The Association of Communitarian Health Services (ASECSA) and the Role of Religion and Health in Central America
Summary and Keywords
The Association of Communitarian Health Services (ASECSA) is a transnational, religiously influenced health program in Central America created during the Cold War. ASECSA was founded in 1978 by a small group of international health professionals with ties to programs started by Catholic and Protestant clergy and laity in Guatemala’s western highlands in the 1960s. It introduced a model of healthcare in which Maya health promoters and midwives became partners in healing rather than objects to be cured. Support for the health programs and ASECSA came from secular and religious international agencies, including the United States Agency for International Development (USAID), German Misereor, Catholic Relief Services, and the World Council of Churches. ASECSA was founded to disseminate knowledge of popular health education strategies used by health promoters and midwives to provide preventive and curative medical services to their communities. The education methods grew from Paulo Freire’s Pedagogy of the Oppressed and its use by religious agents influenced by liberation theology. Although it was founded in Guatemala, ASECSA’s publications and meetings attracted participation by health professionals and paraprofessionals from Mexico, Central America, and even the Caribbean. Ecumenical religious centers affiliated with liberation theology in the 1960s and 1970s facilitated the development of popular health programs that played a defining role in the region.
One strand in the growing field of public health in Latin America is a transnational, religiously defined health program that engaged indigenous paraprofessionals in Mexico and Central America during the Cold War. The Asociación de Servicios Comunitarios de Salud (ASECSA) was founded in Guatemala but contributed to a health network with representatives in Mexico, Guatemala, Nicaragua, El Salvador, Panama, Haiti, and the Dominican Republic. ASECSA grew from work by foreign (mainly U.S.-based) Roman Catholic and Protestant missionaries, politically engaged US and Central American health professionals, and religiously influenced Maya health promoters and midwives. It received support from the United States Agency for International Development (USAID) and other international secular and religious aid agencies. ASECSA claimed to recognize professional health workers (medical doctors, biologists, nutritionists) and paraprofessional “health promoters” and midwives as equal participants. In practice, professionals controlled economic resources and remained the dominant voice in published work, but paraprofessionals were the primary health providers and they worked under the auspices of ASECSA to develop their own networks. Religious currents, most significantly liberation theology and Paulo Freire’s Pedagogy of the Oppressed, defined ASECSA’s popular health education programs. Health services became a nexus in emerging political critiques that highlighted structural injustice as a source of illness and encouraged social organizing to promote political transformation.1
Guatemala was the notorious site of the first post-World War II direct US intervention in Latin America, the overthrow of the democratically elected president, Jacobo Arbenz, whose agrarian reform program threatened the United Fruit Company and offered an alternative, socialist-oriented economic model for the region. Susanne Jonas identified the post-coup country as a “showcase for democracy,” where the United States invested massively to highlight the benefits of opposing communism.2 US intelligence services modernized the Guatemalan police and military state through training and investment and created the infrastructure for repressive surveillance that played a definitive role in the country’s thirty-six-year armed conflict.3 These same US sources of aid contributed to the development of ASECSA. The United States encouraged the post-coup regime of Castillo Armas to accept foreign Roman Catholic clergy in the country, making Guatemala dependent on an international force of foreign diocesan clergy and male and female representatives of religious orders.4 USAID provided extensive funding for social programs linked inextricably with these religious agents’ projects. ASECSA offers a paradigmatic example of this Cold War confluence of religious and state aid, specifically in the expansion of health services, yet it also reveals the complexity of this relationship. ASECSA illustrates what Steven Palmer describes as “the complexity and ambiguity of the link between imperial institution and subject polity, and about the possibilities for those subject polities to shape their own destinies in their inevitable encounters with emissaries from the metropole.”5 While ASECSA grew from foreign support, it was possible only because of the agency of the Maya health promoters and midwives who were the central agents disseminating communitarian health services.
