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Contribution to MMI Annual Report 2010

Inclusive primary health care in Guatemala

 Inclusive primary health care in Guatemala

A story from Guatemala, told by Medicus Mundi Navarra, a member of the Federation Medicus Mundi Spain (FAMME). The story is told twice: how it could have happened, and how it really was. The story illustrates what inclusive primary health care really means and that it can be an important contribution to strenghtening a national health system.

Victoriano lives in Las Barrancas, a very remote, rural, indigenous community in Guatemala. He is suffering from a sharp pain in the chest for some days. The pain comes and goes, but it is worse when he is tired from work. He cannot sleep at night. He has nightmares. He has heard his elders talk of the “susto” (fright). He cannot bear it anymore and decides to go to a healthcare centre in the area. This is not an easy task to do. He must travel for three hours along tracks that are in a poor state.

Victoriano does not have a car. He must spend part of the savings from selling his crops on paying someone else to take him there. The journey seems never-ending. Many thoughts pass through his mind: memories from his childhood, being cared for his mother and the fear of not finding a cure or not being able to continue supporting his loved ones. At last he arrives at the town where the Ministry of Health has one of its modest health centres. Victoriano feels weird sitting there amongst some women and children in a waiting room that is alien to him. A nurse calls his name and ushers him into the nurse office. He tries to explain to this person in a white coat what has been happening to him while she takes notes on a piece of paper. He struggles expressing himself in Spanish. The nurse does not speak “mam”, his mother tongue. It is one of the 25 languages spoken in Guatemala. How will she understand that I have the “susto”? He says, thinking out loud. The nurse makes fun of him. She tells him that the “susto” does not exist and that he should take the medicine she is prescribing him.

After a ten minute consultation Victoriano leaves with a piece of paper saying that he must buy some pills with a very complicated name. He have to look for a pharmacy. In Guatemala there are many, but they are very expensive. On the way home a street market vendor offers him medicines. Victoriano rummages in his pocket. He must keep some money for his return journey. He therefore decides to only buy two pills, instead of the 20 that he has been prescribed for the entire course of treatment. The name of the pills does not mean much to him, but their appearance does. They are red. “Red?” he asks himself. “This cannot be good. Sometimes I feel a burning sensation in the pit of the stomach. This is a hot illness,” he says to himself. Four hours later he arrives at his small house, gets into the bed, and the nightmares and pain continue. The “susto” does not pass off. “Tomorrow I will go and visit the Mayan healer”, he thinks as he tries to fall asleep.

An inclusive healthcare model: a truly intercultural and comprehensive approach

This is the story of what could have happened to Victoriano or many other people who belong to rural communities in Guatemala where 41% of the population are of indigenous descent. But fortunately it was not the case. Victoriano had the good fortune to live in one of the three districts where Medicus Mundi has been developing Inclusive Primary Healthcare Model pilot schemes for the last 12 years. The Ministry has recently decided to sponsor and consolidate the model which will surely be inspiring for an EU-funded proposal for piloting this comprehensive and inclusive healthcare approach – which is focused on the human right to health and the intercultural and gender equality – in Guatemala, Bolivia and Peru. This initiative aims to be one day the basis for a valid model for the whole of Latin America. 

Victoriano Pérez’s true story is not the one told above. It really is quite the opposite. The so-called Inclusive Primary Healthcare Model is based on the idea that traditional medicine (very deeply-rooted and developed in Mayan culture) and Western medicine (academic biomedicine) do not detract from or are opposed to each other. On the contrary, they complement one another from the triple individual, family and community points of view, adding to this as well the human rights and gender equality based approach. Victoriano’s reaction was to try first self-care (by asking his elders and looking for advice in the community), and then go to a pharmacy or visit a “curandero” (medicine man). Only after this did he think of going to the doctor. However when Victoriano felt ill there was no need to travel anywhere to find healthcare. A few metres from his home there was a Community Healthcare Centre, one of the key initiatives of the Inclusive Primary Healthcare Model. There he was greeted by a community auxiliary nurse which is the first level of primary health care in this model. The auxiliary nurse is part of a community team consisting of two or three people who understand the culture and language of the community and who have been accredited by the Health Ministry as well. They represent the first contact with the people and are supported by another team made up of a professional nurse, a physician and family and community program facilitators who can make referrals and possible transfers to higher levels or institutions depending on the healthcare problem they are dealing with.

Victoriano knows this team of people already, because they are integrated in the community daily life. As a result he could calmly explain them about what he was suffering from. He could feel he was being listened to, and properly understood. This auxiliary nurse had previously seen many cases of people who complained of the “susto” like Victoriano before. She can also recognise the symptoms of “empacho” (a gastrointestinal condition), “ojeado” (evil eye) and even “hechizo” (a curse). Some of these illnesses do not always have an equivalent in biomedical terminology, but according to Mayan culture they are related to the harmony in the person’s energy. Considering as well the knowledge about this health approach is very helpful for the detection of chronic problems or serious illnesses. 

The auxiliary nurse also knows that, for Victoriano, what the “curandero” (medicine man) says is as important as the medical examination at the health centre. This will also help the auxiliary nurse to confirm her initial diagnosis. That is the reason why she has no issue with sending him to visit a Mayan healer with great credibility in the community as well. Their work will be complementary. When the Inclusive Healthcare Model was being developed these “curanderos” or healers were contacted and they expressed their willingness to work in a “coordinated, although not integrated” manner. This is enough for combining efforts and providing a health treatment in which both traditional medicine and biomedicine complement each other. The Mayan healer’s main tools are medicinal herbs and energy. The Western biomedicine contributes with all their technical means and chemical findings... Victoriano will then return to the public health care personnel that will benefit from this double diagnosis by means of different data information systems, standards, conventions and procedure guidelines. The health treatment becomes an open path based on trust and interculturality.

However, as important as the remedy is the prevention. For this reason, the Community Health Centres have also become a place where the community members receive and share information about diseases and approve measures related to all aspects of health which extend further than the own individual sphere. People will never be healthy if they are lacking of water supply, balanced diets and a proper management of the resources. All these components are present in a model – which relies on the willingness of the public authorities to support their implementation – aiming to offer a solution for the healthcare problems suffered by thousands  –or millions – of people living in the rural areas of a diverse and multicultural continent.

Download the illustrated contribution to the Annual Report 2010 of the MMI Network as a PDF file. To read more: Juan Carlos Verdugo Urrejola et al.: Del dicho al hecho. Los avances de un primer nivel de salud incluyente. Photo:

Victoriano and his wife Cia (c) Medicus Mundi Navarra

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