Some conversations with healthcare staff in Santiago Atitlan, Guatemala

by Hari Balasubramanian

In January this year, I visited Hospitalito Atitlán, a health care center for the Tz'utujil Maya in the town of Santiago Atitlán, Guatemala. There were two reasons for this visit. First, much of my healthcare work has been limited to the US system; I wanted to get a sense of what was going on in other places. Second, for many years I've been trying to learn about the indigenous cultures of the Americas; this had led me in the past to Mexico, Peru and Bolivia. I welcomed, now, this chance to spend a few days in a Mayan town in Guatemala.

Lake Atitlan Map

Santiago Atitlán, a town of 30-40,000, is a 3-hour drive from Guatemala City, at the southwestern edge of Lake Atitlán. The lake fills a caldera formed in an eruption 84,000 years ago, and is surrounded by lush-green volcanoes, rising to over 8,000 feet. The majority of the people who live in the surrounding towns belong to one of two Mayan groups: the Tz'utujil and Kaqchikel. Santiago Atitlán is almost entirely Tz'utujil, while San Lucas Toliman is mostly Kaqchikel. Tz'utujil and Kaqchikuel also refer to two of the twenty odd Mayan languages in Guatemala (there are a few others in Mexico). All of them are still spoken, in sharp contrast to the fate of indigenous languages elsewhere in the Americas.

I arrived in Santiago Atitlán on a Sunday morning. The town is set along a slope that eases into the lake; Volcan San Pedro rises dramatically across a narrow section of the water, dominating the view. For a small town, the streets were a maze, and I lost my way each time. Many of the homes were make-shift; the farther I ascended away from the town center, the poorer the homes were. Almost all the Tz'utujil women wore brightly colored yarn based textiles with intricate patterns. On the main road along the lake's circumference, Toyota pick-up trucks – a common mode of shared local transportation – carried passengers who stood in the open rear. Then there were the brightly colored tuk-tuks, exactly like the three wheeler autos I knew in India – every one of them that I saw in Atitlán was made by Bajaj.

The pick-up trucks, the tuk-tuks, and even many of the paved roads were all new, I was told – part of the economic growth here after decades of conflict. In the last half of the 20th century, Guatemala, like other nations of Central America – El Salvador, Nicaragua, Honduras – went through a violent upheaval. The Guatemalan Civil War lasted from 1960-1996. A brutal right wing government fought against insurgents in the largely indigenous countryside. The Lake Atitlán region did not go unscathed; hundreds of people from Santiago were killed or disappeared; “everyone you talk to lost someone in his or her family” [link]. Since 1996, there's been a return to normalcy. While the region still remains relatively poor, its coffee plantations have done well, and the beautiful lake setting draws plenty of tourists.


The presence of a modern hospital in Santiago Atitlán is part of that same narrative of recovery. From 1991-2005, for any emergency medical help the T'zutujil had only the government hospital in far-off Solola. To reach there, “trauma patients and women with complicated deliveries had to travel across the lake and up the hazardous mountain road” [1]. Infant mortality rates were extremely high during this period. The dire need for a place in town to treat emergencies, ensure the health of women and children, and have clinical staff who could speak the local language, all led to the creation of Hospitalito Atitlan in 2005. Essentially a Tz'utujil grassroots initiative and even today staffed and run by the locals, the hospital has nevertheless benefited from American and European expatriates, who have managed to attract donations and medical volunteers from abroad [1].

The relatively new hospital building was my main point of reference during my 6-day stay in Santiago Atitlán. Tucked to one side of the road leading to the town center, the building was unlike anything else I saw in the region. And not just from the outside: the offices, the pharmacy, the lab testing area, the two operating rooms, all seemed organized and well equipped. The week I visited, the hospital was a bustle of activity: a number of surgeons from the US were volunteering. The entrance and the lobby were crowded: Mayan patients and their families from the far reaches of Lake Atitlan had come to be assessed and, if possible, to have surgeries or procedures done that week. Dercum Over (Derc), my main contact at the Hospitalito, had warned that this would be an unusually busy week and not representative.

