Guatemala Health Initiative

Origins

In 2005 Penn faculty and students in the School of Medicine and the School of Nursing began to assess the lack of adequate healthcare in Santiago Atitlan. Kent Bream, founding faculty director of the GHI, helped to rebuild the Hospitalito Atitlán that was destroyed in 2005. Bream trains students and coordinates interdisciplinary research, education, and service programming involving the Penn Schools of Nursing, Medicine, Arts and Sciences, Engineering and Applied Sciences, and Wharton to improve the health of the Atitlan community GHI partners with Hospitalito Atitlán, a small, private, non-profit hospital in Santiago Atitlan in the western highlands of Guatemala. Santiago Atitlan, the largest indigenous village in Central America, sits on the southern shore of beautiful Lake Atitlán. It is rugged land with three majestic volcanoes surrounded by a dense jungle. The word "atitlan" is a Mayan word that translates as "the place where the rainbow gets its colors".

Santiago Atitlán is a poor, close-knit community of 44,220 Tz'utujil Maya speaking inhabitants, of which ninety eight percent are indigenous. The primary language for ninety four percent of the residents is Tz'utujil; however, fifty four percent speak and thirteen percent read some Spanish. Residents of Santiago Atitlán are referred to as Atitecos. Eighty percent are Catholics, but the traditional Mayan beliefs have endured. Their Mayan rituals, including sacrifices, ensure that the sun, moon, and planets will continue on their paths. In the highlands of Guatemala, especially around Lake Atitlán, the Maya culture still rules. Atitecos are hard-working individuals sustained mainly by agriculture, fishing, and by tourism. According to the World Bank, Guatemala has one of the most unequal income distributions with fifty one percent of the population living on less than $2 a day and fifteen percent on less than $1 a day. While over half of the population of Guatemala lives in extreme poverty, within the rural indigenous Maya areas of Santiago Atitlán this poverty level raises to ninety one percent.

Guatemala's social development indicators, such as maternal and infant mortality, chronic child malnutrition, and illiteracy, are among the worst in the hemisphere. Santiago Atitlán has the worst access to healthcare in Guatemala. Childhood diseases include respiratory and diarrheal illnesses and malnutrition. In the adult population, diabetes, hypertension, and chronic obstructive pulmonary disease are common occurrences. Santiago Atitlán has the third highest maternal mortality (MM) rates in all of Guatemala. This and other indigenous communities in the Guatemala highlands suffer extremely high rates of maternal and infant mortality with many obstetrical complications, and high levels of pre-eclampsia. Over a woman's lifetime, the expected maternal morbidity is 1 in 71; and maternal mortality is 290 deaths per 100,000 live births with a range of 100 to 650 deaths. In Guatemala, the most precarious living conditions, the highest fertility rates, and the smallest percentage of births attended by doctors belong to indigenous women. Approximately 80% of all childbearing women are attended by traditional birth attendants (TBA's) who have little or no formal education. A traditional birth attendant is defined as "a person who assists the mother during childbirth and initially acquired her skills by delivering babies herself or through apprenticeship. Women in Santiago Atitlán, a medically pluralistic community, remain strongly skewed towards traditional medicine, despite the associated risks.

