First, a bit about me.  I recently graduated from Vanderbilt’s Pediatric Nurse Practitioner Program (just passed my boards on October 3^rd!!).  During my education, I earned the certificate of Public Health, and had the privilege to travel to Nicaragua during the practicum of one of my courses.  I’m not sure what initially drew me to Guatemala, but as I read more and more about the women’s rights issues in the rural communities I became more impassioned on the topic, and decided to apply for the Frist Global Health Leaders Program to work with locals to impact this issue.  I am incredibly grateful for the opportunity—I have learned so much already in a short period.  The people here are knowledgeable, passionate, and forever patient with my questions and (occasionally) broken Spanish.

In the past, I have found that my experience working in public health facilities never goes entirely as planned—even the most well-researched and planned intervention is bound to be railroaded at some point during the execution phase.  My experience here at Primeros Pasos Clinic (PPC) has been no different.  Months were spent in communication with the volunteer coordinator in the attempts to establish a clear-cut plan that was both beneficial, and desired, by the communities served by PPC.  My research into the background of the country led me to discover that the rural areas of Guatemala have the number one incidence of teenage pregnancy in all Central and South America.  In the Palajunov Valley, the area served by PPC, many female adolescents are pregnant and married as early as ages 12-14 years.   Together, the volunteer coordinator and I decided that the school-based reproductive health curriculum needed reform, and I arrived prepared to work on this project.  However, this first volunteer coordinator has since left the clinic.

Upon further investigation into this topic area during my first few weeks I have found there simply are not enough resources to execute expansion the school-based education outreach.  There are two women who claim responsibility for the entire program.  Together they visit 10 communities during the year, and spend approximately 1 month within each.  Within the past few years an effort has been made to integrate a discussion about reproductive health, but priority education continues to fall on the identification and prevention of communicable diseases (namely parasitic infections, which are common in this population).  Additionally, while the need for opening a broader discussion on reproductive health related topics is present, the community desire is not.  Machismo, which translates as aggressive masculine pride or chauvinism, is a cultural theme in Central America that often interferes with women’s rights movements.  In the valley men traditionally show their strength through procreation, and ensuring female submission within their families.  Women in the Valley have been brutally beaten by their husbands simply for listening to a talk on how to prevent pregnancy.  They are often forbidden from seeking contraception, by both their husbands and the Christian and Catholic churches (nearly all Guatemalans identify as Catholic or Christian in the Valley).  Due to this religious influence, sex is a taboo topic.  Even though many girls do become pregnant in the Valley at young ages, parents refuse to acknowledge that it is a problem, and deny that their children might be at risk.  At this point expanding the conversation from general anatomy to a more in-depth discussion to include STI’s, pregnancy prevention, and contraception would not be welcomed by the communities, and might prove dangerous for the educators.  My 3 months with the clinic is not sufficient time to press for this specific change.   

While this realization has been disappointing for me, I have found there are other areas with room for improvement.  I have travelled to some of the communities to assist with sanitation and nutrition education delivery, but I am primarily stationed in the clinic.  I continue to provide medical care, and have learned a lot about parasites.  Primeros Pasos is primarily a pediatric clinic, but we often treat mothers when they come in with their children.  The Guatemalan medical students who rotate in the clinic have not yet received women’s health training, and do not know which medications are safe to prescribe during pregnancy.  I am creating a presentation that each new external student will receive upon arrival at Primeros Pasos to ensure they are prescribing safe medications.  As I mentioned previously, domestic violence is present in the Valley, and is sadly the norm rather than the exception.  Substance abuse is also quite common, among both men and women.  Within the upcoming weeks I will be speaking more with one of our educators, who is also a psychologist, to apply for a grant to fund the addition of a psychology program that will serve the women impacted by these issues.  I have no background in grant writing, so this will be an interesting experience!  I also provide private English lessons in the evenings (gratis, of course) as many medical students have expressed the desire to learn, and view the language as a skill that is becoming more and more important with increasing tourism.  I’ve dipped my hands into many pots, but this is what I love about global health!  No matter how much you’ve planned, nothing ever seems to come together to meet your original vision.  But, if you remain flexible and open to new ideas, there is always a time and place to make an appreciable difference in the community.