Health Conditions in Guatemala
In his 1981 study of health paraprofessionals in Guatemala, Forrest D. Colburn cited devastating statistics for the country, revealing extreme disparity in access to health services and to conditions conducive to healthy living. While the average life expectancy of Guatemala’s urban residents was sixty-one years, that of rural residents was forty-five years. Infant mortality was thirteen per 1,000 overall, but rural infant mortality was as high as one hundred per 1,000. Of the country’s 1,200 physicians only 20 percent lived outside Guatemala City, although 80 percent of the population was rural. Eighty-seven percent of Guatemala’s urban population had potable water, but only 14 percent of the rural population enjoyed access to this same necessity.6 The leading causes of death in Guatemala were acute respiratory illness (20.83 percent), diarrhea (all forms) (18.64 percent), malnutrition (6.82 percent), perinatal disorders (7.35 percent), and intestinal parasites (4.01 percent)—all preventable conditions associated with poverty.7
Even as Colburn’s report detailed these devastating health conditions for the rural Maya majority, a change in Guatemala’s health scene had transpired. By 1977, some 150 health-related private voluntary organizations (HPVOs) were operating in Guatemala.8 Religiously oriented mission groups directed 79 percent of HPVOs, with Catholics composing 79 percent of the total and Protestants 21 percent.9 Together HPVOs oversaw fifty clinics, six small hospitals, 1,175 nutrition sites, and twenty-one training programs and provided 45 percent of total health-related funds expended in the rural areas where they were concentrated in Guatemala’s Maya western highlands.10 In addition to providing a large percentage of the financial support for rural health services, HPVOs surpassed Ministry of Health (MOH) services in the number of patients served. In 1976, MOH facilities together averaged 1,248 patients per year, while HPVO facilities together averaged 11,602 patients per year and did so at a much lower cost.11 The cost savings were due to the fact that Maya health promoters provided 90 percent of the health services.12 Most financial support for HPVOs came from the United States, but Canada and western European countries, including Germany, Holland, Switzerland, England, Belgium, and Italy, also provided aid.13
Health promoters and midwives were at the heart of an emerging health paradigm that became influential throughout Central America and Mexico.14 These health paraprofessionals, most of whom received their training from Catholic and Protestant parish-based clinics, did more than simply provide medical services to their communities. They became educators, facilitators, and intermediaries. For example, Nobel laureate Rigoberta Menchú’s father, Vicente Menchú, was among the first health promoters trained in the Lutheran missionary Carroll Behrhorst’s clinic in Chimaltenango, Guatemala.15 Health promoters could be seen as Gramscian intellectuals or as the realization of Ranciere’s peasant intellectuals or “poor philosophers,” who maintained their status as campesinos while serving as community intellectuals, providing new health practices and educational resources, though sometimes at a cost of social conflict.16 This status was characterized graphically by ASECSA’s logo, which transformed the caduceus as the symbol of medicine by substituting a hoe for the staff and replacing the wings with a sombrero, thereby inextricably linking primary symbols of the campesino with those of the medical professional. The success of the health promoter and midwifery programs resulted from the fact that Maya curanderos (traditional healers) and midwives historically played defining roles in the healing and spiritual guidance of their communities.17 Contemporary Western-influenced Maya health programs were in some measure new iterations of established Maya traditions.
In the only published study of ASECSA, the researcher Luisa Cabrera noted that “the 1970s were a moment when a plethora of foreign missionaries who were doctors or nurses implemented programs for health assistance in [virtually] every parish.”18 This moment dovetailed with the growing influence of liberation theology, which emphasized structural injustice and appealed for a preferential option for the poor.19 At the same time that liberation theology encouraged structural critiques, it also emphasized transformative methods of popular education designed to help “popular” classes become “Masters of their Own Destiny.”20 Catholic emphasis on “integral human development” that took into consideration the “whole man” and the “mystical body of Christ” also contributed to an ideal of health that entailed more than providing medicine to cure sick bodies.21 The “see, judge, act” model pioneered by the Belgian priest Joseph Cardijn, founder of the Young Catholic Workers, had a natural application in considerations of health.22 If observation and evidence demonstrated that malnutrition was a primary cause of death, what was the cause of malnutrition? What should be done about it? Educational models, particularly Paulo Freire’s Pedagogy of the Oppressed, which encouraged literacy through dialogue facilitated by terms of local significance,23 could be transferred easily to discussions about health. Technology also played a role. The rapid dissemination of transistor radios and the pioneering work of the Roman Catholic Church in popular radio facilitated the development of parish-based radio stations that promoted literacy, health, and methods of critical analysis for promoting both.24
