Guatemala

July 12-16th, 2017: Guatemala City

It's been 6 hours since I got to Guatemala, leaving behind a 100 degree day and torrential downpours for just torrential downpours. It is rainy season here in Guatemala City, or Guate, as Guatemaltecos call it. Most everyday it seems like it's about to rain, not that it has dampened my spirit.

Good bye USA. 

I've been thinking how best to share my first couple of days here, and I've decided that pictures just aren't going to do it. Before diving into the divisions between clashing views of medicine and how technology fits into the picture, I want to take a step back and share what I have found Guatemala and her people to be like.

Guatemala is often called the Land of Trees or the Land of Eternal Springs. While neither definition seems to be incorrect, they do seem incomplete. Over three days, before I headed to Xela, I had a chance to explore Guatemala City.

Guate is by far the largest city in the country, with nearly 30% of the population (about 5 million people in the metro area). In many ways, the city is no different than any other in the US. There's a bustling nightlife, new skyscrapers going up left and right, and suit-donning locals heading off to work. The hipster part of Guate is covered in beautiful street art and populated by young techies wearing the latest fashions and eating at English-named juice bars and vegan restaurants. It feels like Nashville. I'm honestly not joking about that. I went to an after-hours screening of The Happy Film (some weird European dude with a lot of problems basically trying to be happy and failing, but an amazing graphic artist so that made it okay) in an Art Gallery, a place called the Aguacateria (Aguacate = Avocado, so basically a place devoted to the avocado in the place where avocados were first domesticated. God's gift to humanity). There's also many, many coffee shops, given coffee is one of Guatemala's top exports. I've still found tea thank god.

At the same time, there are differences. The city, like many in Latin America, is divided into zonas, where different segments of life can be found. There's a hospital district with at least 8 different hospitals and upwards of 30 pharmacies, many devoted to illnesses associated with specific bodily systems. (More on the medical system to come) The financial district, near where I am staying, is crawling with armed guards. Nothing screams safety like walking past a Subway with a doorman/guard with a semiautomatic weapon. Western fast food joints, the strangest of which is a Carl Jrs., can be found throughout the city.

These zonas also serve to segregate the wealthy from the city. The superrich flock to high rise towers and a new development called Paseo Cayalá, the latter of which seems more fitting in Monaco than in Central America.

Little Monaco: Location Guatemala City. Its just wrong

This is not what I expected. And yet, its here... 

Weird naked guy buried in dirt. Definitely did not expect that 

Poverty is what I have left out of this story so far. Not because I want to ignore it, but because it involves unpacking a complicated and brutal history. A history that Guatemala itself seem yet to have comes to terms with, not that I am assigning blame (if anything, it's the good ole USA to blame). While I passed through zonas that showcased great affluence, I also spent time in areas that were quite poor, where pickpockets were common and violence more frequent. Of course, urban poverty and rural poverty are a world apart. Yes, both operate within the informal economy (a vast majority of women's work in particular), but the way in which lack of opportunity manifests is vastly different.

I had a chance to take a bike tour of the city, and Marcos, a Dutch hostel owner of Quetzalroo (very highly recommend staying here if passing through!) who had adopted Guate as home, offered up an alternate explanation. He characterized Guatemala as the Land of the Trapped Eagle: a reference to an old story of a trapped Mayan clan that proudly starved to death rather than surrender to the Spanish Conquistadors. It is still true that Guatemalans are a proud people, in some ways too proud to acknowledge many of the problems faced by its people. At the same time, they also aren't to blame. Like most other Central American nations, there is a history of American meddling. Guatemala had actually had democratic reforms and elections stretching as far back as the the late 1940s. However, when the newly elected President decided to institute land reform, things did not work out.

This "elevator" was basically a conveyor belt where you held on for dear life or plummeted to your death on concrete.

 

Trying not to die 

Glad I wasn't in front here.
The red car didn't stop (Damn Communists)

Land in Guatemala has been owned historically by an elite Spanish and German class that arrived during Spanish colonial times stretching into the mid 1800s. By 1950, you had another major player as well: The United Fruit Company. With so few controlling so much of the land in Guatemala, indigenous Mayans were left with scant opportunities, or what was more likely, forced to work on large fincas (or farms) for few if any benefits. Who needs African slaves when you have a large indigenous population to exploit! But back to how America stinks..

When the new president decided that land reforms were necessary to give landless Guatemalans some land of their own, the United Fruit Company in particular wasn't happy. Thankfully, they had some buddies in the US: namely President Eisenhower and his buddies running the CIA. By suggesting that the President of Guatemala was secretly in league with 🔴🔴COMMUNISTS🔴🔴 and that only a secret heavily armed operation would prevent Guatemala from falling into the grasps of the USSR, the United Fruit Company scared the crap out of Eisenhower and managed to get the CIA to overthrow the government in 1954.

