Outside the Ark

Ak’ Tenamit

The first day in Guatemala consisted of a visit to a health clinic and school run by Ak’ Tenamit, a non-profit that works with a Mayan indigenous group called the Q’eqchi.  In Guatemala, indigenous groups comprise 60% of the population, mostly descendants of the Mayans.  However, most indigenous people are not politically active, Guatemala has never had an indigenous president, and many more indigenous people suffer from poor health and poverty than members of any other ethnic groups.

We docked at Santo Tomas de Bastilla, a small port right beside a larger one called called Puerto Barrio.  If you have ever eaten a Chiquita or Del Monte banana, you have probably eaten a banana that has passed through one of those ports.  Right beside the ship, our group of thirty-some boarded two water taxis that took up down the coast and then up the Rio Dulce.

The view from water taxi ride was one of the most beautiful things I have ever seen.  The ocean was blue and clear, and the shoreline consisted of beautiful hills dotted with houses in front of a backdrop of rounded mountains.  But the best part was when we turned inland and began riding up the Rio Dulce.  The water was a beautiful blue-green, and thick, bright vegetation covered the surrounding hills.  Every so often we rode past a beautiful white stone cliff.

We docked at the Ak’ Tenamit Clinic and met two expatriate doctors, one from the States and one from Australia, who were both there for a three month period.  They showed us the clinic, a pretty, airy building with a thatched roof.  The clinic had a very well stocked pharmacy on the second floor, and it was clear that access to essential medicine was not an issue here.  One main problem the surgeons did discuss, however, was their limited ability to diagnose conditions.  They could diagnose hypertension and diabetes, but for most other illnesses, including malaria, they were forced to treat what they thought was the problem and, if that treatment did not work, send the patients on hour long boat rides to a more equipped clinic at Livingston or even further to the hospital at Puerto Barrios.  It was interesting to hear first-hand the frustrations of practicing medicine in a low resource setting, where two microscopes and a centrifuge were the extent of their lab equipment.

There was a birthing room in the clinic, equipped with a bed and a looped rope hanging from the ceiling.  Birthing women used the rope to support themselves as they squatted upright, delivering their babies.  This way, gravity works with the women.  There were a number of charts in the room, almost all without text. My favorite showed drawings of different levels of dilation alongside smiley faces with expressions of varying amounts of pain.  In the two months that one of the doctors had been at the clinic, only two mothers had given birth in that room.  Most preferred to give birth in their villages with the local midwife.  Ak’ Tenamit did not discourage this, but trained local midwifes to deliver babies safely and with good sanitation techniques.  In Q’eqchi culture, where and how the woman gave birth was not her decision but that of her husband.

I enjoyed seeing the clinic, but was a little disappointed with a few things we weren’t able to see.  The doctors did not discuss traditional Q’eqchi medical practices, which they seemed to be ignorant of.  They were only working with the program for a few weeks, but I hope that full-time staff of Ak’ Tenamit has learned as much as they can about local traditions and encourages the continuation of practices that are beneficial.  One thing that alarmed me was that when my teacher asked what kind of cultural orientation the volunteer doctors received they laughed and said you pretty much learn as you go.  Granted, they were able to work with local “health promoters” who were Mayan, but you would think more cultural training would be helpful while working with a population so different from ours.

After touring the clinic, we made our way to the dental clinic, which was tethered to a dock.  The dental clinic consisted of a flat bottomed boat with two operating chairs in it.  The mobile clinic made weekly rounds to Q’eqchi villages along the Rio Dulce.  I thought this was a creative way to facilitate access to care for the Q’eqchi people.

From there we returned to the water taxi and rode ten minutes down the river to the Ak’ Tenamit school.  After lunch, we went to the library for a presentation from a former student.

Ak’ Tenamit decided to start the school in response to increasing incidence of Mayan students dropping out of public schools.  Mayan families would take their students from the schools out of fear that their culture was being lost as students engaged in a traditional Western education.  Ak’ Tenamit, which means new village, attracts just these students by teaching Mayan culture alongside useful trades.

The class buildings were huge and round, modeled after a Q’eqchi hut.  Teachers did not lecture much, but had students read and complete activities, standing by to help students when they had trouble with a concept.  Students learned a little traditional Western education, but once they arrived in high school they selected a career track, the most popular of which were tourism and agriculture.  I thought these pragmatic curricula sounded like a great way to improve the quality of life for Q’eqchi students.

I had heard and read a lot about how educating women can dramatically improve their quality of life and stabilize population growth, but at Ak’ Tenamit I was able to witness this first hand.  The former student told me that Ak’ Tenamit makes a point to tell girls that they do not have to marry early, or at all, and can have children.  He said that most Q’eqchi girls married around age fourteen and had 6-7 children, but graduates of Ak’ Tenamit tended to marry in their twenties and have two to three children.  They were also less likely to marry an abusive spouse, a serious problem in this area.

