the mission of the volunteer brigades to donors and volunteers and discredit the local health center is a damaging effect that STMMs can have on the communities in which they work.

Another volunteer said that the long-term effects of STMMs were “Profound. Team members often work with local doctors and agencies to procure surgeries.” But “local” here is misleading as it did not refer to the CESAMO, but to “local doctors” in the cities and without relationships to the municipality or people of Playa Felumi.

Other volunteers were less sure than Sally about the effects of medical missions. Some responses expressed “hope” that HMH missions had positive long-term effects, implying a corresponding level of uncertainty. One simply said, “I hope they improve the over all [sic] health of the community,” while others also called upon the experience of lives saved in emergencies to validate ongoing medical mission presence. One wrote:

“I am not sure. I hope that they increase the health of the community, especially because we try to do some education. However many of the diseases are caused by factors that are not likely to go down. It would be hard to measure rates of diabetes/hypertension etc. However we have saved a couple of patients that may have died if our group hadn't come.”

Volunteers also articulated concerns about sustainability and consistency. And greater than 75 percent of responses openly questioned the long-term efficacy of STMMs. Volunteers wrote:

“Positive: improve healthcare level in communities with no access/poor access to other resources. Negative: reliance on short•term, limited actions, that do not have much impact and do not alleviate the long-term needs of these communities.”

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“Some positives from the medical side for the acute issues, doubtful success on long term problems.”

“We provide locals with medications for a few months but if no other teams come then they go back to not having medication and probably get put on something else the next time. Lots of fluctuation in care and meds.”

“[STMMs] are sustainable if there is a team every week—more charting and or communication between teams would be helpful.”

During the rainy season, between mid-October and early February, there are no HMH teams. During the rest of the year, HMH attempts to schedule teams every two weeks, but they rarely fill up each slot, and teams often have to cancel trips without sufficient time to find replacements. This is a fairly typical phenomenon across the STMM experience, within and outside HMH, supporting existing evidence in the literature that STMMs are not sustainable.

Several volunteers were concerned that they were “creating dependency,” and invoked the missioning ideologies outlined in Corbett and Fikkert’s guide, When Helping Hurts (and in one case the book itself), as well as responsibilizing narratives and discourses of lack and need that shaped their vision of Playa Felumians while also securing their own subject positions.

“They can treat mostly short-term (acute) medical conditions well, but are not good for managing chronic conditions. Their role can lead to medication misuse or overuse. Lack of consistency in services can lead to inaccurate or ineffective treatment. It can lead to a dependency on outside organizations instead of local clinics to provide medical services.”

“Not sure... It may lead to the continued dependence on outsiders (foreigners) for their healthcare needs vs. Honduran infrastructure/existing resources. All I know for sure is that the Honduran health care system is pretty lacking and cannot take care of the needs of the people it is meant to serve.”

“Recurring short term missions likely create dependence on the system in the communities served. The goals of personal responsibility and life style change are not addressed.”

“On the medical side, I think short term missions create a sense of dependence on unnecessary treatments.”

“In an ongoing effort they are able to improve the overall health of the people when they are properly diagnosed, treated and educated. If it is not an ongoing effort, meaning the 375

team comes into an area for one week, hands out medicine and leaves it only teaches the community to rely on others to give them what they need instead of empowering them. There needs to be a community leadership in place and consulted to access proper needs of the community. We should be asking them what we can help them do and empowering them with the education and tools to accomplish those needs instead of doing it for them. I read the book "When Helping Hurts" a couple of years ago and it changed the way I look at missions.”

“It's good to give them things they don't have, but they probably are very dependent on us for providing these things.”

“I believe without ongoing education they can be harmful and make people dependent.”

Some of the concerns about dependence echo “dependency theory,” which posits a passive dependence or expectation for “hand-outs,” or as one volunteer euphemized “dependence on the system.” Corbett and Fikkert (2014) note such dependency as a particular threat to efficacy of medical missions and aid in general. This framing ultimately places the responsibility on the recipient and reinforces a hierarchy of power in which the aid recipient is inferior. As Daniel

(2014) notes, the kind of dependency these volunteers invoke is created by the process of therapeutic domination, and the expectation that aid recipients will behave as grateful and passive. They are not consulted about their needs – the needs are assumed by the medical mission organization and volunteers, even the ones who note structural factors or call for

“empowerment” – and are therefore forced to accept whatever aid is available, without complaint

(Daniel 2014).

One volunteer added that long-term effectiveness of medical missions was, “Probably not as much as we want to think. Coordinating with the local clinic would have a far greater impact and patient continuity would be better,” and “there appears to be no sharing of medical records.” acknowledging that medical records are not shared either among teams or between Clinica

Blanca and the CESAMO. At a minimum this threatens accurate and effective care of patients, especially those with chronic conditions, and actively prevents the CESAMO from meeting its

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mandates and eliminates the possibility of the staff or community healthcare workers to follow- up with patients, especially in the absence of mission teams. This respondent also notes that expectation or self-evaluations of the effects of medical missions are probably not as significant as volunteers “hoped.”

Likewise, this volunteer’s comments expressed concern not only about medical efficacy and potential harm, but also about volunteers’ perceptions of their work that lead to “an unrealistic notion of what they have accomplished.”

I doubt that short term teams produce significant long term improvement for the community as a whole. I am not convinced that even long term involvement would make much difference in the community given the current social/political/economic circumstances. I hope that we are able to point a few individuals toward resources that can make a big difference in that individual's life (eg: correction of surgical problems or congenital defects). I suspect that the short term team members experience some long term changes in perspective but that does not necessarily help the Honduran community. One of my concerns about short term missions is that team members come away with an unrealistic notion of what they have accomplished. I hope we are not producing harm. I am concerned about the overuse of antibiotics which can cause increased resistance.

A different volunteer similarly wondered about efficacy. He said:

“Deep down I feel that the groups are putting out small fires and while our efforts are benefitting the people it is hard to measure the long term effectiveness and efficacy of our efforts. We all want to feel that we're making a big difference in the lives of the people of Honduras and I think we are.... I'm just unsure if the compassion of the volunteers or the medications and treatments make more of a difference. Either way, love wins.”

The volunteer does not necessarily believe that medical missions’ treatments have as substantial an effect on Playa Felumains’ health as the “compassion” of the encounter itself. He acknowledges that the effectiveness and efficacy of medical treatment is limited, but also that the social and emotional effects on “the lives of the people” is paramount. The volunteer also indicates, like several others, that “we all want to feel that we’re making a big difference,” indexing the potential emotional benefits of the encounter to volunteers, and the importance of the encounter to self-making.

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The subtler discourses of moral and intellectual authority and divine mission provide the rationale for positive self-evaluation of mission endeavors despite technical, structural, and general failures. For even if the medications are not the cause of the difference being made in the lives of Hondurans, “love wins,” and the discussion about efficacy or improvement of health is truncated. Like colonial missionary medicine before it, the side-effect of improved physical health is less critical than “the conversation” between those involved in the medical mission encounter, because it is in the conversation that the dialectic of self- and Other making takes place (Comaroff 1991).

Structural Violence Within and Without

The discourses that medical mission volunteers circulate have tangible effects on the health of Playa Felumians and their perceptions of self. They also explain the ways that volunteers are able (or compelled) to justify their activities, despite widespread acknowledgement that aside from a few extraordinary situations, they have not been effective.

HMH missions are not filling gaps, and in some situations are widening or generating gaps, and a majority of volunteers recognize that.

Although a number of volunteers desire better communication among teams and collaboration with the CESAMO and residents of Playa Felumi in general, the “dark logics,” namely the structure of the organization and its dominant ideologies and discourses actively constrain individual efforts and forestall (or reinforce) institutional barriers to such paradigmatic shifts. While volunteers recognize practical structural barriers and violence that inhibit Playa

Felumians from “compliance” they continue to divert attention to ineffective and ineffectual interventions – or rebuke Playa Felumians for the consequences of structural problems beyond their control. At the same time, the HMH organization and volunteers actively contribute to 378

structural violence and perpetuate it within their own organization. Moral and intellectual authority, humanitarian exceptionalism pervasive among medical missionary volunteers, and the establishment of those subjectivities through the negations of authority, knowledge, and power of

Playa Felumians acts to create several of the problems HMH volunteers hope to address.

These dark logics translate into therapeutic domination reflected in clinical, social- structural, and cultural iatrogenesis. Assumptions about knowledge, capacity (both material and intellectual) and needs, lead to direct harms due to poor communication. Longstanding (unequal) social hierarchies remain intact and are reinforced, more benefits accrue to medical mission volunteers than to Playa Felumians and force Playa Felumians into a dependent recipient role, in a seeming perpetual feedback loop that justifies the ongoing “need” for medical missions. Equity harms abound, and are reflected in HMH employee concerns with remuneration, gendered remuneration disparities among those employees, and in the effects of individualized (rather than communitarian) aid and unequal distribution and access of that attention, care, and material assistance. The process of self- and Other-making so intrinsic to the medical mission encounter also favors the medical mission volunteer and fosters cultural iatrogenesis through the erasure of local knowledge, healing, resources, and agency-denying dependency. Taken in concert, the perspectives of everyone involved in the medical mission encounter seem to indicate social disruption disproportionate to the intended benefits of aid.

The next chapter elaborates on concerns about fairness and the ways that individualized assistance and discourses of distrust and result in differential treatment of certain children and institutions in Playa Felumi.

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CHAPTER 14

STMMS, THE "ORPHANAGE," AND THE POLITICS OF COMPASSION

In the previous chapter I highlighted the ways Playa Felumians express concerns about equity in the distribution of aid. Fairness is a major concern. How STMMs decide who is worthy of aid and where and how to distribute the material resources is a key factor in the ways Playa

Felumians evaluate their fairness and efficacy. The seeming favoritism afforded to children whom the STMMs call “orphans” is one example and is further analyzed in this chapter.

As part of this research project, I intentionally chose to include the perspectives of children and youth, because youth are disproportionately represented among the intended beneficiaries of aid interventions (Bornstein 2012), whether small medical missions or larger international humanitarian aid efforts. While I discuss the perspective of youth in other chapters, this chapter focuses on the ways volunteers fetishize the idea of vulnerability, especially among children and youth, as an essential part of their own voluntourism experience. I begin this by explaining the relationship that Health Missions Honduras (HMH) has established with the Casa

Hogar.

