Saskia Bunge-Montes, MD, MPH, is the Director of Community Programs at our site in El Trifinio, Guatemala. She spends time at the site every week, developing sustainable preventative health programs that integrate community participation and effective education methods. Roberto Delgado-Zapata, MD, is completing his MPH as a Celgene fellow at Center for Global Health. Dr. Delgado-Zapata makes regular working visits to the clinic for ongoing research projects and community health interventions. Though they have different backgrounds and skills, they are passionate about effecting change in how healthcare is delivered in Guatemala and throughout the world.
Spring 2017 - Roberto Delgado-Zapata, MD
Since I started the global health fellowship, I knew that my area of interest was child malnutrition. Malnutrition in the first two years of age has important implications for children’s health and future. A malnourished child has more risk for delayed cognitive development and infectious diseases. In the long term, this can result in fewer years of schooling, reduced productivity, and earlier childbearing. Therefore, ensuring that children reach their full potential drives me to work towards reducing the problem of malnutrition in early childhood.
Guatemala is the perfect setting to work with this topic, since it is estimated that almost half of the children younger than 5 years old are chronically malnourished. This makes Guatemala one of the countries with the highest rates of malnutrition in Central and Latin America. This problem is the result of interaction between many factors, such as household decisions, the cultural and natural environment in which individuals live, and national policies. Dietary intake is an important determinant that is only partially understood, which is why I decided to focus my capstone project on understanding the local child feeding behaviors and the cultural context that makes it difficult to reduce the prevalence of stunting in El Trifinio region.
We focused on children between 12 and 24 months of age, since this period is critical for children transitioning from exclusive breastfeeding to having solid and liquid foods. From previous trips to El Trifinio, I learned that food insecurity is a critical problem in the area. Children may not get enough nutrients from the food they are given, either because they are not given enough food or because the food they are given is of poor quality. For instance, we learned that meat is not one of the top choices of protein for children. We might think that is because meat is always one of the most expensive food items, but mothers think that because meat is hard to eat, children will not be able to chew it and they will choke. Therefore, they prefer to avoid this food and give more liquid. In this region, soups are the most famous food for children. Every mom you talk with might tell you that the best foods are the “calditos” (local word for “soups”). The “calditos” are made up of instant soup packets with two or three vegetables and less than half a pound of chicken or meat for an entire family of about 6 members. But actually, what the children get is the liquid part of the “caldito”, with barely one or two pieces of any vegetable, and no protein.
Because we want to get information about mothers’ perception and attitudes towards nutrition, gathering data through interviews can help us get a better idea of the cultural context. Surveys may limit what we can learn because it is designed based on what we already know. We were lucky to have Traci Bekelman, MPH, PhD, join our team back in November 2015. Before joining our study, Traci was investigating the variation in diet and nutritional status among obese urban women in Costa Rica. Her expertise in this area has been valuable to my work, because she has introduced me to new data collection tools and to new elements of qualitative research. Qualitative research is topic that I had wanted to learn more about, but I haven’t been a part of a study that fits with this type of research. Getting the feedback from the community will allow us to think about the gaps in knowledge about local child feeding behaviors that we still need to address.
With all the study preparations in place, and after getting all the necessary approvals, Traci and I went down to Guatemala during the last week of February to gather our data. Two nutrition students from a local Guatemalan university, who are rotating at the Center for Human Development, joined us in our data collection. Two weeks before our arrival, Sara and Elisa had been going out to the different communities with the community health nurses to identify potential participants for our study. This helped us to build trust among the community members since the community health nurses have been working with them for a long time. At first, mothers were dubious about the purpose of the study, but when we explained the methods we were going to use, they realized that it was like talking to a neighbor or a friend, so they felt more relaxed. The challenge of doing research in any community is that people believe that there is an exact answer, or a right answer to what you are asking. In our case, the questions were open-ended and there were no right and wrong answers as the information they provided was based on their daily experience. I've done some interviews and surveys before, and I've never thought about what it’s like to respond to a stranger's questions about my personal life. The challenge for me this time was more than to get the mothers to speak, but to make them feel comfortable talking to us and telling us about their experiences feeding their children.
