More thoughts from "the field"

The major causes of morbidity in Central America and the Caribbean are maternal and neonatal problems, depression and violence. This fact, as Peter explained to me while we were awaiting a bus back to Antigua from his clinic in Santiago Sacatepéquez, calls into question the imposition of the appellation, “tropical medicine,” in his words, “wherever it is warm and there are mosquitoes.” Peter’s assessment, that “tropical medicine” is a mythical creation and a relic of imperialism, shed some light on my confusion about the eligibility requirements for the American Society of Tropical Medicine and Hygiene’s certification in tropical medicine: one must work in an impoverished country for at least two months before sitting for the certification exam; this is puzzling because it is implied that the “tropics” are an epidemiologically homogenous zone—somehow, working south of the U.S.-Mexican border is supposed to prepare certificate recipients to manage malaria, even if this work is conducted in the Guatemalan central highlands, where mosquito-borne diseases, as far as I am aware, are essentially nonexistent. This use of the word, “tropics,” reminds me of the equally perplexing use of the word “field” by a certain human rights professor at Northwestern in reference to what amounts to any and all non-First World settings. Such terminology obscures the diversity of different impoverished locales and their inhabitants and, perhaps more importantly, creates the potential for objectifying marginalized peoples and conceiving of their world as laboratories where very real and actively generated death, destruction and disability are rendered “facts of life” that fail to implicate the comforts enjoyed by us who descend from our universities and institutions to work in “the field.”
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On Saturday, I followed Peter and Wicha, a Kaqchikel woman from Santiago who organizes and supports his activities there, on several house calls. Needless to say, the opportunity to enter the intimate sphere of people’s homes and to watch Peter work was unlike anything I had experienced previously, in Guatemala or elsewhere. Despite the relatively slow pace of the work—which is partly due to what Peter calls “the hospitality mechanism”—the relationship-building and patient-centered health education that is made possible through these house calls has allowed the gradual deconstruction of well-founded negative conceptions and assumptions about Western allopathic medicine and its providers. The perspective that comes from this mode of practice, in conjunction with critical analysis, is markedly absent when a physician blames an impoverished HIV-positive patient’s antagonistic posture towards healthcare providers completely on denial (failing to see that physicians are often representatives of oppressive power structures) and when medical students fail to recognize how heavily the Tuskegee syphilis experiments influence some African Americans’ contemporary mistrust of physicians.
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I had asked Peter when we were in the market buying medicines if he and his colleagues had been collecting any quantitative data to demonstrate positive outcomes achieved through their treatment methods. Of course, the collection of such data requires a great deal of time and money, both of which are in short supply for any incipient NGO. Ample anecdotal data, however, directs his work. Again, the limited resources available require definitions of “treatment success” that differ from what would be considered the “standard of care” in resource-rich settings. Peter talks about using what he can to bring a patient’s random blood glucose from 300-400s down to high 100s/low 200s, and, while he admits that this is not “perfect” management and that there are other important treatments and outcome measures to be considered in diabetics, he points to the change in quality of life that he has observed in many of his patients. If the best available care is the ultimate lofty goal, and if the needs of many individuals must be at least temporarily balanced with the needs of a few, then helping a patient progress from a bedridden existence to planting his first maize crop in 3 years can be considered an exciting and unequivocal success—even if his fasting glucose is above 126 mg/dL.
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Today, Monday, I began instruction in Kaqchikel! I learned letters and sounds and some rudimentary conversations (“Good morning. How are you? I am fine, thanks. Where are you from? I am from Chicago.”). Learning a new language is difficult, but it is also a lot of fun. There is nothing more fulfilling than the way one’s head throbs after spending a few hours in the kind of transcendental levels of concentration required by the effort to internalize a completely new vocabulary and grammar. The arrangements for lessons are still a little up in the air, and I’m taking things on a day-to-day basis in terms of teachers and times of day that they are available. The majority of the teachers at the language school are working with a summer class from the United States until the end of this week, which means that things may be a bit disjointed and disorganized this week. In any case, I got a new textbook that Peter suggested and that is a more extensive version than the English language one I got in the United States—this is quite exciting for a Bengali with a book fetish! I also learned from the teacher that I worked with today that the fair rate for personal tutoring with a teacher who lives closer to where we will be spending the rest of the year (that is, on Lake Atitlán) is relatively compatible with our small budget. So, good things, so far—now all I have to do is put in tons of hours and much effort. Ack!

