AT THE FRONTLINES OF THE GLOBAL DIABETES EPIDEMIC: A Personal Account from Western Guatemala

By Ian Huntington 

On clear days, the green cone of the volcano Santa María is visible from the small well-kept courtyard of La Dirección de Salud in Quetzaltenango, a city in Guatemala’s Western Highlands. In July of 2006, on a bright cool morning, I was in the Office of Statistics in La Dirección trying to find information on diabetes in Guatemala. The woman working behind the desk was extremely helpful, and she let me have access to the paper and computerized statistics that I requested. She paused, however, when I asked if I could have the statistics they had on obesity. They only kept records of the underweight.

Guatemala is in the midst of many transitions: emerging from 36 years of civil war, moving into global trading networks like the Central American Free Trade Agreement (CAFTA), and becoming a place where “overweight” will be as medically critical as “underweight.” Processed foods and infrequent exercise are no longer solely the privilege of the developed world, and global diabetes mellitus rates reflect this shift. Of the 194 million people with diabetes in 2003, three quarters are living in the developing world¹. A study conducted by the Pan American Health Organization in one representative Guatemalan community found that 17% of people over 40 years old had diabetes and that about half did not know it². In Quetzaltenango, I found statistics at La Dirección that showed diabetes to be the second leading cause of death in the municipality in 2005. In short, the morbidity and mortality challenge that diabetes poses to global health is rapidly evolving, and our conceptions of the disease must change as well, especially in the developing world.

My interest in diabetes in Guatemala began with Mrs. S. I was in Quetzaltenango to do a summer Spanish language program and to observe clinical care with a Guatemalan doctor. Mrs. S was a middle aged woman accompanied to the clinic by her daughter. She was dressed in the colorful huipil blouse of the indigenous Mayan woman, while her daughter wore pants and a stylish sweater. Clothing choice is intertwined with ethnic identity in western Guatemala, and based on the choices she and her daughter had made, her family seemed to be part of a transitioning demographic. Her chief complaint was a persistent infection of her fingernail, but her history of present illness revealed that she had diabetes; her last blood sugar measurement, nearly a week ago, was over 300 mg/dl. I had become used to the doctor calmly reassuring patients, but suddenly his face became stern, and he began a very serious explanation of the woman’s health situation. “El muerte de diabetes es muy feo” he said, telling her that the diabetic death is very ugly. At these words, Mrs. S began to fidget with the hem of her dress. When the doctor said that she must eat less sugar, she replied softly that she did not eat much azucar (sugar), choosing to drink her daily coffee without it. The doctor pressed on, informing her that sugar hides in many foods like bread, potatoes, and pasta, and not only in the morning sugar bowl. He ended the clinic visit on a note of warning, stressing that her infected nail bed was only a beginning. His sudden change in tone interested me. The doctor and Mrs. S seemed to be interacting about disease in a new way—the education about chronic disease before the onset of serious symptoms—and the success of this conversation across Guatemala will influence the course of its diabetes epidemic.

I soon began observing in the Patronato de Pacientes Diabéticos de Guatemala Filial Quetzaltenango, a government-sponsored clinic for patients with diabetes. There, patients lacking a glucometer could have their morning blood sugar checked for five Quetzals (sixty-six cents) or they could purchase oral hypoglycemics like metformin and glyburide produced in Central America. Although subsidized by the government, these medications still cost about sixty cents per pill. Patients usually were prescribed two pills per day, so in western Guatemala--where a day of field labor can yield about $2 - potentially half of a poor farmer’s wage would go toward these life-long medications. The estimated yearly cost of providing basic outpatient diabetes care in Guatemala in 2000 was $491 per patient. As a point of comparison, the Guatemalan government spent about $94 per person on health care during that period³ . Although the clinic’s small waiting room was filled with patients each morning, I suspect that the patients I saw were a relatively wealthier subset of a much larger diabetic population.

Several mornings a week a single physician would come to the clinic, evaluating new patients and adjusting the treatment of those returning. My morning observations with the doctor assumed a rhythm familiar to many medical students abroad; I asked the occasional question, I took a few blood pressures, I tried to stay out of the way, but most of all I listened to patients telling their stories. The narratives I heard were compelling, but ultimately constrained by the need of the physician to perform a history and physical on 5 or 6 patients in an hour. Disease progression was usually monitored by infrequent blood sugar tests, patients never got Hemoglobin A1C measurements because of the lack of lab facilities, and the doctor never knew if the patient would be able to afford to return.

Every patient we saw had type 2 diabetes. Many seemed overweight, but some were frail and thin. The patients were often men involved in commercial work or housewives from a range of backgrounds. There was a thirty four year old Quetzaltenango businessman, recently diagnosed with diabetes, who stated that he used to drink a liter of Coca-Cola a day, but now had cut back to only a bottle or two a week. A thin woman, wearing indigenous Mayan dress, had woken up at 4 AM to come to the clinic from a village several hours away. She was the only one in her family or her village with diabetes. After her visit, I asked her how she thought she might have contracted the disease. “Well, I once drank a Coke,” she confessed.

