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By Jeneen Interlandi
The roads surrounding the Jerusalem-San Luis Alto Picudito Indigenous Reservation in Putumayo, Colombia, are very expensive in good weather. Built basically of gravel and mud, in some places they slightly shrink the width of a small truck, and in others, especially after a storm, they yield to the maximum absolutely to the many rivers with which they intersect. They also spin, twist and collide with each other without stopping. Then, in the most difficult months of her pregnancy, when everything tasted like cardboard and hurt. even to sit or stand, Marleny Mesa had absolutely refrained from traveling. That meant missing exams at Villagarzon’s clinic, which could take two hours or more to get there. But Marleny wasn’t too worried. A nurse had confided to her early in her pregnancy that her blood tests were correct and that everything was fine. As a midwife, Marleny knew that taking the vacation would be riskier than missing a few doctor visits.
But now, in the last days of your pregnancy, you may not get rid of the feeling that something is wrong. You may only breathe lightly, on the one hand. On the other hand, their anxiety and physical discomfort reached what seemed like an insufferable peak. Her husband, Andres Noscue, called an ambulance. Hours passed and no one came. He had tried to locate a car to take him to the hospital. He had also called Marleny’s sister, Omaira, a prophet from his church, to come and pray over her womb. It seemed to work. Marleny’s breathing stabilized and about a week later she gave birth to a small, twisted boy with jet black hair and soft, curious eyes. The couple named him Eliad.
Marleny’s idea was perfect, but her mother, a retired midwife, insisted that the placenta contained traces of disorder. He was too big, he said, and Eliad too small, probably because he didn’t have enough room in his abdomen to grow. Grandma idea he might want an incubator. Marleny thought it well, however, when the baby was a few days old, she and Andres took him to Villagarzón for an exam, just to be sure.
This turned out to be more complicated than expected. The baby may simply not be noticed at the hospital until he or she has an identity or a civil registration number, which you simply cannot download without a birth certificate, which the hospital simply cannot provide because the baby was born at home. Go to the workplace registration office, the nurses told Marleny and Andrew. But the registrar’s workplace only sent Andrew back to the hospital, where another nurse told them to check the notary’s workplace. It was almost noon. The only bus of the day would soon leave. return to St. Louis; if Andrés and his circle of relatives missed it, they would have to pay more cash for room and board in the city than they spend in a week. So they went home.
The couple backed off a few days later, but the Registrar’s orders were different and more confusing this time. They would want two witnesses to her reservation, she said, and several documents — adding one with the baby’s blood type and another showing the medical care Marleny gained during her pregnancy — to prove that she was born within the country’s boundaries and that he was, in fact, her child. The guy looked suspicious, Andres said, and asked questions of a kind he didn’t ask the first time. “There was nothing we could do,” Andrés told me one sweltering July afternoon as we sat in the shade of his family’s covered wooden porch. “They didn’t know the child was ours, so we went home. “The couple had planned to return to Villagarzón as soon as they finished the night, to fix everything once and for all. But before they had a chance, Eliad developed a terrifying rash, with blisters on his head and face, and began panting.
The circle of relatives returned to Villagarzón for the third time. Marleny waited in the hospital while Andres went to the notary. This time he was lucky: An employee put him in touch with Leydi Rodriguez, a network fitness employee who works with a program known as Colombia Rural Vital, one of many projects submitted through the nonprofit Vital Strategies and Bloomberg Philanthropies as part of a broader effort. to improve birth and death registrations worldwide. The organizations estimate that some two billion other people lack birth certificates, and only a portion of the roughly 60 million deaths that occur each year are meaningfully recorded. The consequences of this failure are multiple and disastrous: families like the Noscues struggle to access the rights and benefits of citizenship. Government officials struggle to allocate resources and formulate evidence-based fitness policies. And a list of identity-based crimes, from electoral chicanery to child trafficking, is allowed to proliferate.
The challenge of under-registration is of utmost urgency in low-income countries in Africa and Southeast Asia. But this is not limited to those regions. In Colombia, birth and death registration is asymmetrical in indigenous and Afro-descendant communities, where the national government tends to have little presence and civil registrars and notaries tend to apply the rules arbitrarily. Colombia Rural Vital created to simplify and democratize this process.