Hidden Agents of Health
In 1977, USAID, working in conjunction with the Guatemalan government, funded a study of HPVOs. The study came on the heels of the 1976 earthquake in Guatemala, which devastated the country, leaving some 23,000 dead, 77,000 injured, and over a million displaced. In addition to revealing the gross inequities of Guatemala’s infrastructure, which protected the wealthy while leaving the poor buried under rubble, the earthquake also revealed the large number of HPVOs, whose number increased as aid poured into the country.25 Although USAID and the government of Guatemala recognized health programs initiated by private voluntary organizations as early as 1971,26 neither appeared aware of their scope before the earthquake. This recognition was due principally to a technical assistance information clearing report (TAICH) completed in 1976 which identified sixty-six PVOs, of which forty-three provided financial data for their operations, revealing total expenditures (not all of which related to health) of $36,775,250.27
A year later, in 1977, USAID funded a study of HPVOs. In the same year, USAID also funded a study of the potential for providing healthcare services to laborers on Guatemala’s fincas (plantations), where, according to the study, “living conditions, health status, and access to health services are among the lowest in the country,” because “isolation results in lack of access to public services and to all types of preventive and curative health services.”28 These studies were designed to encourage USAID and the government of Guatemala (GOG) to take into account existing HPVOs’ services and to incorporate them into government-sponsored national health plans.29 In other words, religious HPVOs not only existed largely independently of the inextricably linked government of Guatemala and USAID, they also provided a base to which US and Guatemalan government agencies might graft their weak, ineffective health programs.30 USAID immediately took control of the health programs initiated by HPVOs on fincas in the southern coastal highlands and lowlands.31
The studies undertaken by TAICH and USAID-GOG followed on the heels of HPVO-initiated efforts to map their own programs and to initiate coordination among them. In the early 1960s, a small number of religious and secular people working independently and without extensive knowledge of others engaged in the same work and in conjunction with larger organizations, initiated what would become the health promoter model for providing primary care to impoverished communities.
In 1964, Maryknoll Catholic missionaries from the United States opened a hospital in the Maya community of Jacaltenango in the department of Huehuetenango. Maryknoll priests had been serving this community since 1943. From the start of their mission, priests provided limited dental and medical care to Maya parishioners. When the first Maryknoll sisters arrived in the country and settled in Jacaltenango in 1958, priests already had established clinics at most of their parishes in the department, with the result that there were about eighteen clinics operating under Maryknoll supervision in Huehuetenango. In 1963, Maryknoll sisters initiated a health promoter program, which was followed by a midwifery program and a nurse-training program. Initially, the program was designed to prepare Maya promoters to give inoculations and follow-up treatment for tuberculosis, but it evolved in response to the promoters’ requests for knowledge to address health needs in their communities. By 1973, there were 172 health promoters trained or in training through Maryknoll programs; this number increased to more than 400 by the end of the decade.32 The Maryknoll sisters’ health programs were one component of a more comprehensive mission that included development of schools, cooperatives, radio programs, and later colonization programs in the Petén and Ixcán regions, all of which promoted the wellbeing of “the whole man.”
In 1962, Carroll Behrhorst, a Lutheran medical doctor from Kansas, opened a health clinic in Chimaltenango, Guatemala. Behrhorst arrived in the country with support from the Missouri Synod of the Lutheran Church in the United States. He selected Chimaltenango, a department of about 200,000 mostly Cakchiquel Maya people situated twenty kilometers from Antigua en route to the Western highlands, as a site to build a clinic.33 Before opening the medical facility or initiating health programs, Behrhorst spent three months in the community listening to people’s health and life concerns and becoming a familiar presence. He recounted that on the first day the clinic opened, they had 125 patients, and by 1973 they never had fewer than 200 per day.34 Behrhorst quickly recognized that health problems resulted from broad structural conditions of poverty. Following a visit to a remote community accessible only by a rutted and nearly impassible road, where 105 out of 450 tested positive for active tuberculosis, Behrhorst initiated a health promoter training program that was integrated into projects to improve agriculture.35 In 1973, Behrhorst opened an extension of his program in Uspantán, in the indigenous department of El Quiché south of the Ixcán, which would become a key zone of colonization in the 1970s.36
