Investigating Social Determinants of Health in the Rural Highlands of Guatemala

Johannah Brady, Sanchay Gupta, Solveij Praxis, Noam Rosenthal, Lauren Wedekind, Emily Witt, Beatriz Magaloni, Ph.D., Paul Wise, M.D., M.P.H.



From June 15-30, 2014, a group of Stanford field research students traveled to San Lucas Tolimán, Guatemala as with Freeman Spogli Institute for International Studies affiliated professors and Bay Area pediatricians through the Institute’s Children in Crisis program. During those two weeks, under the leadership of Dr. Paul Wise (Stanford CHP/PCOR) and Prof. Beatriz Magaloni (Stanford CDDRL/Political Science), we divided our time between conducting in-home interviews with rural community members and health promoters and volunteering in mobile clinics set up by our research team in these communities surrounding San Lucas Tolimán. This research is part of a sustained three- decade-long effort to track health outcomes of rural Guatemalan residents.

The following report summarizes our team’s observations within these settings and discusses multiple dimensions of poverty and development in the region: public health, education, gender roles, governance, land, energy and technology. This interdisciplinary investigation underscores the importance of understanding the determinants of equity if the overall goal is to improve health outcomes sustainably. Our research team invites readers to consider these interdisciplinary insights to fuel possible future global health and health policy investigations.


With half of its population under the age of 19, Guatemala is the most populous and fastest growing country in Latin America. However, rapid national expansion is undermined by pervasive economic, social, and political forces originating from its thirty-six-year civil war between guerilla peasant fighters and the national army in the late twentieth century. Its Gini coefficient is 53.7, indicating that 53.7 percent of Guatemala’s population lives in poverty (living on less than US$2 per day per person).

Our field assessment of patients’ experiences and outcomes in a rural, primary health care system took place in the town of San Lucas Tolimán, Guatemala (abb. “San Lucas”). With a population of 17,000, approximately 90 percent of the town and its surrounding areas are comprised of the indigenous Kakchiquel-speaking Mayan people. Late 19th century government policies transport- ed the notorious finca (Spanish for “farm”) system to San Lucas, expropriating indigenous communal lands in favor of landowning elites to expand coffee harvests. The San Lucas Mission has been instrumental in restoring land ownership to these communities and is consequently revered by the pious community.

Public Health

Guatemala has the highest rate of chronic malnutrition for children under five in Latin America, and the fourth-highest in the world. 49.8 percent of Guatemalan children–nearly one in two–are chronically malnourished. Rather than wasting and marasmus, which are common physical signs of acute malnutrition observed in sub-Saharan Africa, the stunting form of malnutrition observed in Guatemala is such that young children never reach the expected height-to-weight ratio for their age. Guatemala is one of thirty-six countries that collectively account for 90 percent of stunting cases in the world.

In the communities in which we served and ob- served, the rate of malnutrition was as high as 97 percent. Experiencing a long-term deprivation of essential vitamins and nutrients can conceivably weaken one’s immune function, which can result in more frequent cases and extreme manifestations of disease. To gain an understanding of the upstream causes of health outcomes of the residents of San Lucas and the surrounding communities, it is necessary to view the underlying socioeconomic, cultural, and political forces in the context of the region’s health care landscape.

A clinic in central San Lucas currently serves residents from the main town and neighboring areas. This medical facility is outfitted with imaging equipment, an emergency room, delivery wards, hospital beds, and basic medical supplies. Nevertheless, there is an apparent shortage in the volume and variety of urgent medical resources that are available for community members. A single physician, Dr. Rafael Tun, oversees all rounds at the San Lucas Tolimán clinic every day, where the few specialties include pediatrics, ophthalmology, and emergency care. Such low access to health care in San Lucas Tolimán underscores the importance of developing a sustainable pre- ventative approach in cooperation with the community members and health promoters.

Community Health Promoter Program

San Lucas Tolimán’s health promoter program recognizes this need for more sustainable preventative medicine, emphasizing early identification and intervention through community-based networks of health promotion. The promotoras, as they are known, are a group of community elected health care volunteers who undergo three years of training in order to provide health education and other basic services. Through strengthened community ties, the promoters serve as local linkages to higher levels of care by connecting individuals at risk for diverse health conditions to the appropriate care provider.

Although the promoter program has been instrumental in the distribution of Incaparina and the monitoring of children under the age five for signs of malnutrition, it confronts crucial shortcomings. First, the lack of resources and personnel places an unfortunate limit on the capacity of the program. Due to inadequate funding for Incaparina, the nutrition program currently does not monitor children over the age of five. Thus, a child who is in second- or third-degree (moderate to severe) malnutrition as a four year old will cease to receive Incaparina once he or she turns five, even if he or she is still in dire need of the supplement. Second, as of yet, San Lucas’s promoter program does not ensure that the child in need is actually consuming the appropriate amount of nutrition supplement after it is provided.