Painting called "Glorious Victory". Note dead Mayans in corner...not so glorious

Thus began one of the saddest periods in Guatemalan history. Consider this excerpt from the CIA website:

In the late Cold War period and since[...]the American overthrow of the Arbenz government (the guy they overthrew) came to be widely seen as shameful. This is mostly because the governments that followed the 1954 coup in the subsequent five decades were far more repressive than Arbenz's elective government. Even intelligence scholar Christopher Andrew, an Eisenhower admirer, describes the Guatemala affair as a "disreputable moment"--Eisenhower was "directly responsible" for "death and destruction," yet showed no signs of embarrassment then or later over his "bullying of a banana republic." 
Basically, Eisenhower was like whatever...the commies didn't win. Instead, Guatemala fell under a series of military leaders that plunged the country into 40 years of civil war and a series of horrible human rights atrocities that left nearly 200,000 Guatemalans dead, mostly indigenous Mayan, mostly killed by the military. Entire Mayan villages were slaughtered. Fighting for social justice and economic opportunity were cast aside as most fought for their lives. The same time period also cemented the divisions between the rich and poor in Guatemala, a challenge that the country is just beginning to overcome.

With the end of the war in 1996, relative peace was secured, but solid governance was hard to come by. Consider the current president, a former comedian with no political experience named Jimmy Morales who ran on an anti-corruption platform. The previous president and vice-president were forced to resign and arrested in a corruption scandal the year before, and the primary opponent to Morales was the wife of the former president. Earlier this year, Morales' finance minister, older brother, and son were arrested on (you'll never guess) corruption charges...

Guatemalan Financial Office. Funny that the finance minister is in jail for corruption. 

In addition, despite composing nearly 60% of the population, there has not been a President of Mayan origin. Because there are 22 different Mayan communities, each with their own language and customs, its important to not just label these groups as "indigenous" or Mayan. The complexities and relations between these communities are evolving, and in many cases, geographically determined. Power and wealth remain concentrated in the hands of the few super-elites that have continued to cycle through power (and jail) over the past decades promising increased opportunity and access to rural populations every election cycle to win votes, but failing to invest (or instead embezzling from) in basic infrastructure, education, health, and substantive job opportunities for Guatemalans.

On a more positive note, we ended the evening at a delicious restaurant called La Cocina de la Señora Pu. Señora Pu, or Rosita, is this lovely middle-age Mayan woman who studied anthropology at university in Guatemala City. Quite intelligently, she focused on culinary preparation and practices of different Mayan groups and in the process became quite a talented cook. The kitchen is her way to share her learning and love of food. We got a chance to sample a variety of drinks, my favorite of which was xocolatl, a slightly spicy chocolate based drink. In addition, her two quiet sous chefs were from communities in which she had worked: Mam and Kaqchikel .

A traditional prepared tamal, (like proto-tamale) 

Wish pictures came with smells. Just cause I don't eat meat doesn't mean my mouth wasn't watering... 

The menu

My dinner. A collection of spiced vegetables with a chocolate mole, avocado, and tortilla. The chayote is in the middle doused in sauce, but was my favorite!

July 17-23, 2017: Antigua and Arrival in Xela

As I made my way out of Guatemala, I had a chance to pass two days in Antigua, the old capital, as well as a far more touristy destination. However, given the region's susceptibility to earthquakes the capital city was later moved to Guate. With the allure of a highly preserved Spanish colonial center, I was intrigued, but honestly not all that impressed. The church was beautiful, but I saw all I really wanted to in a day. I wish I had more time to visit one of the active volcanoes in the area. Acatenango allowed for an overview of Fuego, which is still active and spurts lava often. Pacaya, another active volcano is one where you can roast marshmallows from the heat of the volcano. Alas, I'll just have to go again!

View of Antigua, Guatemala

Central Cathedral de Antigua

Cerro de la Cruz, with Volcan Agua in the background. It started raining like 10 min later fyi

Typical cobbled streets for which Antigua is famous. Terrible to drive on...

My main destination for my time in Guatemala was Quetzaltenango, or as the locals know it, Xela (Shay-la). Perched at nearly 7,600 ft in the Highlands, the weather was much more brisk than in Guate. A chilly 65-70 degrees Fahrenheit. (Basically it was perfect Chicago weather) In addition, being so high up resulted in absurdly high UV indices. Basically representing how long it takes to burn, the index was consistently in the dangerously or "perilously high" range according to Google (Chicago is a 3, Xela a 12, so you burn 4 times faster). Naturally, I wore no sunscreen and was fine 😎.