Casa Hogar Background

The Casa Hogar, contrary to the ways in which HMH volunteers sometimes characterize it, was established in 1997 by a Catholic Honduran nun at the height of a widespread HIV epidemic in Honduras. Sor Inez is a Garífuna woman, although she was born in a neighboring community, she is a generally well-respected figure in Playa Felumi, recognized in her religious role and in role in caring for the children in the home. She still runs the home and also works with two other children’s homes in different departments of Honduras, one in Tegucigalpa and the other near the city of Santa Barbara. In Playa Felumi, Casa Hogar was established to take in

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children orphaned as a result of HIV and AIDS, but also as a haven for children whose families were struggling financially or socially, or who were exposed to domestic violence or abuse themselves. These distinctions are important, because it means that not all of the approximately

50 children living with Sor Inez at any given time are necessarily orphans defined in the ways that North American volunteers tend to colloquially understand that label. Many of the children have families, often a parent, who need assistance providing a safe, stable environment for their children to live in while facing economic scarcity, domestic violence, or their own health concerns. Some families need assistance providing for a child or children who have disabilities or perceived mental or behavioral abnormalities. Those who do have family often see them, and even leave the home to visit their family and stay with them for special occasions and holidays.

These visits might last for a few days or could extend for a month or more. Sor Inez encourages and advocates for these visits because she “believes in family,” and also recognizes that for some of the children in her care, the home was never the permanent option for the family, but rather a temporary solution until circumstances improve.

When she first established the home, it was in a small ramshackle building next to a disco and liquor store. Over the course of several informal and formal interviews with Sor, it became clear that she has always had to make do with what support she receives, in whatever form it comes. The original home was one such donation. It was insufficiently large for the number of people living in the home and was in poor condition - without running water, several children crowded together in small rooms, inadequate common areas, among other issues. But, as Sor described it with her characteristic unwavering optimism, “it was a shelter.” And without support from the Honduran state, and only sporadic and unreliable support from the municipality

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(depending on who was Mayor at any given time), it was the safest and only place for her and the children to live.

Sor Inez shared with me in an interview on January 19, 2015, that at different times the home has received material support, either in the form of modest financial or in-kind donations of clothing, foodstuffs, or school supplies from a few of the women to hold the title of First Lady in Honduras, including Xiomara Zelaya and Rosa Elena Lobo, and briefly Siomara Girón

(Micheletti). Siomara Girón only helped “un poquitito” she told me, pinching her fingers together and squinting her eyes at an imaginary tiny amount in her fingertips. She added that she had never received support from Juan Orlando Hernandez’s First Lady, Ana Garcia de

Hernandez, despite Sor’s requests for support.

Sor Inez is an advocate for resources and welfare for the children in her care and for women and children in the community who seek support. At times, it has made her an enemy to some. She recounted the story to me about a well-known narco, or drug trafficker, Lando, who lives in Playa Felumi and threatened to kill her. When the hogar was still in the old home next to the radio station (prior to 2009), she was concerned because Lando’s family had just opened a dance hall next door to the home and the health center. “I pay attention and I know that

Honduran laws maintain that there cannot be a disco so close to a school, and an orphanage is considered a school.”

Sor Inez wrote a letter to the then-mayor, noting the law and requesting that Lando’s disco either not be allowed to open or be asked to move. Lando has significant power and substantial influence, especially where bribes or violent force are easily applied. Like a

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venomous snake, he is cautiously respected.17 Most people were hesitant to criticize him openly, and certainly not within earshot of anyone else.

Upon receiving Sor Inez’s letter, the mayor invited her to a meeting at the muni

(municipal building). But when she arrived for the meeting, she found that the mayor and Lando were the only people there. The mayor told her that the disco would stay put. She pleaded, “But

Mr. Mayor, do you not know the children’s law?” He dismissed her, “Yes, I know it, but I gave my permission for the disco to go there. I am the law here. We have this document for you to sign, saying that the disco will stay there.” But she couldn’t sign it, she told them. “I cannot sign.

I have a board of directors and I have to ask them for permission to sign this.” Upon hearing this, the men retracted their request for her to sign because, she told me, they thought she was working alone. “But I was not alone!” she told me with a mischievous grin on her face, as though celebrating a sneaky win even as we spoke.

She continued, “Then, I was outside in the little yard between the home and the disco where the children plays. [Lando] came to say that I was ‘causing trouble’.” She told him that she had an obligation to care for the children and that it wasn’t a personal attack on him. But then, she said, he reached behind him and pulled out a gun and aimed it at her. She believes he would have shot her, had it not been for the fact that the children, who had been playing in the yard where the confrontation occurred, encircled and “protected” her. Short in stature, generally soft-spoken, Sor Inez is calm under pressure and seemingly fearless. She undoubtedly knows, as do the children who encircled her, that they were risking their lives in an act of resistance to this

17 He is feared so much that I would frequently be shushed if I asked a direct question about him out loud. Even when not in mixed company, my friends and research participants would look around cautiously before continuing conversation. He was universally considered responsible for the assassination of a young boy (twelve) in February 2015, but when his family hosted a novenario (a celebration of life and all-night party), most people chose to make an appearance – even if they didn’t want to. 383

man and the power he represented (and represents still). Sor Inez and the children she cares for were not murdered that day, and the disco opened all the same. Some police came to investigate

Lando’s assault on her, but “did not find” Lando or the mayor that day and did not follow up.

In 2009, Buck and Marjorie, then still only at-large board members of HMH, took an interest in Sor Inez’s home for children and decided to establish a non-profit organization in the

United States to raise funds to build a new Casa Hogar, or as they called it an “Orphanage.”

Buck and Marjorie established a 501(c)3 in the United States. They fundraised using images of the Casa Hogar and their own narratives about it, and within a year had raised enough funds to build the current Casa Hogar in a new location. The land, an approximately one-acre plot near the high school, was donated by a Garífuna woman who was born and raised in Playa Felumi, a nurse who had worked with Sor Inez and with HMH since they each respectively came to the small town.

The new home is a much larger space. A tall chain-link fence is mounted atop a shorter wall of cement about two feet high. Barbed wire crowns the top of the fencing circling the entire perimeter of the donated land. When I visited between 2014 and 2015, there was a wooden swing set and play area in the large, dirt yard where children ran around playing chase or soccer. The home is very large. There are two sets of double doors that face the yard, set back on a large, covered concrete porch. Concrete pillars support the second floor, where the children’s dormitories are located. All of the windows on the large building are screened - an improvement from the open windows that left everyone exposed to mosquitoes, other pests, and the elements at the previous home. Inside there is a large common area, with long picnic-style tables where children eat meals and do schoolwork and catechism. The tables can easily be moved to leave the large living space open for indoor playing, or to organize chairs to watch movies on the TV that

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mission volunteers donated. There is a large kitchen in the main area, in addition to the outdoor kitchen, which is used more often to keep it cool indoors (as is the case with most homes in

Playa Felumi). Volunteers did not build the outdoor kitchen. Sor Inez had the space built adjacent to the home. Upstairs are children's dormitories, the girls’ rooms on the left and boys’ rooms on the right. There are additional rooms for storage downstairs, Sor Inez’s office and sleeping quarters, and rooms where the adults or older teenagers who work at the home sleep.

As part of the donated land, there was a small house that had fallen into disrepair since it was last used by the original owner and her family. It was about 100 yards from the main house.

That building, while I was there, had recently become a temporary schoolhouse for the children.

Shortly after I left Playa Felumi in the summer of 2015, the fate of the schooling program became much more precarious, the circumstances of which I explain in more detail below.

“Orphans”

Sor Inez calls the home Casa Hogar, which translates to children’s home, but in colloquial conversation she, and most other residents of Playa Felumi, call it the huerfanato.

Huerfanato translates literally to orphanage in the English language. However, as mentioned above, many of the children that live at Casa Hogar are not what North Americans colloquially understand as “orphans.” Regardless of knowing whether children in the homes have family with which they are actively involved, STMM volunteers refer to the children as “orphans” and talk about them and their experiences as if they are without family. While true for some, this is not the case for most of the children under the care of Sor Inez.

There are myriad reasons that STMM volunteers are invested in ascribing this term to vulnerable youth living in non-nuclear or atypical homes in this way. The first is a semantic trick of translation. There being no simple or universal way of explaining these kinds of living 385

arrangements to North Americans, Hondurans use the simple, one-word, colloquial term, huerfano, to describe children living outside of their natal homes. For Hondurans, this term has nuance and does not imply that a child is without family or has been abandoned. Playa Felumi residents often acknowledge the living parents or relatives of children living in Casa Hogar, many of whom still live in Playa Felumi. Hondurans will use the term huerfano while, at the same time talking directly about that child’s existing family. “Orphan” is not a permanent condition, but a temporary one. But, as I explain below, mistranslation is a convenient mechanism for an often-intentional construction of vulnerable children’s identities.

There are three main reasons this misinterpretation is critical to evaluating the social impacts that STMMs, and voluntourists more broadly, have in the places where they impose themselves. First, to ignore the nuanced meaning of the designation huerfano in its culturally specific context erases the familial relations that exist in most cases. Second, this flattening reinforces power dynamics that position voluntourists as saviors, which creates the justification for how they treat children and families and the kinds of actions and care they decide to provide.

Finally, categorizing children in the home as “orphans” reduces them to a Dickensian vulnerability, recreates them as ideal humanitarian subjects (Bornstein 2012; Fassin 2011), and satisfies the consumption of suffering and poverty porn that has become characteristic of the voluntourist experience (Bornstein 2012; Daniel 2014; Guiney 2018; Guiney and Mostafanezhad

2015). As a related consequence, the favoring of children may also contribute to a deprioritization of adult care.

STMM volunteers use the term “orphan” to connote a fixed identity and permanent lack of immediate or extended family. This may be because most STMM volunteers are white and middle class, and the practice of missioning and volunteer interventions comes from a white

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middle class traditions (Comaroff and Comaroff 1986; Hardiman 2006). There are well- documented reasons that those two factors, whiteness and class position, have a direct bearing on how STMM volunteers understand and interpret non-nuclear family organization and kinship. In the United States, white, middle-class values have been institutionalized in the idea of the nuclear family, characterized by a male head of household (father), mother, and children (Stack

1976). Margaret Mead’s (2001 [1935]) research famously challenged the supposed universality of this idea. Within different communities in the US, as well as numerous other parts of the world, including Honduras and Playa Felumi, extended kinship networks are parts of everyday life and included in the family unit.