Before going out to the communities and collecting the data, everything looked perfect. We had our forms ready, all the team member knew how to use the data collection tools, and we have already a list of potential participants to enroll, and we had set up meetings with them. But as everything in public health, you need to prepare for anything that comes up. Especially when you are working in an environment you don’t know. This happened the second day: we only enrolled 3 participants in the entire day, the participants had a hard time understanding the interview questions and we had to explain the questions about 3 times, and our tuk-tuk broke down in the middle of the road close to sunset. After years of working in rural communities, I should be already expecting that these things can happen; but this time I was leading the study and I felt more pressure to get things right. Along with the rest of the team, we reframed and shortened the questions that mothers were struggling to understand. Also, we designed a new enrollment strategy and as a result, we enrolled 8 participants the next day. These kinds of experiences help you learn how to overcome challenges with the resources and time you have.
Winter 2016 - Saskia Bunge-Montes, MD, MPH
Five months ago I transitioned from being a fellow at the Center for Global Health (CGH) to being an employee at the CGH affiliated site in Guatemala. This meant that after two years of living in the USA, I was moving back to Guatemala to live in the rural lowlands of the Trifinio region. While the move obviously took some getting used to, my experience working onsite throughout my fellowship made it an easier transition. My numerous trips had made me very aware of how far from everything else the site is and how hard it can be sometimes to work here, both physically and emotionally. It’s a very rural area and people here live in harsh conditions, which is both what makes it hard to work here and what makes it so important that we do.
The staff, which has grown significantly over the past two years (both in capacity and numbers), was very welcoming and eager to start working on some changes. We now have over 20 full-time employees at the site, and many even wear two or more hats, such as our groundskeeper don Rey who is also the ambulance driver and the in-house mechanic who looks after our tuk-tuks and motorcycles. People’s commitment to do more than what’s required of them is something that has amazed me about this place. Everyone that works here goes above and beyond what his or her duties are in order to make this site a success. It’s been exciting to watch this as a fellow from afar, but even more exciting now that I can see this here and witness the growth of the staff.
These past months I’ve been working with the community nurses who are now training in midwifery with physicians and midwives from the University of Colorado. The newly inaugurated birth center already had 8 deliveries in which our local nurses delivered the babies and were supervised by a physician or a midwife. I was lucky to be there for one of these births. The birth center gives women a very different experience than what they get at the public hospitals and clinics in the area. Unlike those clinics, our birth center allows women to have their family members present at the time of birth, allows them to walk around and drink water, and also choose in the most comfortable position to give birth. While those might sound like standard allowances for a woman in labor, in public hospitals women are alone, confined to a gurney and are forced to deliver in the lithotomy position. This birth was so different than what I witnessed throughout my training in the Guatemalan public hospitals. The patient’s traditional birth attendant stayed with her throughout the birth (and was compensated for it), the patient’s mother was also there. Her husband remained outside while the woman pushed, but once the baby was delivered she asked him in to cut the cord and see her and their newborn son. I’ve been (either present, assisting or delivering) in over 100 births, and this was the first time I saw a patient have her family present at birth. It sounds crazy but it’s true.
Overall, these past months have been an excellent opportunity for personal growth and learning. I am very happy with the work I’m doing here and am hopeful that in time we’ll be able to show that our efforts here are resulting in benefits for the people in this area.
Spring 2016 - Roberto Delgado-Zapata, MD
Going down to El Trifinio is always something indescribable. Even though you think you have learned almost everything the last time you were there, there is always something different and new to explore. I think that is the best reward of these trips, learning something you didn´t expect.
This summer, Saskia Bunge and Claudia Luna-Asturias joined me, and together we piloted a sex education program for adolescents called “Big Decisions.” This program is a 10-session curriculum that emphasizes abstinence as the best choice, but also provides information about condoms use and other contraceptives methods to prevent teen pregnancy, HIV and other STDs. We decided to start this program in a high school near the clinic as a response to the Zika outbreak, but also due to the concern of the community leaders regarding the increasing cases of adolescent pregnancy in the area.
Overall, one might think that sex education is important, and this is just as true in this region. In Guatemala, it is estimated that 4 out of 10 women aged between 13 to 19 years have already had sex. Of these, more than half reported having had sex for the first time before 14 years old. This is more dramatic considering that 3 out of 10 adolescents aged 15-19 years have already at least one child. Although 60% of the adolescents have received basic information about sex education and 90% report knowing at least one contraceptive method, only 12% had ever used one. These numbers show that the problem is prevalent, and that more effective approaches are needed. Adolescents do not have access to quality information about these topics, and the lack healthcare services makes them especially vulnerable. These teens don´t go and ask for contraceptives methods at rural health posts, because they will always have the same answer: there are none available. What is even worse is that the staff is not trained in adolescent health and so they avoid giving these services altogether.