On Mayan medicine

A quick disclaimer: of course what is written here is the result of just 2 days in Guatemala, and some of the perspectives and information are liable to modification over time (and rightfully so, I think) as we gain experience and knowledge. So the following entry is really just a representation of where I am and what I’m thinking about right now on this journey. Thanks for your patience. Without further ado…

On Saturday morning I woke up early to make sure I had time to stop by an Internet café to print a copy of my proposal before meeting Peter, who is serving as an advisor on my project in San Lucas Tolimán, in Antigua’s central park. I arrived a bit early, so I sat and reread my proposal briefly. I spotted him after a few minutes, walking quickly to catch up with him and calling out to get his attention. We shook hands and headed to the market—we had spoken the evening before, and he had told me that he needed to stop by the market to purchase some medicines.

I followed closely behind him so that I could hear what he was saying and so that I wouldn’t lose him in the maze of shop stalls. Finally, he stopped in front of a large corner stall full of fresh produce, which he looked at and said, “This is the woman I usually buy stuff from.” I looked more closely at the stall’s wares, searching for strips of pills and bottles of ointment, but saw none; I looked around me at the other stalls, searching for a small stash of allopathic medications or medical supplies, but all I could see was more fresh produce. Peter got the attention of the woman who runs the store and, speaking to her in Kaqchikel, began asking her for things.

The only word I understood was “manzanilla”—chamomile—and I quickly realized that, given Peter’s avid interest in ethnomedicine, when he said he needed some “medicines,” I should have understood that he meant medicinal herbs. He proceeded to collect a sizeable bunch of different herbs and vegetables, and in between speaking in Kaqchikel to the storeowner and her assistant, he explained to me in English the rationale and principles for using alternative medicine. Medicinal herbs are cheaper and, for a physician who has not yet received what will be a nominal license to practice, more easily accessible than allopathic medications. The usual issue of cost and accessibility is compounded by the fact that generics are, according to Peter, virtually impossible to come by in Guatemala. I do not know the reasons for sure, and nor did Peter, but I have a bad feeling that this is the result of predatory, “neoliberal” policies akin to the stipulation that the sums of money recently promised by the United States for the purveyance of anti-retrovirals in sub-Saharan Africa be used to purchase only non-generic medications, converting what could have been a huge humanitarian gesture into a kick-back to First World pharmaceutical companies. (I use quotes around “neoliberal” because I think that cheap drugs should be the outcome of a neoliberalism that fosters and is based upon truly equal competition.)

Reasons other than cost (and Peter’s current student’s-stipend-budget) drive the use of herbs. First, the structural violence that has and continues to characterize relations between indigenous and non-indigenous peoples is manifest between practitioners of Western allopathic medicine and indigenous patients, and the use of medicines that are a part of indigenous Mayan medicine fosters trust and adherence to treatment regimens. On our walks between patients’ houses, Peter explained several examples of patients who quietly refuse to take allopathic medications but whose diseases have nonetheless been brought under relatively good control with only herbal medicines. Second, the use of Mayan medicines, in conjunction with activities such as Peter's financial sponsorship of Mayan religious ceremonies, serves the ostensive mission of Peter’s newly founded NGO, Wuqu’ Kawoq (see sidebar for Internet link), “strengthening Mayan culture and medicine”: the study and use of medicinal herbs contributes to the effort to preserve and revitalize Mayan knowledge and culture. In any case, after this interesting introduction, and after two days of continuing to learn from Peter about medicinal herbs, I am convinced that they should be appropriately incorporated as first-line treatments.