This mislabeling is not unique to Playa Felumi or the experiences of the STMM volunteers I observed there. It is a common phenomenon that has been documented in India,

Cambodia, Thailand (Guiney 2018; Guiney and Mostafanezhad 2015), in several countries in

Africa (Cheney 2014; Daniel 2014) and Eastern Europe (Disney 2014; Stryker 2012), and throughout Latin America and the Caribbean. And, as in Playa Felumi, it has caused controversy and confusion. After the devastating earthquake in Haiti in 2010, and the mission and NGO chaos that ensued thereafter, missionaries were arrested for removing dozens of Haitian children from the country (Miller Llana 2010). In the Haitian case the mislabeling was intentional, as the missionaries involved knew that the children had families and had in fact collaborated with some of the families to take the children.

Scholars and critics of the practice, particularly in the wake of the widely covered case in

Haiti, emphasize the importance of familial reunification and cite extremely low adoption success rates in instances where children have experienced serious traumas, in addition to the common difficulties that come with language variance and acclimating to new, foreign customs.

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Sor Inez, is one such critic of adoption practices. According to Dr. Collin, the two children that have been adopted by well-meaning STMM volunteers since 2010 have struggled to adapt to their new lives along with their adoptive families.

The story of their adoption highlights the consequences of mislabeling children living in atypical family situations. Dr. Collin recalled that during the adoption process, that Sor Inez “had been an…obstacle,” he paused in the middle of the statement to consider his words (February 9,

2015). He said the process had already been delayed by bureaucratic turnover that required the two women adopting children to reinitiate their respective petitions “two or three times.” When the women came to Honduras for the obligatory month before they could take the children out of the country, “[Sor] found and dragged up all kinds of even distant relatives who had never even seen the kids,” in an effort to influence the adoption rulings. Ultimately the adoptions were approved, and the women, unswayed by the presence of family, took their respective “orphans” to the United States with them, not grateful to Sor for her role in the process.

In Honduras, as in several other countries (Bornstein 2012; Cheney 2014; Daniel 2014;

Joyce 2017; Stryker 2012), children are not commonly “abandoned” to non-familial homes out of neglect or disregard for the children. Instead, a parent or guardian may be forced to leave the child in the care of a children’s home or welfare service as a result of society’s abandonment of the struggling poor (Bornstein 2012). Children do not cease to have kinship ties in these circumstances, the form and dynamic of their kinship relations merely changes. North American volunteers, however, superimpose their own understandings of kinship and belonging onto children deemed “orphans” and establish a moral superiority and imperative to rescue these children from perceived abandonment. Indeed, as Bornstein (2012, 104) suggests, the fact that a foreign individual with greater wealth can claim an “abandoned” child as their own “is a critical

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factor in the political economy of orphans and [personal] humanitarianism.” But that imperative also comes with its own hierarchy, as children truly abandoned - those abused or left to the care of a children’s institution because of physical or mental disabilities, are at the bottom of the adoption hierarchy. Young, healthy, males, like those the HMH volunteers adopted shortly before my fieldwork took place, are at the top of the adoption hierarchy, followed by healthy, young girls (Bornstein 2012).

Bornstein also draws a distinction between the kind of local informal adoption of relatives’ or neighbors’ children and adoption by wealthy foreigners. The former is a social practice of care and mutually beneficial kinship practices, or negotiations if moving from biological into non-biological kinship networks. The latter, however, is marked as another way that “white saviors” are consuming poverty (Cole 2012), and in the case of adoptions, poor children in the Global South (Bernstein 2012). In the case of Playa Felumi, it is also a way that

STMM volunteers ignore local norms and knowledge, practices of community and kinship, and impose their own norms about what it means to be orphaned and how children should be treated or cared for in such circumstances. This stance on “orphans” and adoption is reflective of broader power struggles that played out between STMM volunteers and local actors in Playa

Felumi.

Power Struggles

The STMM encounter is rife with power dynamics. Among the more apparent of these dynamics revolve around the subject positions of each participant in the encounter. STMM volunteers enjoy a disproportionate amount of power in the form of social prestige and capital, economic capital, and the power to intervene with respect to everything from nutrition to personal grooming to childcare. This is in large part a legacy of the imperialist concentration of 389

global wealth in the Global North. Volunteers, and humanitarians do not see their participation in the furtherance of imperialist power inequities as abuses of power; instead, they speak of feeling compelled to “help the needy” and being motivated by their “good intentions” (see Chapter 9 for a discussion about the significance of this linguistic coding). I do not question the stated intentions of STMM volunteers, but they must be analyzed alongside the material and ideological effects of their actions. As voluntourism scholars point out, voluntourists are embedded in a broader neoliberal system (Vrasti 2013; Mostafanezhad 2014) that

“(re)produce[s] subjects and social relations congruent with the logic of capital in seemingly laudable and pleasurable ways” (Vrasti 2013:4). In other words, STMM volunteers perform subject positions that neoliberal capital demands of them. Their volunteering and “helping” are tied to moral and ethical sentiments that legitimate their work, even when it does harm.

Woven into this tapestry of neoliberal subjectivity are older inscriptions of colonial and racial subjectivities (among other symbolic categories reified through violent political economic processes) tied to U.S.-American Exceptionalism. All of these systems, and volunteers’ embodiment of them, influence how power dynamics play out in Playa Felumi. During my fieldwork I saw these power relations on display most evidently in the interactions of STMM volunteers with the Casa Hogar and Playa Felumi residents’ perceptions and discourses about the Casa Hogar and its relationship with the STMMs.

Trust and Local Knowledge

Sor Inez established the Casa Hogar before STMMs began visiting Playa Felumi and well before they became directly involved in the activities of the Casa Hogar. She is an influential person in Honduras and even international circuits where the UN and other international aid and humanitarian agencies have called on her experience and expertise, 390

particularly with respect to HIV/AIDS in Honduras in the 1990s. Casa Hogar is also her third established children’s home. She visits the others, which are in continuous operation, in their respective locations (Tegucigalpa and Nueva Esperanza). Children at Casa Hogar, especially teenage girls, are often transferred to the other locations to attend high school as they age out of

Casa Hogar and their needs change. Young women are also more frequently transferred once they reach high school age, because, according to Sor Inez, they become increasingly attractive targets to human traffickers that reportedly lure young teenage women with relatively large sums of US dollars into prostitution.

Despite Sor Inez’s experience and intimate knowledge of Playa Felumi, Garífuna language, cultural practices, and heritage, and her expertise, I witnessed numerous encounters between Sor Inez and STMM volunteers and documented several conversations wherein Sor

Inez’s integrity, expertise, and efforts were questioned, derided, or dismissed. It was in these encounters that I began to wonder about expressions of trust and hierarchies of knowledge.

As part of their regular activities, STMM volunteers bring extra suitcases packed to the brim with cheap toys, flip-flops, and candy. Importantly, the suitcases of gifts are carefully guarded and stowed out of reach and sight of the general public and any patients coming into

Clinica Blanca. The toys are for “the orphans,” specifically. Children brought into Clinica

Blanca may get stickers or candy, or more often toothbrushes, soap, and travel-sized toothpaste.

This is the first important material difference that is readily observable regarding the treatment of patients, and in particular, children, in Playa Felumi.

The toys STMM volunteers bring were often light, plastic and had been donated or purchased from a dollar store or a discount bin at a grocery store or Wal-Mart. Cheap, plastic toys, like small toy cars or dolls made of thin plastic materials that easily disarticulate, kazoos,

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pinwheels, or items with finite length of use, like bubbles, nail polish, crayons, coloring pencils or markers, are common gifts from STMM volunteers to the children at Casa Hogar. Sometimes they bring coloring books. These gifts are also always gendered. The toys are divided according to strict gender norms, with “masculine” toys like toy cars or jacks going only to boys and

“feminine” toys, such as dolls and nail polish going directly to girls. STMM volunteers make efforts to get the number of children and current gender breakdown prior to bringing and sorting donated toys and become visibly and audibly frustrated when there are incongruencies.

It is entirely possible that children will go without toys if volunteers do not have “gender- appropriate” toys to hand out, or that some children will get something different from the volunteers in order to stick with the gender norms and expectations of the volunteers. Rather than abandon rigid gendered gifting practices, I observed that STMM volunteers often directed their frustration towards Sor Inez. STMM volunteers considered it a failure of duty on Sor Inez’s part if she did not provide them with “accurate” information. STMM volunteers, especially those involved in the organization that supported the Casa Hogar until 2015, expressed even greater frustration when there were more children than they believed were living at the Casa Hogar.

This interfered with their expected giving rituals and practices and was a major point of contention outside of the gift-giving relations.

Another item STMM volunteers bring are flip-flops or knock-off Crocs. The knock-off

Crocs are slightly hardier rubber shoes, and practical in Honduras since they are all-weather shoes and relatively comfortable to have to walk or stand in all day. But they are made of cheaper, less durable materials and are accordingly much cheaper for STMM volunteers to acquire for the purposes of giving them away. Importantly, that style of shoe, whether name- brand or knock-off, are very expensive by Honduran standards running anywhere from USD$20

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to USD$70. These shoes are so recurrent a gift to the children at the Casa Hogar, that they have earned the name “orphan shoes” (zapatos de huerfano) from Playa Felumians. (STMM volunteers have also begun calling them “orphan shoes.”) Flip-flops, while ubiquitous footwear, are not so hardy. The straps and toe-stops break easily and are difficult or sometimes impossible to effectively mend. But, like dollar-store toys, or not-Crocs, they are inexpensive, disposable, and thus easier for STMM volunteers to bring in large quantities.

Sor Inez and the children at Casa Hogar seemed genuinely happy to receive the toys and gifts and for the “birthday” party that the volunteers would sometimes throw. Sor Inez and the children performed their gratefulness well, with a full production for each volunteer team’s visit to the home. The smiles, laughter, and contentment registered in the faces, body language, and interactions of the children were convincing indicators of their pleasure and happiness at the arrival and attention of guests and at the receipt of toys and treats (often cake and soda, with cake being a rare treat reserved for only the most special of occasions in other homes in Playa Felumi primarily because of the prohibitive cost, but also because few people bake).

Children often seem less enthused when it was time to perform for the volunteers after receiving toys and greeting their visitors. The first items on the agenda were always a prayer, that included requests for blessings for the volunteers, followed by an explicit statement of gratitude to the volunteers. A different child, usually a teenager, read each scripted piece. Then, the children performed choreographed dance routines - first the girls, then the boys - to English language pop songs. The volunteers sat in chairs, watching, smiling, laughing, sometimes commenting to their audience neighbor, and many often recorded the performances. Next, two of the boys retrieved traditional Garífuna drums, placed them between their knees, and rapped out rhythmic beats with their hands while both girls and boys danced punta. If the rhythm shifted to

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parranda, the young boys would display their impressive, fast-paced footwork in front of the drums. While many of the children seemed less enthusiastic about the choreographed dance routines, most seemed excited and eager to dance with the live drums. Upon completion of this part of the program, the lead youth announced a close and made another overture to the volunteers to thank them and to pray for their safe travels home.