In 1966, shortly after Maryknoll and Behrhorst initiated health promoter programs in rural Guatemala, David Werner, a biologist and educator from Palo Alto, California, became active in Ajoya, a small community in Sinaloa in the Sierra Madre region of Mexico. Werner embarked on the journey that led him to Ajoya seeking a site for students from the school where he taught to engage in immersion education. Werner’s focus on health grew from his own health challenges and his direct experience of the community, where he spent weeks passing time with people, sharing their homes and experiencing the community’s wealth of generosity and its poverty of resources. Werner found that the people’s greatest problem that was amenable to ameliorative assistance was poor health. Although he recognized and sought to work with local healers, Werner noted that while many of their treatments were effective, they had limited knowledge about preventable diseases and minimally invasive Western medical treatments for illness and injuries common to the region. He also recognized that poor health was the result of structural problems of poverty. In addition to developing health auxiliaries, Werner wrote a book destined to become a bible for global health providers in regions lacking access to formal, Western medical care: Donde no hay doctor (Where There Is No Doctor).37
These three programs, which became the cornerstones of ASECSA and the health model based on training of health promoters and midwives, shared a starting point of long-term commitment to community through which health programs evolved from dialogue with residents and depended on their initiative. In 1973, a decade after the first programs were initiated, David Werner embarked on a journey through Central America with Martín Reyes, a health promoter from Sierra Madre. Many religious health agents had written to Werner following the publication of Donde no hay doctor to share and request information.38 Werner and Reyes traveled to Central America with the hope of finding these people and others engaged in alternative popular health programs. As Werner encountered programs, he shared with each of them knowledge of the others; as a result, interest grew among key members in organizing a meeting among representatives of the health programs engaging promoters and midwives to disseminate knowledge about education methods.39
In 1975, the first “Regional Encounter of Rural Health Programs” took place at Emaús, an old union center south of Palín in Escuintla, Guatemala; sixty-five representatives from thirty-one different programs attended the meeting.40 One participant recounted that the organizers confronted an immediate challenge because they wanted Maya health promoters to participate. This participation represented a somewhat radical act in the context of Guatemala because it recognized Maya promoters as potentially equal participants and agents in a professional health network, thereby threatening the status of Ladino (people culturally defined as western/non-indigenous) professional medical providers. Medical professionals opposed the development of health promoter programs from the moment the first ones appeared in the country.41 A cartoon in ASECSA’s magazine made light of this competition by depicting an indigenous woman declaring, “My cup of tea de pericón (a medicinal herb common to Mexico and Central America) is very good for my nerves, for stomach ache, and for rheumatism.” A doctor appears next to her with a worried look and observes silently: “It looks to me like this could mess up my whole business.”42 Guatemala’s virulent racism also meant that not only was it rare for Mayas to be recognized as intellectual equals, but also that many facilities refused to permit indigenous people on their premises except as laborers.43 Those reported to be present at this meeting included representatives of the Maryknoll hospital in Jacaltenango, the Behrhorst clinic in Chimaltenango, nuns from Centro de Salud, El Novillero, Santa Lucia Utatlán, and Sololá, Lutherans from Puerto Barrios, representatives of parish programs in Jocotán Chiquimulla, San Lucas Tolíman, and, Santo Tomás la Union, Protestants from Baja Verapaz, Protestant Wycliffe translators from San Jeronimo, representatives of World Neighbors, and a few nonsectarian women and men who worked independently but in conjunction with Catholic and Protestant HPVOs. 44 Together, these representatives’ health work spanned the length and breadth of Guatemala from the western highlands through the eastern coastal region to the southern fincas and extended to southern Mexico on the north and Nicaragua on the east. After the first meeting, others were held in Las Hortencias outside San Lucas Sacatepequez and subsequently in Chimaltenango at a public school.45 At the time there was no telephone service to most remote communities. Organizing meetings depended on people driving from one remote community clinic to another, passing the word about time and place. At a meeting held in 1977, “The group of [health] promoters expressed their great desire to organize a reunion for themselves; not for the doctors, nor the nurses, nor for the directors of the programs, but for the health promoters.”46 The meeting did not come to fruition until three years later in 1980, when Werner’s program, Proyecto Pizxtla de Ajoya, Sinaloa, Mexico, initiated a three- to five-day international meeting of promoters and invited fifty health promoters to apply to participate through ASECSA. Nonetheless, it offered Maya health promoters an independent forum to discuss their work and to develop their own innovations.
