July 22, 2010 - CHP/PCOR, FSI Stanford News
SHP core faculty Paul Wise blends medicine, politics to improve health of Guatemala's poorest
By Adam Gorlick
SAN JUAN EL MIRADOR, Guatemala - Dozens of children are heading into a metal-sided, one-room building in this tiny village overlooking Guatemala's western highlands. On most days, this is the community school. But today is special. It's a free health clinic, and the children are coming to see the American doctor.
Paul Wise, a pediatrics professor at the Stanford School of Medicine, fellow at the Freeman Spogli Institute for International Studies and core faculty at Stanford Health Policy, has medicine to settle their stomachs, help their breathing and stop their skin from itching.
"The thing that's motivated my whole career is the nonprovision of highly efficacious services to people in need."
Wise diagnoses ailment after ailment: Diarrhea. Pneumonia. Scabies. He doles out ointments, capsules and powders. Almost every child leaves with a bag of vitamins - something to help offset the malnutrition that's stunted their development and left them too small for their three, four or five years.
These are what Wise calls "diseases of poverty." And they're rampant in San Juan El Mirador and the 14 other rural Mayan communities near the small city of San Lucas Tolimán, where the average income of $3 a day usually comes from picking coffee and other crops grown on this lush land.
But there's more at play here than just a lack of money. A history of political oppression mixed with a 36-year civil war pitting government militias against guerillas in a struggle for land and civil rights has battered Guatemala's indigenous population to the country's fringes.
The volatility has made regular health care largely inaccessible for many of the Mayan, even with peace accords that halted the fighting in 1996.
Politics are as necessary as medicine in places like this. That's the premise behind Children in Crisis, a program created by Wise to blend Stanford's expertise in medical research and international studies to provide health care to the world's most vulnerable patients: children living in politically unstable regions.
"It's not enough to make sure everybody is vaccinated, or that everyone who needs them gets vitamin supplements," Wise says. "It's about understanding and beginning to address the political requirements for the provision of these kinds of resources."
Treatment with dignity
During his three-week trip to Guatemala this summer, Wise worked with two Stanford medical school students who helped examine patients in makeshift clinics like the one in the San Juan schoolhouse. He was also joined by Kate Leonard, a pediatrician at the Lucile Packard Children's Hospital and the Palo Alto Medical Foundation. Leonard spent a year in San Lucas Tolimán and returned for this trip to help oversee four undergraduate FSI interns collecting data about maternal health care by interviewing women in the western highland villages.
There isn't much to immediately identify Wise as a doctor when the group arrives in the flatbed of a battered Ford pickup. Just a stethoscope dangling around the collar of his sweaty black polo shirt, enough hand sanitizer to rub into his palms before seeing a new patient, and a plastic tub filled with medicine.
What's never missing is his respect for the people here.
"We will not cut any corners in the care we give just because these people are poor," Wise, 58, tells the students the night before they head to San Juan for the first time. "We will treat each of these people with dignity."
They won't hand out cheap or expired drugs. They won't ignore a patient's question or dismiss her concern, no matter how trivial. They won't rush, even when the line of mothers and children waiting to see them seems to grow instead of shrink.
When he wasn't in the countryside, Wise made the three-hour drive to Guatemala City to meet with academics, researchers and bureaucrats to discuss ways that government agencies could take a stronger approach to improving the health of the country's poorest citizens.
The talks are exploratory right now, but they're an important step toward building relationships and identifying places where Wise and his FSI colleagues - economists, political scientists and lawyers who understand the needs of developing nations - could help.
His work tucks neatly into FSI's mission of supporting policy research aimed at solving global problems.
"There is a lot of technical capacity in health care and medicine," says Belinda Byrne, FSI's associate director for administration, who travelled to Guatemala with Wise and the Stanford students. "But what's preventing it from getting to these people down here? Paul is trying to set up systems where the best medicine and the best health care can be accessible to the poorest people."
Malnutrition is one of the world's biggest killers of children younger than 5, accounting for about 5 million deaths a year. In Guatemala, 44 percent of children in that age group are malnourished, giving the country a higher rate than any other Latin American country.
"Our role is not to fix Guatemala's troubles, but to see if there are ways that an academic institution like Stanford could help facilitate the conversations or help provide the analytic groundwork for more constructive policies here," he says.
The Children in Crisis program isn't limited to health care in Guatemala. Wise is building similar strategies with government officials and health care providers in Central Africa, and has been approached by health advocates in the Middle East.
"What makes this program different is that it requires a collaboration between the political science people and the global security people and the people they don't tend to work with, who are the health people," Wise says. "Well, that's me."
Four decades of medicine and justice
Wise made his first trip to Guatemala in 1970. He had just finished his freshman year at Cornell and came to work in a children's hospital. He had no understanding of Guatemalan culture and no idea that the country was embroiled in a civil war. He taught himself a few Spanish words on the plane ride from New York.
What he saw at the hospital shocked him: scores of malnourished children left by their parents. How could this happen, he wondered. How could parents not feed their children? Where were their values? Their morals? Their shame?
His anger toward the parents grew each day during his first week on the job.
Then Sunday came. Visiting day. Wise watched as a crowd of mothers and fathers rushed into the hospital to be with their sons and daughters. They cried. They doted. They wanted to make sure everything was being done to make their kids better.
The parents were poor. Wise could see it in their clothes. He heard about it when talking to them about their skimpy diets of corn, beans and salt. This malnutrition didn't stem from parental negligence. It came from poverty.