This performance, the entire agenda, happens at every visit STMM volunteers make to the Casa Hogar. I observed eleven of these performances, and it was apparent that the volunteers expected this performance of gratitude and entertainment. Many of the children also draw pictures or write letters to thank the volunteers or individual volunteers. There is an incredible amount of physical and emotional labor expected of the children and Sor Inez in the receipt of gifts and their performance of gratitude.

The STMM volunteers and leaders placed additional expectations on Sor Inez. Her motivations and actions were constantly called into question by STMM volunteers and leaders.

In addition to their speculations about Sor Inez withholding toys or limiting play and recreation, volunteers also spoke critically when Sor Inez brought new children to the home. As I discussed in Chapter 9, Sor Inez was subjected to aggressive questioning about the absence of donated items and threatened with disinvestment when HMH board members were frustrated about her management of the home. Rather than recognizing that less funding would exacerbate any identified concerns or shortcomings, HMH’s (or any funding entity’s) response would be to punish “bad behavior” as an incentive to change it. Sin and personal failings require discipline interventions. More effective, however, would be to increase funding and pay full salaries for support staff at Casa Hogar.

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HMH volunteers complained that Sor Inez was neglectful or “would leave the children alone,” however they did not offer to fund or hire additional support staff or teachers. If Sor Inez was not at the home, it was usually to handle official business on behalf of the children, the legal status of Casa Hogar (Honduras is a Weberian iron-cage of bureaucracy), or to plea for material support to keep the home functioning and the children fed and clothed. Again, an issue that would be resolved with additional support staff and consistent operational (not just programmatic) funding.

Additionally, in her narratives about Sor Inez and the conditions at Casa Hogar, Ruby suggests that small children are left unattended for long periods of time, which she frames as neglect. However, there are teenage youth living in the home at any given time, who like most

Honduran children over the age of ten (sometimes younger), are expected to assist with childcare and supervision, and are trusted by the younger children and adults alike. This is a norm, a practice both necessitated by structural limitations on resources that enjoin every member of the family to play a role in the daily tasks of survival and work, and a result of different (and no less valid) views on the capacities of children and youth among Hondurans.

North American STMM volunteers see these unremarkable everyday practices through the lens of their own cultural norms and legal mechanisms. At the very least, leaving a child unattended by an adult or professionalized late-teenage babysitter is considered morally reprehensible and is a sign of personal irresponsibility within certain, predominantly white U.S. communities. At worst it is considered neglect, a punishable legal offense.

While observing a team at Casa Hogar in 2014, a nurse practitioner, Vikki, expressed this very concern. Vikki came over to where I was standing in the long open living area of the home. She was holding an infant with very light green eyes. A six-year-old followed the little

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one around and was very attached to the baby and cooed at her while the volunteer held her. The volunteer had a protective stance, holding the baby out of reach of the young girl. She told me in a worried tone that “the older one is very interested in the baby.” When the girl reached to hold the baby, Vikki stopped her from doing so. She said that the older girl wanted to pick her up but that she “just didn’t know,” and indicated an explicit level of discomfort about letting the children interact. I smiled and commented that she probably carries the baby around all the time.

“She probably does….” the volunteer said uneasily, frowning.

Trying to relieve her anxiety, I told her that kids that we might consider too young to do so often walked alone, ran errands, and kids barely older than their toddler siblings often were responsible for making sure they got home. Vikki raised her eyebrows and her jaw fell open as she let out an exasperated “ugh.” Eventually she let the little girl pick up the infant. The girl beamed a smile and carried the baby awkwardly, but steadily and promptly outside. I tried to reassure the volunteer that the baby would be fine as she fidgeted nervously. The volunteer stepped away briefly but came back to where I was standing and asked about the baby and added a preemptive disclaimer, “you said it was ok!” I popped my head outside the heavy, carved wooden doors to see the infant holding herself up with the help of a bench next to a woman who works at the orphanage, both smiling.

Volunteers like Vikki and Ruby were dedicated to the mission experience. They were both veteran volunteers who have visited Playa Felumi multiple times and believe they have a good understanding of everyday life. But as these examples show, they, like nearly every volunteer, both openly and tacitly questioned the actions, decisions, and value of everyday experiences based on their own ethnocentric perspectives. These asides and everyday conversations with volunteers are examples of the ways that they express distrust in the bodies,

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words, actions, and decisions of Playa Felumians. Trust and knowledge are indelibly linked and ideas about the trustworthiness of the poor are already deeply inscribed on their bodies (Fassin

2011; Jung [Gilchrest] 2014). It is local knowledge that is questioned, with HMH mission volunteers believing their knowledge is not only superior, but correct.

Discussion

HMH volunteers’ focus on Casa Hogar and its children underscore the discourses of deservingness and also highlight paradoxes in their approach to “local” cooperation. I have already discussed the effects of individualized aid and the preferential treatment (whether real or perceived) that medical mission encounters involved. These contribute to equity and group and social harms, amplifying the effects of iatrogenic violence by disrupting social relations and increasing the potential for conflict.

The relationship with Casa Hogar also shows that HMH can and will collaborate with

“local” individuals and institutions, even invest substantial sums in their physical and material infrastructure. While volunteers held and acted on beliefs about Sor Inez’s capacity and trustworthiness, they continued to cooperate and work with her. This poses a sharp contrast to the efforts to cooperate with the CESAMO and Dr. Muñoz. Although both individuals were respected authorities, and both were similarly distrusted and questioned by HMH and its volunteers, Casa Hogar remained a favored institution. This further supports the notion that

HMH viewed the CESAMO as competition, rather than as a key local resource to which it should be a supplement rather than a duplicate or replacement.

The relationship between HMH, its volunteers, and the children living at Casa Hogar also speak to the processes of self- and Other-making, and the critical role the emotional labor of children (and even adults) plays in the experiential subjectivity of medical missionaries. Children 397

are constructed as always needy, always suffering, and vulnerable. But that suffering and vulnerability is also consumed. As an exchange for resources, they are expected to perform

(literally) and show their gratitude. Before many of them can speak, they are already being shaped into grateful recipients. Their faces, personal stories, and performances are circulated as success stories of medical mission encounters, their fetishized suffering becomes affective fodder for donation campaigns, and their performances and lives serve as emotional restoration for the volunteers and contribute to the crystallization of their identity as morally good.

In the process, social hierarchies are reinforced, and social disruptions occur at the community level. “Orphan shoes” become visual markers of unequal distribution of resources or, at a minimum, unclear processes of distribution, which make “orphaned” children and Sor Inez targets of “envy” and serve as visual reminders to other suffering Playa Felumians that they have somehow been left out of much-needed support networks.

* * *

The next chapter wraps up the dissertation. I summarize the main arguments and discuss the significance of the study and its broader implications.

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CHAPTER 15

RETHINKING SHORT-TERM MEDICAL MISSIONS

Short-term medical missions are expected to “fill the gaps” in host country resources. But very few studies have evaluated whether or how medical missions do so, or what their effects are. This study provides new evidence that medical missions in Playa Felumi do not fill gaps in substantive or desired ways, and though there are some positive results from time to time, there are significant real and potential harms inherent in the contemporary medical mission encounter.

The methods used to evaluate these outcomes and effects are promising tools for a broader assessment of medical mission throughout the country and region.

Via data collected through ethnographic methods I illustrated the ways in which contemporary STMMs are extensions of centuries-old colonial missioning projects that continue to perpetuate hierarchies of knowledge and racialization in their current formations. I found that the ways HMH volunteers characterized their work and the ways Playa Felumians valued the medical mission encounter were significantly mismatched. Medical mission discourses of divine calling, need and lack, reinforced their moral and intellectual authority as well as pernicious social hierarchies reminiscent of colonial medical missioning projects. Meanwhile Playa

Felumians articulated knowledge STMM volunteers presumed they lacked and identified different critical needs than STMM volunteers accounted for or considered.

Unfilled Gaps: MOH Identified Priorities

In practical terms, I evaluated HMH activities in terms of the system-wide health priorities identified by the Honduran Ministry of Health. Those needs included:

• Access to healthcare and health equity

• Insufficient health personnel 399

o Specialists

o Capacity-building, placement of personnel, and personnel distribution

• Non-communicable diseases – especially Type II Diabetes and hypertension with the

following barriers of care:

o High costs of care

o Poor health service response

o Poor promotion of healthy habits

• Social Determinants of Health

o Environmental factors, including climate change and chemical

exposure/pesticide poisoning

o Intermittent and unreliably purified water

o Water sources contaminated by raw sewage

To the challenge of “insufficient personnel,” HMH volunteers represented an increase in the available number of health personnel on a sporadic and inconsistent basis that helped to alleviate the pressures of an overburdened public health system in one-week spurts between the months of February and October. However, limited or no cooperation with local medical personnel limited or precluded to address capacity-building. Occasional surgical teams count as specialized medical practice but did little to improve availability of specialists on a regular basis.

HMH occasionally employed local unemployed doctors, but the practice was sporadic and insufficient to address larger issues of distribution and placement. A more significant approach would be to fund permanent physicians at the CESAMO.

While HMH teams nominally improve “access” to general medicine, and free medical care and medications relieve short-term economic barriers for general medicine, their temporary

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nature and various practices of HMH and its volunteers actively threatened long-term healthcare access and health equity. Refusal to cooperate with the public health center (CESAMO) in Playa

Felumi including complying with global best practices and national policies requiring the collection and reporting of specific epidemiological data threatened the credibility of the

CESAMO. These actions also threatened the CESAMO’s ability to comply with its local mandates and meet the needs of Playa Felumians for which it was responsible, which posed a significant threat to the funding and material support the CESAMO received and the job security of existing medical personnel.

Tendencies of HMH missions to treat the CESAMO as competition or discourage Playa

Felumians with chronic illness from seeking treatment for diabetes and hypertension functionally decreased the resources available to Playa Felumians and imperiled long-term health equity.

These practices also resulted in increased poor health service response on the part of medical missions and actively and systematically impeded CESAMO staff’s ability to identify and mange care for patients with diabetes and hypertension.

While medical missions often acknowledged structural concerns, none addressed social determinants of health identified as existing health challenges during the course of the research project. (2020 organizational documents and program information suggest they have since established a plastics recycling program in an effort to reduce its presence in burned refuse.)