The pieces for a health network were thus in place before the 1976 earthquake, when USAID stepped in. One activist explained, “None of us was very enthusiastic about the source of funding at the time, but the study was actually very helpful and interesting to all of us in the sense of building contact between groups that were scattered all over the country. We probably would have managed it anyways after Dave Werner’s visits, but the study made it easy to get funding which was nice to form the association. The association is what became ASECSA.”47 Another person explained the concerns more explicitly: “Of course, we were very suspicious of who these people were because … it did not protect the indigenous people as we wanted to protect them … There were a lot of things going on that identified people who were subsequently killed. So we were very, very protective of the lists of the names of who was involved in all of this up in our area.”48
The Asociación de Servicios Comunitarios de Salud (ASECSA) grew from the independent encounters among HPVOs and from the USAID-sponsored report. The purpose of the organization was to disseminate knowledge of preventive and curative health practices, to serve as a means of communication among people engaged in health promotion, and to facilitate the development of popular education models that would improve health and provide means of analysis of the conditions that contributed to poor health and methods that could be used to transform those conditions. One component of this effort was the publication of El Informador, a health-community newsletter that grew from El Informador Comunitario, initiated by the Behrhorst clinic in Chimaltenango.
The authors of El Informador designed it to inform people in clear, direct Spanish about health-related issues and to provide them with concrete resources including recipes, points of discussion, and illustrations that they could use directly in their practices as health agents. The principal authors of the articles were evidently educated, ladino Guatemalan and foreign professionals, but the paper also included extensive interviews with health promoters and midwives, and a letters section with detailed excerpts from health promoters in the field who described their programs and the ways they used materials from El Informador. Standard features of the newsletter included an editorial by Mary Hamlin de Zúniga, a North American with a master’s degree in public health who had been expelled from Nicaragua by the Somoza regime; articles on nutrition by Susan Emrich, a biologist with a master’s degree in tropical medicine from Tulane University; articles by John Emrich, a medical doctor, on diseases, causes, and cures; and articles by Marcelo Zúniga, a veterinarian, about ailments common to farm animals crucial to campesinos’ survival and daily life. Women appeared prominently in the newsletter, which featured a special section on “La mujer campesina en acción,” (The Campesina Woman in Action)—short accounts detailing the individual lives and experiences of women health promoters and often recipes provided by them. The newsletter also disseminated information about global health programs and concerns, making health activists aware of their place as agents in a larger transformative force seeking to improve the health conditions and lives of the poor.
The newsletter was designed to provide educational tools, and it linked the challenges of poor health directly with poverty. These characteristics are evident throughout the various features of the paper, but they are graphically illustrated in the cartoons developed by J. Israel Perez P. that occupied at least three pages of each 10–12-page issue of the newsletter. The cartoons featured two central characters: a Ladino (or possibly foreign) young male educator, Pepo, and an indigenous campesino health promoter, Chus. Both men were depicted as stereotypes, with Chus unshaven in tattered clothing and a hat worn and bent at the brim and Pepo neatly dressed in a simple shirt and appearing literally wide-eyed. The cartoons rarely focused on health per se. Instead, they served, on the one hand, as educational tools by introducing effective teaching strategies and offering “stories to discuss” with groups, while on the other hand, they provided knowledge about structural conditions of poverty and how promoters could teach, organize, and transform their own communities.
Health promoters and directors from throughout Guatemala and from El Salvador, Costa Rica, Panama, Mexico, and Haiti sent in letters expressing gratitude for the knowledge they gained from the publication. Sister Trudy from the Centro Apostolico, Morales, Izabal, for example, tells us that “these responses come from the base, and they are the opinion of 38 promoters who ‘sometimes’ have the opportunity to receive the newspaper, and that those who receive it are few, but they share it little by little … we receive a copy of El Informador that by turns passes to the 38 promoters of her community, who more or less read it or listen to what the newspaper says, some 118 more people besides the 38 promoters … of these 38 promoters, 15 said that the first thing they read are the articles about: health, illnesses and their remedies; 14 said they first read the graphic articles (chistes, cartoons); 5 first read the letters that come from other places where other promoters recount their experiences and 3 said that they read, La mujer campesina en acción.”49
In 1980, ASECSA gained a physical location at the former site of a cooperative training program in Chimaltenango. This year also marked the beginning of what would be the most intense period of violence in the country. Many Maya health promoters were killed by the US-trained military, yet ASECSA survived, becoming a key intermediary force between Mayas forced to flee to Chiapas, Mexico and those who remained in the country in “communities of people in resistance” (CPRs). Some health agents argue that the organization’s survival depended not only on the strength and breadth of its popular networks, but also on the depth of its funding from international agencies that provided security by ensuring that violence against promoters and directors would be publicized globally and might have broader political repercussions for Guatemala. ASECSA and the Committee for Campesino Unity (CUC) were, in fact, the only Maya-dominated national popular organizations that survived the country’s armed conflict.