"You idiot," he said to himself. He had spent the past week blaming people who needed help.
Wise went on to receive a bachelor's degree in Latin American studies and an MD from Cornell. He studied at Harvard's School for Public Health and became an expert on American and international child health policy.
"The thing that's motivated my whole career is the nonprovision of highly efficacious services to people in need," he says.
In other words, his medical work is driven by a commitment to social justice.
So just about every year since the summer of 1970, Wise has returned to Guatemala for weeks or months at a time to offer medical assistance, conduct research and figure out ways to provide basic health care that's often taken for granted in wealthier countries like the United States.
Helping the health promoters
After two days spent making house calls and seeing patients in the schoolhouse, Wise and the medical students have examined and treated about 75 children in San Juan.
They worked closely with some of the local health promoters, a group of 30 volunteer women from the area's 15 villages. Many of the promoters have no more than a third-grade education, but they're all trained by doctors and nurses to spot common sicknesses and recommend basic treatments.
The promoters bring Wise up to speed on the conditions of some of the patients and fill him in on the medication they've been taking. They also help translate Kaqchikel, the local Mayan language, into Spanish.
When Wise or other visiting doctors aren't around, promoters help connect villagers with the government health care services available in Guatemala City and San Lucas Tolimán, where a Catholic mission runs a hospital and the government funds a clinic.
But it's often hard to convince people to make the trip into the cities. Transportation can be expensive and difficult to arrange. The dirt and poorly paved roads can be washed out or flooded, especially now during the rainy season.
Social and economic differences create another barrier.
"The doctors in the city often come from rich families," says Vicente Macario, a nurse who has helped organize and train the promoters. "They sometimes don't understand poor families and the problems they have. There are language problems. Poor families are made to feel like they're not important, so they don't want to go to a government clinic."
But the promoter program has served as a stopgap and lifeline in an otherwise inefficient health care system.
It developed in several stages alongside a land redistribution program spearheaded by the Catholic mission in San Lucas Tolimán trying to make things more equitable in a country where about 2 percent of the people control roughly 80 percent of the land.
The mission has bought several fincas - coffee plantations where Mayan farmers essentially worked as indentured servants with hardly any access to education or health care - then doled out the land to the workers. The government agreed to give the new landowners enough metal and cement to build a few houses, and communities with local governments began forming on the hillsides.
For many of the young villages, like San Juan, health care became a priority.
With Wise's support, and about $30,000 in donations he's raised through Stanford, the promoters have put together a project to track child malnutrition cases and help families guard against the condition.
During frequent and informal get-togethers with mothers, the promoters talk about the importance of basic hygiene. They discuss the need to boil water contaminated with parasites, the upside to breast-feeding babies and the benefits of serving the most malnourished children Incaparina - a pasty porridge enriched with vitamin supplements.
The promoters have managed to enroll 1,300 kids, all younger than 5, in their program. And they're eager to share what they've learned with Wise and the students travelling with him.
They set up a laptop computer and projector on a plastic table in one of San Juan's community centers. Images of charts, photographs and bullet points are beamed onto a white sheet hanging against a paint-chipped cement wall.
This is the story they tell: 250 of the 1,300 children in the program are severely malnourished or at high risk of becoming so. But there is help. About 570 bags of Incaparina have been handed out in the past two months, along with 256 bags of a month's supply of vitamins.
The numbers give Wise more data to help make the case that problems are dire but not hopeless as long as the health promoter program is in place. There's talk that the Guatemalan government might partner with the promoters, giving them more resources, training and a broader reach.
The data also augments a recent study done by Asya Agulnik, a pediatrician at Boston Children's Hospital who just graduated from the Stanford School of Medicine and spent months during the past three years as Wise's research assistant working with the promoters on the nutrition program.
Agulnik's research focused on how children's nutritional status changed in the years since families moved from fincas onto land of their own. Four of the five communities she studied were on property bought by the Catholic mission in the last few years. Families that resettled on that land were given plots to grow their own food and build houses with running water.
Before the moves, about 37 percent of kids younger than 38 months were moderately malnourished, while just over 7 percent were severely malnourished. After families resettled, malnutrition rates dropped among children in the same age group; roughly 19 percent were diagnosed with moderate malnutrition, and 5 percent were severely malnourished.
"Unless you're planning on supplying food forever, you have to come up with another solution to prevent malnutrition," Agulnik says. "Making sure people have their own land isn't very cheap, but we've demonstrated it has long-term effects. We're showing that land reform isn't only a social issue in Guatemala, but it also leads to better health."
A family resettled
Leonzo Upun and his wife, Adelaida Soco Gonzales, were among the first people to move to San Juan after the Catholic mission bought the land and gave them a piece of it in 1991. They've raised their four sons here - short, skinny boys now 15, 13, 10 and nine.
In some ways, life is better than it was on the finca they left behind. They don't worry about losing their house or being kicked off their land. But except during the coffee harvest between December and March, work is hard to find. And no work means no food.
"Then you suffer," Soco Gonzales says.
Still, they're among the lucky ones in this area. Their sons haven't developed severe malnutrition. And while it's still too expensive for them to make it to the clinic or hospital in San Lucas Tolimán, at least they have the health promoters to rely on for the most basic medical needs.
"On the finca, there was never any medicine," Upun says. "Now we have medicine."
And from time to time, when a pediatrician like Wise comes to this tiny spot in Guatemala's western highlands, the children can see a doctor.