Iatrogenic Violence

Not only were medical missions not filling gaps at times they were engaged in various forms of harm. HMH and its volunteers engaged in iatrogenic violence, which occurs when the social disruptions are disproportionate to the intended outcomes of aid (McFalls 2010).

Combining and applying theoretical models to analyze and evaluate medical mission activities I 401

identified patterns of therapeutic domination and various forms of clinical, social-structural, and cultural iatrogenesis.

Figure 14. Iatrogenic Violence

HMH medical mission volunteers' discursive characterizations of Playa Felumians' knowledge and access to resources had significant implications for the adequate provision of medical care. Othering and colonial White Savior discourses were deeply embedded in medical mission volunteers’ articulations of who and what the (non-white) poor are with relation to their

(white) counterparts and directly affected the medical mission encounter. These discourses provide justification for how HMH volunteers decided what kinds of interventions were needed or were not worth their efforts, and who was worthy of their attention and cooperation. The assumptions of the authors of When Helping Hurts permeated the ideologies and practices of

HMH mission volunteers. Volunteers constructed need and scarcity based on their own 402

discourses rather than readily available evidence. Mission volunteers did not trust members of the community who seek out missions' resources to "behave" responsibly, to be intelligent enough to make decisions for themselves, understand their own health, manage their own care or their own community.

This led to problematic healthcare practices that resulted in over-prescription, misdiagnosis, and likely worsened chronic illness or morbidity. These STMMs also influenced shifting perceptions about the importance and quality of biomedicine and indigenous medicine.

Many Playa Felumians downplay or hide their use of local healing practices, while a few openly disparage or have abandoned entirely aspects of ancestral healing, parroting the colonialist discourse that reinforces the supremacy of (white) Western knowledge ways. I documented the often invisible, but nonetheless real social and financial costs of this form of "free" healthcare to patients.

Direct and psychological harms, which constitute clinical iatrogenesis, included malpractice, negligence, and human error. Human error and institutionalized negligence resulted unacceptably high rates of false positives at Clinica Blanca, and HMH did not follow requirements to assure the quality of microscopic diagnosis. Clinica Blanca diagnosis and treatment protocols for malaria contravened national health policies and global best practices, resulting in patients being prescribed unnecessary treatments, increasing risks of antimicrobial resistance, and missing or inaccurately diagnosing and treating other potentially serious febrile illnesses.

Elements of clinical and social-structural iatrogenesis overlapped to compound direct harms and contribute to long-term equity and opportunity cost harms, and ultimately meant that

HMH missions did not fill gaps and in several cases widened them or the risks associated with

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those identified priorities. Willful disregard for well-established best practices, and laws governing medical missions meant that, HMH teams did not collect or share critical epidemiological data about malaria, febrile diseases, diarrheal diseases, diabetes and hypertension with the CESAMO. This refusal was the result of intentional negligence and malpractice (volunteers did not want to collect data or “do paperwork,”), misplaced distrust amplified by dominant discourses of incompetence rather than evidence, and a latent competitiveness in lieu of cooperation.

Figure 15. Categories of Analysis for Iatrogenic Violence

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Refusal to cooperate with the public health center (CESAMO) in Playa Felumi including complying with global best practices and national policies requiring the collection and reporting of specific epidemiological data threatened the credibility of the CESAMO. These actions also threaten the CESAMO’s ability to comply with its local mandates and meet the needs of Playa

Felumians for which it was responsible, which posed a significant threat to the funding and material support the CESAMO received and the job security of existing medical personnel.

Tendencies of HMH mission to treat the CESAMO as competition or discourage Playa

Felumians with chronic illness from seeking treatment for diabetes and hypertension functionally decreased the resources available to Playa Felumians and imperiled long-term health equity.

Because HMH did not operate as a supplement to local healthcare or systematically coordinate with the CESAMO, they duplicated care or wasted resources on inefficient and ineffective projects with dubious and even widely acknowledged undesirable health outcomes

(particularly in the case of chronic diseases). These opportunity-cost harms are examples of social-structural iatrogenesis and contributed to public health iatrogenesis and equity and group and social harms.

Distrust and discrediting local health providers meant that the medical mission organization and its volunteers assumed care for chronic diseases. In the process volunteers directly and indirectly discouraged or prevented people with diabetes and hypertension from accessing continuous, managed care at the CESAMO, by competent healthcare workers otherwise valued by, relied upon, and necessary to residents of Playa Felumi. Because HMH

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volunteers were reluctant or refused to share pertinent health information with the CESAMO, local healthcare workers could not follow up on or coordinate care for patients with chronic illnesses when HMH teams were absent more than four months each year.

Many if not all of these iatrogenic consequences were the result of dominant medical mission discourses that functioned as a dialectic of self- and Other-making. Volunteers’ assumptions about knowledge, capacity (both material and intellectual) and needs of Playa

Felumians, perpetuated through dominant ideologies and discourses further lead to direct harms due to poor communication and reinforced longstanding (unequal) social hierarchies. Racialized assumptions and moralizing discourse that informed “responsibilizing” approaches to care, shifting focus from the structural violence and social determinants causing illness to “individual responsibility” and the moral failings of Playa Felumians. These approaches constituted group and social harms that reinforced stigma and stereotypes about Black bodies, Garífuna communities, and “the poor” more generally. These biases sometimes contributed to mis- (or missed) diagnoses, because assumptions about individual responsibility, or “genetic” predisposition to certain conditions, or disease prevalence (as with malaria), precluded accurate interpretation of symptoms.

Tellingly, despite many volunteers recognizing direct and indirect harms, HMH practices rarely varied. The temporal and ideological restrictions, the “dark logics” embedded in the structure of Health Missions Honduras limited impetus and the agency of its volunteers to address structural solutions to chronic illness and health access. The discourses that medical mission volunteers circulate help explain the ways that volunteers are able (or compelled) to justify their activities, despite widespread acknowledgement among them, that aside from a few extraordinary situations, they have not been effective.

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Beyond the fact that the data demonstrate that STMMs can and do cause harm, this ethnography also reveals notable patterns in the beliefs, values, practices, and ideals of North

American STMM volunteers. That is, it tells us about under-examined aspects of (white) North

American culture and that missionary medicine never ended. It thrives in the contemporary short-term medical mission model. Though this study encountered volunteers who are often explicitly aligned with the Methodist Church in the United States, the STMM encounter was similar regardless of volunteers’ religious affiliations. In that way, missionary medicine has expanded from its 18th and 19th century configurations. While this study focused on volunteers in

Honduras, the ethnographic data reveal the ways in which missionary medicine, and its foundational epistemologies and ideologies, are institutionalized and far-reaching.

Significance of the Study

This study contributes to Illich’s theory of iatrogenesis (2013) and the subsequent scholarship on iatrogenic violence and therapeutic domination (Daniel 2014; McFalls 2010). I developed an analytical tool for qualitative analysis of medical mission activities, synthesizing existing literature and theoretical models for practical evaluations of the real and potential effects of medical mission encounters. I organized Lorenc and Oliver’s (2014) categories of harm through in terms of Illich’s (2013 [1976]) categories of clinical, social, and cultural iatrogenesis

(Figure 15). I developed a useful visual rubric for assessing iatrogenic violence, synthesizing the categories of analysis for iatrogenic violence and recent literature on public health and structural iatrogenesis to demonstrate the overlapping relationships of each category (Figure 14).

This study is a contemporary ethnography of missionary medicine. It contributes ethnographic data to the existing anthropological studies of colonial missioning, linking seemingly disparate literatures on missioning, global health, and voluntourism. This study makes 407

interventions into these literatures by demonstrating the ways that 1) STMMs are a revival of missionary medicine and 2) current missionary medical practice and malpractice are related to the colonial roots of biomedical healing. I expand on Comaroff’s observations about the mission encounter as a dialectic of self- and Other making (1991). I identify dominant discourses medical mission volunteers circulate (Handman 2018) about themselves, their counterparts and their respective homelands, and the role they play in establishing moral and intellectual authority and rationalize ongoing interventions.

I show how contemporary medical mission volunteers are invested in the evangelical effort to bring “Christ’s kingdom” into existence through their “service” (Corbett and Fikkert

2014, 43) or to demonstrate evidence of God’s existence in their lives (Howell 2012). The benefit of personal salvation is implied in the medical mission experience, especially for those who “answer the call” from God. They are not only ensuring their place with the evangelical community, but in Heaven as well (Bialecki 2017; Handman 2018; Luhrmann 2012). These discourses allow contemporary medical missionaries to assume the position of superiority within the medical mission encounter. Doing the divine work of God, they have religious authority.

Their religious authority and identity as North Americans solidify their claim to authoritative knowledge. Their relative wealth and comfort are divine rewards for their personal decisions and acceptable discipline.

Whereas previous studies have looked at the missioning project or the legacies of missionary medicine around the world (and primarily on the African continent), this study employs more recent innovations in anthropological approaches to examine the missionary medicine encounter in Honduras as a dialectic and mutually constitutive process – putting the

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experiences and narratives of local communities at the same level of analysis as that of mission volunteers.

This study offers new ethnographic evidence of the importance of understanding the social contexts, feelings, and symptoms associated with illness in particular contexts and the meaning of illness to those experiencing it, contributing to the literature on illness narratives

(Kleinman 1989), semantic illness networks (Good 1977), and idioms of distress (Nichter 1981,

2010). The study demonstrates the ways that Playa Felumians use semantic illness networks that incorporate the biomedical language – belying the lasting cultural impacts of contemporary missionary medicine to the hegemony biomedicine – to make sense of their physical experiences and illness and secure material or emotional resources necessary to alleviate suffering. In the process Playa Felumians communicate idioms of distress in seeking out STMMs for care, the ways they take or refuse medicine, and the use and requests for diagnostic tests. In Honduras,

STMMs have become a culturally effective way to cope with and communicate distress. Until

STMM practitioners are able to recognize and incorporate the social meanings of illness

(Kleinman 1989), making use of semantic illness networks and idioms of distress, they will not be able to effectively treat the people who come to them for care (even and especially when the care sought is not biomedical).

The discussions about idioms of distress raise interesting questions. For example, what if we used the same frame of analysis for STMM volunteer behavior, situating their actions and narratives within a socio-cultural context that signals their need to participate in medical missions as an idiom of distress? There is a significant body of research that affirms that medical mission volunteers enjoy several lasting personal benefits as a result of participating in STMMs.

Nurses experience less frequent burn-out (Campbell et al. 2009), doctors return to their practice

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with improved empathy for their patients at home (Elliot et al. 2012), and STMM volunteers acquire valuable social and cultural capital as a result of their participation (Vrasti 2013;

Mostafanezhad 2014).

