Privatization and the New Medical Pluralism:
Shifting Healthcare Landscapes in Maya Guatemala
“The public health system, which has always been underfunded and inadequate, is evolving as it increasingly contracts out health services to nongovernmental organizations. The nongovernmental and private sectors are rapidly expanding. Private foundations and corporations are assuming a growing role in dictating the health agenda. And these dynamics have important effects for Maya people.”
Two of our Leadership Team— Anita Chary and Peter Rohloff—wrote and edited this volume. Many other members from Wuqu’ Kawoq—David Flood, Shom Dasgupta, and Nora King—contributed enlightening chapters based on their work here with Maya Health Alliance.
We sat down with Anita, David, and Peter to find out more about the book.
How would you describe the book in a few sentences?
AC: This is a book about the reality of what it’s like to try to access health care services for poor indigenous Guatemalans. For the most part, it’s extremely difficult. The opportunities that do exist tend to be open only to enterprising people who speak at least some Spanish and live in urban and tourist heavy areas. Many of the people who need health care the most are locked out. But we are optimistic.
PR: Mayas are resourceful and the achieve health care in incredibly creative ways. Increasingly, they do this by engaging with private or nonprofit health care providers, rather than government services, and they usually pay for these services. This is the new context for designing healthcare solutions in Guatemala.
What pushed you to write this book?
PR: We wrote it because we felt there needed to be an up-to-date account of how Mayas achieve health care. There have been so many changes, including privatization, outsourcing, etc since the Peace Accords. Most accounts of healthcare haven’t adequately dealt with this.
AC: I actually remember a series of patients that WK had in the summer of 2010. One of them was a young mother on the coast, Gloria, whose daughter had been sick with a cough, and we were really struck by the number of healers and doctors she had gone to seeking treatment for her daughter. On top of going to the herbalist in the local market, a pharmacy, and one of the community elders, which were, for us, expected sources of care for someone in a rural community, Gloria had actually gone to a private clinic a few towns away and an NGO mission clinic sponsored by Americans. She had collected an assortment of remedies at quite a high price, but was too afraid to use any of them, because she was so accustomed to getting poor medical advice that she didn’t know who to trust. What really struck us about this case was that in a sense, this family had very little access to care, but in another sense, there were actually a number of options available to them – the options were just of varying quality and costs, none of them were connected, and the whole experience was extremely fragmented.
As a team, we borrowed from the language of anthropology to talk about how patients were engaging in “medical pluralism” – that is, accessing diverse healing systems, both traditional and biomedical, and turning to multiple sectors for their care: the public government health system, private for-profit clinics, and the increasing number of NGOs providing health care throughout the country.
Peter, Anne, Shom and I had numerous conversations about the challenges that this fragmented sort of system posed to our patients. It also posed challenges to us as providers in terms of knowing how to help patients navigate through all of the options, and how to be there for them, accompanying them through it all.
The idea for putting together this book emerged because we really wanted to understand, in-depth, exactly how our patients experience on one hand, such limited access to health care, and on the other, a fragmented, unpredictable variety of services.
What was the writing process like?
AC: The writing was a very collaborative process. All of the contributors read each other’s chapters, and we worked together extensively to identify some of the main themes and how they might relate to providing better care.
What makes this book unique?
DF: For me, what makes this book so compelling is that it describes beautifully the complexities and chaos of the contemporary healthcare system in Guatemala. I’m also proud to be involved in this project because I think the book is very focused on the real-world suffering of rural Guatemalans — and especially the Maya. The book is not overly theoretical or abstract. The authors are health and development workers working on the ground in Guatemala, so they are passionate and concerned about practical things. This really shines through because the stories point out so much injustice.
AC: I think what is unique about this book is that the contributors are both social scientists and clinicians. Having both perspectives means that we can be very practical about going forward and taking the findings both of research and on-the-ground experience and turning them into better programming, and ultimately better health outcomes for our patients.
How did you pick the topics for the chapters?
AC: The whole book falls under the genre of ethnography, which involves researchers documenting and analyzing what they see on the ground – whatever is salient, important, whatever they encounter on a daily basis. The chapters reflect the experiences of our patients. They also reflect some of the important epidemiological features of Guatemala right now – a number of chapters concern chronic diseases, and there is important information about maternal mortality and teen pregnancy, and mental health. These are just some of the issues that we encounter in everyday clinical practice in Guatemala.
DF: My chapter is about the experiences of Maya indigenous patients with diabetes in Guatemala. Since 2013 I have been managing a cohort of about 200 diabetes patients for Wuqu’ Kawoq. I have heard so many stories and learned so much from patients about the challenges of getting care in a place where high-quality chronic disease care is essentially impossible.
What do you want people to get out of the book?
DF: I want people to understand that diabetes is increasing in rural, indigenous Guatemala, just like in the rest of the world. The difference is that the health system in Guatemala is completely unprepared to deal with the cost and complexities of chronic diseases like diabetes. As I wrote in the book, patients are relentless and show incredible creativity in trying to access diabetes care, but there are so many barriers.
AC: We are hoping that this book provides people with a sense of some of the challenges and opportunities that rural indigenous Guatemalans face as they try to get health care on a daily basis. It is the only book that really describes in detail Guatemala’s health system, both the history of it and what it looks like today.
What is your hope for the future now that the book is released?
PR: We are hoping the book will spark new conversations about medical anthropology and health delivery in Guatemala: conversations that take seriously how rapidly healthcare is changing and that our solutions need to be up to date.
AC: In this book, we showcase the difficulty of accessing health care in Guatemala. But we can learn from these experiences, and there are success stories. There are windows of opportunity, places where we can intervene. Once we know how a health system works, in nitty-gritty detail, we can anticipate the challenges and work with all of the potential avenues, all of the loopholes, to provide our patients with the high quality care they deserve.
Any last thoughts you would like to share with people who may read your book?
PR/AC: Ultimately, we hope that this volume will encourage ongoing engaged scholarship and activism in healthcare, in solidarity with Maya people.
The book is now available for sale in hardcover and ebook HERE
Other chapter contributors include experts Alejandra Colom, Rachel Hall-Clifford, Jonathan Maupin, Carla Pezzias and Paul Wise. Peter Benson wrote the conclusion.