The class day following this trip, several of my classmates expressed frustration with how Westerners have forced Western practices on groups like the Q’eqchi and look down on indigenous people when cultural incompatibilities create problems.  Problems we identify, such as large families or unequal influence on decisions between men and women, may not have been issues in the context of Q’eqchi culture but are considered such because they do not gel with Western practices well.  And so often we then go try to fix these problems with further Westernizing, without considering whether reverting to indigenous practices might be a more organic and sustainable means of raising quality of life.  I think we need to start asking these questions, and remembering that deciding whether a social condition is problematic should depend on whether the locals consider the condition a problem, not whether it is a considered a problem by the culture of the expatriate.

HIV/AIDS in Honduras

The first day in Honduras was my HIV/AID field practicum. We began on the ship with a lecture by two Honduran doctors who work for USAID. Both presentations were excellent, and it was neat to see how the public health concepts we’d been discussing in class really are being used in the “real world”. We discussed the three major MARPs (most at-risk populations) in Honduras, and what efforts are being taken to address each group. Like in the States, men who have sex with men and commercial sex workers are MARPs. One group I hadn’t heard about before was the Garifuna people, an ethnic group with a distint language and culture. I found Dr. Pinel’s reasons for the high prevalence among the Garifuna people interesting. The usual suspects were contributors- low condom use and sex with multiple partners. However, the primary factor was that for a long time the council of elders refused to believe that the cause of HIV/AIDS symptoms was medical, instead holding that it was a curse. This made it impossible to treat HIV/AIDS or teach preventative practices. It amazes me that such a small group of individuals were able to impede on a public health effort so drastically. However, a small group with such a strong pull over a community could also make a public health effort much simpler, because only that small group needs to be convinced to comply, not a whole population. After lunch, we went to a local community center to an HIV/AIDS information fair. There were several stations with games, puzzles, and activities about condom use, safe sex, and HIV/AIDs. 8th and 9th-grade students came from school in waves to take part in the fun. One thing that surprised me was how many questions the students got right. At least academically, most of these students knew how to be safe. Hopefully that knowledge will translate into practice, but volunteers said they are still working to make condom use a part of the culture. Earlier in my nursing course we watched a TED talk with Melinda Gates in which she discussed what public health could learn from Coca-Cola. One of her points was that while Coke’s advertisements associate its products with happiness and whatever the targeted population associates with happiness, public health campaigns usually try to attach negative associations with not using their products- You’ll die if you don’t wear a seatbelt, you’ll get HIV if you don’t wear a condom. We assume because someone needs something, we don’t have to make them want it. Gates thinks we need to question this assumption and try to create positive public health campaigns similar to what Coke does. Perhaps such a positive public health campaign could help these students not just know they should be safe, but actually want to implement safe practices. After the HIV/AIDS fair, we went to a youth leadership workshop. About 25 Garifuna youth (aged 17-22) were gathered in circle in a community space. We joined them for an ice breaker called “kiss the pig” and then watched a demonstration on putting a condom on a wooden penis, a recurring theme of the day. Twice during the workshop we took a dance break, during which a few of the guys would play drums and everyone danced. The Garifuna had a good laugh watching the gringos struggle to dance. After being at the workshop for about an hour, we went to a street surprisingly close to where our boat was docked that was the center of commercial sex work. In Honduras, sex work is not addressed legally- it has neither been declared legal nor legal. However, it was obvious that sex work was not as taboo as in the States. When our bus-full of students invaded their workplace, the sex workers did not seem ashamed that they were being exhibited. Many were very friendly. An NGO was also there holding workshops on condom use and safe sex (many more wooden penises). One women put a condom on with her mouth, to the cheers of her peers. The women seemed to enjoy the attention the program gave them and had a lot of fun with it. At least for the women there, the program seemed to be effective, although I don’t know what percentage of commercial sex workers is open to working with such programs. In addition to the education program, there was also a mobile clinic that provided rapid HIV/AIDS tests to the sex workers and their partners. One thing that surprised me was how many of the sex workers had a stable husband or boyfriend and children. It seemed that many Hondurans viewed sex work as just another profession. The most heart-wrenching moment the whole day was when one sex worker told us her story. She began sex work when she was fourteen, and had her first child when she was fifteen. The same year she was diagnosed with HIV. She believes a Filipino man from a cruise ship infected her, and she then infected her husband. A year later she had a second child who died was born infected with HIV and died as an infant. She talked about how none of this, gesturing to the educational activities all around, existed when she was infected. Now thirty, she is so thankful that the program exists to prevent more people from suffering as she is. She showed us the bottles of Anti-Retrovirals she takes daily as part of her treatment. This field practicum was encouraging because we witnessed successful programs that were relieving real suffering, but also difficult because we knew that there are so many who weren’t being reached by such programs. In Honduras, about half of those with HIV/AIDS are being treated, but many do not know that they need to seek treatment or do not have access. Honduras is fortunate to have a government who recognizes the seriousness of an HIV/AIDS endemic and invests in treating victims and preventing more incidences. Its hard to think about other countries who don’t have a government committed to addressing this terrible disease.