Letter from the Field by Dr. Juan Carlos Luis Chirgwin

By Dr. Juan Carlos Luis Chirgwin

Department of Family Medicine, McGill University

In our different health professions, we sometimes need to step back to review what we do, how we practice and whether we are making a significant impact in our environment.

As a family doctor working in a community health centre (CLSC) in Montreal, I was able to do this last April by traveling to Guatemala and meeting its people.  I would like to share this experience with you and encourage you to embark on a similar exploration of what health means to people, regardless of where they reside.

On March 18, 2005, I leave Montreal and the connecting flight through Atlanta brings me to Guatemala City. This is my fourth visit to Guatemala as a voluntary doctor with Pueblo Partisans. Pueblo Partisans was started more than twenty years ago after its founders, Tom Grauman (social worker) and Wendy Neander (nurse and professor in nursing) met Nicolasa, a Guatemalan Mayan woman who told them about her community in the town of Comitancillo, San Marcos department. With Nicolasa’s help and after many meetings with townspeople to assess their needs, Pueblo Partisans slowly and successfully developed with the people an agro-forestry project, a women’s income generation project, health promotion projects, human rights education projects and a yearly mobile medical clinic. The active participation of the townspeople in these projects was essential. Elie Wiesel encapsulates Pueblo Partisans operating principle as he states:

“We must be with those who have suffered and we must be with those who have tried to prevent suffering. This is the real community: it does not deny differences but rather enhances and transcends them.”


Many Guatemalans are forced to live on marginal lands subject to flooding and landslides, with little access to services. Photo: Amy Lindstrom

In past years my wife Kaberi and I had helped Wendy and other nursing instructors to supervise and teach nursing students from Edmonton and the United States as they conducted clinics in rural villages. For thirteen consecutive years Tom and Wendy have brought students from the University of Alberta, Red Deer College (Alberta), University of British Columbia, the Oregon Health and Sciences University and the State University of Puebla (Mexico). Health science students from nursing, medicine and dentistry have participated in the program. The purpose of these trips is to expose students to experiences which will help them to be more effective professionals in their home countries.

This year the group of nursing students works around Guatemala City , in the central departments (Guatemalan equivalent of provinces) of Alta and Baja Verapaz, Sacatepequez, the southern department of Santa Rosa and near the northern jungle region of El Peten. We have found excellent accommodations with Padre Noe, the head of a Catholic seminary in the neighbourhood of San Gaspar, located in the cooler hills away from the traffic-choked, sweltering city. In addition to the bustle of activity which comes with the nursing team and their suitcases of medical supplies, the seminary before Easter is a busy place as Padre Noe and his seminarians prepare for the Easter celebrations and the religious procession through neighbourhood streets. Similar processions of much larger magnitude will be happening in the city: gigantic decorated wooden floats of religious themes will be carried aloft by up to a hundred men or women dressed in long gowns.

After unpacking and settling into my room, I meet old friends, the numerous seminarians who come from different departments of Guatemala , and Doņa Flor, who often cooks the meals. The five nurses come from Oregon and two of them are accompanied by their husbands, Daniel and Eric, who will help with their carpentry skills. Our team is also strengthened by Chris Nelson, women’s health nurse practitioner, and Jan Meyer, pediatric nurse practitioner, in addition to Tom and Wendy, whose contacts and close relationships with various Guatemalans will take us to different parts of this country.

The work had already begun prior to my arrival. The nurses had visited a rural school in Santa Rosa department, which borders El Salvador. Jan, Chris and Wendy supervised the nurses as they did general physical exams for the children and PAP smears for the women, while Daniel and Eric found out from the teachers what repairs were needed in the school. The following day the nurses and their instructors run a PAP clinic at the office of Alba and Rafael, Guatemalan doctors who know Padre Noe and who directed us to the Santa Rosa school. Tom continues the day by giving his Spanish language lessons to the team. He meticulously covers verbs, medical phrases and, most importantly, ways of using expressions in a socially appropriate manner. The nurses will be expected to attempt speaking Spanish, no matter their degree of fluency.

The population of Guatemala is over 10 million with only 38% living in urban areas. The life expectancy for men is 62 years and for women it is 67 years. The majority of Guatemalans are of Mayan descent (60%) and the indigenous population is divided into 22 distinct ethnic groups. The daily wage for a skilled labourer is between US$5-7/day, or 35-50 Quetzales/day in local currency, and unskilled workers earn less than this.

Within three days of my arrival I am driving Padre Noe's van and our medical team around the city's congested streets. There is no idyllic scenery here and definitely no donkey-riding Juan Valdez caricature selling coffee. Delapidated school buses converted into brightly painted over-sized taxis rumble about, cutting me off and spewing black smoke from leaded gasoline motors. Trucks, cars, pick-ups with armed security guards in the back and pizza delivery motorcycles all compete for limited road space, while pedestrians of all ages jaywalk and squeeze past each other.


“Doctor Here” reads the sign announcing a Pueblo Partisans medical clinic in Chahal, Alta Verapaz. In March and April 2005 Pueblo Partisans conducted medical consultations in four Guatemalan departments. Photo: Amy Lindstrom

Sister Sara, a Catholic nun from the US, runs a busy community clinic staffed with Guatemalan doctors in Mixco town, and she has requested that we visit a smaller town farther up the hills. An accountant from the clinic guides us up the well-paved highway, which shrinks to a tight street in the town of San Juan, Sacatepequez department. I steer our way through a maze of streets and monstruous speed bumps to another municipality. Dirt roads and 4-wheel drive terrain announces our arrival to Las Caņadas, a poor neighbourhood of shacks made from wood, cement and corrugated tin roofs scattered over hills and valleys.

The residents are milling about a 4x3 meter structure with a tin roof. They have stretched a plastic tarp over the entrance to block out the blazing sun while people crowd around in the shadow. Our suitcases are piled inside and we set up chairs for clinical assessments. Dogs and children slide between our legs while we call names of patients to our stations: three simple chairs set together. Inside the shack or in its front yard, the nurses take short histories with the assistance of the Spanish speakers, myself, the nursing instructors and Wendy's teenaged children.

Ideal working conditions are impossible: limited privacy, no examining table and the hillside wind blowing into our faces and snapping the overhead tarp. Acute or subacute complaints are commonly fatigue, dizziness, headaches, sore joints and nervousness, the latter having strong ethno-specific undertones. In our short interviews and even more limited physical exams, I feel we can only skim the surface of the more basic problems stemming from their poverty: malnutrition, crushing physical labour, exposure to air pollution, fear of violence and financial worries. A listening ear and counselling are provided by the nurses under supervision, as well as the occasional use of "Western" medicine (acetaminophen, multivitamins, iron tablets and NSAID's). A man tells me how he has used battery acid to treat what looks like scabies. Requests for antibiotics, especially in their most prized route of administration---the intramuscular injection---are turned down when not clinically indicated, and alternatives are offered. Nonpharmacologic therapies and cheap, available Guatemalan herbal remedies are recommended when possible.

Chronic illnesses are more problematic. A woman, diagnosed in the past as having Parkinson's and given Sinemet once daily, does not receive regular follow-ups and uses the medication haphazardly. Someone with a history of diabetes, untreated because she cannot afford the medications, tells me she feels exertional chest pain. Obviously we cannot institute therapies which require periodic reassessments, so we arrange for these patients to be followed at Sister Sara's clinic in Mixco. We return to the Las Caņadas the next morning and run a clinic all day with the addition of PAP exams. A future visit will be mainly for the vaccination of children. The demand for medical care has been great, and we have had to limit the number of people we assess. We return to the seminary to eat and rest in preparation for the next big day.