With crucial assistance in translation and clinic flow from health promoters, the Freeman Spogli Institute team of physicians and researchers set up ad-hoc clinics daily in the San Lucas communities to screen patients. The promoters performed large-scale outreach on the days leading up to the clinic dates, identified individuals who were in need of additional care, and brought important cases to the attention of our doctors. Those patients who were for some reason unable to at- tend the clinics were seen in their own homes. After the patient visit, the health promoters from the patient’s community periodically perform necessary follow-up to monitor treatment progress and determine subsequent care.

Women’s Roles

Women’s empowerment is fundamental to family health.
As in much of the world, women in the rural communities we visited are expected to and often do adopt traditional roles of caretakers in the family. Globally over the past four decades, with each one-year increase in the average education of women of reproductive age, the child mortality rate in a given country was reduced 9.5 percent. This study’s interviews observed that women who reported they breastfed their children longer and spaced their births more widely had, on the whole, healthier children.

Although promotion of family planning resources is not the main thrust of the promoters program, the promoters serve as resources for connecting interested women with family planning resources. Government health clinics provide many family planning methods at no or little cost, although they appear to be insufficiently promoted and severely underutilized.


In regards to land ownership, major patterns observed were those of redistribution, inheritance, and scarcity. Several generations ago, plantation owners gave tracts of land to their indigenous workers as payment for work that had long been unpaid. Today, most of the residents we interviewed had inherited their land from their parents or grandparents who had gained the land through these processes of land redistribution. However, the consensus is that, as families grow and seek to expand, the land inherited is no longer sufficient. With a farmland distribution Gini coefficient of 0.84, less than two per cent of farms own over fifty percent of the country’s agricultural land.

At a community council meeting in the San José highland community, members voiced a shared issue of land scarcity. In almost every case, several extended families lived together in the same space, and while families in one generation could have their own house to themselves, their children in the next generation have no space to raise their families separately.

Electric Infrastructure of Lake Atitlán Communities and the Potential for Renewables

San Lucas Tolimán and its neighboring communities boast an extensive electrical infrastructure constructed by the government. When the electric grid was first constructed, costs were split between the government and San Lucas residents, who were each charged a one-time fee of approximately 500 quetzales (Q). The average utility rate is approximately 2.43 Q/kWh. In conversations with local residents, the cost of electricity was considered exorbitant and therefore consumed sparingly.

By all these means, the renewable energy system in Nueva Providencia demonstrated the feasibility of such systems to operate in these towns, at the community level. Nevertheless, energy poverty for cooking remains the greatest health risk to families in the region and the most challenging to resolve, in light of cultural preferences and infrastructural requirements.


Not all of the 26 communities in the municipality of San Lucas Tolimán have access to affordable, potable drinking water. This is a significant detriment to the wellbeing of the people in the vicinity, as drinking contaminated water can lead to a bacterial infection, which results in diarrhea. It should be noted that there is a strong connection between diarrhea and malnutrition.

In interviewing the community representatives of San Martín, it became clear that the people are certainly aware of the negative health impacts and economic burden associated with not having easy access to a natural spring, nor having a reliable, sustainable filtration system. Funding for a water program must come from an outside source, but realization of such a program must take into account local experience as well as outside expertise in order it to be sustainable and effective.

Government Involvement in San Lucas Tolimán

In the past, the Guatemalan government has instituted programs to benefit the country’s indigenous poor, such as: Mi Famila Progresa, Mi Bolsa Segura, Mi Bono Seguro, additional money transfers, and Unbound. This section discusses data gleaned from interviews with patients and Web documentation regarding the past successes and failures of each effort, and concludes with comparisons of these programs and comments on their sustainability.

While Mi Familia Progresa once provided many impoverished families in the San Lucas Tolimán municipality with monetary aid, these families now have received reduced instillations at a far more infrequent rate since the program became Mi Bono Seguro under the new government. Most interviewed did not have a positive view of the government, either alluding to its corrupt tendencies or directly citing government apathy. In sum, governmental programs benefiting poorer indigenous communities have been acknowledged as helpful, though they are seriously lacking in accountability and sustainability.


Guatemala is not uniformly poor, underdeveloped, nor medically underserved. Our research team has observed disparities in environmentally-influenced health outcomes, access to medical care, ownership of land, employment, and contact with governmental aid programs within indigenous communities of San Lucas Tolimán.

With cooperation from interviewed patients and health promoters in Guatemala, our research team was able to glean insight into these issues, and intends to continue collecting data on child nutrition and health outcomes, in partnership of San Lucas Tolimán’s community health promoters, as part of the Freeman Spogli Institute’s Children in Crisis Program (a joint initiative of the Center for Development, Democracy and the Rule of Law and the Center for Health Policy/ Center for Primary Care Outcomes Research). Moreover, as stated in our analysis of San Lucas Tolimán’s community health promoter program, Stanford University has been actively engaged with the communities’ promoters in developing a mobile health program to supplement the promoters’ monitoring of child health conditions. In sum, through sustained local partnerships with members of the San Lucas Tolimán community, this program seeks to continue investigating the social and environmental determinants of residents’ health, and thereby help form the founda- tion for culturally-sensitive solutions.



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