27 Sept 2012

The clinic’s Guatemalan doctors and American coordinators periodically give conferencias, something of a cross between a seminar and a lecture, for the students.  From these and from small lessons as we’re working with patients, I’ve collected a small store of information about the healthcare system in Guatemala. (All numbers are approximations.)

The country has 16,000 medicos for an estimated population of 15 million Guatemaltecos.  That comes out to about 1 doctor for every 1000 people, or a doctor-patient ratio of 1:1000.  In the US the ratio is 1:400.  In Cuba, whose state-run healthcare system has received a lot of praise, it is 1:170.  The WHO recommendation is 1:600.

At first glance, Guatemala doesn’t seem *that* far off from the WHO recommendation.  But the numbers are misleading.  Seventy percent of these physicians reside in Guatemala City (Guate), the capital and the main urban center.  Here the country’s resources – doctors, technology, economics – are centralized.  Guate’s doctor-patient ratio is as low as 1:200.  In the more remote and poorer areas of the country it is as high as 1:tens-of-thousands.

Healthcare in Guatemala has four arms:

[1] Public healthcare is run by El Ministerio de Salud.  In some smaller towns there are clinics called Puestos de Salud or posts of health.  There may be a doctor on staff, but finding a nurse is more likely.  In much bigger towns are the larger Centros de Salud where there will be doctors on staff, and where I regularly send parents to have their children vaccinated.  In the capital cities of Guatemala’s 22 departments (states) are the large public hospitals.  This system is supposed to provide free healthcare to the 90% of the population not covered by the other three arms.

[2] There are private clinics and hospitals where the wealthiest 5% of the population pays out of pocket.  A consult fee ranges from 100 quetzales to upwards of 300 quetzales to see a specialist.  And, like in the US, the fees for lab tests, imaging, and other diagnostic tests are off the charts.

[3] Instituto Guatemalteco de Seguridad Social (IGSS) provides a variety of great benefits, including healthcare, to the few lucky enough to have legitimate jobs that pay in to this social security.  Most Guatemaltecos work in jobs where no records are kept: as farmers, drivers, maids, sellers in markets.  An interesting thing of note is that IGSS spends more than 20% of the health budget though it only serves 5% of the population.

[4] Sanidad Militar or military health is the oft-forgotten fourth arm of the healthcare system.  In one of our conferencias we were told that reviews of the Sanidad Militar’s spending are prohibited.  This was a stipulation of the Peace Accords of 1996 that ended the civil war.

The system sounds ideal. “Free healthcare for all,” at least via the public arm of El Ministerio de Salud.  The reality is that many, as much as 40% of the population, do not have access to healthcare.  They cannot afford the perhaps 9-hour journey to the nearest doctor, neither in money for the bus nor in time away from work.  The public hospitals are crowded and understaffed – patients are often turned away and asked to return another day, after they have made the trip and waited in line for hours.  Communication between and even within arms is poor – a patient might leave a hospital with a new diagnosis of AIDS, which may or may not be communicated to his nearest Puesto de Salud via snail mail.

Instead much of the population relies on traditional practices.  Comadronas, traditional midwives, often become the medical practitioners of their communities. Most of these women do not have formal training, but rather generational knowledge passed down from mother to daughter.  There are Curanderos who practice natural herbal medicine, which can work but not for everything.  In very remote areas people depend on brujos (yes, this does translate to “witches”) who practice magic and cure problemas de los espíritus.

There is a considerable gap between medical need and supply.  And the rate of medical graduates does not promise to make up the difference.  Medical school in Guatemala is seven or eight years directly after high school.  Diploma in hand, a new doctor can work as a general practitioner without attending residency.  Of the 400 medical graduates each year, already a trifling number, 300 enter residency to specialize; only 100 stay in primary care.

Unlike the US, medical students in Guatemala are trained to set fractures, perform appendectomies, and do C-sections, so they can immediately be general practitioners.  One of our clinic doctors, Wilder, believes it is okay to work in primary care after eight years of school because, “los problemas no son complicados.” The main problems aren’t that complicated: primary prevention, malnutrition, infections, maternal conditions and childbirth.  (I should note that city populations have seen rising rates of high blood pressure, diabetes, cholesterol, and GERD and gastritis.)

Over 50% of Guatemalan children suffer from stunting (height-for-age below -2 SD) because of chronic malnutrition, a millstone that continues a cycle of:  poor nutrition → developmental effects / diminished intellect → weak educational achievement → poverty → poor nutrition.  More than 10% have acute malnutrition, marasmus or kwashiorkor, making for the highest child malnutrition rates in the western hemisphere.

Curable infections are an everyday problem.  One of the causes is poor sanitation, especially contaminated water.  Diarrhea is a leading cause of death of children under five.  Parasites are a familiar annoyance, which does not help with chronic malnutrition.  Pneumonia and other infections are no strangers to our clinic.  Add to this that any Jose off the street can buy antibiotics from a pharmacy, without a prescription.  The other day I wrote another student a “prescription” for UTI meds, in pencil on a torn-out piece of spiral notebook paper.  She came back five minutes later, Bactrim in hand.  This lackadaisicalness of pharmacies must breed resistance.  But resistance patterns are unknown.  No one has done these studies yet.

Maternal and neonatal mortality are significant.  Only about 30% of births are managed by doctors.  The rest are overseen by conmadronas.  We were told that these traditional midwives, usually, have only a bucket of hot water and several clean towels as their tools.  They are adept at handling normal births, and the vast majority are normal.  But if there are any complications they do not have the training or the equipment to cope.  One of the school’s teachers tells a story of a man who strapped his hemorrhaging wife to a chair and carried her on his back, while she was bleeding, from the midwife’s house to the hospital.

Wilder once held a clinic in a community where there lived 306 dogs (he remembers the exact number) and many children; all of the dogs were vaccinated, in contrast to only a handful of the children.  Poverty and lack of education are the heart of these systemic problems.  Guatemaltecos have given me mixed reviews about how things are progressing.  Some believe that, since the Peace Accords, there has been slow but steady improvement in healthcare, the state of the economy, and freedoms in general.  Others have told me that, other than fewer gunshots, they find little has changed.