In August 2018 I spent a week volunteering with a project in Guatemala called the Integrative Health Project. It was established by two American practitioners of Chinese Medicine in 2012 to bring care to under-served communities principally in Guatemala and the Caribbean. Specifically, it integrates Traditional East Asian medicine, Mayan medicine and conventional biomedical diagnosis and treatment.
Guatemala is currently in the news because of the number of its people who have joined the so called “migrant caravan” attempting to reach America via Mexico on foot: they are fleeing extreme poverty and a country still recovering from a vicious civil war (1954 – mid ‘80s). The civil war suspended development of good governance, including a public health care system, and its development since the end of the war has been limited by inadequate funding. The system, such as it, comprises public sector (free and provided by the government), private (fee paying, provided by the private sector), not-for-profit private provision (voluntary and NGO projects) and traditional Mayan healthcare practices. The public sector accounts for 88% of provision, which means that limited resource are stretched very far indeed. At the time of writing this article, a coup is threatening to undermine Guatemala’s fragile democracy.
The main health issues affecting the people of Guatemala include i) infectious diseases (notably diarrhea and acute respiratory infections) ii) Type 2 diabetes (which is a genetic predisposition of the population, exacerbated by their diet) iii) parasites (which are one of the biggest threats and spread easily through food and water) and, iv) malnutrition which affects 50-70% of the population, the worst affected living in rural areas. A staggering 56% of the population lives below the poverty line, and access to medical care, adequate nutritious food, and health education is severely limited. Additionally, people undertake hard, physical work in an effort to grow enough food for themselves and to sell; have experienced psychological trauma from the war; and, live in poor housing lacking modern sanitation.
The Integrative Health Project’s key initiative is the use of ear acupuncture for the control of blood glucose levels. Hence the overall goal is to train local providers who can deliver a basic but important service to communities throughout the year. The organisers started the project by identifying existing community structures and individuals who could be trained to deliver free treatments in clinics set up in remote areas. Local people initially learn the basic NADA protocol, an ear acupuncture treatment which helps manage stress and substance abuse, and then learn the Boccino Protocol for Type 2 diabetes (another ear acupuncture treatment). This protocol has been proven to lower blood glucose an average of 45 points fasting and 109 post-prandial. (Read more here.) They also learn other Chinese Medicine techniques such as moxa, cupping, gua-sha and massage, and undertake basic health screenings for diabetes and hypertension. These screenings are vital to catching problems requiring immediate referral to biomedical doctors.
The biannual jornadas are staffed by volunteers mainly from America, averaging about 10 in number, and are a mixture of experienced practitioners and students of Chinese Medicine who are seeking practical experience before graduating.
The creation of the IHP showed real vision, tenacity and energy, and its operation still demands tremendous commitment from the organisers. Just to run the two, week long clinics they need to be sure of having access to suitable premises, volunteer interpreters, appropriate clearances from Local Government, clearances from airport security to bring in supplies and equipment, places to store surplus equipment and supplies between visits and, suitable accommodation and transport for all the volunteers.
Upon arrival in Guatemala City airport the volunteers are met by pre-arranged transport and driven to the beautiful city of Antigua for overnight stay and onward travel the next day to a small town called Panajachel on the side of Lake Atitlan. Although this town is known as a tourist town, and has a good range of services and facilities, it is also relatively remote and therefore offers access to the Project for rural populations.
The IHP’s biannual clinic is set up in a spare room in the (very basic) ministry of health office in Panajachel, and comprises an intake and basic screening station for patients, 12 treatment couches and a herbal dispensary. One to two days after arrival, the volunteers start the week at 8am by setting up the clinic, with the first patient intake and basic screenings beginning by 9am. Patients start to move through to the treatment area shortly after their intake, and as the day progresses the queues waiting to be treated build up. Up to 20 people may be waiting in a corridor while the 12 treatment couches are fully occupied. The qualified volunteers each command 2-3 couches at the same time, juggling their patients’ diagnosis, needle insertion, and removal after 20-30 minutes.
If necessary, herbs are prescribed for patients to take away. The working day finishes when the last patient is seen, which is usually about 6pm but can be much later. The total number of patents seen each day can reach about 130, and it’s long, demanding day for the volunteers working in hot, humid conditions (there’s no air conditioning) with only 20-30 minutes break at lunch time. Finally, when the clinic has been swept, tidied and set up for the next day, the volunteers return to their lodgings for a well-earned cold beer, dinner and an early night.
Conditions treated by the IHP clinic are very diverse, reflecting the issues and challenges noted above.
A significant proportion of patients seen every day include those suffering from peripheral neuropathy (nerve damage caused by chronically high blood sugar in type 2 diabetes) which causes numbness, tingling and pain in the limbs.
Another significant group are those with all kinds of muscular skeletal pain, particularly back, hip, knee and foot pain. Besides undertaking all kinds of physical work (most don’t own a washing machine or a hoover, let alone a car or modern farm machinery) people don’t wear good footwear, partly for reasons of affordability but also because of the climate, which is hot and humid in the dry season and torrential in the rainy season. People therefore wear the same lightweight sandals to work in their small holdings, walk to the market and shops, and places of employment. Additionally, the Guatemalan diet of maize-based foods and sugary drinks is causing rising levels of obesity, and the extra weight no doubt contributes to additional strain on the joints.