Communitarian health programs in Guatemala and their linkages to Central America, including religious health networks which received funding from international aid agencies, provided a space to “popular” health educators from throughout Central America to engage in health education and critical analysis of the conditions that contributed to illness. The topic raises questions about health and religion, and hints at their relationship to political activism. As one health promoter from the Behrhorst clinic concluded, “Curing diseases without touching their origins is an error, a mistake[;] a sick and malnourished person might recover here at the hospital, but confronted with the same situation at home will soon get sick again. If sickness comes from lack of our own care, we can combat it, but if it is the result of economic problems, the solutions are hard to come by.”50 In Guatemala, it was difficult to overlook the relationship between illness and poverty, especially in the particular context of the Cold War and the corresponding development of liberation theology. In this context, health could never be simply about providing medicine, and health promoters could never serve as simple administrators, if the goal was an end result that truly led to good health for all.
Discussion of the Literature
In their comprehensive review of the historiography of public health in Latin America, Anne-Emanuelle Birn and Raul Necochea note that studies of medical models of imposition associated with colonialism, neocolonialism, and imperialism shifted to more contemporary postcolonial perspectives, emphasizing public health and science as points of encounter, exchange, and engagement. Steven Palmer’s pioneering work on the expansion of the state through provision of medical services in Costa Rica highlights the dynamism of this process and the ways that local agents in rural communities transformed, improved, and owned medical practices.51 Marcos Cueto, Gabriela Soto-Laveaga, and Mariola Espinosa highlight the ways that Western scientific knowledge was predicated on encounters and exchanges (rarely acknowledged) between US and Latin American scientists, but also, as Cueto and Soto-Laveaga illustrate, with “organic intellectuals.”52 In his research on epidemics in Peru, Cueto highlights the crucial role played by Seventh Day Adventists led by Manuel Núñez Butrón, who created “health brigades” composed of Aymara men who became agents of scientific knowledge about health.53 Soto-Laveaga examines the defining role that local knowledge of barbasco (a native tuber) played in the development and globalization of modern birth control.
While recent studies thus center Latin America in emerging public health paradigms, Birn and Necochea note lacunae in the research. They observe, for example, that “secularization and the increased control of the delivery of health care by state institutions resulted in effective challenges to the discursive authority of the Catholic Church,” yet clergy continued to direct health centers and to provide health services throughout Latin America in the 20th century.54 Although religious agents remain crucial figures in health services in contemporary Latin America, their role has not often been studied directly.55 The authors also observe that most studies conclude before the 1930s, leaving the era of the Cold War a central gap in the literature.56 I would add that, while historical research on public health in Latin America and as a component of global health efforts has increased, it tends to emphasize Mexico, Argentina, Brazil, Chile, and Bolivia, with occasional reference to Venezuela and Colombia. With the exception of Steven Palmer’s examination of Costa Rica and the Caribbean,57 Mariola Espinosa’s analysis of yellow fever and US intervention in Cuba, and Alexandra Stern’s study of US public health policies in Panama, Central America and the Caribbean remain largely absent from historical research on public health. Moreover, while more recent postcolonial studies have identified local actors’ roles in providing health services and disseminating scientific knowledge, the emphasis (with the exceptions discussed) remains on professionals (foreign and national medical doctors and scientists) in the expansion of Western medicine and science.58 Finally, while research on social medicine has highlighted the ways that provision of health services became a component of leftist and socialist governing ideals, less has been done to examine health services and medicine as forces in political transformation.59
Research on ASECSA, health, and religion Central America and Mexico during the Cold War may help to fill some of these lacunae by introducing a neglected region, focusing on the central role of religious actors, and highlighting the continued importance of licensed “empirics” in public health during the Cold War era.60 Moreover, the research may offer crucial insight into the political nature of popular health. Secondary literature on religion and health in Central America is limited. Medical anthropologists conducting research in Guatemala have addressed indirectly the impact of religious health programs in Maya communities in Guatemala’s western highlands. A few examples include the anthropologist Clyde M. Woods, who wrote extensively about changing Maya beliefs associated with healing in San Lucas Toliman.61 Sheila Cosminsky examines the impact that medical choice, including the presence of a clinic staffed by foreign clergy, had on a Maya community in the department of Solola.62 Lois Paul and Benjamin D. Paul’s studied midwives, providing important insight into the cultural context in which health promoter programs grew in Guatemala.63 David Carey’s Our Elders Teach Us introduces Maya testimony recounting beliefs about illness and disease and experiences with Western imposition of programs for disease eradication.64 Sandra L. Orellana’s Indian Medicine in Highland Guatemala provides crucial insight into the intersection of Catholic mission and Maya medicine during the colonial period, as does Martah Few’s For All of Humanity.65
Paul Farmer’s Pathologies of Power places health and human rights in the framework of liberation theology; one chapter examines health programs introduced in Chiapas, Mexico based on the health promoter model.66 Sandy Smith-Nonini’s Healing the Body Politic examines contemporary movements for health rights in El Salvador and traces their origins to liberation theology and health programs associated with Christian Base Communities.67 Luisa Cabrera’s Otra historia para contar, commissioned by ASECSA, offers the most comprehensive study of the organization.68 Cabrera undertook the study before the conclusion of Guatemala’s armed conflict, making the conditions of research and interviewing especially challenging.
