Xkam rujite’ Vicente

Öj tz’uyül chwäch ri kaxa. Najin ye’ok, najin ye’el ri winaqi’ pa jay.

Nuwäch nojnäq rik’in sib’, nutz’am nojnäq rik’in ruxla’ pom. K’o b’ey ninna jun itzel uxla’, kojol ruxla’ pom.

Nqayab’ej.

Rachajil ri kaminäq ndok richin yojruq’ejela’. Man ndoq’ ta chik wakami. Yan q’axnäq oxi’ ik’, oxi’ ik’ tzaqät pa ruxikin ruch’at, tz’uyül warnäq ri 90 q’ij qa. Rija’ nukw’aj rukiy pa ruk’u’x, najin nuchajij ri kaminäq chuqa’ taq rume’al wakami.

Nqayab’ej chik. Tew ri ya’, b’uyül ri kaxlawey. Ral ri kaminäq ndok, nuq’etej Katy. Najin ndoq’, ndoq’ chik rija’. “Gracias, doctora,” ncha, ndel ël.

Nqayab’ej chik.

Nqak’oxaj jun oq’ej. (Ay Dios, rute’ rujite’ Vicente! Majani ri’j ta ri kaminäq.)

“¿Por qué esto le pasó a mi hija? ¿Por qué se murió? ¿Por qué nos dejó? ¡Se ha ido de su casa! ¡Yo no sabía que le iba a pasar algo así a mi hija! La matan…Ayyyyy! ¡Mi hija! ¿Por qué? Señor, ¿por qué?”

Qitzij. Atyux roma?

Npe raxtew chuwij. Npe ya’ pa nuwäch. Man roma ta ri tew ya’, man roma ta ri sib’.

Atyux roma? Man wetaman ta. Rik’in jub’a junan ri kitzolintzij ri taq k’utunïk chik:

Atyux roma xb’anatäj ri k’ayewal pa b’ey pa ox’i ik’ qa? Atyux roma ri aq’omanela’ man xkiq’alajirisaj ta ri situación k’a xapon ri doctora Katy rik’in rupalaj mo’s? Atyux roma xkiya’ jun aq’om chupam betametasona kichin rusokotajik roma ri ch’at? Atyux roma Vicente xojroyoj taq xek’oje pa b’ey, xetzolin pe, richin xuk’utuj achike xekowin xkib’an richin ri itzel uxla’, roma ri man xkiya’ ta formaldehida ke la Roosevelt? Atyux roma man xqatamaj ta si xojek’ulun pa jay, roma ri majun gasolina pa ruch’ich’ Lencho roma ri jotol rajal ronojel wakami?

Röj yojb’a ël ri lunes petenäq. Pero ri k’aslem xtub’an seguir wawe. Röj yojb’a ël, pero ri kamïk manaq.

Kan ke ri, ri kaslem? Pa jaru q’ij xtiq’ax ri uxla’?

...

[Us, seated before the casket. People are entering and exiting the house.

My eyes are filled with smoke, my nostrils are filled with the scent of incense. Sometimes I smell an ugly smell, between wafts of incense.

We wait.

The widower enters to greet us. He is not crying anymore. He’s already spent three months, three months to the day, by her bed, sleeping sitting up for the past 90 days. He carries his pain in his heart, now he is caring for his late wife and for his daughters.

We wait a bit more. The soda is cold, the bread is soft. The daughter enters and hugs Kate. She is crying. She cries more. “Thank you, doctora” she says and steps out.

We wait a bit more.

We hear weeping. (Oh God, it is Vicente’s late mother-in-law’s mother! She was young, yet.)

“Why did this happen to my daughter? Why did she die? Why did she leave us? She has left her house! I did not know that something like this would happen to my daughter! They kill her…Ohhhhh! My dauther! Why? Lord, why?”

True. Why?

A chill comes over me. Water comes to my eyes. Not because of the cold soda, not because of the smoke.

Why? I don’t know. Perhaps these questions have similar answers:

Why did the accident on the highway three months ago happen? Why did the doctors not clear up the situation until doctora Katy arrived with her cara de gringa? Why did they apply an ointment containing betamethasone for her bedsores? Why did Vicente call us when they were on the highway, coming back with the body, to ask what they could do for the smell, because they had not embalmed her with formaldehyde at Roosevelt? Why did we not know whether we would make it home, because the tank in Lencho’s car was empty because everything is expensive nowadays?

We are leaving this coming Monday. But life will go on here. We will leave, but death will not.

Is that just the way life is? In how many days will the smell pass?]

Accompaniment and conversion

We are scheduled to fly to Atlanta on June 3, and the proximity of our departure date has provoked a good deal of reflection on the 9 months we have spent here with the health promoters.

