May-June Updates

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I am sitting in La Aurora airport in Guatemala City writing this update. Flights have been cancelled due to a number of hurricane-related rains squalls, so I have some time to kill. I am just finishing up a short 5 day trip that we put together mostly for administrative purposes (meaning lots of meetings, all weekend long).

ACOTCHI. On Friday I went to Comalapa to meet with the ACOTCHI board of directors, as we are trying to put together our common plan for the coming year or two. A major focus of the next few months will be securing continued funding for the training classes in 2009, which we feel fairly confident that we will be able to do, as our data are compelling. Additionally, however, we are really interesting in getting the concept of a midwifery “school” off the ground, as we have a large cohort of brand-new midwives, many of whom have not yet attended deliveries independently. I will probably be shopping this idea around to some funders in the next few months as well. Also in collaboration with ACOTCHI, we have managed to secure an excellent source of low-cost, high-quality medications in Guatemala. This is a major step forward, because it will allow us to avoid the headache of hand-carrying drugs, as well as putting this aspect of our programs more squarely in the hands of our local staff, which is where it belongs.

It remains as always extraordinarily stimulating to be able to hang out with the ACOTCHI folks. It is quite common in anthropology and other circles in Guatemala to bemoan the demise of the traditional health provider. The evidence used to predict this sad fate is three-fold: (1) Midwives are all old and do not pass on their knowledge to the next generation; (2) Midwives have no mechanism for self-organization or self-regulation; (3) High rates of illiteracy keep midwives from moving forward on the national stage. On the contrary, in our work with ACOTCHI, more than 25% of our affiliates are young women just beginning to learn the trade, the organization itself is strongly self-regulated and making good first steps toward sustainability, and many of our illiterate midwives are enthusiastically attending literacy classes.

Pa K’in. On Saturday, we had a clinic in Santiago. This included a brief review of the diabetic patients, but most of our time was devoted to a number of interesting new cases and complicated old ones. A few of these cases illustrate the larger problems of lack of access to care that we continue to try to address in our work. For example, we have one young woman, about 20 years old, who has had one leg amputated. She has a genetic nerve disorder which led to the development of a foot ulcer. Because she had no money to pay for antibiotics, this ulcer got so large that she had to have the leg amputated when she was about 16 years old. She came to us just a few months ago, because she was starting to develop an infected ulcer on the other foot and was afraid she was going to lose it as well. We were able to successfully treat the infection, as well as make some wound care suggestions. The ulcer is nicely healed at this point.

Another case is a young man who suffers from incapacitating agoraphobia and panic attacks. As a result of this condition, he has been unable to work for almost 10 years and, in fact, never leaves his bedroom. The fact that he does not work places considerable financial strain on his family, and his wife also is at her wits’ end. He has had no effective treatment, mostly because there is no access to psychiatrists nor to basic psychotropic medications in Guatemala. For those well-connected few who do manage to find a psychiatrist who will see them, they quickly find that the requisite medications are among the most expensive they have ever had to purchase. For example, a generic antidepressant in Guatemala can easily cost the equivalent of two weeks’ salary every month. Our treatment goal for this unfortunate man will be to find a steady source of affordable medications in the United States and get him hooked up as quickly as possible.

In other exciting news, it looks like we are approaching an agreement with the owner of a property in Santiago that we are attempting to purchase. This property is quite large, and would allow us to expand our services in a number of importants ways, including stocking a larger pharmacy, setting up a diagnostic laboratory, and have community space for health training classes. We will keep you informed of developments.

On “Alternative Medicine.” Recently a friend of ours from Santiago went to see a chiropractor in Guatemala City. This was apparently after seeing an ad for relief of back pain. She describes the strangeness of the experience, especially of having someone pull on her neck, which she feels probably made things worse. Also, she called me after this appointment to ask my advice; the chiropractor had told her that she had back pain because her back molars where compressing her jaw and neck and, therefore, she had to get them pulled. This concerned her greatly, and she did not understand why she had to get her perfectly good teeth pulled.

What this shows is the number of cultural barriers presented to her by such a foreign medical practice. In particular for me it highlights what I perceive as a big problem in the area of current talk about traditional indigenous medicinal practices. Namely, “complementary and alternative medicine” (CAM) has become quite fashionable on the international scene, and this is tending to get rolled up with talk about traditional indigenous medicine, as if they were the same thing. Just to give one example, right now there is a good bit of funding available to teach acupuncture to Maya. There is no discussion at all about whether or not this is a helpful or useful thing to do. Rather, it is assumed that because they are “into” their own traditional medical practices they will also be “into” acupuncture.

The point here is not whether or acupuncture is helpful or not, but rather that we want to resist the tendency to conflate indigenous medical wisdom with all the various things that go under the fashionable heading of “complementary and alternative medicine”. Although there certainly are similarities between CAM and indigenous medical practices, to assume that they are natural blood relatives without any sort of questioning is irresponsible, and also another example of telling indigenous people who they are and what they should do. CAM springs out of the luxury of postindustrial society, where we have now in our time of long and healthy lives seen fit to question and deconstruct the assumptions of our dominant medical culture. But for Maya, who have life expectancies more than 20 years less than us and incomes a fraction of ours, traditional medicines are neither alternative nor complementary, they are just what there is available at hand, at relatively low cost. Nor do they engage in the use of traditional remedies out of a sort of critique of Occidental instrumentalism, as we do with CAM. As our own research and that of others also has shown, they will use any and all remedies, including the most invasive, chemicalized ones, if they can afford them, if they trust the referring provider, and if they think there is a chance it will keep them alive. This is a dynamic of need, and one of poverty, and that is why we cannot conflate it with CAM.

Advisory Board. On Sunday, we had our first reunion of the Wuqu’ Kawoq advisory board, which has representatives from each of the various towns we work in. Many of the members of the board work directly for Wuqu’ Kawoq, but others are from ACOTCHI, or are affiliated with other NGOs. The purpose of this board is to guide Wuqu’ Kawoq’s programs and also to serve as a forum for folks from across the region to get to know the resources available and problems confronted in the various places we work. This is a tremendously productive activity, and one which all the participants enjoy. The people we work with have many experiences and insights that they are anxious to share with others. Just to give one example, a large portion of the discussion on Sunday had to do with the possibility of expanding ACOTCHI’s midwife organizing work into all the other represented towns. We plan to have meets of the board every few months, both to keep all members informed about projects that they are not involved with day-to-day and also to maintain a forum for problem-solving, critical thinking, and planning for the future.

Socorro. Finally, on Monday we were in Socorro for the usual clinic but also and more importantly for a brief community meeting to bring folks up to speed on the water project, as well as on the child health work that Anita and Sarah will be doing there starting in July. It has been raining nonstop for 5 days, and the sound of rain beating on sheet metal roofs makes it almost impossible to hold a meeting without shouting, but all in attendance were content to be there. What’s more, we prefer the rain to the scorching heat.