For many the experience allows them to “appreciate” what they have, and in medical settings be more appreciative of the available infrastructures (technologies, facilities, equipment, supplies). Participation in STMMs starts out as an expression of dissatisfaction with aspects of their own local health systems. Ultimately it serves as a temporary numbing agent to the legitimate complaints of an inequitable, bureaucratic health system that is dehumanized and dehumanizing.

This also raises questions about resilience, a topic de jour in academic scholarship and popular culture. Medical missions are purportedly a response to poor healthcare infrastructure in

Honduras. Though ailing, there are health resources and there are doctors and nurses and medical staff who are overworked and underpaid, but whose potential burnout does not result in revival of colonial missioning projects to rejuvenate themselves. Instead, they take to the streets (in their own country) to demand change. So, if medical missions function as an idiom of distress for

North American medical volunteers, we might evaluate participation on medical missions as an idiom of distress communicating the effects of a grossly unjust capitalist healthcare and labor system. We might also understand it as a maladaptive coping mechanism given that STMMs exacerbate inequalities in Honduras and do nothing to address the structural iatrogenesis that lead to burnout at home.

Challenges and Limitations

With few exceptions, there are unexpected challenges in the process of ethnographic research. Within a few months of beginning my research in Playa Felumi, I realized there were 410

some potentially significant ethnographic patterns emerging that I had not anticipated in my research design. There seemed to be high rates of both hypertension and diabetes within this relatively small community and the two conditions came up in everyday conversation as much as during my observations at Clinica Blanca and the local CESAMO. I knew I needed to adjust my research questions to account for this and collect data specific to this phenomenon.

I also was pleasantly surprised to discover after the start of my research that the mission organization had started keeping medical records for patients in 2005, potentially offering nine years of health data and vital statistics. This was an unanticipated opportunity to evaluate, analyze, and compare health data from both the mission clinic and the local health center. As a result, I obtained permission from the mission organization directors and from the Chief of

Medicine at the health center, as well as relevant permissions from IRB to access and review medical records.

While this study was limited by constraints of time and funding, it is currently the only study of short-term medical mission activity that observes more than ten teams and over 100 mission volunteers over the course of a year. There was insufficient time to gather comparative data in other regions of the country and among other mission organizations. Researchers, including me, are limited by the realities of funding and time (and sometimes by the level of stability/danger in the field), but with adequate funding (which so often allows for more time), more thorough ethnographic studies of medical missions and their affects can yield exceptional data. Evaluating medical missions using the “dark logic” model and the model for analysis of iatrogenic violence would yield data with greater generalizability as well.

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Ethical Considerations for Encounters with Violence in the Field

As anthropology has reoriented itself over the past few decades, it has ventured into studies that bear witness to the ravages of unequal power structures, social inequality, and other injustices. Anthropologists like Philippe Bourgois, Joao Biehl, Adriana Petryna, Ruth Behar,

Nancy Scheper-Hughes and other field-defining scholars embarked on research that not only inspires and pulls our heartstrings with the full weight of human experience but has also become foundational literature in the training of new generations of anthropologists. Ethnographies that recount trauma are common and they are compelling. Less common are methodologies and training that prepare junior ethnographers for the possibility of witnessing or experiencing trauma in the field.

Global concerns of the 21st century, including health and economic inequality, war, refugee crises, racism, and xenophobia among others are the foci of anthropological study. In seeking the narratives of the people embedded in these experiences anthropologists bear witness when our interlocutors recount trauma(s) related to these phenomena. As ethnographers, immersing ourselves in the same everyday realities as our interlocutors, we are likely to not only bear witness to but also to experience trauma ourselves. Outside of the stories we have been told through ethnographies, our research methods curricula do not currently include training, and in some cases not even discussion, about trauma in the field. Anthropology and its practitioners must address this oversight, especially as the field grows and seems to aim its scholars toward traumatized and traumatizing fieldsites.

This is not to suggest that ethnographers must become psychologists, therapists, or counselors. Rather, we can (and should) be informed about trauma and have adequate tools and resources at our disposal to deal with trauma as it manifests in our anthropology. Specifically, it

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would be beneficial to prepare our researchers for the possibility that they will encounter trauma in the field, how to recognize it when they do, and to ethically and compassionately interact with research participants who share their traumas or whose trauma the researchers witnesses directly.

In the same way that we are required to consider and accommodate any discomfort or distress for our participants that might arise during the course of our research, we must ensure that our discipline considers the safety and health of its researchers and is prepared to provide them with the support and resources necessary in the increasingly likely event that they encounter trauma in the field. We might think of this as not only the ethics of human subjects research, but an ethics to self and our fellow anthropologists.

What a Global Pandemic Tells Us About STMMs

Similar to what Sullivan (2018) and Benton (2016a) have noted in their own analysis of health-centric interventions, the underlying assumption of contemporary medical missions is that their presence, no matter how limited, is better than nothing. But, as the data show, and Playa

Felumians attest, there are resources absent STMMs. The missions have only ever been one among them. Ironically, the global pandemic in 2020, the most significant global health crisis in a century, underscores the ability of local communities to survive without STMM volunteer presence.

STMM organizations and their volunteers have been grounded and have demonstrated just how quickly and easily they can reconfigure their support models. Rather than hoarding the substantial medical supplies and resources, HMH and other organizations have been forced to open their warehouses in Honduras so that local organizations can utilize and distribute medicine and equipment. STMMs have been forced to trust local community members, local leaders, to identify and respond to needs, managing resources, and developing innovative responses. The 413

ease with which organizations have coordinated their cooperation and resource-sharing underscores that medical missions have the capacity to shift their assistance models, but lack the imperative and ideological motivations to do so. Attending to structural damage, whether physical, economic, social, or political, after the pandemic and Hurricanes ETA and IOTA, should be the most important goals for STMM volunteers if they seek to transform their work.

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APPENDIX A

RECOMMENDATIONS FOR THE FUTURE

I argue that a reimagining of STMM models is necessary and that voluntour and missioning interventions must abandon postcolonial legacies and build a solidarity-based, human-centered model that emphasizes a preferential option for the poor and directly targets the structural causes of impoverishment, ecological destruction, and corresponding poor health in communities like Playa Felumi.

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APPENDIX B

SPANISH TRANSCRIPTION OF BUYEI INTERVIEW

Buyei: 00:01 [inaudible] que tengamos buen salud. Entonces hay personas que siempre padecen de dolor de cabezas. Hay personas que siempre padecen, que no pueden dormir, que andan soñando sueños raros, que sueños con vacas, con mal espíritus, con 00:31 [agua negras], con enemigos, con víboras, cosas que no es adecuado, verdad.

Entonces, hay personas que siempre también están con ataques, que no pueden caminar y no se pueden levantar de la cama. Muchos dicen que el espíritu, que cuando muere, muere. Ese es la bomba en el mundo. Que cuando el espíritu, que cuando muere, muere. Que uno muere, que ya no regresa. Pero lo que es garífuna es sagrado, y, como dijo la biblia, en la biblia está, dios murió, y al tercer día resucitó. Okay. La gente que creía en él, lo pudo ver. Sí. La gente que creía en él, lo pudo ver. Entonces, yo 01:34 [padezco] de enfermedades que yo ya había dicho. Yo tengo la medicina. Tengo la cura para todo eso.

Entonces, y yo trabajo con tratamientos. Es un tratamiento de siete días, depende de la enfermedad de cada persona. Sí, depende de la enfermedad de cada persona. Si es una enfermedad que es bien grande, bien pesado, entonces mis ancestros, ellos hablan conmigo. Mis seres hablan conmigo. Tengo cuatro personas, que eran mis bisabuelas, mi bisabuela también ella era curandera. Ella era buyei. Entonces, yo no la conocí pero ahorita sí ya la conozco. Ella habla conmigo. Ella me dice qué tengo que hacer. Cómo tengo que, que planta tengo que arrancar. Para qué sirven las plantas que tengo que hacer. Para qué clase de enfermedad tiene que servir. Y para qué, no. Pero lo que es mal, no va con nosotros. Y yo siempre cuando trabajo, siempre dedico...

Low voice: Hello.

Buyei: ...lo que trabajo, siempre primero lo que menciono, lo que digo es dios. Antes de empezar a trabajar y después de empezar, después de trabajar. Dios. Entonces todo lo que yo hago me va bien. Y los que también reciben lo que es mi medicina le van bien. Y han superado. Han superado y nadie se ha quejado, gracias a dios. Exacto. Nadie se ha quejado. Entonces ellos me dicen qué clase de planta tengo que arrancar para hacer la medicina y para qué es.

Laura: Mm-hmm.

Buyei: Esas enfermedades. Okay? Varios tipos de enfermedades que le digo. Hay personas que se dedican a hacer daños. Ahorita en el mundo, se ha crecido la envidia, no solo aquí en Limón sino que en varios lados. La envidia. Que si tu tenés carro, que si tú tenés buena casa, sos mi vecina, voy a ver cómo hacer buscar un brujo. Porque hay brujos, hay buyei, y hay rosas cruz, hay espritistas. Hay varios tipos de...

Pero yo soy curandero, buyei como lo decimos nosotros en garífuna. Entonces, yo solo me dedico a hacer lo que es bien, para bien. Entonces, la gente buscan los brujos para que le hagan daño, para que le hagan daño, para que no puedan progresar a hacer algo por sí 416

mismo, entonces. Y eso existe, máximamente aquí. Siempre existe. En pueblos 05:00 [morenales], en pueblos ladinos, existe. De repente, ya se mira que, bum, ya se cayeron. Perdieron la casa. Perdieron los coches. Y perdieron hasta la vida 05:15.

Laura: Mm-hmm.