When we arrived in San Lucas, I had expected to spend the year investigating etiologies of child malnutrition in the health promoters’ catchment area. It became clear very quickly that this would be difficult, if not impossible. The parish expected us, as foreign visitors, to do nothing more than “accompany” the people we met—that is, observe their work and their lives and ask a few questions, learning about another people mainly for our own edification. Attempting anything more would mean we were trying to “become indigenous” (a preposterous but perplexingly real concern of the parish; I never got up the courage to point out to the gringo priest and co-administrators that, as a Bengali, I am, in fact, indigenous); or that we were “interfering” (I learned not to ask, “with what?”) or “generating dependency” (similarly, “how, and on what?”). Ultimately, I agree that my research plan was naïve, over-ambitious and, if actually executed, would have been potentially disruptive of a locally driven program whose broader objectives I did not fully understand.

Moreover, it seemed that my attempts to fulfill the most basic requirements of critically engaged, quality ethnographic research—learning the preferred language of the communities, living in an indigenous aldea, and responding responsibly and justly to the petitions and opinions of my indigenous colleagues—engendered passive-aggressive and patronizing skepticism towards me and, more importantly, towards Vicente and his team of health promoters. The treatment we received, and the overflow to Vicente, was confusing and painful for all of us, and I decided that insistence on my part could endanger the program.

Despite the apparent failure that this “research year” has been—my mother has been asking all year when I will start my study, which was supposed to be the basis of my MPH thesis—I think that we have done something infinitely more valuable than a limited, qualitative study on child malnutrition. In light of the parish administration’s hostile perception of our activities, it is ironic that the best way I have of describing what we have done here is precisely what they told us to do—“accompany” Vicente, Dominga, Rosa, Abelino, and the rest of our friends and colleagues living and working in the aldeas around San Lucas.

The “accompaniment” prescribed to us by the parish co-administrators is inspired by the philosophy guiding organizations like Peace Brigades, International. Such organizations focus on situations (such as exhumations of mass graves) where marginalized actors are predisposed to acute, severe human rights violations. The role played by international “observers” in such instances is a very crucial one; even if the “accompaniment” required amounts to little more than physical presence, the transfer of our symbolic power confers protection to otherwise vulnerable individuals.

Nonetheless, the “nonpartisanship” and “objectivity” that are a part of this sort of accompaniment cannot be applied beyond the limited involvement of short-term accompaniers. In forging substantive relationships with the people we are accompanying, and in coming to a fuller understanding of the milieu in which we are working, we would have to suspend our intellects and/or our hearts to continue a shallow and ultimately inconsequential form of “bearing witness.” And in our particular situation, we are faced with morally clear decisions when our new friends ask us to contribute our relevant skills and resources to support their work.

It is hard to define neatly the kind of accompaniment we have been engaged in here. For me, it has involved learning to communicate in Kaqchikel, and living, working, eating and recreating with our indigenous colleagues and friends on a daily basis. It has meant talking with Vicente in the small anteroom of his house, discussing his dreams, both for the community health program and for his life. It has meant sitting with Rosa working on her backstrap loom on a cloudy day, listening as she weaves personal concerns into conversation about her community and family. It has meant being woken up in the middle of the night to attend to neighbors’ medical emergencies. It has meant frustration and anger at the care that our friends are forced to beg or become indebted for at health centers and hospitals. It has meant being acutely aware of my deficiencies—in speaking Kaqchikel, in speaking Spanish, in providing healthcare, in learning from and teaching others. It has meant becoming acutely aware of how distracted I am by mundane and selfish concerns.

In short, our “accompaniment,” while profoundly fulfilling, has been quite nebulous, variegated, and difficult. It is difficult because there is no endpoint. We cannot exit the friendships we have made and experiences we have had—we could try to suppress the memory of them, only to suffer pain when they resurface. It is difficult because we have, in some way, begun to see our lives as dictated by the experience of communion with our neighbor. How can my life remain unchanged by the encounters we have had? It becomes increasingly more difficult to consider a life that is dedicated to something other than the people whose lives have become so tangible to us. This, I think, is the beginning of the “conversion to the neighbor” described in Gustavo Gutiérrez’s spirituality of liberation. How much can I really rejoice about studying medical anthropology (a strange area of study to most of our friends here) next year at Harvard University (which, similarly, none of our friends here have ever heard of), when that year of study means that I will not be here to continue helping and will be simultaneously postponing the completion of training that will allow me to provide effective, pragmatic services to the poor?

Xkojb’a ke la Boston!

During our time here in Guatemala, I have been forced to reflect quite a bit on how to respond to our experiences here. When we arrived, I had thought that all I needed to do was apply my existing skills in medicine and public health and my linguistic capacity in Spanish, and I would be able to do good work.