Throughout my time, I did a homestay with an awesome home stay mom named Maria Elena. She had a tendency to make too much food (not that I really complained), but aside from that, she was really accommodating of my irregular schedule and I had some really interesting (both interesting and weird) conversations with her children and grandchildren. My favorite part, however, was her pet bird, that she had named Trump.

That hair

I also focused on getting my medical Spanish back up to par at a Spanish School called Celas Maya. While I have taken a few years of Spanish, it has been a few years, and by no means is it fresh. In addition, having a conversation with a doctor while not knowing half the words I want to use or ask is embarrassing and a waste of both of our times. As such, I made it my mission to not sound totally inept. Miriam, my teacher, very much made it her mission to make sure I sounded inept. Not 100% true, but she definitely thought I learned more by making more mistakes. I didn't disagree, but when my brain felt like it had been rubbed down with sandpaper at the end of the day, I can't say I liked the feeling. Nevertheless, I knew I was getting better, so while brutal, I definitely got results. She was also extremely knowledgeable about Guatemalan and more specifically, beliefs communities about the medicinal properties of plants. The school also organized a variety of activities during my time there. Everything from tortilla making classes (literally mix flour and water nowadays or buy them super cheap...the real thing takes like 3 hours) to hikes and visits to different communities. I'll sprinkle those in as well.

July 23-Aug 10, 2017- Primeros Pasos and some other stuff

It's been about a week since I began volunteering at Primeros Pasos, a clinic located in the Palujunoj Valley near Xela. The clinic primarily serves 10 villages, almost entirely of indigenous Q'iche Mayan descent, in the valley. In addition to offering general medical services, the clinic also has dentists, a nutrition program, and an education program. This past week, I found myself thrown right into action with the mobile clinic. Initially transported in a rickety pickup, and later by camioneta (old US schoolbuses now the primary transport in the region) along some less than stellar roads to a school within the valley, the clinic offered up its services to many that may otherwise not have had the means, time, or knowledge of the clinic.

The story of the clinic itself is interesting. A former Keegan fellow (or some variation of the program, still fuzzy on the details) visited Guatemala back in 2001, and he returned to open the clinic in 2002. 15 years later, he is a doctor based at Hopkins who has maintained his support for the clinic. What I find to be more of importance, however, is that the program has grown organically with investment by Guatemalan doctors, dentists, nutritionists, and educators. However, outside funding and volunteer time and resources from the US and other parts of the world are still key to the success of the clinic so click here to find out how to give time or money and make a difference. I think the graphic below does a good job of capturing the original motives as well as the governing mission of the clinic. 

Stole this from the Primeros Pasos website, but it does the job. Also, I link the site so its not totally stealing right?

I wish I had more pictures to show for this time, but I hated the idea of taking pictures of people as they are getting medical care. So, I'm going to use my words here instead to describe the mobile clinics, which over a week saw roughly 800 kids.

The reception desk was set up in the local schoolyard, with mothers already lined up and kids running around all over. A rather raucous scene. All mothers were issued numbered cards for each child that noted their height and weight. This card would guarantee them free or very heavily subsidized follow-up care at the main clinic as well as at future mobile clinics, as well as make the patient intake process easier.

The first thing collected was a stool sample. It seemed to me that just about every 3rd or 4th kid had a parasite. A problem that is so outside the realm of occurrence in the US that it initially took me aback. Basically, samples would be collected from the kids and the lab tech would analyze them under the microscope. It seemed she had a pretty good eye for the big culprits in the area. Treatment would consist of one of four anti-parasitics usually, sometimes in tandem with zinc (we ran out like day 1).

After stool sample results, the child and parents would go to the doctor, this was the most involved time, a 5-10 consult on what may be troubling the child as well as health advice that the doctor would provide. Usually the only tools available in these situations were a stethoscope and those small lenses with lights to see into a patient's throat or ears.

La Doctora Maria José (left) and Dulce (Head of the Education Team) 

Sample Set-up for Mobile Consult with "externo" or a 4th or 5th year medical student from a Guatemalan university.

If the child received a prescription, they then went to the pharmacy. I had a couple chances to work in the pharmacy, and it was insightful into what needs the children most often had. High occurrences of respiratory infections were due to air quality for one thing (anytime you took a bus, it would kick up a mountain of dust and occasionally a huge amount of black exhaust) but also how most young kids lived. Because they spent so much time with their mothers, they were exposed to many of the same factors at home. In addition, because many of the houses still used wood burning stoves to cook, often in enclosed room, mild smoke inhalation was inevitable. Ibuprofen and Acetaminophen were also common given their multiple uses.

As mentioned, anti-parasitics were also common. With a lack of awareness or lack of alternative when it came to food or water, some risk seemed inevitable. Consumption of street food certainly didn't help that one.

