For the last week I have been in El Salvador as part of a human rights delegation. I am new to the group and the youngest person to go on the trip. The delegation was made up primarily of people who had helped rural communities fight for human rights during El Salvador’s civil war in the 1980s and early 1990s. Following the civil war, the group has continued to maintain close ties with the rural communities they helped and have continued to forward assistance in both money and time to help these communities gain literacy and organize in ways to improve nutrition, water supply and even health care following the war.
Because of the delegation’s prominence during and after the war, we had the opportunity not only to meet with the community organizers in the provinces and villages that were the focus of support, but also to meet with high-ranking officials from the Salvadoran government in charge of ensuring basic human rights and the integration of previously marginalized groups into the active citizenry. We also met with leaders of non-governmental organizations who are combatting the growing problems of narcotics trafficking, youth violence, and underemployment that plague San Salvador, the capital city. I learned a lot about the social and political conditions that led to the civil war as well as the struggles now to implement the changes in a bureaucratic system even when the desire to make change is there.
One of the areas I learned a bit about was health care delivery in El Salvador. Not surprising I am sure to anyone; if you are wealthy, high-quality health care is available. Indeed, the leader of our group (a native Salvadoran who came to the U.S. as a political refugee during the war) returns regularly to have some medical issues addressed. Here in the U.S., for example, the simple removal of a skin tag on the neck would run about $150 each. In El Salvador, a well-trained dermatologist charges $6 per removal. Even with the cost of the flight, if you have a bunch of skin tags or moles that need to be removed it is cheaper to go to El Salvador to have it done, especially if you are going there to see family as was the case with our delegation leader. The problem for most Salvadorans, though, is that even with the apparent bargain prices, paying for medical care is often out of reach.
If you are not rich, health care in El Salvador can get pretty expensive. If you are working for a business, you are levied a tax that is deducted from your paycheck and pays for health insurance for you and your family, which then allows access to the public clinics and hospitals. Most people, though, work in a shadow economy of cash-paying work and don’t have access to affordable insurance and as such they go without and pay cash when they need medical care.
I saw many people with evidence of their lack of health care access. Adults with poor vision due to lazy eyes and abnormal gaits due to poorly mended fractures, for example. Interesting, though, after looking up life expectancy on the World Health Organization website for El Salvador and the United States when I got home, I learned that if you survive your first year in El Salvador, your life expectancy is more than 68 years if you are a man and 76 years if you are a woman. The Salvadoran government spends 6.4% of their GDP on health care at a rate of $427 per person per year. Here in the United States life expectancy is a bit longer (76 years for men and 81 years for women) and the rate of death for children under 5 years old is half the rate of El Salvador’s but the U.S. spends 16.2% of our GDP or about $7,410 per person each year on health care.
I understand that money isn’t the only factor to consider and of course a much higher quality of life is seen here since conditions that could hobble but not kill you in El Salvador are managed more completely here to minimize morbidity. But what is common to both countries, despite the huge differences in the amount spent per capita, is the lack of access to basic and specialty medical care to those who can’t afford it.
In rural communities, most areas don’t have access to a medical doctor and instead rely on health promoters who aren’t necessarily even trained as nurses but rather are interested in health and gain some additional training to help provide guidance. Nobody outside of San Salvador is likely to have routine testing or exams, nobody is likely to get guidance about heart-healthy behaviors and nobody is likely to give birth anywhere but in their home. Children do receive vaccinations by way of a group that comes to the village intermittently but the administration of vaccines is not accompanied by any other health guidance for children.
Both the U.S. and El Salvador have a long way to go to provide high-quality routine and specialized care in a cost effective way to everyone. I am glad to live here with our research and cutting-edge opportunities to get care, but when I see the huge number of people here without insurance when we as a nation are so incredibly rich I understand that our system is fatally flawed. Given how much we spend on health care and given the potential access to care that our infrastructure provides, it seems even crazier to me that we are doing a billion MRIs and spending billions on medications when some folks can’t even get routine health maintenance exams done here because it is cost prohibited. We certainly don’t want to go the extreme that El Salvador shows us with lifelong preventable problems ignored, but we certainly aren’t spending our health care dollars wisely if we have a significant percent of people who have no insurance and can’t afford to pay for care. We’ve got it pretty good here…. But there’s definitely room for improvement.