Dr Lyall Black's Journal - Life in a Highland Village and Observations of Medical Services

On Friday Feb. 11, Vivienne Rotondo and I, Lyall Black, spent the day in a Mayan village, in the western highlands of Guatemala working in the converted school bus. To start off, some relevant background information will be helpful.

San Francisco el Alto is a large rural area, about a one hour drive west of Quetzaltenango, our home base for the stove building trip. The area contains a number of villages. Our village, which is fairly typical, is 10,000 ft above sea level. It is reached by a rough dirt road, with dirt walking trails to individual houses.

The houses are scattered, in no apparent order, each with its own plot of land. These vary in size. A typical house consists of one or two rooms, surrounded by a small palisade made of tin or wooden stakes. As well as the house, there is usually a lean-to storage shelter and an area for doing laundry. The house has an irregular dirt floor and no windows. Furniture is sparse or non-existent. The fireplace or cooking area, if there is no stove, consists of stones in the middle of the room, with no vent. Consequently, the air quality when the fire is lit, is atrocious. As for the water supply, some homes have a well with non-potable water. There are standpipes scattered through the village which provide a thin stream of allegedly potable water. For personal cleaning, each family compound has a type of sweat lodge where the entire family can cleanse themselves.

Pictures Below show various homes, a well and yards situated on the sloped sides of the mountain.

There are usually some hens and turkeys and their chicks and occasionally a pig. These are not usually consumed by the family, but sold to make much needed money. The plot of land is cultivated to grow corn - this comprises most of the family's nutrition. There is no mechanization at all here - all farm labour is done by hand. There is sometimes not even a wheelbarrow that could be used for making mortar. Consequently all members of the family have to work to provide enough food to survive. There is electricity in the village. It is used for lighting and radios and a very occasional TV. There are some entrepreneurs in the village who make a small income from making and selling clothes. Their economics are marginal at best. One husband and wife make school backpacks. For each backpack, the material costs 8 quetzals and they sell them for 10 (about $1.20). Out of their profit margin, they have to pay for depreciation and repair of their sewing equipment and cost of travel to Guatemala City to sell their wares. There is also a school in the village, which has two shifts per day, to accommodate the large number of children. Given this background, it is not difficult to forecast the type of health problems which exist, such as: chronic respiratory disease, tuberculosis, skin infections, parasitic infestations, both skin and internal, chronic pain in shoulders and back, eye infections and malnutrition.

	A woman cooks over a smokey open fire inside the home
	Families earn income by sewing articles of clothing
	Pigs and other animals are kept for selling - they are rarely eaten by the family

Existing health services:

Until recently, a medical team visited the village about once per month. The 4 person team consists of a physician, a nurse, a health educator and a secretary. In the past few months, due to a WHO (World Health Organization) grant, CEDEC - the organization which provides health services to the area, has increased the number of health teams and visits presently take place every 10 days or so. When the team visits, patients are seen on a first-come, first-served basis. A local lady acts as interpreter - Kiche to Spanish. The team brings a limited number of medications; no lab tests are taken - a requisition can be given to the patient and it is up to him or her to have this done. In my admittedly limited exposure of 2 days of clinic observations, such requisitions are infrequent. There is no mobile x-ray, although according to the physician, TB is a significant problem in the area. On arrival at the bus, the Cuban-trained Guatemalan physician asked if I would carry out the examinations, while she acted as interpreter - English - Spanish and the local lady interpreted - Spanish - Kiche. This was very gracious of Dr. Andrea Vital, and I gladly accepted the offer. From observing her the previous day. I judged her to be a competent and conscientious physician.

Nurse Vivienne Rotondo has well described the clinic day in a previous letter, so I will not repeat the details. Some observations will suffice:
1. The mobile clinic provided a degree of privacy which previously did not exist.
2. Lab speciments can now be taken on the spot and kept in the fridge until transported to the laboratory.
3. Minor lab examinations can now be performed on site.
4. Most patients received a supply, albeit limited, of medication as we had brought a wide-ranging supply of medications from Canada. Without these, many patients would have gone without. A notable problem was the lack of any medication for scabies, which is endemic the village. Due to the intervention of the Stove Project director, Tom Clarke, a supply of medication arrived in the afternoon.
5. The treatment room allows for the performance of minor procedures, such as excisions and suturing lacerations. However, there is no local anesthetic available although we brought a supply of suture materials and instruments. There is no doubt that the use of the mobile medical clinic will enhance the ability of CEDEC to provide primary health care services, although operating costs are higher than for a pick-up truck. The reality, however, is that such enhanced services will not produce a significant increase in the level of health care, until underlying causes of ill health are addressed. I recognize that this will require determined and coordinated action and commitment from all layers of government, and also that this will not happen any time soon. It is greatly to the credit of CEDEC that a health educator is included in every medical team.

	Visiting retired Doctor, Lyall Black helps with examinations
	A mother waits patiently for her appointment
	A CEDEC Doctor completes his examination in the Mobile Clinic
	CEDEC Doctor examines a young girl in the GSP Clinic

 Some issues to be dealt with include:
- An adequate supply of potable water is needed. Children and adults are often dehydrated and do not have safe drinking water at their disposal. Wells are often contaminated by poor toileting facilities.
- Keeping children in school as long as possible. The time between survival and starvation is narrow and often children are required to work in the fields to ensure an adequate harvest to the detriment of their education.
- Nutritional augmentation is needed, particularly for the children, as nutrition appears to be marginal in many.
- Financial support and training to develop the home-based cottage industries. There is already an active garment industry in the area, but the profit appears to be minimal.
- Financial support to provide an adequate and ongoing supply of medications, once it has been clearly determined what level of financial support is required and can be justified.
- Consideration by CEDEC of the training and employment of a local person in each village who could function, not only as a health educator, but also as a primary health care provider, ensuring an ongoing health presence, as well as a link with the visiting health team. There are successful models of the approach in other parts of the world, including Canada. There are also excellent Spanish language training manuals for basic health care workers, produced in California for this.

Finally, it is essential that the work of the Guatemala Stove Project continue. This alone will reduce the burden of eye disease, respiratory distress, spread of diseases such as tuberculosis and the elimination of burns due to cooking fires in the home.

	Limited medicine is available in the local Clinic
	CEDEC nurses help distribute medicine and explain procedures in the native language to visiting patients