Antibiotics, such as Amoxicillin, were also common. Certainly, there was a high occurrence of bacterial infections, but what was more concerning was the way in which they were prescribed. As I talk about the pharmacy at the clinic, I have to speak to one aspect of the medical system at large as well.

The pharmacy set-up with some cool volunteer peeps. 

There are pharmacies everywhere in Guatemala. The kicker is that most do not require a prescription. Therefore, many people will go to the pharmacy first before the doctor, where someone who has been tasked with memorizing a list of medicines with no formal medical training will recommend what medicine you should buy based on your symptoms. There are a number of problems with this system. The first is misdiagnosis. These guys definitely don't know everything, and while a doctor can be wrong, these guys are notorious for being wrong because if they are, guess what, you'll have to come back and buy something else! Secondly (and thirdly), treating symptoms and treating the cause are quite different. I can prescribe medicine for a headache, but if you're a diabetic, the medicine may not alleviate your symptoms. Just as well, treatment regimens change based on lifestyle. Not having the time or concern to ask a patient for more information or clarification doesn't allow a pharmacy to accurately prescribe. With regards to the antibiotics, the issue becomes overprescription and patient underadherence. Antibiotics, much as in the U.S. (YAY factory farms), are over"prescribed" in Guatemala and Central America. Telling patients to rest, drink some OJ, and give your body a few days to kick the viral infection isn't going to fly. They want the tablet, the psychological placebo of receiving treatment because of the way in which Western medicine has been "sold". As an example, during a visit by a US GI specialist, he gave a woman an injection for a vitamin deficiency. She returned less than 10 minutes later lauding the sudden burst of energy she had and how everything felt better. The doctor, slightly mystified, accepted her gratitude, but later commented that the injection wouldn't have a noticeable effect for days to come and that there was no way years of malnutrition had just been reversed by one injection. A trip to a doctor in a white coat diagnoses your problems, gives you this mysterious white tablet, and you feel better. While, in theory, that's how it works, in practice, trying to bypass the doctor undermines the whole system. Then, when patients go to the doctor, and (s)he doesn't give you medicine, the patient feels deprived of treatment and begins to mistrust doctors.

Returning to the Primeros Pasos mobile clinic (where prescriptions are indeed required), vitamins, both prenatals, as well as supplements for young children were also common (courtesy of an organization called Vitamin Angels). In many of these villages, despite the production of many vegetables sold throughout the area, there is a significant gap in most people's diets (eating corn-filled tortillas every meal every day is not the best from a nutritional perspective). Some of it is because of inability to afford necessary components of a healthy diet. However, some of it had to to do with education. In the last weeks, I had the opportunity to participate in a food security survey, and I was shocked by how little some people knew about diet (although being put on the spot and asked what specific foods have minerals in them would probably also leave me scratching my head). Prenatal vitamins were also critical, given the many mothers we met who would have 2 or 3 kids under 5, placing enormous burden on her body. While breast-feeding was slowly becoming less taboo in Guatemala, nursing a child while pregnant is particularly demanding when the mother isn't adequately nourished. Prenatals offered some essential vitamins and minerals, but were one part of a larger cultural challenge in which machismo culture often dictates when a man can demand sex, can refuse to wear condoms, and is similarly irate when women use contraceptives or exercise family planning (A simplification of a whole different conversation).

I was mostly working with Doña Francia Angel, the dentist, collecting medical data into the online record system, REDcap. Mostly, it was noting cavities, missing teeth, any other major dental issues, as well as noting if a child needed an extraction and what medicine would be given in that case. I can't say I've ever been a fan of the dentist, and I can't say this experience made me love it any more. The high count on cavities was a whopping 22! And this was only by visual inspection. Unlike the dentist here who pokes and prods everything (somewhat unnecessarily I might add) and has a light and tools galore, the mobile clinic consisted of a quick fluoride treatment with a Qtip in a chair, where the best light sources were the classroom window and a small headlight used pretty infrequently. The most unpleasant part were the extractions. If a child needed a tooth extracted, they received a local anesthetic before getting the tooth yanked about 30 minutes later and receiving a small quantity of Acetaminophen for the pain. My sister recently had her wisdom teeth pulled, and based on her experience, I would want something a little stronger if I am about to have something pulled out of my face. I am 100% a wimp in that way. Nevertheless, the lack of technology was just as revealing.