Clearly, poverty, hunger and disease all leave their mark on happiness and wellbeing because most patients list “stress” as one of their primary complaints. There are also psychological scars from the civil war that ended 18 years ago. Besides the trauma and fear of further violence in those that survived, many people simply disappeared, victims of atrocities that were committed all over the country. Their bodies were never discovered and, as in our own culture, in order for there to be closure, families need to bury their dead. The inability to do this causes lasting grief and grievance.
Gaining local confidence and interest in the Project has not been a problem because the Guatemalans are already accustomed to NGOs of all kinds working in their country. Moreover, some aspects of Traditional East Asian medicine are similar to Mayan health care practices. So persuading people to come for treatment, accept advice about diet and lifestyle and take herbal medicine is generally not difficult. The issues that limit the number of attendees are awareness that the IHP is actually working in Panajachel, being able to reach the Project from remote rural areas and being able to afford to leave their work and pay for a bus or ferry trip to reach the clinic.
Expectations about what can be achieved must be tempered with a number of realities. Firstly, the fact that the Project’s volunteers are unable to offer more than one week at a time means that it is only be able to provide a maximum of five treatments for each patient. (By contrast, in Ireland, a patient might be treated once or twice a week for 6-8 weeks in order to get good improvements. Allowing a couple of days between treatments gives the body time to ‘process the instructions’ it has been given and allows the patient time to reflect on what has and hasn’t worked, and then provide feedback to their practitioner accordingly.) Of course, not every patient is able to attend for 5 days. Nonetheless, it clearly makes a difference to patients to get even short term relief from their complaints from a small handful of treatments.
For example, we treated a woman aged about 45 complaining of a constant feeling of intense emotional tension following a hysterectomy a year previously. She returned to the clinic the next day saying that the feeling had lifted completely immediately after her treatment. She then asked if her poor sleep could be addressed. On the third day she was delighted to tell us that she had had the best night of sleep in a year. From experience I would estimate that this woman probably needs 6-12 treatments for her sleep to become consistently better, but there is no doubt that the relief she got was very much appreciated.
Secondly, the fact that Type 2 diabetes and obesity is so common, and that so many other types of health problem are rooted in poverty, means that treatment with acupuncture can often only expect to offer relief.
Some cases are particularly sad. On the last day of the August 2018 clinic, a 34 year old woman came to the clinic complaining about ongoing discomfort in her throat. Upon questioning, it became clear that she gained weight easily and suffered from fatigue, and her limbs were ice cold to touch – which was striking because temperatures in the clinic were about 30 degrees. There also appeared to be swelling at the base of her throat. This young woman was thought to be suffering from an under active thyroid, and although we treated her throat discomfort with acupuncture that day, she was advised to go to a medical doctor to have her thyroid tested. Unfortunately, her response was that she could not afford a consultation with a doctor and blood test, and certainly couldn’t afford to pay for daily Eltroxin tablets. This situation is common: people suffer or simply die from treatable diseases.
However, a few factors mitigate against the limitations of the project and circumstances in Guatemala. Firstly, treating a patient daily for a week is considered a high and intense dose of treatment. Additionally, practitioners of acupuncture who work in underdeveloped parts of the world observe that patients generally appear to respond extremely quickly and well to acupuncture treatment. It is thought that this reflects the fact that they haven’t taken many (or any) pharmaceutical drugs or had other forms of medical treatment. In the west, people are likely to have used all kinds of strong pharmaceutical medication throughout their lives and for this reason it is thought that western patients respond slightly less quickly and well to treatment with acupuncture.
Also, the herbal dispensary that runs alongside the acupuncture clinic means that patients can be given a container of herbs in pill form that can be taken for a couple of months after being seen by the IHP’s clinic. These are effective for a range of conditions such as digestive complaints (including bacterial and parasitical infections), menopausal symptoms and insomnia to name a few.
Monitoring outcomes, for reasons of practicalities, time and resources, is not something the IHP is able to undertake. However, a few informal ‘exit surveys’ have been done and these suggest that people value the service even though it only lasts a week, and very much want to see it integrated with other programmes and their own health care traditions. For example, dietary advice according to the Chinese Medicine understanding of food energetics will only be practical if the recommendations can be applied to Guatemalan food and cooking traditions. There is little point asking diabetics to eliminate tortillas (which raise blood sugars) from their diet because they are a cheap mainstay of their diet. It is more productive to suggest food combining to modulate the spike in blood sugars.
As for the volunteers, the experience definitely sharpens our skills because it exposes us to a wider variety of conditions than we might normally see in the developed world, and to large numbers of patients with variations on similar themes. For example, patients in Ireland with a genetic predisposition to Type 2 diabetes rarely present in an acupuncture clinic with symptoms of peripheral neuropathy because their condition is managed by attendance at diabetic clinics and treated with drugs such as metformin. Being able to get experience treating many such patients in Guatemala can give volunteers useful insights.
On reflection, my experience in Guatemala also illustrates a point once made by one of my lecturers, Professor Wang Ju-Yi, who said: in ancient China, diseases were related to “deficiency”, meaning, not enough food and clean water, not enough rest from physical work, not enough protection from the elements. People in the modern, developed world now experience different kinds of threats to their health. These are related to “excesses”, meaning too much food, too much sitting, too much mental stress – which lead to different but just as deadly illnesses.
So, I left Guatemala with the sense that the conditions we saw would be very similar to those seen in ancient China. Knowing that this is the context out of which Chinese medical knowledge grew gives me a greater appreciation of its applications.