Rodriguez, a petite woman in her thirties who exudes serious courage, ran to the notary shortly after the clerk called her. He asked Andrew a series of questions about Eliad, entered his answers into an app on his tablet, and rated the baby. Birth and fatherhood, all in less than an hour. Andres would want to fill out a few more forms, he explained, but Eliad now had a birth certificate and could see the doctor right away. Andrés took the certificate to the hospital. The news was far less comforting. Eliad had a serious bladder infection and several imaginable birth defects. The boy was very sick, the doctor told them. The couple deserves to have brought it sooner.
The world’s wealthiest nations are inundated with so much non-public knowledge that knowledge theft has become a lucrative business and protecting it is a common concern. From that perspective, it would even be hard to believe otherwise: the lack of identification data. Not at all, let alone deal with its implications. But undercounting human lives is widespread, knowledge scientists say. The resulting evils are important, and recent history is littered with missed opportunities to solve the problem.
More than two decades ago, 147 nations rallied around the Millennium Development Goals, the United Nations’ ambitious new plan to halve excessive poverty, lower child mortality and defeat infectious diseases like malaria. and HIV. Fitness goals have become the subject of countless foreign summits and mainstream media coverage, eventually attracting billions of dollars in investment from the world’s wealthiest nations, including the United States. But a fierce debate temporarily ensues. Critics said fitness officials at the United Nations and elsewhere had little idea of the basic situations in many of the countries they sought to help. They may simply not say whether maternal mortality was rising or falling, how many other people were sick with malaria, or how fast tuberculosis was spreading. In a 2004 article, former World Health Organization testing director Chris Murray and other researchers described the agency’s estimates as “serial estimates. ” Without this baseline data, progress towards a given purpose (for example, cutting hunger in half) may simply not be measurable.
There were many barriers to achieving those benchmarks, but the underlying challenge was clear. Because many low- and middle-income countries lacked functional systems for civil registration and important statistics, about one-third of all births and a large majority of deaths were not counted in the first place. Instead of creating such systems, health officials had come to rely on a mix of surveys, censuses, and computer models that provided only raw estimates of express diseases. Effective birth and death records would help paint a much more accurate picture. , critics argued. But surveys and censuses were faster and cheaper, and with a list of rapid disease systems competing for resources, system-wide reforms were relegated to the background.
“It’s a bit like a catch-22,” says Prabhat Jha, a professor of global fitness at the University of Toronto. “When you don’t have wise data, you turn to wise mathematical models. They may be wrong at the country level, yet global donors and politicians think, “Oh, we have data,” which then undermines the case for making an investment in physically more powerful patches.
In 2015, the United Nations set out to correct this problem with another ambitious measure: to ensure that all births and at least 80% of deaths are systematically registered until 2030. But more than seven years later, this effort is far from being achieved. his objectives. “This is probably the largest critical progression failure in the last 30 years,” says Philip Setel, a demographic and medical anthropologist who leads the vital registration initiative at Vital Strategies. “Not only because of the scale or underestimation of the problem, but also because of the magnitude of its impacts. ” Bangladeshi widows cannot discharge land rights or survivor benefits without the means to sign on the death of their spouse. Rwandan street youth cannot go to school or enter the legal economy because they do not have a valid birth certificate. And Southeast Asian women cannot escape forced marriages without a way to determine their age or identity. “It’s disastrous,” says Stephen MacFeely, director of insights and analysis at the World Health Organization. “Especially considering that it is a basic and fundamental measure. They are the two bookends of life, and we still don’t have a teacher in either one.