International Breast Feeding Week March (and Education and Nutrition program):
As I mentioned, education is a big part of the efforts of the clinic. The reason they've been involved in the valley for the past 15 years is not simply to provide medical care, but also to sustainably develop the community and serve as as a resource for all. Quite literally, they are taking the "Primeros Pasos" (First Steps). The breast feeding march is a cool and photo-filled way to demonstrate that. As part of an international event, women from the surrounding community gathered in the center of Xela for this march. These women were all participants in the nutrition programs ongoing in each of these communities. Led by Monica and Scarlet, the nutrition program coordinators, the march wound through the streets of Xela highlighting the benefits of breastfeeding, something that remains taboo in parts of Guatemala. As such, it has been the goal of the program to stress the importance of breastfeeding for the first two years of life, and by extension provide continued support for the first 1000 days in anyway possible. Talking about proper technique, hygiene, questions of cultural taboo, monitoring child height and weight for adequate nourishment and explaining the benefits to children are all encompassed in monthly "charlas" or talks that place in each community. In order to remain part of the vitamin program and receive free medical care, these talks are mandatory. At the same time, the community that exists in them is also strong, as I got to observe. The march offered a chance to share this awareness with others who continue to doubt the benefits, or wean children earlier (often switching children to things like coffee as young as 1).

While I didn't work hand in hand with the education program while I was there, the focus on hygiene, healthy eating habits, self-esteem, sexual health, and other topics are also covered in classes for children as they continue to grow. In addition, they provide a healthy vegetarian soy based protein source for the mothers, which as an unbiased vegetarian, I was all for.

Note: All photos were obtained here with permission.

Doesn't matter if your boobs are pink, yellow, purple, green, or red, we support y'all 

The mothers helped! 

Breastfeed and Work: Together we can make it possible. 

They're so happy with single boob! 

Get ready to march! Girl in front gonna karate chop anyone that doesn't believe her.

Sustaining maternal breastfeeding together! 

Even got the local school band to drop a beat for this shindig! 

Lol at the kid 

Breastfeeding > Pantene 

Raise your boobs and be proud! 

Onward! 

This guy was not at all photographed an absurd amount of times for being awesome and actually supporting this event. 

TFW you go to the breastfeeding march in your local city. 

A long march demands a good sit. 

Note the hats in hand

They heard the food is coming soon. 

Superdad's back 

I really just wanted her mango. 

Sebastian, one of the volunteers, looking fierce. 

This kid was just adorable. 

Until I saw this girl being even cuter. 

Lunchtime: We don't mess around when it comes to food

Daily Routine, Los Médicos Voladores and Medical Technology:

Primeros Pasos opened around 8:30am and was open until about 12:30pm everyday. Most days, there would be a ready line of patients first thing in the morning that would need to be checked in. This process was online using a data collection platform called REDCap, conveniently developed at Vanderbilt! The patient record would be searched for a system of nearly 10000 organized by name, community, and patient ID. After some finicking, the record was usually found, and patient height and weight could be entered to complete check in of the patient. Most checkups or requests cost no more than 20 Quetzales, which while significant for some people, is a good compromise in my opinion. In addition, for those participating in the education, mobile clinic school visits, and nutrition programs, almost all care was free. After, patients were directed to either of the available dentists: Doña Francia or Luis, or to the doctor Maria Josè or one of the "externos" (medical students doing final year rotations). The pharmacy was also open to fulfill any prescriptions provided by the doctors. 

This issue of collecting patient data struck me as the most significant challenge at Primeros Pasos, simply because the clinic was not large enough to have bigger problems associated with Western medical technology (a problem itself). While the system has its strengths in that there is offline data collection (IDEAL for mobile clinics in remote settings) or offline search capability, the system was not designed to be used in a medical record capacity. It is slow, it is bulky, and it is not intelligent enough to recognize cues that are unique to doctor-patient interactions. While great for surveys and planning and orchestrating clinical trials or engaging in intercollegiate research, I found it more suited as a research tool, not a medical record program. It will be interesting to compare to efforts on the ground in other countries such as Kenya, where the organization I will be visiting is implementing a mobile-compatible, offline medical record system called CommCare. 

                                        