Peter also explained that at this point he is using about 20 or so such remedies, and that an important criterion for use of a specific medicine is scientific literature verifying its benefit—of course, not all of this evidence is from head-to-head randomized controlled trials comparing herbs to allopathic medicines, and Peter also noted wryly that it is a little imperialistic to make decisions based on Western allopathic standards, but that it is an easily rationalized way of selecting from the hundreds of herbal therapies for various ailments.

That's all for now. Thanks for reading! I'll post more soon.

¡Bienvenidos a Antigua!

Antigua is an enchanting place to begin our journey... the former Spanish colonial capital of Central America, Antigua was founded in 1543 and - according to our Lonely Planet guidebook - it is one of the oldest and most beautiful cities in the Americas. (In the photo above, you can see Shom standing in front of the famous Antigua landmark, el Arco de Santa Catalina, built in 1694. This is one of the few Antigua constructions that withstood the 1773 earthquake). Antigua is a city of cobblestone streets, crumbling ruins, brightly painted buildings, and (unfortunately) crawling with gringos. I am shocked by the number of Americans and Europeans walking down the street... I have never seen so many in my previous travels to Latin America, and it is a bit overwhelming for someone who came to Guatemala to experience Guatemalan culture. Foreign culture is everywhere - from bagel shops to Thai restaurants to Irish pubs. Nevertheless, I am looking forward to sight-seeing and learning more about the history of this wonderful city.

This morning I took a walk around the Parque Central (the park which serves as the main meeting point for everybody here because of its central location) and witnessed a motorcade of teen beauty pageant contestants waving at passersby from their perches atop the roofs of various brilliantly decorated cars and trucks (see photo above). I also noticed the municipal police force - whose uniforms consist of full head-to-toe camouflage fatigues and huge machine guns slung over their shoulders. Scary. Even scarier, however, is that the non-police security guards stationed in front of every bank also carry machine guns. Woah. My guess is that this militarization of security and police is left over from the civil war, but maybe this has been the norm here for longer than that. All I know for sure is that we´re certainly not in Kansas anymore...

In other news, we are staying with a Guatemalan host family for these 2 weeks here (see a photo of our homestay to the left) and I am very excited to begin my Spanish classes on Monday. Shom has had some trouble finding a Kaqchikel instructor, but hopefully by our next update that will be straightened out. In the meantime, we would love to hear from any and all of you! We both now have Guatemalan cell phone numbers which you can call fairly cheaply using Skype or http://www.onesuite.com/ . If you´d like to give us a call, just let us know and we´ll e-mail you our numbers.

Much love to all,
Elena

Welcome to our blog!

Our departure is fast approaching - on Friday July 27, 2007 we fly from Atlanta to Guatemala City! Our plan is to spend the first two weeks in the city of Antigua, Guatemala living with a host family and taking some intensive language courses in an attempt to linguistically prepare ourselves for the coming months. I will be working on my Spanish, and Shom will be learning Kaqchikel, the Mayan language spoken in the region where we will be living this year.

I am thrilled to finally begin this journey we have been planning for and talking about for so long. I am also feeling a bit anxious, an emotion that often surfaces whenever I am faced with situations that are new or difficult to predict. I am finding comfort, however, in a prayer that a dear friend of mine gave me when we said our goodbyes a week ago. The prayer is written by Joyce Rupp, and comes from her book, "Praying Our Goodbyes."

A Prayer for Moving On

Guardian,
Guide,
No pillar of cloud by day
Nor fire by night,
Yet I sense your presence with me,
God of the journey.

You are walking with me
Into a new land.
You are guarding me
In my vulnerable moment.
You are dwelling within me
As I depart from here.
You are promising to be my peace
As I face the struggles
Of distance from friends and security,
The planting of feet and heart
In a strange place.

Renew in me a deep trust in you.
Calm my anxiousness.
As I reflect on my life
I can clearly see
How you have been there
In all of my leavings,
You have been there
In all of my comings.
You will always be with me in
everything.
I do not know how I am being
resettled,
But I place my life
Into the welcoming arms of your love.

Encircle my heart with your peace.
May your powerful presence
Run like a strong thread
Through the fibers of my being.
Amen.