The pandemic has made those shortcomings hard to ignore. From the early days of the first outbreaks, as scientists struggled to perceive how fatal the coronavirus is or how long a given wave can last, elected officials and their constituents were traversed through stunning exponential maps and graphs and expansion charts. But while those trademarks of the crisis created a sense of perception and control, the facts remained elusive. As with the Millennium Development Goals, at least one component of the challenge was reduced to a benchmark consultation. knows,” MacFeely says. You can’t distribute vaccines well, or say how bad a given variant is, if you don’t know how many other people it kills. “
Three years into the pandemic, the actual number of deaths from covid remains a maximum not a maximum likely to be determined. In May 2022, the World Health Organization concluded that it was probably 2. 5 times higher than in the past: 15 million, up from 6 million. At the time, scientists estimated that India’s death toll from covid was probably six times higher than what the government had said in the first place. A 2021 report in eLife magazine also pointed to wide discrepancies between figures provided by government officials and what an impartial investigation would recommend: in Belarus, Egypt, Nicaragua, Russia, Tajikistan, Uzbekistan and elsewhere. Some of this underestimation was planned and political; the lower the number of deaths in a territory, the greater the reaction of a certain leader to the pandemic. But not everything was like that. The number of deaths has remained low in sub-Saharan Africa for most of the pandemic. But death records are low in this part of the world, and scientists say it’s unclear whether those countries were literally spared, or whether thousands of Covid deaths were simply never reported. “I think we’ll find it eventually,” says Chris Murray, now director of the Institute for Health Metrics and Evaluation at the University of Washington School of Medicine. “But it’s remarkable how much uncertainty there is about an issue that’s pretty important. “
In the meantime, it is clear that when it comes to strengthening our knowledge systems, time is not on our side. As the pandemic subsides, a host of other pathogens (mpox, measles, flu) are wreaking new havoc. With global warming, scientists say we may soon be facing pandemics at once. “The only way to protect ourselves from such attacks will be to protect everyone,” says Tom Inglesby, director of the Johns Hopkins Center for Health Security. “Especially those who are the most vulnerable or least able to protect themselves. “The first step to achieving this, to perceiving who they are, how they live and what they are most likely to die of, will be to count them.
Marleny comes from a long line of midwives and had already had 4 children, but she can’t forget to bring a baby to the hospital. She was baffled when doctors in Villagarzón told her Eliad needed to be transferred to a hospital. largest center in Puerto Asis, a city two hours in the opposite direction. And she was angered when nurses in Puerto Asis took the baby from her arms and, without preamble, took her to intensive care. How can only this assistance be separated from its mother?Why can’t she just go into intensive care with him?A nurse advised her to go back to her reserve because the baby would remain there for a while. Treat him if she wanted to.
The next morning, he says, he discovered Eliad under intensive care, bloodless and wet, covered in vomit and turning purple. He groaned. Marleny sought to take him home immediately. If he died, she thought, it was better for her to go there, where she could take care of him herself. Finally, a doctor explained to Marleny why the baby was staying: she needed an incubator and antibiotics and at least a few weeks to heal.
The couple spent those weeks in Puerto Asis, staying with relatives and using the maximum of their savings to cover non-public expenses, as well as hospitalization costs for diapers and other supplies. Marleny, who was only allowed to see her baby during visiting hours, Doesn’t help yet I think she could have been spared all this suffering if Villagarzón’s doctors hadn’t given her back her first weeks of life.
The party of Noscue’s circle of relatives did not surprise Edna Margarita Valle, principal coordinator of Colombia’s national statistics department, DANE. Valle was founded in Bogotá but spends most of the year visiting communities that can only be reached by river or air. He met other people in their sixties and sixties who never had a legal identity. He also met dozens of families whose parties are similar to those of the Noscue. When I visited her workplace in July, she showed me a video in which a circle of relatives from La Guajira, across the country from San Luis, described riding a motorcycle for 4 hours with her newborn in tow, only to be dismissed through the registrar. “That’s the norm,” he said. Registrars have worked in those positions and treat it as their own store or personal business. Sometimes families are forced to pay for their birth certificates, a document that is, in fact, a fundamental human right.
For much of the country’s long history, births and deaths were registered primarily through the Catholic Church, and the most productive way to obtain a birth certificate was to baptize a baby. But in the early 1990s, a new charter strengthened the separation of church and state; a law granting some physical care to all citizens created new incentives for parents to sign their children with the national government; And a new company has begun to collect this knowledge and produce statistics. But while those advances have improved the government’s ability to count and analyze its population, they have also created a huge disparity between wealthy urban centers, such as Bogotá and Medellín, and the deficient. rural spaces that claim the maximum physical space in the country.