In addition to the clinics everyday activities, I was around during one of the bi-yearly (maybe more) Fly-In Doctor visits. These visits completely took over the grounds of the clinic and brought with them a number of specialists that the clinic did not have (Primeros Pasos only has a general practitioner) such as a Gastroenterologists, Gynecologists, Internal Medicine specialists, a massage therapist, an orthodontist, a larger general dental hygiene team, and a collection of sunglasses and prescription glasses for eye exams. I got to talk extensively with Otto, a particularly sassy and talkative externo, and Dr. Ernesto Beltràn, a soft-spoken but well-respected doctor from El Salvador over the time they were at the clinic. Working with Otto, I saw what is the next generation of doctors in Guatemala. His willingness to embrace the online system was unexpected. Given that it tended to be slower and have more Wifi issues, I expected more resistance (which I found elsewhere in Guatemala) but he saw the importance of building a patient profile. During this week, many people that had never used the clinic's facilities passed through its doors, and the general conversation almost always went, "What can I help you with today?" Because of the nature of the Fly-In doctors (and mobile clinics to some degree), they were there to catch and address whatever they could while they were there, give people medication and hope they took it, and rarely return. Without follow-up care for many of these more chronic issues (especially a malnourished child), future visits looked just like the first one. What problem do you have today? Not, "Wow you've had pain here or problem X for the past year and I see you received treatment that was ineffective. Maybe its time to try something else." I'm not a doctor, but I would think having more information is generally a good way to inform medical decision. That was in my opinion the greatest strength of Primeros Pasos and the greatest weakness of programs like Fly-In Doctors: the continuity of care and familiarity that Primeros Pasos offers offsets the services they are unable to provide.

However, the clinic is fighting an uphill battle. These battles are broadly cultural, economic as well as structural. By cultural, I mean that sometimes, the beliefs of those in the valley are at odds with Western medicine. A few examples. The existence of concepts such as empacho. The idea that if someone is constipated or has stomach pain, there is food quite literally stuck somewhere in the GI tract. Otto told me that on the first day of medical school, they learn that empacho does not exist. As such, treating patients who have firmly held cultural beliefs that completely are discredited by the tenets of Western medicine can undermine the doctor's credibility. Instead, people go to the pharmacist, their aunts, mothers, family elders, the neighbor, or basically anyone else that will validate their beliefs rather than undermine them. Ernesto told me about when he is dealing with someone who suggests that their child has "susto", or that their spirit has been scared out of their body by a sudden event resulting in anxiety or insomnia. The only treatment (that the patient often has actual faith in) is to go to a traditional healer known as a curandero. As such, Ernesto is in a difficult position of treating symptoms that supposedly occur because of a non-diagnosable cause. His solution has been to avoid any discussion on culture entirely at risk of alienating the patient, but as a result his ability to build a relationship with his patients, often those that he wants to help the most, is compromised. However, with the alternative being that the patient doesn't come to the doctor, it is a small price to pay. Otto, while a little more aggressive in discounting such beliefs, also sidesteps the topic in favor of getting patients to take their medications rather than drive them away. Similarly, with a condition called "mal de ojo" (like the evil eye), parents trust curanderos more than they do doctors because of the confidence gap. In addition, for many that have never received a medical consult in a room with a random person in a white coat, the experience is simply intimidating. They hear of surgeries gone wrong, people misdiagnosed, or of the greater success of curanderos, and choose to not go to the doctor. Thankfully, I saw this more in adults, with a greater willingness to take kids. 

The other aspect of that is a lack of awareness about Western medicine. Those that come to the doctor expect to state their problem, have the doctor listen, and then be prescribed medications that will address these specific problems. I've already written about this, but it is worth reiterating. Often, information is left out if the patient doesn't think it is relevant. Sometimes, it is difficult to communicate with the patient. Ernesto had a hard of hearing patient who only spoke Q'iche. In addition to yelling into this guy's ear through a translator, he only caught every third word, often with a high degree of uncertainty. How do you diagnose a patient that you can't understand? I recently read about a Hmong community from Northern Laos that didn't speak English called The Spirit Catches You and You Fall Down. The American doctor, when asked how he proceeded in such cases, stated that he practiced veterinary medicine. 

In this spirit, Ernesto told me something that really resonated. Medicine in such low resources settings, where you can't ask for an X-Ray, get an MRI, ask for a specific blood test, is an empirical science. In other words, based on my (the doctor's) experience, what information I am able to glean from the patient, and what I know about this setting and the lifestyle of people in the region, what's my best guess as to the problem?

The economic challenges are quite plain. When living in poverty, going to the doctor is simply not an option. Its too far or too expensive. Yes, a consult may be free, but a day traveling back and forth via bus and the lost productivity working your land as a result have very real costs. A simple cost-benefit often leads people to not go. 

Finally, structural. I've already talked about the ubiquity of pharmacies throughout the country, most of which do not require a prescription. Therefore, when someone is sick, the first thing they do is consult their family, neighbors, or pharmacists. Not doctors. As such, there is a diminished value in going to the doctor. Even in the US, people may know what they have, or simply need their prescription re-filled. It still requires the doctor. In Guatemala, that is simply not the case. Additionally, Guatemala invests only about 1.5% of GDP in health, a paltry number compared to the US that invests an absurdly high 18% (to what end, one may argue, but that's a completely different issue). As such, Guatemala has a system where the services of doctors are free to the public at large Centros de Salud. However, there are huge caveats. For any procedure, the patient is liable to pay for all the utilities and supplies required. That is, the surgery may be free, but you pay for anesthesia, the pre-op post-op recovery space, even the damn bandages and sutures. In addition, there are huge waits in the system. Therefore, private hospitals are necessary, yet at the same time, the ability to pay for robust medical care further reinforces the inequality that exists in Guatemala. In addition, the horror stories I mentioned are often extrapolated to all of Western medicine making it difficult to build trust in the community to as great a degree as Primeros Pasos hopes to. 