In encountering the limits of my abilities in medicine and public health, my perspective on my remaining training has changed significantly. Before, I thought of the years of training before me as a series of prerequisites; now, I have become aware of the clinical opportunities I need to seek out if I am to become a competent physician to impoverished populations in complex healthcare landscapes like the one we have encountered here. Honestly, in light of our experiences, I feel that 3 years of residency training is not enough—I need to gain an internist’s knowledge of medicine, a pediatrician’s knowledge of children’s health, a psychologist’s aptitude for psychiatric elements of illness, and an obstetrician’s experience and surgical dexterity. This makes the prospect of choosing a specialty for residency more complicated. In any case, this past year will make me a more deliberate learner as I continue in my clinical training.

Another unexpected realization of this year is the narrow scope of the training and education I have pursued thus far. Issues of cultural and socioeconomic justice have only been touched upon in passing in my medical and public health education. While I have a natural predilection to trying to contextualize my experiences in broader perspectives of political economy and history, I have neglected this as a focal practice in my life, partly because I have been overwhelmed by the pace of medical school and partly because this is not something that is emphasized as important for medical students, at least not in my experience at my school. I have experienced a growing awareness of the necessity of anthropologic perspectives and ethnographic practice through my engagement here in Guatemala. I have had inklings of this awareness over the past three years, and I somehow knew that at some point I would probably pursue studies in medical anthropology—to the point that when I started thinking concretely about applying to programs this past fall, I already knew where to look and which schools to consider. In December and January, with the encouragement of Elena, friends and mentors, I submitted applications to a number of schools that offer Master’s programs in anthropology for healthcare professionals.

Of the programs to which I was accepted, I decided that Harvard University’s MA in Social Anthropology with a focus in Medical Anthropology was best suited to my needs. The program offers a broad introduction to anthropological theory and the opportunity for in-depth study of a variety of topics of utmost importance to a student of the health and lives of the global poor. In addition, the institutional partners participating in the Program in Medical Anthropology at Harvard (e.g. Partners in Health and the Dept of Social Medicine and Health Inequalities) are exciting to me as a physician-in-training who hopes to couple critically engaged scholarship and social justice work to clinical medicine.

So I am taking another leave of absence from the MD/MPH program at Northwestern, and Elena and I are making preparations to move to the Boston area this summer. We are looking forward to this next step in our journey, and Elena has already begun to look for jobs in Boston’s non-profit sector. Once we have an apartment, we would love visitors!

An "accident" near K'ix ya'

There was a pickup accident outside San Lucas last Sunday. The pickup truck belongs to somebody in Sololá, and the driver was doing a favor for the owner by taking the car out. Apparently it was the first time this driver had ever taken people in a pickup, plus it was a different type of pickup—a little higher than most. The car came down to Quixayá, and on its way back up towards San Lucas, it started to swerve, and the people started grabbing hold of each other and screaming. There was an oncoming car, and the driver swerved away and smashed into a rockface. The vehicle didn’t turn over, but people were thrown out of the pickup. The pickup was full. 18 of the passengers were so badly injured that the parish clinic referred them out to the larger hospitals in Sololá (14) and Escuintla (4).

Another pickup on its way from San Lucas towards Cocales slowed down at Quixayá to inform people that there had been a crash, “y que parece que son su gente” (“it looks like they are your people”). Vicente and his wife Gloria were at home and got news that their family members had been in the pickup that crashed. They went up to the scene of the accident. Gloria’s mom hurt her head—a flap of skin on her forehead and scalp was avulsed away, and she was bleeding a lot, as you might expect. They took her to Sololá immediately, but they couldn’t do the right studies there (head trauma), so they then referred her to Roosevelt, the government hospital in the capital. Her first CT wasn’t read until the next day, but thankfully it was negative, at least for an acute bleed. As of today, she has not spoken yet, and she is currently unconscious, but it seems that she was more conscious before (looking around, moving a little bit), so she may be medically sedated for some reason. Vicente said that Dr. Tun (the parish clinic doctor) said he was worried that she had broken her neck. Gloria’s sister’s 8-month-old girl was also in the crash, and she was sent immediately from SLT to the IGSS hospital in the capital, but this may have more to do with the fact that they have IGSS coverage than with the actual severity of her injuries (IGSS stands for Instituto Guatemalteco de Seguridad Social, and is basically a government-administrated, employer-funded health insurance system). Apparently one whole side of the baby’s face got swollen, especially her eye. Today Vicente said that they got news that there is a fracture in her skull, but it is unclear to me where. Either way, this sounds serious.