“Nationwide lately we have about 85 to 90 percent coverage,” Victor Hugo Alvarez Castano, former director of epidemiology at Colombia’s Ministry of Health, told me. “But this last 15% is the poorest and most marginalized segment of the population. population. You’re talking about five or six million people. And since they are not registered, it is as if they do not exist. As a result, fitness officials are still struggling to identify and respond to fitness crises in those communities. In the Sierra Nevada de Santa Marta in northern Colombia, a recent outbreak of whooping cough has likely been intensifying for weeks. violation of rights through the Colombian government. And in Putuwouldn, where many births and deaths still happen far from hospitals and clinics, families like the Noscues are frustrated by bureaucracies they can’t master or navigate.
At least in principle, Colombia Rural Vital’s technique for this challenge is simple. When a baby is born or someone dies outside a hospital, other people join the event: family circle members, funeral directors, network leaders – text a toll-free number. The text is channeled through a telephone network and computers that allow gym staff like Leydi Rodríguez to see it. An investigation is opened, the fact of civil prestige is verified and a birth or death certificate is issued.
But while those steps are clear, so are the obstacles. People and establishments still need to be persuaded to sign their births and deaths in this way. And since many villages don’t have reliable cell phone service, it’s hard to say what proportion of sent SMS makes it to the platform. The program is operational in only 25 of the country’s 317 heavily rural municipalities. Supporters are eager to see it grow, however, in the wake of Covid, with an economy disrupted and limited resources, expansion has been difficult. Most rural hospitals do not have the resources to rent and exercise enough staff, and in those that do, managers do not see the point. Only seven of the thirteen municipalities of Putumayo, where the Noscues live, have bothered to register. for the pilot project. ” We are waiting for the strategy to become law so that municipalities are obliged to have at least one user fully exercised and committed to this work,” Franqui Moreno, a doctor at Putumayo’s epidemiology department, told me.
In the meantime, he said, good fortune depends almost entirely on the tenacity of netpaintings fitness staff like Rodriguez, who are underpaid and tend to work on contracts that will likely be canceled by city leaders. Despite those challenges, Rodriguez, and others like her, fulfill a triple task: selling the program to the communities in which they paint (a task they call “socializing the program”), tracking successful reports on the platform, and employing their own methods on the floor to capture births and deaths that still fall through the cracks. Paintings can be tedious and risky. Armed teams control many of Rodriguez’s territories, and the motorcycle he relies on to travel from one outlying town to another is old and prone to breakdowns. Even so, he loves his homework. we passed through Putumayo in mid-July. “We know what it’s like to be overlooked through our government, and it’s our job to keep that from coming down to others. “
Counting projects can be a hard sell. The discovery of disorders such as preventable diseases or poor nutrition can increase pressure on policymakers to solve them. And overcoming individual apathy can be tricky in places where the benefits of citizenship (education, physical care, social services) are negligible and barriers to civil registration are high. In many low- and middle-income countries, a significant proportion of births and deaths still occur far from the eyes of institutions. Families wishing to register such occasions will have to not only gather documents (a daunting task for those who cannot read or write), but also summon witnesses and make arduous journeys to the nearest registrar.
One of the keys to solving those difficulties, says Anushka Mangharam, a former technical advisor at Vital Strategies, is bringing the registrar closer to the population. This is a fairly simple proposition when it comes to births: parents who need physical care or education for their young people have apparent incentives to receive such intrusions. But when it comes to death, the benefits would arguably be harder to discern. And seeing a painful loss back takes a high emotional toll.
To inspire others to sign off on the death of their loved ones, fitness staff use a strategy called a verbal autopsy, which is precisely what the call suggests: a standardized interview with the deceased’s circle of relatives, in which a series of questions are asked. They are asked and the answers are entered into an app on a pill or cell phone. This data is then analyzed through algorithms and fitness officials down to the maximum probable cause of death. Critics say the algorithms are far from the best and it’s terribly complicated to distinguish between situations with similar symptoms, such as lung cancer and respiratory infections. But advocates say that even with those shortcomings, verbal autopsies can still give fitness officials a much clearer picture of where and how other people die.