The Centro de Investigaciones Regionals de Mesoamerica (CIRMA) has a partial collection of El Informador, a catalog of newspaper clippings on health promoters in its Inforpress Collection, and the records of the Congreso Nacional de Medicina in 1966 and the Congreso Nacional de Salud in 1971. CIRMA also maintains some records of the Behrhorst clinic in Chimaltenango, which has been the subject of a number of monographs. These works tend toward hagiography, but they nonetheless provide useful information about the clinic’s health programs.69 Carroll Behrhorst also wrote a book about his work in Chimaltenango and published various articles in the field of public health.70 The archive of the Evangelical Lutheran Church of America has a small number of folders devoted to Carroll Behrhorst and the Chimaltenango Development Project.
The United States Agency for International Development (USAID) maintains extensive records on its support for health promoter and midwifery programs. Many of these USAID reports can be found online. However, they rarely identify the linkages to religious organizations, presumably because they sought to maintain the separation of church and state. Additional information about USAID and its support for development projects in Guatemala can be found in the USAID Bureau of Latin American Development (RG286) Collection and the Records of the Department of State (RG59) at the National Archives and Records Administration in College Park, Maryland.
David Werner has made the early journal accounts from his travels to Ajoya available online. Additionally, Donde no hay doctor is itself a valuable source for analyzing a Western-trained scientist’s efforts to adapt medical knowledge to the reality of an indigenous community. Werner illustrated the book using images recounting experiences he shared with members of the community in his efforts to develop health programs. In addition to these sources, Werner, who became active in global public health programs, published extensively.71
The Maryknoll Catholic missionaries maintain records about their work in Guatemala that include a collection devoted to the sisters’ hospital and medical programs in Huehuetenango and subsequently in the Petén and on the southern coast of Guatemala, where they later became active in HIV-AIDS health programs. These materials can be found at the Maryknoll Mission Archive. Maryknoll health providers in Guatemala also worked with Dr. Roberto Gereda to develop an oral health promoter program. Gereda has published extensively about this program, and a number of theses written by students at the University of San Carlos in Guatemala have examined it.72 The University of San Carlos has a searchable catalogue online that provides access to theses.
Special thanks go to the organizers and participants of the Health Activism Symposium at Yale University and to the University of California, Santa Barbara Symposium on Science, Health, and Medicine for comments on preliminary versions of this essay. Thank you also to the reviewers for outstanding editorial suggestions.