Santiago Atitlán has the fourth highest malnutrition in the world and seventy percent of children in western highlands have stunted growth from chronic malnutrition. www.santiagoatitlan.com Extreme poverty and severe gastrointestinal illnesses are main contributors to malnutrition. Gastrointestinal illnesses result from contaminated water sources. In 1990, the Santiago Atitlan water supply was chlorinated after a cholera outbreak, but social determinants affect drinking water beliefs and practices among the Tz'utujil Maya. Memories of the Guatemalan Civil War and Hurricane Stan, attitudes about Lake Atitlán water, and the taste and smell of chlorinated tap water, as well as, differences in ethnicity, literacy, years of schooling, and tap water quality influence Tz'utujil Maya water preferences. Despite criticism of chlorination, ninety percent of residents do get their drinking water from household or public taps, but many still drink from contaminated sources or self treat the water. Demographic, socioeconomic, social, cultural, political, and historical factors continue to be significant determinants of water-related health. Public health water interventions need to address the inequalities related to these underlying factors in order to achieve maximum effectiveness. Interestingly, both the forty four percent rates of obesity and chronic malnutrition are significant health problems. In Guatemala, twenty three percent of households contain a growth stunted child with an overweight mother. Poor diets were associated with these disparities. Biomedical health professionals express increasing concern that rising consumption of soft drinks and processed foods in Mayan and Latin American lead to detrimental nutritional and health consequences. Scholars debate whether the pervading presence of Coca-Cola and Pepsi in developing countries represents "Coca-Colonization," synonymous with cultural imperialism, or cultural hybridization. Coca-Cola has been uniquely hybridized into the health beliefs, religion, culture, and environment of the Tz'utujil Maya eating patterns. The Atitecos have been Americanized as they have incorporated Coke into their daily drinking habits. They drink it in place of alcohol and instead of contaminated water and use it in celebrations and to cure sore throat and coughs. This dietary inclusion likely increases malnutrition, diabetes and body mass index (BMI). The BMI of the Tz'utujil Maya of Santiago Atitlán, Guatemala is positively associated schooling, income, literacy, marriage, market visits per week, and water drinking. Two-thirds of the high-income respondents were obese, whereas slightly over half of low-income respondents had either normal or underweight BMI. Public health interventions for obesity should target high income, married Atitecos who visit the market frequently. This coca-Colonization and cultural hybridization appear to be complementary rather than mutually exclusive processes that contribute to dietary transitions, economic development, and differential health beliefs related to soft drink consumption.

Many Global Health Programs: governmental, non-governmental (NGO), private, and voluntary organizations work to support the people of Guatemala. The World Health Organization (WHO) directs international health activities, supplies training and technical assistance, develops standards, disseminates health information, promotes research, collects and analyzes epidemiologic data, and develops systems for monitoring and evaluating health programs in Guatemala. The Global Health Initiative sponsored by United States Government, targets women, newborns and children under five in Guatemala. It concentrates support efforts, aligning the NGOs and engaging the private sector in reducing maternal and infant mortality, reducing the pervasive levels of chronic malnutrition that affect fifty percent of all Guatemalan children, increasing access to voluntary family planning services, prevention of HIV and other communicable diseases and improving health systems and health services. In addition to these large organizations, private voluntary organizations contribute twenty percent of the external health aid to distressed areas.

GHI, a voluntary organization, established a partnership with the Hospitalito Atitlán in the summer of 2005, when University of Pennsylvania medical and nursing student volunteers conducted a community health assessment in Guatemala. The predecessor to Hospitalito Atitlán, Clínica Santiaguito, opened in the 1960s. The Clinica was abandoned, after the massacre of thirteen Atitecos by the Guatemalan Army in 1990, leaving the town without medical services. In 2002, K'aslimaal, a grassroots organization, began to raise funds and make plans to reconstruct the hospital. Through their efforts, Hospitalito Atitlán opened on April 1, 2005, providing in-patient, surgical, and 24-hour emergency care to the people of Santiago Atitlán. Unbelievably, barely six months after opening, on October 5, 2005, mudslides triggered by Hurricane Stan, buried Hospitalito Atitlán in eight feet of mud. The mud slide destroyed the town and killed hundreds and the area was declared a mass grave. Two Penn medical students were present during the disaster and participated in the relief efforts. Through the heroism of hospital staff and volunteers, and the generosity of donors, Hospitalito Atitlán, amazingly, re-opened just two weeks later in a temporary location. Groundbreaking for a new permanent building for Hospitalito Atitlán began on September 30, 2006. In November of 2010, the first floor of the new hospital opened. Today, Hospitalito Atitlán is a flourishing health organization that offers curative and preventative hospital services in the poverty stricken Atitlán area. Medical care is accessible to all, with a focus on women and children. Social Workers are available to evaluate the resources of the patient and family and provide up to a one hundred percent discount for those with limited resources Local physicians, nursing, and administrative staff work closely in collaboration with volunteer medical personnel from around the world to provide a comprehensive scope of care, including the only 24/7 emergency and surgical obstetrical care within a 2-hour radius. For the many patients that speak only Tz'utujil. Hospitalito Atitlán staff translates Tz'tujil to Spanish. Hospital Atitlán is truly the lifeline for the people in the remote community of Santiago Atitlan.

