Guatemala's Social Determinants of Health

I have been wanting to write a little bit about this beautiful and complex country that we are in. A lecture that we attended a few nights ago provided me with the perfect information to share and confirmed a lot of what we have observed in our short week here.

We went to a cafe to hear Sue Patterson, a previous Peace Corps volunteer in Colombia and a former U.S. Foreign Service Officer who served in Guatemala for a number of years during the height of the civil war here. After her final post in Italy, she decided to retire in Guatemala and started a non-profit called WINGS (http://wingsguate.org/) that works on reproductive rights and education for women (among other areas of health). Below are some of the highlights of what she shared with us. I have supplemented her talk with some other references as well. If you don't want to read this whole post - at least read the Maternal/Child health segment. It's fascinating information!

Background:As I previously described, one of the primary reasons that we chose to study Spanish and volunteer in Guatemala is because of the vast needs of the poor people in this country. The WHO, UN and other organizations measure the disparity between rich and poor through something called the Gini Coefficient index. This index measures the degree of inequality in the distribution of family income in a country. Guatemala's Gini Coefficient ranks them 13th in the world for income inequality. Significant research demonstrates that a disparity between rich and poor causes poorer health for everyone in the society (not just those at the bottom) (Sources: The Spirit Level, Wilkinson & Picket, 2009). Sue Patterson shared some thoughts on why this is the case.

Indiginous Peoples:
Nearly 40% of the population in Guatemala are indigenous. Over 23 Mayan languages are still spoken in pueblos in the country and many rural people (especially women) only speak their indigenous language. The problem is that most education in the country is only offered in Spanish. Therefore, a large percentage of people in rural areas are also illiterate or uneducated. This leads to a challenging political landscape (among other issues). Sue noted that while many people are 100% Mayan, if they have a western style of life, they do not consider themselves to be indigenous. The term (as I will use it in this post and as she used it) refers to both the genetic lineage and the way of life (often rural).

Maternal Child Health:
Guatemala has one of the fastest growing and youngest populations in Latin America. The average number of children per Guatemalan family is about 5.6 (Source: UN Habitat). Guatemala ranks 6th in the world for the percent of their population under the age of 15 (43%, source: world population data sheet). Family planning and the use of birth control are rare. According to Sue Patterson, by the age of 19, 50% of women in Guatemala have at least one child. About 50% of children under the age of 5 in Guatemala are mal-nourised. A phenomenon that results from a lack of clean water, families that continue to be large in rural areas, and devalued agricultural industries. Agricultural work has been replaced by other industries (like tourism), thus the income of a rural farmer is no longer even close to enough to feed a family. Clean water is not readily available in this country. Upper class families seem to drink exclusively bottled water (from El Salvador) that most in this country cannot afford to buy. 

Sue described how she often visits rural pueblos and sees healthy babies right at birth (however, it should be noted that maternal mortality is high in Guatemala since obgyn services do not exist outside of big cities). When she returns 8 to 9 months later, the babies are typically no longer nursing since the mother may be pregnant again or is malnourished herself. She explained that she finds them thin and malnourised, eating tortillas and drinking local water. This can have a spiraling effect as it dramatically impacts cognitive development. Children reach school age and either don´t understand what they are beginning to learn in school or cannot concentrate. They return home and often tell their parents they are not interested in learning. Families, who struggle to make ends meet in agricultural settings, then remove the child from school and bring them out into the field to help with agricultural work. You can see from this cycle that no one here intends for their children to become mal nourised or to work at such an early age. It is a vicious circle. 

So what is the solution?


Sue´s organization believes that educating women and men about reproductive health and family planning options can aid a lot. While still challenging, $2 a day goes much farther in a family a 4 (for example) compared to a family of 10. The majority of rural and indiginous people here do not talk about family planning, reproduction or gynocological issues, both for religious reasons (highly Catholic country) and because it is somewhat taboo to speak openly about this topic. Sue noted that the number one cause of death for rural women in Guatemala is not heart disease or breast cancer, but cervical cancer. Because people only visit the doctor here when they are very sick (there is no national healthcare and doctor´s visits are expensive), HPV and cervical cancer are not detected and treated early on. 

Sue´s organization "Wings" works using a promotora model wherein they train local champions from the pueblo to provide education about family planning and reproductive health, starting slowly with questions about what the locals might want to know but have not been able to ask (note that rural and even many urban populations here only go to the doctor when they are very sick due to the cost). Her organization has had early successes both in education (of women AND men who are often the decision makers) and in treatment. They provide screening for HPV and have provided hundreds of tubal ligation to mothers who already have multiple children. 


What Else Contributes to the Problem?

Politics:
Guatemala has elections every 4 years and is considered a democratic state. Similar to many other countries in this area, corruption is still present and hard to trace. In the last election, Guatemala had candidates from 14 different political parties. According to Sue Patterson, only about three of those parties still exist. Many parties are formed by one individual without a true platform or vision (these parties don´t last). This means that there are not truly political parties in Guatemala. In the elections they have had since their establishment as a democratic state, they have never elected the same president OR party to another term. As Sue explained, each time a new individual assumes office, they bring in all new people (not just a new cabinet). This has made it challenging to keep social or educational programs going for more than one term (the people who manage them leave with the outgoing president) and to keep any type of ongoing foreign relationships strong. As a result, programs start and end and problems are rarely addressed in a continuous way though governmental means. 

The government itself has much to address (beyond health) just in working to make the country safer. Nearly 50 people per day are murdered in Guatemala (which is a small country of about 13 million people - smaller than Shanghai, China and slightly bigger than New York City and the surrounding suburbs). The judicial system is unable to investigate many of the murders for reasons that are too complex to address in this post. Gangs are increasingly prevalent in big cities and drug trafficking often hits Guatemala as "products" are moved up to Mexico and the US from Colombia. 

While the number one source of income in Guatemala used to be agriculture, it is now "outside aid" from Guatemalan workers in the US. They send about $10 million dollars EACH DAY back to family members. This has created a reliance on the outside workforce and, in many ways, has led to an upper class in Guatemala. Sue noted (and we have observed) that much of this money goes towards "things" like car improvements, televisions, stereo systems, etc. This is not much different than the US, but in such a poor country, you can see how the money might be better used for basics like healthy food, educational improvement, etc. Interesting to see how societal "perception" influences even those who live in deep poverty. I believe this is similar (or perhaps even worse) among the poor populations in industrialized countries. 


Here are some photos from the work that WINGS has done (note, these are not my photos).