Before we did the pilot, we met for about 3 months with the director and the teachers of the high school we worked with, in order to evaluate if the curriculum was suitable for the students and their level of knowledge. This helped us understand how they had been teaching the topic, and allowed us to exchange ideas about how to engage the adolescents in the activities. Generally, talking about these kinds of topics about sexuality can be difficult. Combinations of cultural and religious beliefs create the sense that sexuality is a forbidden topic to discuss since it is thought that will make the adolescents start having sexual relationships at younger ages. This is why we also met with the parents and community leaders before staring the program, to inform them of all the topics we were planning to discuss during each session, but also to answer all their questions and try to break down the idea that talking about sex is a taboo. We even did a workshop with them about “how to talk about sex with your child” that was very well received and they seemed eager to learn more by the end of the session.
With all the things set, we started our pilot. We did 2 sessions per day for about 2-3 hours. At first, it seemed it was going to be easy because we had practice the sessions and knew the information, but things in public health can change once you are in the field. We didn´t take into consideration that our classes were from different years and therefore their level of knowledge and concerns were also different. By one hand, the first year students needed more time to understand the basic concepts and were very shy to participate. On the other hand, the third year students already knew some concepts and so the session focused more in answering their questions. We wanted them to feel relaxed and not think that these sessions were like a traditional lecture where a teacher is standing in front and the students are taking notes, we developed a lot of activities and games. This not only made them feel more comfortable talking about sex, but allowed them to participate more actively. Even the teachers were impressed with the way they participated, because they had told us in advance to expect having a very quiet class. The way they engaged with the sessions and saw us as peers was so positive that even during the most difficult conversations, they were happy to share.
The most moving part of the sessions was when we did an activity about their goals and dreams. Each one of them started thinking what their goals were for the future and what things they need to do before in order to reach them. Also they think about how a pregnancy or getting HIV or an STD can affect their plans. It was hard to hear that they have big dreams but recognize that their opportunities are limited. I encouraged them to dream big and work hard, because they don´t lose anything with only dreaming.
This is the first step in finding effective solutions on how to decrease the cases of teen pregnancy, by informing the main actors about the problem and how they can prevent it. There is a lot of work to be done not only with the students, but also with the parents, teachers and other community key agents to effectively approach it. Not only educating communities makes me feel that we are on the right track, but also starting to empower them to being able to make healthy choices is promising. There are still other factors that we will need to address but at least we have started walking the right path.
Winter 2015 - Saskia Bunge-Montes, MD
I’d like to think that after so many trips down to the El Trifinio region I have a good sense of what I can expect. However, every single trip has had its challenges, lessons and adventures – but such is life in global health.
This last trip included a combination of activities (mapping, translating, supervising, etc.), throughout which the message I took away was “increased capacity.” I left this last Guatemala trip reflecting on how much growth the clinic and projects have been through and the amount of time and resources spent on building the capacity of people at the site. Nurses, administrative staff, lab technicians, even cleaning staff have undergone training in some aspect of their work. They’ve learned new skills or how to do old skills more efficiently. While it is an ongoing process, capacity building is definitely one of the developments that is most exciting about this site. It not only assures the quality of the services provided but it also the sustainability of having locals in charge.
While capacity building methods like workshops, lessons and experiential learning are direct, I think that exposure to other people and ways of thinking is an important motivator to learn more.
As an example, pharmacists in Guatemala aren’t trained as they are in other nations, so they are mainly just in charge of sales. Knowledge of dosing, interactions, pharmacokinetics and pharmacodynamics are definitely subjects not addressed in their training. However, when I was there this month, a University of Colorado pharmacology student was rotating through the clinic pharmacy and spent a month exposing Carolina, our pharmacist, to subjects such as antibiotic use and resistance, dosing and interactions. It was gratifying to see Carolina’s interest and the pride she took in her new knowledge. Even better was seeing how this exposure then inspired her to want to learn more. Weeks and even months after the pharmacy student left, Carolina still emails asking for books and websites where she can find specific information. She’s been instrumental in having people who come asking for antibiotics - which you don’t need prescription for in Guatemala - come to the clinic instead to make sure their use is warranted. People come to the pharmacy asking for an antibiotic because it’s a cultural practice to take them for almost any ailment, however, more often than not it’s not something they really need. With her new knowledge on antibiotic use and resistance, Carolina asks people what they want it for and then suggests that they come into the clinic to see the doctor instead. So, even short exposures to people that have a different skill set can have endless positive spillovers on the people in the clinic and in this community as a whole.