Buyei: Entiende. Entonces, por una simple camisa o simple cabello o algún objeto, alguien te puede con esa misma cosa que 05:33 [vos asás] porque es, ya va con tu sudor. Entonces, si está con tu sudor, ellos, es como que tiene el tesoro en la mano. Ya te tiene en la mano. Entonces hacen eso por sus santos malos. Porque hay santos malos y hay santos buenos. Hay santos malos y hay santos buenos. Entonces, yo he visto aquí han venido varias personas, personas que han estado buscando trabajo y no hay, que quieren trabajo, que buscan, buscan dos años y están en lo mismo. Entonces, yo le hago la consulta porque yo me consulto con mis seres. Y ellos me dicen qué tengo que hacer para que se pueda vencer eso, para que se pueda solucionar, y se soluciona. 06:34 [inaudible] soluciona, y 06:36 [es esas] personas que han venido a buscar eso, y hasta en su trabajo. Tienen su trabajo y están bien gracias a dios, gracias al altísimo. Sí. Han venido personas que de repente le hinchó una pierna o le hinchó un pies, o le hinchó la mano, o que estaba macheteando y de repente se dio cuenta que bum, le marcó ya. Entonces, acude al médico. Va al médico. Hay cosas que el médico puede atender y hay cosas que el médico no puede solucionar. Más 07:23 [inaudible] cuando hay, cuando se trata, como le decía 07:27 lo que es, es cosa espiritista, cuando se trata de los que es brujería. Cuando se trata del daño, cuando se trata de enfermedades del mundo, el médico no puede. Porque el médico solo te dice, no tienes nada. Pero si es enfermedad común, que se da siempre que diabetes, que anemia, que próstata, que infecciones del hígado, que, okay. Esos, sí, para eso, el doctor sí lo puede tratar.

Laura: Como del cuerpo.

Buyei: Del cuerpo.

Laura: Lo que pueden ver, como los síntomas.

Buyei: Sí lo que ellos pueden ver en todas sus máquinas. Pero hay cosas que no pueden ver, no pueden solucionar, que son cosas que nosotros los buyeis tratamos. Que sólo nosotros tenemos esas curas. Y sólo nosotros podemos vencer eso, entiende. Porque el buyei, Dios nos mandó para curar, no para hacer el mal. Aquel buyei que hace mal, esas personas tienen pacto con el diablo. Entonces esa persona no es salvo, y no se salvará. Porque viene con un propósito porque está 09:04 [demandando] la ley. Dios no lo perdona. Dios no lo perdona.

Y también he mandado a varios jóvenes, porque hay jóvenes que se sacrifican para lo que es ir a los Estados Unidos. Así, en ríos que se arriesgan la vida.

Laura: Mm-hmm.

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Buyei: Que muchos no llegan. Muchos no llegan ¿por qué? La migra está en cada esquina. Los Zetas también están en cada esquina. Si vos no tenés suerte, bum, te matan, y no regresás 09:52 [inaudible]. Y yo he mandado jóvenes de aquí a los Estados Unidos. Y gracias a dios, han llegado, y están bien. Gracias a dios están bien ellos.

Laura: Ellos vienen a usted antes de su viaje?

Buyei: Antes de ir allá. Ellos llegaron. Me dijeron que le diera medicina para la suerte o para el daño o para envidia. Que ningún mala [biblia/ vibra] 10:23 del mundo que lo retrocediera, que les diera 10:28 [inaudible] en el camino. Que no diera nada de retraso en el camino. Entonces le di la medicina. Le pedí el nombre y el apellido. Y yo le hice el trabajo. Y gracias a dios allí están. Están bien. Están bien. Entonces, me alegro de que usted venga para informarse de eso.

Laura: Sí.

Buyei: Son cosas que, que hay personas, hay jóvenes que se olvidan, porque lo que es buyei, eso mas bien es desde ahorita. Desde ya tiempo está entre nosotros. Y no va a haber nadie ni nadie que lo puede vencer. Porque eso viene de nuestra sangre. Y son cosas que aquí en Limón hasta la lengua de uno, él estaba olvidando. Y esas personas nos sirven de protección, porque nos protege de todo mal, de todo peligro. Nos 11:36 [inaudible] protege. Así es. Y usted tiene un buen trabajo, y gracias a dios halló ese trabajo. Y es algo que también se tiene que cuidar. Porque hay personas, los que le decía envidia. Que le puede retroceder en el camino. Pero siempre usted 12:08 [inaudible] toda la mañana, toda la noche. Y qué bien. Qué bien. Y él, donde sea que usted vaya, él va con usted. Él va con usted. Hay un don que la protege. Él le va a proteger siempre.

Entonces. Ahorita estaba haciendo una 12:31 [inaudible] caliente 12:33 [inaudible].

Laura: Sí, 12:36 [inaudible] caliente.

Buyei: Allí tengo unos clientes allí que, bueno, me tienen encima que le haga eso. Y yo voy a viajar en toda esa semana. Tengo otro trabajo que ir a hacer fuera de aquí. Entonces, le voy a entregar esa medicina hoy, si dios quiere.

Laura: ¿Qué es?

Buyei: ¿Mm?

Laura: ¿Esa medicina, qué es?

Buyei: Esa medicina es con pura hierba. Sí. Es con pura hierba...

Laura: ¿Cuál hierbas? ¿Y cómo se llama la medicina?

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Buyei: La medicina es para daños y para suerte.

Laura: Okay.

Buyei: Sí, para daños y para suerte. Hay varios tipos de hierbas, que las hierbas me dicen cómo se llaman y para qué sirven. Entonces ellos son muy buenos.

Laura: Sí, estoy aprendiendo ahorita las diferentes hierbas que usan la gente para curarse, como de caseras 13:37 pero también por cualquier uso que la tienen.

Buyei: Sí, exacto, para infección, por ejemplo, si te viene empezando un tumor, o algo de lo que es operación si te viene empezando para todo eso. Eso sí es tratable. Hay varias hierbas en el mundo que la gente no sabe para qué sirven. Tal vez una hierba que sirve para sanar alguna enfermedad o para sanar algún, cómo le dicen, cómo le dicen la enfermedad que no me acuerdo. [Colaica] 14:29 [garífuna word] entonces la gente le van bum, bum, bum con el machete, a cortar las plantas. Y no saben que esas plantas sirven para curar personas. Son cosas que nosotros no tenemos que deforestar todo el mundo cortando las plantas 14:53 [inaudible] tan siquiera 14:57 [inaudible] para que 14:57 [inaudible]. Así está la cosa. Y como supo que, quién la mandó que me 15:06 [crosstalk].

Laura: Aaa, pues, yo estaba buscando un buyei y como estoy haciendo entrevistas entre la gente hablando a ellos, de vez en cuando, pido a alguien, "¿Conoce un buyei? ¿Conoce una de esta, una de esta?" Y uno me dijo el nombre de 15:32 [Marlito/Maylito], y fui a visitar a Marlito pero él no estaba y su mujer me dijo, "¿Por qué no visites a Memo?"

Buyei: Aaaa, sí, sí.

Laura: Entonces vino para buscarte y a lo mejor porque yo vivo aquí cerca aquí en Cocalito. Entonces 15:47 [inaudible] okay. Como no puedo encontrar a Marlito ahorita, está en mi barrio.

Buyei: Qué bien, no hay problema. Cualquier cosa, entonces, estoy a la orden. Porque yo empecé en eso cuando tenía ocho años.

Laura: Ocho años. ¿Y cuántos años tiene ya?

Buyei: Tengo 23. Voy a cumplir 24 el otro año. Este año el 25 de junio, cumplo 24. Empecé a los ocho años.

Laura: ¿Y quién le enseño?

Buyei: Mis ancestros.

Laura: Sus ancestros.

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Buyei: Son gentes que no cualquier persona lo puede mirar. Sólo si tenés el espíritu bien liviano o si sos una persona elegida en eso, sólo esa persona los puede mirar a los seres difuntos.

Laura: ¿Quería ser buyei, o era como estaba tocada a ser buyei?

Buyei: ¿Quién?

Laura: Usted. ¿Cuando tenía ocho años, pensaba "Yo quiero ser buyei"? ¿O estaba como, alguién te mandó? Sus ancestros...

Buyei: Sí. Alguien me eligió. Alguien me eligió. Yo, o sea, desde cuando yo era pequeño, me gustaba esto de los buyeis que hacían siempre. "Uy, qué lindo," decía yo. Pero yo no me imaginé que lo iba a ser, que alguien iba a reencarnar en mí a enseñarme, a hablarme muchas cosas. Sí. Entonces, yo empecé de repente, me acuerdo muy bien, a mis ocho años, que hasta me dejaban dormir en el monte. Y me perdía de mi familia, y mi familia preocupada, que dónde estaba. Esos espíritus me llevaban allá para enseñarme qué clase de plantas que fue lo que yo iba a hacer. Hasta mi familia se preocupaba que ¿qué le pasa a Memo? ¿qué le pasa a Guillermo? Que ¿será que se está volviendo loco? Tenemos que salir a buscar un doctor. El doctor no 18:08 nada 18:10 [inaudible]. Entonces, fueron también donde otro buyei.

Pero antes de eso, me acuerdo a los nueve, que iba hacía medicina, ya empezaba a hacer medicinas. Pero como que no había nadie que creía de mi propia gente. 18:31 [inaudible]. Entonces, mi familia se preocupó y salió a buscar medicina. Que esa misma buyei le dijo, "viera qué lindo, qué cosa." Y todos nosotros 18:53 [inaudible] afuera. Eso fue en Triunfo. Esa buyei se llamaba Lenny. Pero ahorita le hicieron daño a la pobre, se descuidó. Pero ella da medicina todavía pero ya no es la mera mera como era antes. Entonces, esa buyei me dijo, aquí hay una señora que se llama [Regina] 19:18 . Esa señora la conoce? Mi mamá después dijo, "Sí. Ella es mi abuela," le dijo. Entonces es algo que uno se tiene que decir, y ¿cómo sabe que se llama Regina si no la conoció? ¿Cómo sabe que el abuelo se llamaba Pedro que no lo conoció? Yo me quedé [jeta] 19:42 . Allí yo [fije, que es buena]. Cuando entramos consulta, ella me dijo que desde pequeño, que se reencarnaba en mí, que estaba esperando que yo me creciera, que yo hiciera algo por mí, y que después se 20:03 quedarse a dedicarme que yo fuera un buyei mejor. No un buyei 20:11 como muchos hay. Entonces, yo me quedé sorprendido. Pero me dijo la señora, "Pero todavía puedes trabajar, puedes ir a Estados Unidos porque estás más pequeño. Ellos te tienen el día, el momento, el año cuando ellos van a decidir que vos marchés." Entonces, tranquila. Y habló con mi mamá, a mi mamá le dijo que tenía 20:43 [inaudible] lo mismo, que no se preocuparan la familia, que eso era lo que estaba pasando. Que ellos bien sabían que eso estaba en la raza de nosotros. Que eso no es nada de que, bum, se murió, y se fue, y se terminó. Eso es algo 21:02 [inaudible]. Si vos fuiste buyei, cuando vos te mueras, lo vas a tener que heredar a otra persona 21:10 [inaudible]. Así es la cosa.