The doctor had me give each departing patient a pre-printed sheet with two columns specifying the foods that should and should not be eaten in a diabetic diet. As I ripped each sheet off the pad and briefly explained the columns, I knew that this was the only diabetic diet education they would receive. The doctor did emphasize that the two best ways to control diabetes are through exercise and diet. In response to his queries about exercise, patients described long days of work. But working 12 hour days behind a store counter or cooking, cleaning, and tending to a family of seven does not provide the sustained cardiovascular work-out called for in diabetes prevention guidelines, and no one in the room thought it likely that 30 minutes of “cardio” would be added to these tiring days. Once the prescription pad came out at the end of the visit, attention then seemed to shift away from the “two best methods” of control.

During clinic visits, the doctor would briefly describe diabetes etiology, mentioning the dysfunctional pancreas and the role of insulin. But in western Guatemala, this was not the only explanation for diabetes. In telling me the story of her diabetes, one woman mentioned the word susto. I soon learned that susto means ‘fright’ in Spanish, and it is a well documented belief throughout Central and South America that a sudden shock or strong emotion can trigger a disease process. As she described it, fourteen years previously her daughter was beaten by thieves in the street, and learning of this event gave her a susto. Several days later she reported increased urination and upon visiting a doctor, she was diagnosed with diabetes. Now, she says, any susto raises her blood sugar. Once I knew to inquire about it, I found many patients had a susto story. Being aware of the meaning of susto is not only important in western Guatemala; clinicians working with diabetic Latino populations in the U.S. may also encounter susto as a parallel explanation⁵ . In the wider Guatemalan context, the country is still recovering from a horrific civil war during which 100,000 to 200,000 people were killed or disappeared. To Guatemalans who believe in an explanatory model linking fright and suffering to diabetes, the rise in diabetes seen over the last thirty years has a compelling explanation.

Alternative theories of diabetes extend to treatment as well. Herbal teas predominate, and I heard salesmen on public buses or at the market with loudspeakers proclaim the effectiveness of their particular mixture of herbs. The district of Quetzaltenango has a population that is nearly two thirds indigenous Mayan, so the connection to an ancient Mayan pharmacopeia is strong. Nearly everyone I asked had an herb for diabetes, although I encountered fewer who were actually using the herbs. Some of these herbs have been shown in the laboratory to have hypoglycemic effects⁶ ; in the maintenance of a chronic disease condition that requires life-long treatment, an efficacious herb that could be grown individually in rural areas would be a welcome addition to diabetes care.

Diabetes is not rampant everywhere in western Guatemala. During my stay, I did another clinical shadowing in a Mayan village high in the mountains above Quetzaltenango. This was a village that had been relocated after being completely destroyed by Hurricane Stan in October, 2005. No one in the village was in danger of getting diabetes. Men and women both performed many hours of manual labor, tending corn fields that clung to the sides of cliffs, and there was no money for processed foods or large amounts of granulated sugar. The most common medical conditions I observed were respiratory illness and muscle aches due to the work of subsistence farming. Populations like this one are the reason Guatemalan public health authorities are monitoring the underweight.

The backdrop of rural poverty is also part of the reason why diabetes care in developing countries like Guatemala is so complex. To a public health official, an urban migrant to Quetzaltenango who becomes a clerical worker represents a switch from an “active” to a “sedentary” occupation. To the worker, it may represent a chance to escape brutal manual labor and provide a more consistent income for his family. A water pump closer to a village means that women have an easier time getting drinking water, but they simultaneously lose an opportunity for physical activity. Before coming to Guatemala I did not think in terms of these trade-offs between disease and development. However, for patients like Mrs. S, diabetes is part of a rise from rural poverty. Ultimately, successful diabetes care will mean advocating for economic and social policies that will alter the current situation in which people are prosperous enough to get diabetes but not prosperous enough to effectively treat it.

IAN HUNGTINGTON is second year student at Weill Cornell Medical College. He can be reached for questions or comments at iandarin@gmail.com.

Footnotes:

1. Narayan, KM. How should developing countries manage diabetes? Canadian Medical Association Journal 2006; 175(7):733.

2. Preliminary Results: Prevalence of Diabetes, Hypertension and Their Risk Factors in the Municipality of Villa Neuva, Guatemala. Pan American Health Organization, 2003.

3. Barceló A, Aedo C, Rajpathak S, Robles S. The cost of diabetes in Latin America and the Caribbean. Bulletin of the World Health Organization 2003; 81(1):19-27.

4. Poss J, Jezewski MA. The role and meaning of susto in Mexican Americans' explanatory model of type 2 diabetes. Medical Anthropology Quarterly, 2002 Sep;16(3):360-77.

5. Jezewski MA, Poss J. Mexican Americans' explanatory model of type 2 diabetes. Western Journal of Nursing Research, 2002. Dec;24(8):840-58.

6. Andrade-Cetto A, Martinez-Zurita E, Wiedenfeld H. Hypoglycemic effect of Malmea depressa root on streptozotocin diabetic rats. Journal of Ethnopharmacology , 2005. Sep 14;100(3):319-22.

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