For one thing, they allow fitness staff to count more deaths. On the other hand, they help normalize an overlooked procedure. In many parts of the world, doctors are not sufficiently trained to assess cause of death or, as they should be, complete death certificates. In communities where the shortage of qualified fitness professionals is significant, that bureaucracy is filled by other people with no medical experience. Verbal autopsies allow even those with minimal education to collect the mandatory information. Early tests of the technique were revealing: in Sierra Leone, maternal mortality turned out to be much lower than expected. In Bangladesh, drowning has been found to be a leading cause of death among children, with injuries at structure sites killing more adults than previously thought. In India, the Million Death Study, a pioneering verbal autopsy test designed through Jha and carried out in 1. 3 million households since 2001, replaced the country’s understanding of disease and death: malaria was much less unusual than expected in adults, H. I. V. it was rarer, and snakebites claimed tens of thousands more lives than the government assumed.
In Colombia, fitness officials have promoted verbal autopsy as a form of death registration in rural areas such as Putumayo. In my week there, I went to Orito, some other rural municipality about a hundred miles from where the Noscues live, to practice those efforts up close.
He planned to spend the day with Dora Burbano, then a nurse at Orito General Hospital who was tracking and verifying deaths for Colombia Rural Vital (the Vital Strategies program). A new armed group, which gave the impression of being a branch of the Revolutionary. The Colombian Armed Forces (FARC) had just flooded the town with leaflets claiming ownership of the territory and issuing several new restrictions, adding the five-o’clock ban on curfew. As we discussed whether to replace those plans, we learned that a funeral director the team worked with had been shot dead that morning. The cases of his death were unclear. The only thing that can be said with certainty is that he had been stopped at a checkpoint on his way to one of the remote villages. the hospital, or halfway.
Burbano, a 44-year-old single mother with two young children who grew up in Orito and followed in her mother’s footsteps by hiring a nurse at the local hospital, has remained calm in the face of those developments. His own mother summoned through armed men to tend to her wounded and, at least once, prepare a corpse for burial. In the year since Colombia Rural Vital presented its initiative in Orito, he had something of a medical detective, traveling from town to town. village, cultivating springs and digging up unreported deaths. At the time of my visit, she was keeping an eye on several who had not yet been certified. hanged to make it look like suicide; a guy who was crushed to death by a falling tree; and several grandparents whose lifestyles might never have been recorded in any way but whose deaths would now be counted.
Our first case that morning concerned a guy named Rudolph whose wife and daughter had recently passed away. His wife’s death had been recorded (it had occurred in hospital), but not his daughter’s (because she died at home). Rudolph was cursed when Burbano first contacted him. He saw no explanation for talking about such a painful occasion with strangers, he said. He would prefer his circle of relatives to stay in peace. The plan was replaced and he was asked to go to the hospital to get it home, he went there of his own free will.
Now he was sitting across from her in an empty convention hall. He looked into the distance as she explained the verbal process of the autopsy and then began with her questions.
Did the baby have seizures? No, he replied.
Did you lose consciousness, had a stiff neck, or did you have a look?No.
Did he have rashes on his body? No
His abdomen looked bigger than the general here, as if it was swollen?No.
Now Rodolfo’s eyes were watery. He moved in his seat and began tapping his left heel fast enough to make both knees tremble. He seemed fit to get up and leave. Burbano had learned from joy when to offer condolences, when to touch a shoulder or hold a hand, and when to give a larger bunk. He stopped now, tilted his head slightly, and looked at his consumer solemnly and warmly. When her knees stopped shaking and she could find her gaze, she resumed her interrogation. About fifteen minutes later, they finished.
The intensive care unit in Puerto Asis is a hell between life and death. Eliad spent several weeks there before his bladder infection disappeared. Doctors said he would want to see several specialists. But it would take weeks to schedule those appointments, so in the meantime, his parents were on the loose to take him home.
Casa Noscue, a spacious wooden design but only partially enclosed, lacked the comforts of a hospital. The electrical power was too abnormal to force a refrigerator. The rains and humidity brought moisture that was very unlikely to evacuate. The things that space may be offering more than make up for those deficits: the peace of mind for the baby to rest, the constant presence of loved ones, and an abundance of plants that would allow you to treat at least some of your child’s illnesses. .