I wanted to make sure I got as many T'zutujil perspectives as possible. Over the next few days, with Derc's help, I managed to speak to the hospital's social worker, its newest board member, and visit a small rural clinic staffed by a nurse. In what follows, I try to summarize these conversations [2].


Vicenta Chavajay Cortez, a Tz'utujil woman in her thirties, handles the social work for the Hospitalito. She lives in San Pedro – a neighboring lake town – and commutes to work every day. With so many patients at the hospital that week, Vicenta was very busy. As I waited outside her office for my appointment, several women – probably relatives of patients – came to consult briefly with her. After they left, I spoke with Vicenta for 30 minutes. Derc translated my questons and her responses.

Chenta home visit 2No one is denied care at the Hospitalito, but services are not free either – there are some basic fees. If the patient cannot pay, the Hospitalito covers the charge with the donations it receives. Vicenta's work is assessing whether a patient qualifies for subsidized care. For this, she visits homes to assess the patient's socioeconomic conditions. She works in a fairly tightly knit community. More than 90% of Santiago Atitlán's residents are T'zutujil; there were probably extended families and distant cousins, all living in close proximity. Not surprisingly, Vicenta is well known in Santiago Atitlan. When she visits a patient's home, kids and families in the street always greet her: “Hello Vicenta!” In the picture above, Vicenta is on the left, visiting a home.

What does she typically look for? Vicenta said she evaluates the condition of the home, the number of children, sanitation, electricity and utility bills, to make a qualitative assessment. With money involved, I imagined things could get tricky. Vicenta said that her cases fell into two categories. “The families who truly cannot pay are grateful. The people who have something to hide, they often ask: ‘What day are you coming?' or ‘What are you coming for?'”

Vicenta spoke with confidence and smiled with ease. I asked about her background. Vicenta had started her career as a teacher; she'd done that for 4 years, enjoyed it, and could have continued. But after spending some time with a microcredit NGO, she became interested in social work. Like most other Tz'utujil, she worked and studied at the same time. She graduated with a degree in social work from University Rafael Landivar near Guatemala City; that now gives her the formal title Licenciada (graduate) — Licenciada en Trabajo Social, to be precise. This is still rare among the T'zutujil, even more so among women. Vicenta admitted that among all her peers in middle and high school, she was the only one who had succeeded in completing a university education. “It's hard,” Vicenta said, “there's a lot of desertion. Many [T'zutujil] women marry young at 18-19.”

The point about obstacles to education – both at the school and university level – kept coming up again and again. The previous day, I'd met Lidia, who recently beccame the only Tz'utujil woman to join the board of the Hospitalito. At 24, Lidia is about 10 years younger than Vicenta and is similarly passionate about doing something for the Tz'utujil cause. She currently works as a manager at a hotel in Santiago Atitlan while simultaneously trying to finish her degree in business administration during weekends (due to a lack of options, most T'zutujil have to commute to a different lake town or sometimes even farther on their off days). When Lidia started primary school, there were thirty odd students who began with her. Only six made it through. She experienced a lot of resistance from her family. “Why don't you stop studying?” was the constant refrain. Even now this persists, as she continues to pursue a university degree. Lidia spoke softly but with a quiet intensity. At the end, when I was about to leave, she said: “Hari, I want to tell you that the pressure is so much that many of the girls do not have the energy to resist. It is easier to give in.”


On my second morning in town, I went along with Derc and Victor to the puesto de salud (literally a “health post”) in the little Tz'utujil village of San Antonio Chacaya, about 30-40 minutes by car from Santiago Atitlan. I was curious to see what sort of healthcare was available in a rural setting. It was Victor who arranged this visit. He handles the Hospitalito's program for managing diabetes (from what I gathered, economic growth and new paved roads have brought trucks with huge bottles of coke and junk food; so diabetes, paradoxically, is as much an issue as malnutrition). Victor also helps coordinating the rural outreach activities of the hospital. Underserved Tz'utujil villages such as San Antonio Chacaya now get bimonthly medical and prenatal visits from Hospitalito specialists; there are also education programs for health workers in these villages.

