Come on a journey with me, into the world of a diabetes clinic on the edge of the largest urban landfill in Latin America.
Guatemala City is at the same elevation as Denver, situated in the northern part of an unusually active ridge of volcanoes, and home to nearly 4 million people. Our house is a 45-minute drive up and over the hill, blessedly far from the city chaos. On clinic days I get up with the sun around 5:30, drink half a pot of coffee, put on scrubs, and throw an orange, a granola bar, and a liter of water into my medical bag. I drive down the valley into town along with the other half a trillion people that come into city to sell produce at the market and work as maids and security guards and cooks and gardeners. There’s a lot of traffic.
I wind my way past the entrance to the actual dump (el basurero, translates literally as trashcan and is shorthand for being the armpit of the city) and turn onto a narrow street crowded with diseased dogs, piles of garbage higher than my car, children playing in the street, legs of men sticking out from under dilapidated cars. At the end of the block there is a large maroon metal gate, usually with half a dozen patients hanging around outside who recognize me as I get out of the car to ring the bell and bombard me with questions about whether they can be seen without a number (a). Eventually the gate opens, and I drive into the courtyard, park my car, say hello to the crowd of patients waiting outside the clinic entrance, and make it inside to my exam room to start the day.
When I started coming to clinic in the spring of 2019, Dra. Layla Chanquin was running the place largely on her own. She is the wife of Pastor Saúl, and together they lead a large church in a neighboring community. The clinic has been open for about 10 years at this point, and has slowly grown both in physical and professional capacity. There is now a lab, a hospital-grade ultrasound machine, a physical therapist, and a dentist that donate their time to see patients on a weekly basis — and me, running the diabetes program.
Diabetes is, arguably – numbers are hard to nail down here — one of the leading causes of morbidity and mortality in this country. It is a key part of the “double burden of malnutrition”, the downward spiral whereby poverty creates infirmity which contributes to more poverty. It is also the most unsexy, hopeless disease to work on. Most Guatemalan physicians have an understandable degree of diabetes burnout, given the lack of resources (b) to manage this long-term.
When I showed up, Dra. Layla asked if I could “do something” with the diabetic patients, and after about 6 months of working in clinic, teaching classes, making home visits, and scouring the literature for relevant evidence, I put together a program, a medication formulary, purchased a hemoglobin A1c machine, hired and trained a diabetes educator from the community, instituted an appointment system to get people out of the early morning line, and launched the thing. Just two months shy of Covid’s arrival and everything (including the clinic, temporarily) shutting down.
During my years in primary care in Oregon, nearly all of my diabetic patients had Medicaid. Their office visits and labs were free, and meds cost less than $30/month most of the time. I could count on being able to refer them to a dietician, order labs to check renal function, glucose levels, and cholesterol a couple of times a year, and know with certainty that they would be able to pick up a full month’s supply of the same medication regimen each month between office visits. All of that is a laughable luxury here — diabetes is managed as an urgent care problem, as is everything else — patients go to the doctor when they’re sick, they buy their medicines off of open tables in the market or at the corner pharmacy when they feel ill and/or can afford it, and generally regard diabetes as a diagnosis similar to cancer: everyone knows someone who has died of it, often someone in their family.
There is a paucity of research about how to treat this disease in this setting. A review of the literature turned up studies done in Africa, rural parts of Latin America, Cambodia, India, and urban cross-cultural communities in developed countries, but nothing accurate to my setting.
I was looking for something like a recipe: a replicable study that documented some specific strategies and interventions that would produce decent outcomes. I ended up putting together my own recipe from a hodgepodge of sources, and the cake is now in the oven. To drive the analogy into the ground, the Covid shutdown amounted to a power-outage. The lights are back on, but I have no idea if what is coming out of the oven will be edible or not.
When I rolled up to the clinic last Monday, a woman named Wendy was one of the first patients in my exam room. She’s about my age, and we have gotten to know each other over the last couple of years. She was diagnosed with diabetes in her early-30’s after her last pregnancy, and already has several grandkids. Her life is difficult— she and her kids all work in the basurero, money is scarce, anxiety and fear are high. Her initial HgA1c was 11% (c), and we chatted about how she had been doing over the past 12 months.
I had started her on insulin a year ago, and she had been pretty consistent with picking it up and taking it, along with the metformin and blood pressure medicine. She said she’d been drinking more water, trying to get some exercise when she could, and paying attention to eating less sweets. I sent her upstairs to the lab for a repeat HgA1c, and was totally floored when she returned to the exam room with 8.3% written on her lab card.
What ensued was the most beautiful conversation: I confessed how pessimistic I’d been, and praised her for incredible hard work and fortitude in what has arguably been the worst year of her life. She gave all the credit to God, who cares for her, walks with her, lifts her up, and binds up her wounds.
The rest of the morning was not like that — most people have not been able to get meds consistently during the pandemic and mostly numbers have gone in all the wrong directions. But Wendy’s story gave me a lot of hope, something I’ve mostly avoided the heartache of letting myself feel in the past year.
My husband, a psychiatrist, and I talk a lot about the psychology of disease in Guatemala — my patients often believe that they are forgotten by God, and tend to approach treatment in a mystical way. Like sick people everywhere, they are on the hunt for a cure, for freedom from the malady itself, and the conversation lining every office visit deals with the reality that there is no cure, but the ultimate healing is found in Jesus. I put Zephaniah 3:17 on the front of their diabetes program cards, which says:
“The Lord your God is with you,
the Mighty Warrior who saves.
He will take great delight in you;
in His love He will no longer rebuke you,
but will rejoice over you with singing”
I am working on the idea of research as mission — there is so much we don’t understand about how to treat disease and save lives in this part of the world, and as we approach these communities with compassionate curiosity, relationships open up in the most beautiful ways, bringing opportunities for gospel renewal and healing that far exceed numbers on the page.
Footnotes:
a. Without a number: care at the clinic is first-come, first-serve. They hand out numbers (usually 30-50) starting at 5 am, so people get up and get in line before that. Office visits start at 8:30, so it makes for a long day.
b. Lack of resources: patients make 10q a day, roughly $1.25. All medicine is out of pocket, so people often literally have to choose between food and medicine. We charge 5q for office visits, and never refuse care for people who can’t pay, which includes medicine.
c. Hemoglobin A1c: the gold standard for diabetes diagnosis, telling us how saturated red blood cells are with glucose and giving us a pretty good idea of average blood sugar for the previous 3 months. Major medication changes ideally will be evaluated for efficacy with a repeat HgA1c about 3-4 months later. Diabetes is diagnosed at 6.5%, and the goal for treatment is 8%. My machine reads levels up to 16% and I’ve had a few critical highs, but the average starting value for patients in my program is 11-14%.
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