Andrés wanted to make several reforms to the house, but those plans were delayed, partly because of the low price of pineapples. He grew them and the market became saturated. As the maximum number of families on the reservation, and about 40 percent of families in the country, the Noscues were close to the World Bank’s poverty line of $8. 60 per day for a circle of four relatives. In Putumayo, the surest way to overcome this line from pineapple to coca. The governments of Colombia and the United States have been involved in the United States. The U. S. has spent decades trying to derail this calculation. Their interventions come with aerial fumigation campaigns, the creation of a palm oil industry and the constant persecution of farmers like the Noscues. But most of the world’s cocaine still comes from Colombia, and Putumayo is once again one of the country’s top producers.
The 2016 peace deal between the FARC and the Colombian government was intended to curb the appeal of coca cultivation, in part by bringing government pitfalls — not just roads and clinics, but also plumbing and electricity, schools and shops, economic opportunities — to breakdowns like Putumayo. . But progress has been icy, and armed teams still wield far greater influence over many communities than the national government. Colombia is one of the most unequal nations in Latin America, a fact that neither the ceasefire nor the economic gains of recent decades have replaced much. And in the wake of the pandemic, indigenous teams, like the other NASA members to which Marleny and Andres belong, have only been left further behind.
Nowhere are the disparities more obvious than in fitness care. Technically, it’s been available to everyone for a long time, thanks to the Universal Health Care Act passed when Andres and Marleny were kids. But in practice, the barriers to access are insurmountable: the lack of reliable transportation; clinics that are understaffed and difficult to access; doctors and nurses who would possibly be hostile to the Black and Indigenous communities they serve; and a bureaucratic tangle of referrals and authorizations that exacerbates all those things. Eliad spent almost a month in intensive care in Puerto Asis, but it wasn’t until his follow-up appointments, at 3 other hospitals in 3 other villages, that the nature and extent of his condition have become clear.
Pasto was the most difficult to succeed of those towns. The circle of relatives had to go from San Luis to Villagarzón, spend the night, and then take a six-hour bus to Pasto early the next morning. The distance between Villagarzón and Pasto is less than a hundred miles, yet a stretch of highway connecting the two towns is considered to be the worst in all of Colombia. Known as the “springboard of death” and crawling with ghosts, it meanders along thin mountain ridges that give way to hundred-foot drops on one side and steep cliffs to dirt slides on the other. Marleny was already uncomfortable, having recently injured her hip in a fall, but Eliad wasn’t a complicated baby; she slept peacefully in Andrés’s arms for most of the trip. Pasto’s doctor was nice. He saw Eliad immediately and pored over the notes Marleny had brought from the other hospitals. But she was also firm. The baby had several serious birth defects, plus a central murmur for which she would need surgery and pulmonary stenosis, which meant that a valve connecting her center to her lungs narrowed as she grew older. He would like to grow a little more before performing any surgery, and in the meantime, Marleny and Andrés deserve to keep an eye on medical appointments and follow-up. They also had to keep their hopes in check: Some children, like her son, recovered through surgery and survived into adulthood, but many did not.
Back home, Eliad showed no sign of feeling those long probabilities. She nursed willingly, smiled and cooed, enchanted her mother. Marleny took dozens of photos and videos of himself on his mobile phone, silencing Andres every time he reminded him to put away the battery in case of an emergency. His son fighter and fighter, he thought. And it seemed to get stronger. As they waited for her to grow in her first operation, she couldn’t help but nurture a little flower of hope.
For decades, the burden of resolving birth and death records, of counting the uncounted, has fallen primarily on fitness officials. When MacFeely joined the World Health Organization in 2021, he was surprised to notice how intractable the challenge seemed. “I wrote a blog post about it, and other people were telling me, ‘Oh, we made the same arguments 30 years ago,'” he told me recently. “I’m like, how the **** is it still a challenge these days?”But in the years since, he has realized that the challenge of birth and death accuracy is as much a topic as the fitness ministries tasked with addressing them. It’s not just that fitness officials don’t control ledgers or portfolios. It is that registries involve and concern themselves in all facets of the State: public suitability, local governance, basic human rights. MacFeely came to see the factor as a tragedy of the commons. Birth and death numbers are like the environment or the ocean, he says: because no one owns them, no one takes on the duty to solve them.