Paul Farmer talks about how the shitty roads and crappy tap-taps in rural Haiti cause lots of accidents that ruin lives, and how these risks (the risk of being in an accident, and of not being able to navigate or adjust well to the sequelae thereof) is disproportionately high amongst the rural poor. I have been trying to figure out if this most recent accident is similar. Can what happened on Sunday be interpreted in a critical anthropological perspective; can the impact on peoples’ lives be placed in the context of poverty and marginalization?

The difficulty I have been having with contextualizing the accident is that it was so random that Vicente’s family members happened to be on that particular pickup. There are many people who travel on pickups and camionetas (chicken buses), many of which pass by Quixayá every day. It just seemed like what happened to Vicente’s family was out of horrible chance. I suppose that because Vicente and all the people who live in the rural areas here, including me and Elena now, have this same baseline risk, it seems random that some people get hurt and others do not. But the fact is that Vicente and his family would not have the same baseline risk if they were commuting in Chicago—I do not fear for my life every time I am faced with the prospect of taking the CTA trains and buses in Chicago. But Vicente is definitely afraid of camionetas, to the point of insisting that we not take them. When I asked Rosa, a health promoter from Pampojila (the community where we live), if there were less deaths in the colonia after the highway was paved (thinking that she would say yes, because more people could get to the San Lucas hospital on time now), she said no, there are more deaths because the cars crash and sometimes even run over people. The risks related to automobile accidents here are so widespread that they become normalized for me, someone who is living here and thereby taking on, to some small degree, the risks that are a daily part of life for people here. There is a reason that “traumotología” is such a popularly claimed medical specialty here—the majority of the population in this country is not riding around in their own car with a valid license, and that is why there is so much automobile accident-related trauma (and why it is lucrative to be a traumatologist).

A long, integrated process of poverty and marginalization have made it normal to ride around the Guatemalan highlands standing up in the back of a small pickup truck that struggles to move uphill under the weight of the other 20 people standing with you; the same process has created inadequate numbers of corrupt traffic police and allowed many people, including many drivers of public transportation, to drive without a license. And these same processes have made emergency and rehabilitative medical care relatively or absolutely inaccessible to most people in our communities here. So for instance, Vicente’s mother-in-law needed a head CT immediately, and she probably didn’t get it for another 4-5 hours; when she finally got it, her husband had to pay 400 Quetzales (two weeks’ salary for a campesino around here) for it. Nobody should ever have to pay to see a doctor or get diagnostic tests or medicine. But this is only the last part of a long sequence of problems.

An artefact of inequality

There is an old (ancient) centrifuge in Quixayá, donated to the health promoter program. It works. But I don’t know what they would use it for in Quixayá. Vicente seemed to think it was to be used to run bacterial cultures. The lab at the parish clinic doesn’t even run cultures. Vicente said that we could lift the lid and use it as a fan, as the air in the community center in Quixayá tends to get hot and stagnant in the summer. We all had a good laugh.

But seriously…places like Guatemala get our garbage. They get people who are confused and lost, or idealistic and energetic but without any applicable skills. They get our junk—whether or not they want it, need it, or know what to do with it other than put it away and out of sight. So while no diabetic in Quixayá is on metformin (first-line treatment in the States), an old centrifuge collects dust, hidden under a large (and largely unused) examination table in the community center.

Vitamin B King Kong

Doña Candelaria was told by a local NGO that Rosbin is malnourished. Later, when Lesvia asked Rosbin to hand her a basket that was high on a shelf, he said he could not: “I can’t help you because I am malnourished!” Again, we all had a good laugh.

What is Doña C supposed to do with the information that Rosbin is malnourished, now that he is 7-years-old? Especially when the advice given to her was to take a Vitamin B-complex supplement and “pay attention to how he is eating”?

At least Rosbin can use his malnourishment as an excuse to avoid helping around the house. And this morning at breakfast he was running around the kitchen saying that the vitamin supplement will turn him into King Kong, similar to the effect of spinach on Popeye.

Joia Mukherjee on sustainability

"One criticism often lobbed at PIH is that its projects are not 'sustainable,' said Mukherjee, as the traditional view of a successful development projects is to have it be self-sustaining after the development organization leaves. '[But] we’re global citizens and we’re not leaving. We’re in this together. You don’t exit from humanity,' countered Dr. Mukherjee. 'You don’t have an exit strategy.' The only thing that is truly self-sustaining is entropy, she added.

'If you teach people to fish, then they can fish for a lifetime,' she said, quoting a common sentiment of sustainable development. 'But in fact, if the rivers are dry, and there are no fish, and you have no fishing pole, you can’t learn to fish,' she said."

(PIH E-Bulletin, October 2007)