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Entonces eso pasó conmigo, nuevamente, me eligieron a mí. Me eligieron a mí como buyei y he tenido varios, muchos sueños todavía. Y yo les digo siempre 21:33 [inaudible] les digo, "esperen que yo tenga mis 40 o mis 39 años para yo dedicarme de todo en todo con ustedes." Porque yo todavía quiero trabajar. Tengo que comprar mi casa. Mi mujer, estar juntos, okay, haciendo lo que yo quiero y después 21:52 [dedicarme]. Porque yo ahorita sólo tengo para la comida para algo que, pero no tengo nada que es algo que nos va a servir para la vida. Pues no sabemos qué es lo que nos va a pasar día de mañana. Entonces, ellos me entendieron, y me dijeron que sí que no había problema. Okay. Entonces, ya mi familia de repente se 22:19 [resignaron/reiniciaron], toda mi familia. Estas casas, aquella que mira allá, todos somos familia. Esta, todos aquí somos familia. ¿Qué? Primas, tías, hermanas. Entonces, ahorita mi familia ya creyeron en mí. Ya aceptaron todos. Ya aceptaron. Mi padre también era otra persona que nunca quería. Nunca aceptó. Que eso era una mentira, que eso era una loquera mía, que estaba loco, que dejara eso. Que me iba a amarrar en un palo. Así me decía. Y mi gente me aceptó y me decían, "23:06 [no le hagas] caso. No le haga caso. Algún día te va a pedir perdón y lo va a aceptar." Hace poquito el año pasado, mi papá vino y lo aceptó. Y me pidió unos baños que le hiciera un trabajo. Yo mismo le hice el trabajo. 23:26 [inaudible]. Entonces, aquí estoy madre, linda. [Paro aquí] 23:33 cuando dios quiera, mis ancestros quieran. Esto es para servirle al mundo para bien, no para mal. Quien quiera protección de todo mal, aquí está. Quien quiera baño para suerte también. Quien quiera baño para daños, para el trabajo, para mal sueños, aquí está. Dolor de estómago, infecciones, también. Exacto.

Entonces, hay otro punto que no le había explicado, que ya voy a explicar, esto de siempre los ancestros, a los ancestros nosotros comúnmente, nosotros garífunas, nos acostumbramos a decir 24:21 ["Gubida"]. Gubida tienen varios formas de cómo actuar, de cómo golpear. Ellas son buena gente. Gubida son personas, seres, que se han ido, como nuestras mamás, nuestros padres, hermanos que ya tiene seis, cinco años de haberse muerto, le llamamos Gubida. Entonces, son personas que los familiares se olvidan de hacerle una celebración, una misa, 25:02 [inaudible], un velorio, o un chugu, o un dugu.

Entonces, cuando esos seres miran que nosotros no le hacemos esto, no nos acordamos, ellos vienen con una ira y nos golpean. ¿Y golpear en qué punto? Que de repente, estás en el monte, estás con el machete, y bum, de repente estás en un palo, te caés, te fracturás y ya no puedes caminar. Y vas al doctor, y el doctor te dice, "no tienes nada." Pero si vas con un buyei, el buyei te dice, "tu abuela era que estaba. Ella fue la que ocasionó eso, que no le diste un 25:44 [inaudible], que no le diste un chugu, o que no le hiciste una celebración de misa. Pero si vos aceptás, te curás. Pero si no aceptas, esa misma persona te lleva. Te complicás y te morís. Yo siempre lo recalco y lo digo, sí vive, porque viven, vive. Y viven para protegernos, no para hacerle mal. Es lo único que les puede decir.

Laura: 26:11 [inaudible] Tienes razón. He visto un dugu una vez, pero sí, es... Tienes razón porque hay que dejar a los fallecidos a descansar.

Buyei: Descansar.

Laura: Hay que ponerlos, hay que arreglar todo para que...

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Buyei: Exacto. Para que ellos estén bien, para que ellos estén feliz donde que están. Hay personas que siempre... Ha pasado también. No es que estoy criticando a la gente cristiana, a la gente evangélica, porque todos somos cristianos. No es que yo critico a la gente evangélica, sino que ellos, por no creer, por tener eso en sí. Dicen que eso no existe, que eso no va, que esto por aquí que esto por allá. Pero ellos mismos también son víctimas de eso. Han habido varios que han sido víctimas en eso, que le han ocasionado heridas, que le han ocasionado mal de salud, que han acudido al doctor, y el doctor no le han hallado 27:32 [inaudible]. Y los mismos pastores allí como tontos, disculpando la palabra. "Ay que dios padre que era la cura [la que busque] 27:43. Que esto por aquí, que esto por allá. 27:45 [inaudible]." Entonces, siempre sigue en lo mismo, ¿me entiende? Hasta que, si no eres 27:51 [inaudible] hasta que [resignan] y hallan la cura, porque yo he visto a varias personas así que son evangélicas que han acudido a un buyei, a que el buyei le haga cura y que lo cura. Entonces no tenemos que criticar. Tenemos que amarrar la lengua para que no critiquemos. Claro, está bueno tener religión, pero del mismo dios. Es el mismo dios. Pero eso es algo que es, ya tiempo está. Yo creo que mi abuela estaba todavía, cuando empezó esto. Entonces, no hay nadie que lo puede quitar, sólo dios. Sólo dios. Pero dios siempre apoya lo bueno, no lo malo. Me imagino que él me va a apoyar porque yo hago de todo para que alguien recaído que vuelva a levantarse. Un enfermo que se recupere no que vuelva a caer. Ese es lo que yo hago. Yo sé que es dios. No le pido una corona, pero tan siquiera un peso se lo pido. Ese es lo que pasa.

Laura: Entonces, pues, puede mostrarme unas de las hierbas que usa para...

Buyei: Sí.

Laura: Porque yo quiero aprender de cuáles son y para qué, y qué se trata.

Buyei: Si puede venir acá porque ya las tengo ya cocinando.

Laura: Aa, bueno.

Buyei: Venga. Si hubiera llegado más temprano, la hubiera enseñado esa hierba porque esa la busco-

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APPENDIX C

CHILDREN’S ART

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APPENDIX D

VOLUNTEER SURVEY QUESTIONS AND HOUSEHOLD INTERVIEW GUIDE

Survey Questions (Mission Volunteers)

1. What is your age?

2. What is your gender?

3. Where (in which state) do you reside?

4. What kind of work do you do when you’re not volunteering?

5. How did you get involved with short-term medical missions? (Check all that apply)

6. How many short-term medical mission teams have you volunteered for?

7. With which organization do you most frequently volunteer?

8. How many times have you been to Honduras?

9. Why do you volunteer on short-term medical missions?

10. On your most reecent trip to Honduras, what were your teams goals?

11. Please indicate the degree to which you agree or disagree with this statement: On your

most recent trip to Honduras, the team accomplished its goals.

12. What did your most recent short-term mission team do? Check all that apply.

13. What was your role (what were your assignments) on your most recent mission trip.

14. On your last trip, what were some of the challenges you faced?

15. On your last trip, what were some of the team’s successes?

16. What are the most common health concerns your team encountered on your last trip to

Honduras?

17. Based on your experiences, what are the most common causes of poor health where your

mission team worked? (All perspectives are valued, regardless of role or expertise.)

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18. What do you know or what did you learn about local healthcare options where your most

recent team worked?

19. What long-term effects do you think short-term medical missions have in the

communities they serve?

Informal Interview Questions (Mission Volunteers)

1. How did you decide to join a brigade to Honduras?

2. Have you ever been to Honduras?

3. Have you ever been on a medical mission before? If yes, how many other and with what

organizations?

4. What did you know about Honduras before you came?

5. What did you know about this community before coming with the brigade?

6. What do you believe are the needs of this community?

7. What kinds of services does the brigade provide?

8. How does the team decide what services to provide?

9. As a doctor/nurse/physician’s assistant/nurse practitioner/dentist what kinds of decisions

do you make about healthcare? How are they similar to or different than protocols or

practices that you are used to in [US/Canada]?

10. Are there services you wish you could provide, but can’t? Like what? And what prevents

you from providing those services?

11. Do you think the services provided this week meet the needs of the community? If so,

how? If not, what do you think is missing and why?

12. Are you aware of any political, social, or economic issues that might make healthcare

difficult for this community? 428

13. Do you think [name of brigade organization] addresses those issues? If so, how? If not,

why not?

14. Have you learned anything new about Honduras, Hondurans, this community in

particular, or medical missions during this trip?

Houshold Interview Guiding Questions

1. How are you feeling? (Como se siente?)

2. Do you feel well? (Se siente sano?)

3. What does it mean to be healthy? Que significa ser sano?

4. What are the root causes of illnesses for you or for the community in general? Cuales son

los causas raices de enfermedades para os o para la comunidad en general?

5. What do you use in or outside of your home to stay healthy? Caules cosas usan dentro o

afuera de su casa para mantenerse sano?

6. Do you visit the health center [CESAMO]? Visita al centro de salud?

7. Why do you go there? Por qué la visita?

8. How do they treat you there? Cómo le trataban?

9. Are there things that you think the health center does well? Haya cosas que piensa que les

hacen bien al centro de salud?

10. Or things that they should change or improve? O cosas que deben de cambiar o mejorar?

11. Do you visit the medical missions when they come? Why do you visit them? Visita a

brigadas cuando vienen? Porque las visita?

12. How do they treat you at the medical mission clinic? Como le trataban a os a la clinica

brigada?

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13. Are there things that you think the medical missions do well? Haya cosas que piensa que

les hacen bien las brigadas?

14. Or things that they should change or improve? O cosas que deben de cambiar o mejorar?

15. What effects do you think medical missions have had on your health? Que efectos piensa

a tenido las brigadas en su salud?

16. What are successes of the medical missions, for you? Cuales son los exitos de las

brigadas para os?

17. And what are their limitations? Las limitaciones de ellos?

18. What changes have you observed in the community as a result of the medical missions?

Cuales cambios ha observado en la comuidad como resuelto de las brigadas?

Children’s Workshop Activity Prompts

1. What do you think health means? Qué piensas que significa salud?

2. What are some examples of good health practices? Cuales son algunos ejemplos de buenas practicas de salud?

3. What are examples of things you think are bad health practices? Cuales son algunos ejemplos de malas practicas de salud?

4. How did you learn about these practices? Cómo aprendian sobre estas practicas?

5. What do you do when you get sick? Qué hace cuando te pongas enfermo?

6. Draw an picture of something that reminds you of health. Pinta un dibujo de algo que te recuerda de la salud.

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7. In groups of 5-6 develop a mini-drama (skit) that describes an interaction at the health center/at the brigade clinic. En grupos de 5-6 elabora un mini-drama que describe una interacción al centro de salud o a la clínica de las brigadas.

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