However, progress is being made. In Rwanda, the government has amended legislation to facilitate registration and has particularly increased the number of registrars in the country. In Bangladesh, the national government has established a cabinet-level workplace committed to the progression of a major statistics and fashion civil registration program. And in Colombia, a new automatic central formula will soon facilitate the transformation of knowledge of important events into a type of statistic that can be used to determine fitness policy. Verbal autopsy projects are taking root and cell generation is being used in all those countries. and beyond. ” It’s no longer a pipe dream to say we can count all births and deaths everywhere,” says Setel, the anthropologist at Vital Strategies. “We have the generation to do it. It doesn’t even necessarily have to be very expensive.
But for the dozens of individual pilot systems that are emerging lately to be remodeled into strong national institutions, leaders in all spheres of government will want to step up their efforts. he started looking for it as a whole-of-government factor,” MacFeely says. Ministries of fitness will not be enough. Heads of State will have to get involved, and they will have to do more than just identify or record. They will have to expand social facilities in tactics that pay more than empty words for the marginalized. Citizenship is priced only to the extent of the rights and protections it provides. And the challenge of birth and death registration is inextricably connected to the challenge of social safety nets.
In this regard, the story of the Noscues gives a kind of parable: in principle at least, each and every one of the Colombians has access to the country’s fitness formula. But with no reliable pathways or clinics available, Marleny was forced to bring in and deliver her baby without the benefits of this recourse. As a result, her enlarged placenta went undiagnosed and her baby was caught in a vicious cycle: he was born at home because his parents didn’t have access to fitness formula and then he couldn’t access fitness formula because he was born at home.
While they waited to see how he managed, Eliad’s circle of relatives did everything they could to spoil him. Every time he woke up from a nap or started cooing, he would stop him and flock to him. Andres encouraged Marleny to put aside her other everyday jobs and spend any and all moments she can with the baby, partly to make sure he’s okay, but also to savor him as much as possible.
So when he started spitting excessively on a Friday, just about two weeks after his stopover in Pasto, his parents immediately noticed. He didn’t have a fever or other symptoms, but he didn’t seem to be there at all. Marleny chose plants and prepared an anti-nausea infusion, which seemed to calm her stomach. But the couple agreed that if the disease returned, they would take him to the hospital.
The weekend passed and Eliad, once back, seemed to triumph over his difficulties. On Saturdays, he would lull and smile back, well enough to sign up for the circle of relatives at church that night. But on Sunday, when Marleny woke up, she was out of breath. “We deserve to leave,” he said, waking Andrew. The bus wouldn’t come for hours. Andres called an ambulance, without much hope, and then went out to get transportation while Marleny alternated between preparing Eliad for the hospital and seeking to calm him down as productively as possible. He yelled at his father to bring a blanket (“We don’t know what to do in this desperation,” he told me later). But before I could wrap it, the baby fell asleep. And then, after a few short breaths, his center stopped beating.
His funeral is unclear. Marleny only remembers that the stopover and mass lasted a full day and her church venerated her with an official street procession in the direction of the cemetery. Remember to leave the space with the baby in your arms and return several hours later, absolutely empty.
A few weeks later, when spring gave way to summer and she and Andrés were grieving, Rodriguez, the physical worker, and several nurses visited the circle of relatives to perform a verbal autopsy and deliver a death certificate. They spent an entire hour asking Marleny and Andres about Eliad’s illness and the cases of his death. The data they collected would be fed into a computer and sent to a national repository, where it would be recorded for a mountain of similar knowledge. This knowledge would be remodeled into statistics about who died in Colombia and how, and in the end those statistics would serve to shape policies and consulting resources. But nothing in this long procedure would replace the fundamental facts: Eliad Noscue Mesa lived 87 days and died in the same space where he was born. His life was infinitely short and filled with much more than his percentage of suffering. But he had still known joy. He had met the love of his circle of relatives and his time here had meant to them.
Marleny and Andrés found a certain convenience in that, at least, their life was already numbered.
Juan Arredondo is a photographer whose paintings focus on social inequality and human rights.
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