Just as with Carolina, there are many examples of people whose growth I’ve enjoyed watching for the last two years. From specific skills like doing an ultrasound to learning how to drive and getting a tuk-tuk license, to those developed though experience like leadership and public speaking skills. I can safely say that everyone that’s worked at this site has learned or been incited to learn through exposure to different people, obligations and experiences. Continuing to watch and be a part of this growth is something I definitely look forward to.
Fall 2015 - Roberto Delgado-Zapata, MD
As soon as I started as a Celgene Fellow at the Center for Global Health, all I heard about were the projects currently developing down in Guatemala. The first month, I had the opportunity to meet with some of the project managers to get to know what each one was doing and how could I get involved. First, I decided to focus my research interest in child health and development and so along with my mentors, Stephen Berman, MD, and Maureen Cunningham, MD, MPH, we planned a trip to El Trifinio so I could check the real nutritional status, and find out what nutrient deficiencies the children from our communities are most risk. Our goal is to design and develop a nutritional intervention that takes into account the limited resources in the communities.
Before the trip, what I knew about El Trifinio region is that it is a geographically, cultural and socioeconomic diverse area, surrounded by many crops for export. Also, not so different from many rural areas in Latin American countries, most of the population struggles with poverty and lack of access to health, education, and sanitation. Overall, it looked very familiar, in terms of necessities, to the communities I had worked with in Peru, but this time I was not working in the dry and cold highlands, but rather in the very hot and tropical lowlands.
From the very beginning of our way from Guatemala City to El Trifinio, we could see breathtaking scenery: volcanoes and mountains surrounded by a thick mist; and as time passed, the landscape quickly turned to green rolling hills with some houses along the road. But it is incredible how this natural wonder contrasts with the high rates of chronic malnutrition exacerbated by the political, economic and food insecurity crisis the country is facing.
About half of Guatemala’s children are malnourished, and they will face physical and developmental challenges in a very complex scenario that offers few opportunities to their families. I got the opportunity to interview the nurses from our clinic, nurses from the health posts in “Los Encuentros” and “Chiquirines” communities, mothers from “Carrisales” and merchants also from “Chiquirines” local market. It is surprising that even though these communities are surrounded by crop plantations and most of the population works for them, they have very limited access to fresh vegetables and fruits, which are available only from a local market that opens twice a week. They also have limited access to meat and chicken, and they cannot buy much because of lack of refrigeration. It very difficult to stand there and observe that despite being surrounded by an incredible valley, very little of those crops actually make it into local market and homes.
More surprising yet is that in contrast to the poor diversity of fruit, vegetables, and grains sold in the local markets, the number of infant formula from different brands and size is much higher. Through my conversations with the mothers and health post nurses, I realized how contradictory it was that some people say they don’t have money to buy fruit or vegetables but they do for buying expensive infant formula, rather than breastfeeding. So the problem is not just necessarily economics or poverty, is combination of lack of education and opportunities that make this paradox.
This trip was informative for me, not only because I got the opportunity to meet each one of the team members at the Center for Human development, and get to know the great job they are doing to improve the health of the local population, but also because it reminded me why I decided to join the Center for Global Health team. It has been about 4 years since I last worked in rural communities, and seeing the day-to-day struggle these people experience is very moving. The problem about malnutrition is and will be challenging, but I look forward to future trips so we can start working together with our communities to tackle it.
Another curriculum development project includes the community health nurses. We believe we have an obligation to their professional growth, which also ensures the highest level of service to our patients in the Trifinio. A group of educators at the Center for Global Health is developing this curriculum with another new technology. We are using a telehealth system – Vidyo, licensed by Children’s Hospital Colorado – to do weekly teaching. This system provides a platform for a core group of instructors to cover important material without the cost of regular travel to the site. We conduct teaching sessions on a near-weekly basis, which allows the community health nurses to engage through interactive questions and case discussions. This method is cost-effective while actually increasing our contact time with the team. We have piloted the system for several months with great success but are now developing a full curriculum with goals, structured teaching plans, and evaluations to create a robust program that can then be shared with other institutions as an effective, cost-saving educational model for community based health care. I look forward to continuing this work throughout my fellowship.
Summer 2015 - Saskia Bunge-Montes, MD
This summer I had the opportunity to travel back to the Center of Human Development in El Trifinio, Guatemala. This rural region in southwest Guatemala is about 5 hours away from Guatemala City and has more than 20 communities that are mostly reached by dirt roads. There are no real maps of the area and the last population census was done in 2002, so we don’t really know how many people live in the area or basic demographic characteristics of groups we want to serve. So, to provide better services in our community outreach programs and clinic it was decided that maps and a census of the area were needed.