Fun Times Throughout

Volcán Santa Maria:
Guatemala is made for people that loves the outdoors. During my time in Xela, I got to enjoy a variety of other activities. There are 37 volcanoes found throughout Guatemala, and climbing them is a popular past time. The ones near Antigua are the best known, but Xela, being in the Western Highlands, has a great cluster of them. The one we climbed was Santa Maria, which stood above 12,000 ft. and was the 4th tallest in Guatemala. While most of the volcanoes are dormant, a few are still active, such as Santiaguito, which was right next door. I'll let the pictures speak for themselves. 

Santiaguito

Standing above the clouds

5 volcanoes that are visible from the top of Santa Maria (I climbed San Pedro, the furthest one, later)

  

Who needs a fence when you leave them at the top of a 12000 ft volcano?

Fuentes Georginas: 
With all that volcanic activity, the area around Xela is also known for its high concentrations of hot springs. These areas were absolutely beautiful and relaxing on the hot rocks was a welcome break.

You smell weird afterwards

A really big leaf

Semuc Champay:
Literally one of the coolest places that I have been! Getting there, however, was a pain in the ass because this place is in the middle of nowhere. We decided to leave Friday morning at 2am and take a 4 hr bus to Guatemala City. After arriving in what is apparently the most dangerous part of the city and standing around like idiots for an hour figuring out how to safely get to the other bus station, we finally got on a 5 hr bus to another city called Cobàn. Unfortunately for us, there was an accident and we lost another hour of time on the road. After that, we took another 3 hr bus to Lanquin, an even smaller town that provided the only access to Semuc. Yet we weren't done. After standing in the back for about an hour of a 4 wheel pickup on what can only in the broadest terms be called a road, we finally arrived at our hostel at 6pm on Friday.

Basically, Semuc is a set of natural pool that flow over limestone. In addition, the river that provides water for these pools flows through a system of caves that you can explore. We started in the caves. The only things you can take into the caves are basically a GoPro and a candle. I was an idiot and brought my glasses with instead of wearing contacts. Seeing as I can't see squat without them, I decided to wear them. As such, imagine walking and swimming through cold flowing water holding a candle above your head. That's what this is like. Then you throw in sharp rocks you can hardly see, ladders, slides, small spaces to crawl through, and walking through a rushing waterfall, and you basically get what I'm talking about. It was awesome!

Semuc from above

Technically still above

In addition, they had a huge swing where you could dive into the river.  Also, there was this bridge that you could jump off of into a rapidly moving river. You had to swim against the current quickly to the side or something bad would happen. I'd say it was about 40 ft. Basically amazing. 

Aug 10-Aug 15: Lago Atitlan and back to work(ish)

I slowly began making my way back to Guatemala City by way of the area around Lake Atitlan. This beautiful area is home to a number of indigenous Kaqchikel Mayan communities, amongst others. After missing the bus to San Pedro, I instead took a bus to another town on the lake called Panajachel, or simply Pana. Pana is a tourist trap, and I was not about wasting my time surrounded by a mix of weekend visitors from Guate and a bunch of Gringos. I instead made my way to San Pedro la Laguna, which instead was known for its hippie community of Reiki loving, shroom-taking, Yoga-lovers along with Tz'utujil Mayans. Apparently the town was quite popular with Israelis, as I found at least four different falafel joints during my 10 minute walk to the hostel I was staying at.

I mostly went to San Pedro to climb Volcan San Pedro. This 9900 ft volcano towers over the lake and I wanted to see the Lake from above. After leaving at 4am, we made our way up in about 3 hours. The best part though, was racing David down the volcano. Despite the 5 minute head start he gave me, he still beat me, but we were back down in about 40 minutes without dying, so that was pretty great.

Hour 1

Hour 2

Hour 3

Work(ish): Hospitalito Atitlan

That same day, I made my way over to Hospitalito Atitlan in Santiago. Santiago is one of the most Mayan communities around the Lake, as compared to the hippie/ex-pat filled towns around it. I was shown around by one of their Princeton in Central American fellows, Danielle, and was immediately impressed. (Again, no pictures because there were patients around.) The hospital was of a different scale as compared to Primeros Pasos. In addition to having an actual reception (we would sometimes lug a desk and the scale outside and call it reception), it had operating theaters, a radiology department, and an ER. Like Primeros Pasos, it offered a number of education and social programs and charlas to engage the community in sustainable preventative care, especially for diabetes (a unique and really necessary undertaking), reproductive health, and maternal care. 

