Washington DC faces meeting (and traffic) gridlock whenever world leaders gather. This week the "spring meetings" of the International Monetary Fund and the World Bank drew officials from every corner of the world. Meeting topics ranged from banking, food, and refugees to early childhood education and mental health. If you believe (as I do) that the heart of the matter is social justice, meaning that everyone everywhere deserves a fair crack at a decent and happy life, all these topics are vital. But the rounds of meetings and dark suited panels often felt far removed from the pain and hope they are truly about.
The realities were much closer several weeks ago in Guatemala, where a small group wrestled with the challenges poor Guatemalans face for even the most basic health care.
Health care everywhere is intricately tied to poverty and that's profoundly true in Guatemala. The 36 years of conflict there eroded health systems, such as they were. The 1996 Peace Accords marking the end of the conflict promised a special focus on rebuilding health care and extending it to the rural population, and especially the indigenous Mayan communities that had suffered grievously during the conflict. But despite twenty years of efforts there is far to go. A new government took office in January 2016 amidst a flush of hope, following a tumultuous period that saw senior officials including military officers and the ex-president indicted for corruption. But the health system was quickly catapulted into deeper crisis as funds and supplies were cut off from public hospitals and clinics.
In Guatemala, as in many fragile states, the health care "system" is a patchwork of different providers and facilities, public, private, and somewhere in between. Widely varied health providers include many linked to religious institutions and the faith inspiration is palpable in the way they speak of challenges and in their caring for the people they serve. Guatemala's dynamic religious landscape includes a wide range of Catholic health care facilities and programs (the Catholic Church is the largest, long established religious institution in Guatemala), many generally decentralized Protestant church efforts (Guatemala has the largest share of Evangelicals in the region), and, woven through, traditional Mayan spiritual practices, beliefs, and healers. Medical missions (generally short term visits) especially from the United States offer care but also make the challenge of building long term systems more complex.
It's a challenge to figure out how it all works, much less how to fill gaps and coordinate the many partners, faith and secular, public and private. How can all work together to achieve what all have, for decades, agreed are urgent priority objectives? But models of excellence exist, reminders of what can be achieved.
What then are the priorities? The group we gathered in Guatemala focused sharply on three: maternal health (including reproductive health services), children, and youth. What is complicated is that each of these topics quickly leads to the broader problems facing Guatemala and Central America, including sharp inequalities and exclusion of many groups from education and employment, gang violence and drugs, and perhaps most of all, deep-seated poor governance, meaning political dysfunction, inefficiency, and deeply embedded corrupt practices.
Maternal mortality is high in part because women often hesitate to come to clinics or hospitals to give birth. Private health services are often beyond their means. Use of contraceptives is low both because of lack of knowledge or stigma. Around 50 percent of maternal deaths, we were told, occur during deliveries at home and 50 percent in hospitals, because many women arrive there in critical condition. Around 40,000 midwives work nationwide, but few are linked to the public health system. There are too few medical centers in rural or semi-rural areas so pregnant women from rural areas must travel long distances to regional centers to give birth at a hospital. A popular saying: "it is cheaper to die than to go on living in Guatemala," conveys frustration about unregulated growth of private, expensive health care.
The health challenges for young women are especially urgent. Reaching girls at a young age helps dispel stereotypes and promote good health practices. Adolescent pregnancies in both rural and urban areas are common and on the increase, often affecting women already vulnerable due to poverty and lack of education. Both Catholic and evangelical denominations are seeking ways to reconcile their teachings in the light of the grave problems they encounter day to day, especially daily violence and abuse of women in the communities where they operate. But intimidation of women who use contraception in rural areas is not uncommon; a colleague was told at a clinic that only unfaithful women use contraception.
A host of urgent challenges for Guatemala surround the vulnerability of children. Malnutrition is a critical issue that can be addressed only in part through health care systems. Many children and young people are victims of labor or sexual exploitation and of organized crime. Often illiterate, children are forced to sell and distribute drugs such as marijuana, cocaine, and other illegal drugs. Youth are susceptible to gang recruitment; the two main gangs in Guatemala, Mara Salvatrucha and Barrio 18, recruit children who do not attend school or lack adult supervision and protection. Once in the gang, children are forced to steal or engage in illegal activities to help support the gang. Poverty can lead parents to encourage their children to bring in extra income; by working or begging rather than attending school, a child may bring in around $35 a month. The cycle of poverty is perpetuated.
Religious organizations work with children and their parents on literacy campaigns and other creative programs. But they do so convinced that broader and deeper solutions are essential if the hope that all see as vital to realizing both individual and national potential is to be achieved.