I was part of the group that organized this project and was tasked with the job of training surveyors and local project coordinator in Guatemala. This was an exciting opportunity since I had been looking forward to working more closely with community members since I first visited the site a year ago. One of the goals of the the project is to incorporate community members and have them participate in the mapping. We hired four young surveyors aged 19-24 who lived in different local communities. One of them is a single mom, the second is a lawyer-in-training, the third just finished school, and the fourth is a secretary-in-training. These four young surveyors were happy with the offer of temporary employment and were very eager to learn about using the GPS and Palm Pilots we were using for the project.
We also hired a project coordinator, a young local pastor who is also studying business administration on the weekends. I wanted someone with a sense of leadership, who was able to speak easily with community leaders and was eager to learn, so he was the perfect person for the job. As a pastor he was an excellent and natural communicator and helped create a good environment amongst team with the surveyors and community leaders. A pastor in this area holds a position of distinction and is a trusted and respected person; having someone like him at the forefront helped when approaching community leaders. This was especially helpful since we were starting the project in the middle of a very controversial and heated election season in Guatemala, and tensions were high in these communities. For two weeks we approached community leaders and told them of our project and assured them that they would be getting the resulting maps and census data for their communities too. This was very good news to many of them because there have been projects in the past were people have gathered data from their communities but failed to communicate any findings back to them. We had community leaders appoint community members as guides or participate themselves with the survey. A community leader or an appointed guide accompanied each of our four surveyors in the communities, presenting the surveyor at the household and assuring that leaders knew about and approved this project. We’ve been successfully surveying for over eight weeks now and the team of surveyors and coordinator are doing an excellent job. I’ve loved being part of this process and seeing how motivated local leaders are and excited to be included. Through my conversations with leaders I’ve learned that maps and census data can empower these communities much more than I initially thought they could. I look forward to going back and being able to relate our findings back to the people that really want and need them most.
Spring 2015 - Saskia Bunge-Montes, MD
I’ve had the opportunity to visit the Center for Human Development in Guatemala three times over the past year. Every time I come here, I’m in awe of the families that live and work in this area. This dry, hot, secluded land is scattered with people living with little to no access to water. I am constantly struck by what they do here with so little, out of necessity. Every time I’m at the site I have the opportunity to spend the week tagging along with the nurses to maternal-infant care groups, individual house visits, and sometimes see patients at the clinic, too. I have enriching interactions with a variety of people in the area including nurses, engineers, plantation workers, mothers, infants, and traditional birth attendants – to name a few. Over the course of my visits, each person I’ve encountered has provided me with more insight into the community and surrounding area.
From an outsider’s perspective, this area seems geographically and culturally diverse, and therefore lacking one community identity. It’s a community is defined in part by the businesses that surround it. Within the same small area there are a mix of socioeconomic levels, a mix of ethnicities (indígenas, ladinos and mestizos) and a mix of cultural influences that make it hard to generalize the community as a whole.
This area derives some identity from its close proximity to the Mexican border. Additionally, there are three different Guatemalan states (San Marcos, Quetzaltenango and Retalhuleu) that converge in this area – giving it its name “El Trifinio.” It is an isolated area that is still heavily influenced by the surrounding cities and the active commerce that bustles through. Perhaps surprisingly, even the most remote homes have a radio, TV, or cellphone, so although they may be isolated, they are by no means disconnected.
One situation in particular made me realize how diverse even small groups within the community can be. At a recent maternal-infant care group, one of our community nurses asked a group of women what they would do if their child had a fever. The variability in answers surprised me. In my experience working in rural communities in Guatemala, I have observed some communities with “western” influenced responses, and other communities that reflect more traditional practices in their responses. This group had both. In response to the question of fever, one mother mentioned she would rub the child with alcohol and remove his clothes, or take him to the curandera. Another mother said she had seen on the Internet (on her phone) the correct dose of acetaminophen to give her child. Yet another woman said she’d probably take her child to a clinic first. So, in this small group of six women we had a range of answers that revealed the diversity of perspectives that are found in this area.
Community identity and diversity play an important role in health seeking behavior and health education. Both factors impact our clinic and our community outreach projects. The more we know about the community the better we’ll be able to serve the families that reside within it. I look forward to future visits and to better understanding the dynamics that shape their lives.