San Antonio Chacaya is a small village set on a hillside at the edge of the lake. Everything in Chacaya – as in other villages of Lake Atitlan – primarily revolves around plantations and small scale agriculture: coffee, avocado, jocote (a fruit), maize, beans. The health post (image below) was a simple, single story building at the base of the hill. There were two rooms and a porch-like space served as the waiting area. One of the rooms was an office with a few chairs and a desk. There we met Pedro, the nurse and principal clinician at this health post (a doctor from outside only visits once in two weeks). Pedro and Victor (featured in the image below; Pedro is in white) knew each other very well; Victor said I could ask his friend whatever I wanted. Again, it was Derc who translated.


Pedro himself is from Chacaya. After middle school, he had decided to specialize in nursing and had trained in Solola (the town across the lake). Before his current job, he used to keep vaccinations at his home to help those in the village who needed them. He has been working at this puesto de salud for 8 years now, ever since it opened. How did it all begin? A coffee plantation owner provided the small plot of land. Unex, a coffee import/export company, purchased the materials and paid the salaries of the construction workers. Even today, Pedro's salary is covered by Unex. The Guatemalan ministry of health contributed supplies.

The clinic opens at 8 am and closes at 4 pm. Pedro is helped by an assistant, usually a nurse in training. The most common complaints include respiratory issues, sore throat, diarrhea, dermatology, gastritis, conjunctivitis. Between 25-35 people visit every day, most of them women. The women use it either for themselves or for their children; this trend repeats itself everywhere in the towns of Lake Atitlan. As another nurse in Santiago Atitlan told me: “Women are the biggest users of healthcare. Men feel embarrassed or ashamed to get a consultation. They prefer to use the pharmacy and self-medicate.”


As I talked with Pedro, I noticed some paper graphs on the walls. They measured vaccinations for the 34 infants in the village by month (Hepatitis B example above). There was also a detailed map of Chacaya on a wall in the adjoining room; colored pins were used to indicate the homes in which pregnant women, and low weight and malnourished children (if any) were. Pedro told me there were 273 families and a total of 1200 people in the village. It struck me that because he was from Chacaya, had worked here for so long and kept all these records, he was perhaps the only one who knew something about the medical histories of all the families. Even a highly qualified doctor visiting from outside Chacaya would find it hard to match this.

I asked Pedro what the priorities were for Chacaya. Like everyone else, he mentioned education, though I couldn't get into the details; I only learned that there were two primary schools and one middle school in the village. But Pedro also emphasized improvements in hygiene, proper recycling of trash, and clean drinking water. Many in the village take their water directly from the lake, and this causes health problems. (Later I learned that since 2008 the lake has seen potentially harmful cyanobacterial blooms [3].)

Clearly, Pedro was sincere in what he did, and he seemed to love his work. After looking at the vaccination graphs, I asked if there were other records. There were no computers, but Pedro eagerly brought out paper records. He had plenty of them, going back a long time, all neatly organized. Each row on a page indicated, among other details, a particular patient visit, the diagnosis, and the patient's signature. Except that in most cases, patients had left their thumbprints. This was the first tangible evidence I saw of the lack of literacy, so often mentioned, among the Maya of Lake Atitlan.


Footnotes and Acknowledgements

1. The full story of Hospitalito Atitlan, its challenges and successes, is here, and a short video history is here.

2. My thanks to Dercum Over (grant writer in the development office of the Hospitalito) and Alverta Lyn Dickey (one of the founders of the Hospitalito). Despite a very busy week, Derc handled all my questions, set up the visits I requested, and, crucially, helped with translations. Also, Victor's help was essential in making the Chacaya visit and the conversation with Pedro possible. Errors in this piece are entirely my responsibility.

3. Rejmánková, Eliška, et al. “Cyanobacterial blooms in lake Atitlan, Guatemala.”Limnologica-Ecology and management of Inland waters 41.4 (2011): 296-302.