However, I found there to be some interesting ways in which Primeros Pasos was actually ahead of the game as compared to Atitlan. Despite Hurricane Stan having destroyed the facility in 2005, the hospital still maintained a paper medical record system of nearly 30,000 records instead of an online record system. I didn't get a chance to see what their current status on the online medical record system was (again using RedCap), but an important concern was the doctors. While they weren't trying to undermine the effort, they simply didn't have enough prior exposure to online systems using tablets and computers. Recording patient information is certainly slower, but ultimately better in the long run. However, when slowly typing information means seeing less patients, its understandable why doctors lean towards a tried and true practice.

I also had the chance to chat with their head of maintenance, Ezekiel. It turns out they had been particularly excited about my interest in visiting because they thought I could fix the ultrasound. Let me just say, that thing was ancient. Like 1980s maybe. There was no way I was fixing it. This pretty much highlighted the challenges in technology. Ezekiel, who would travel the 4 hours each way on weekends to take electrician classes in Guatemala City, was doing the best he could with what he had. What he had, however, was a jumble of old mismatched equipment. While the light and camera worked on one of the surgical lamps, the monitor didn't. The ultrasound was essentially a very large paperweight, as it lay waiting for the next round of technicians from Guatemala City to come by and inevitably say they couldn't find the part needed to fix the device. The danger of donations in this case, was quite apparent. A hospital in the US thinking it was doing well, sending over a "used" piece of technology, but actually just adding to the existing stockpile of dysfunctional technology. I've heard that Manu Prakash (look this guy up!) saw a centrifuge being used as a doorstop in Uganda to inspire his interest in low resource design. Now he's a MacArthur genius grant winner and renowned bioengineer. Well Manu, I raise you a ultrasound paperweight. 

This isn't to say that donations aren't welcome or useful. Of course, they are. But they must come with certain guidelines and an understanding of where they will be used. Power is different in different countries. What's the point of a new (read:used) ultrasound if it can't run on 50Hz 240 Watt power, which is the norm in many developing countries? Or what if you require a consumable every time you use the device? Or need specialized parts available only in the US or that are quite expensive? Or there's no training and no one knows how to use it? Solving part of the problem isn't solving the problem, and technology is only useful if it can be used.

Moore Surgical Center - Guatemala City
I ended my time in Guatemala with a visit to Moore Surgical Center. I was quite intrigued to see the differences here, since a group of Vandy biomedical engineers actually visits this center. The equipment at the hospital was top notch, and continually maintained because of teams constantly coming through from abroad. The center only operated for about 22 weeks a year, as all the teams were trained from the US or Europe. There were basically 1 week "super surgery" weeks where teams would do upwards of 100 procedures, all for free. Unlike the Fly-In Doctors, they had a local team that could provide the continuity of care that was lacking in Xela. 

The interesting thing I learned here was not about the technology, but rather about the medical education in the country. Many of the doctors at the center were from abroad, as many surgical specialties were not taught in the country until quite recently. With the first batch of neurosurgeons being educated for the first time, it highlighted the systemic issues in Guatemala. For example, physical therapy quite simply does not exist as a profession, so people recovering after stroke, orthopedic surgeries, amputations associated with diabetes, or are persons living with disabilities are simply not offered and cannot be offered the resources that are necessary. Engineers that can address these gaps and provide means to return mobility to those that are stigmatized in a country where disability is hardly talked about is a monumental challenge.  

Tikal
Before leaving, I made some time to go to Tikal, the former Mayan capital. Its hard to believe, but the Mayans are even older than the Aztecs and Incas. And I couldn't help but marvel at the amazing architecture of Tikal, despite the unpleasant and absurdly cold 12 hours bus ride I needed to get there. As I was going from the bus to my hostel for the night, the girl next to me pointed out the scorpion sitting on my backpack about 6in from my hand. I'm pretty sure my blood pressure shot through the roof, and it took every ounce of my willpower to not freak out. While we eventually got him/her off without biting me, it was definitely not the start I wanted. So here's just a bunch of pictures instead that make it look like it was perfect. 

Sunrise. (Think Star Wars Episode IV)

A still buried pyramid. Only about 20% of the structures have been excavated.

Main Plaza

Key Takeaway:

A key point that I think my time in Guatemala has hit on is that yes, obviously there are major technical challenges associated with the spread of Western medical technology. However, there are more fundamental challenges associated with introducing Western medicine, and perhaps even more rudimentary, the notion of Western. Ruminate on that.