The mission of Guatemala Health Initiative is to work with Hospitalito Atitlán to strengthen the medical services in a socially relevant and ethically acceptable way in resource-poor Tz'ulujil Maya community of Santiago Atitlán in Guatemala. GHI collaborates with the Hospitalito Atitlán to improve the health of Atitecos by increasing clinical activities and community health promotion via community health research, personnel, and material support. GHI provides education through video tapes, lectures and community health projects. GHI strives to educate mothers on the importance of prenatal care, safe deliveries, and postnatal care. GHI informs residents about the pulmonary problems that arise from the open cooking fires in homes and the importance of safe drinking water. Central to the goal of GHI is to put the knowledge gained through participatory research and clinical and cultural experiences into developing effective, sustainable, and culturally sensitive health interventions. A number of potential collaborative projects between Penn and its Guatemalan partners are being conducted or explored, including scientific and clinical training with bilateral exchanges of students and faculty, as well as research on issues related to: violence prevention, food and nutrition, road traffic safety, chronic disease and trauma treatment. In 2011, Dr. Kent Bream, students, medical school librarians, and hospital IT specialists brought the Penn mobile technology project to Hospitalito Atitlán. The Penn mobile technology project, a most promising telemedicine program, uses smart phones and other mobile technologies to improve physicians' access to clinical information in Guatemala. The smart phone technology allows images and information to be relayed to Penn doctors for instantaneous diagnosis and second opinions. They can also use electronic devices to tap into extensive electronic medical databases and e-journals to get information on diseases and treatment options. This immediate access to medical information will advance the quality of care in this rural area.

GHI raises funds, procures medical supplies, and provides personnel support for Hospitalito Atitlán. Penn medical and nursing student rotations benefit both Penn and Hospitalito Atitlán. The GHI also informs the Penn community about health and human rights in Guatemala. Contributions from the Guatemala Health Initiative, a voluntary organization, positively impact both the Penn and Guatemalan communities. Global health programs, albeit, large or small, governmental or private, although mostly valuable, must be evaluated for their tangible value. Just like a noble deed may be of great importance and worthy of high praise or it may, no matter how well-intentioned, be worthless. In all types of organizations and at all levels, volunteering or donating is not necessarily a valuable service unless it is addressing an identified need and the purpose is valid. The verifiable need must be adequately and efficiently met and it must be sustainable. Health research plays a critical role by identifying needs; developing and evaluating interventions and applying knowledge and put it into action. Monitoring and evaluating the results of the system is essential and open sharing of knowledge and communication is a main objective. Nonprofit, voluntary organizations form the bedrock of the global health care delivery system, but they are not alone in their efforts as global health care systems are pluralistic. The Guatemala Health Initiative (GHI) of the University of Pennsylvania, through its humanitarian contributions to Hospital Atitlán and the people of the Santiago Atitlán region of Guatemala, is significant and its importance should be recognized. GHI was born of good intent, with solid direction, expanding endeavors, and is succeeding in its mission to improve the health of the indigenous people of Santiago Atitlán, Guatemala. Interestingly, the health care and community outreach has its roots deep in the Penn community. The earliest hospitals were founded by religious and civic communities. The Pennsylvania Hospital was founded in 1751, through the philanthropic efforts of Benjamin Franklin, founder of the University of Pennsylvania. GHI carries on this proud Penn tradition in its mission to improve access to healthcare for the people of rural Guatemala. Through education, research, medical care, and the use of new technologies, GHI continues to advance the health of the Santiago Atitlán people, primarily through its support of the Hospitalito Atitlán, an essential part of the vulnerable community's safety net.