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Orellana, Sandra L. Indian Medicine in Highland Guatemala: The Pre-Hispanic and Colonial Periods. Albuquerque: University of New Mexico Press, 1987.Find this resource:
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Roldán, Mary. “Acción Cultural Popular (ACPO), ‘Responsible Procreation,’ and the Roots of Social Activism in Rural Colombia.” Latin American Research Review 49 (2014): 27–44.Find this resource:
Soto-Laveaga, Gabriela. Jungle Labaoratories: Mexican Peassants, National Projects, and the Making of the Pill. Durham, NC: Duke University Press, 2009.Find this resource:
Steltzer, Ulli. Health in the Guatemalan Highlands. Vancouver: Douglas & McIntyre, 1983.Find this resource:
Werner, David. Donde no hay doctor: Un guía para los campesinos que viven lejos de los centros médicos. Mexico City: Pax-México, 1984.Find this resource:
(1.) Sandy Smith-Nonini, Healing the Body Politic: El Salvador’s Popular Struggle for Health Rights from Civil War to Neoliberal Peace (New Brunswick: Rutgers University Press, 2010), 75–97, examines the parallel and linked process in El Salvador; Paul Farmer, Pathologies of Power: Health, Human Rights, and the New War on the Poor (Berkeley: University of California Press, 2003), analyzes one long-term development of this process in Chiapas, Mexico. Anthropologist Christine Kovic brought to my attention with the following document the fact that participants in El Primero Congreso Indígena de Chiapas Bartolomé de Las Casas in 1974 identified health as one of six central concerns: Gaspar Morquecho, “El Congreso Diocesano Pastoral de la Madre Tierra,” writes that “La Salud es vida: Los medicos están concentrados en las ciudades y nunca salen al campo … Ignoran la lengua tzotzil … no conocen nuestras costumbres y sienten un gran desprecio por el indígena … En los Centros de Salud nos tratan mal, por eso no tenemos confianza … ” (“Health is life: doctors are concentrated in the cities and never go out to the countryside. They do not know the Tzotzil language … they are unfamiliar with our customs and feel a great disrespect for the indigenous … in health centers they treat us badly, so we have no confidence [in them].”)
(2.) Susanne Jonas and David Tobis, Guatemala (New York: North American Congress on Latin America, 1974), 6.
(3.) Greg Grandin, The Last Colonial Massacre: Latin America and the Cold War (Chicago: University of Chicago Press, 2004); Kirsten Weld, Paper Cadavers: The Archives of Dictatorship in Guatemala (Durham, NC: Duke University Press, 2014).
(4.) Bruce Johnson Calder, Crecimiento y cambio de la Iglesia Católica Guatemalteca, 1944–1966 (Guatemala: José de Pineda Ibarra, 1970); Richard N. Adams, Crucifixion by Power: Essays on Guatemalan National Social Structure, 1944–1966 (Austin: University of Texas Press, 1970), 195, 292.
(5.) Steven Palmer, “Central American Encounters with Rockefeller Public Health, 1914–1921,” in Close Encounters of Empire: Writing the Cultural History of U.S.—Latin American Relations, edited by Gilbert M. Joseph, Catherine C. LeGrand, and Ricardo D. Salvatore, (Durham, NC: Duke University Press, 1998), 311–333, 312.
(6.) Forrest D. Colburn, Cornell University Rural Development Committee: Special Series on Health Paraprofessionals, Guatemala’s Rural Health Paraprofessionals (Ithaca, NY: Center for International Studies, Cornell University, 1981), 1–5.
(7.) Charles Keaty and Geraldine Keaty, “Private Voluntary Organizations in Health,” in Guatemala Healthcare Sector Assessment (Washington, DC: USAID, 1977), 5.8‐30.
(8.) Charles Keaty and Geraldine Keaty, A Study of Health-Related Private Voluntary Organizations in Guatemala, 5.8‐2.
(11.) Ibid., 5.8‐62. The forty-two PVOs interviewed for this study (5.8-2) spent $1.3 million to see 615,000 patients in fifty-three facilities, while MOH spent $11.4 million to see 637,000 patients in 566 facilities.
(14.) Smith-Nonini, Healing the Body Politic; Mexico initiated rural health programs that relied on health promoters during the era following the revolution. It is not clear to what extent or even if these programs influenced those established later in Mexico and Central America. Stephen Lewis, “Modernizing Message, Mystical Messenger: The Teatro Petul in the Chiapas Highlands, 1954–1974,” The Americas 67.3 (2011): 375–397.
(15.) Interview by author with HPVO worker, April 12, 2009, Petén; Luisa Cabrera, Otra historia por contar: Promotores de Salud en Guatemala (Guatemala City: Asociación de Servicios Comunitarios de Salud, 1995), 26; David Stoll, Rigoberta Menchú and the Story of All Poor Guatemalans (Boulder, CO: Westview, 1999), 94.
(16.) Jacques Ranciére, The Philosopher and His Poor, edited and with introduction by Andrew Parker, translated by John Drury, Corinne Oster, and Andrew Parker (Durham, NC: Duke University Press, 2003), provides a brilliant analysis of the challenge of “allowing” the poor to become intellectuals despite their impoverished status and condition as laborers. In practice, medical innovations brought by religious agents were one component of a much more dramatic social transformation that redefined Maya communities in Guatemala’s western highlands. See Douglass Brintnall, Revolt Against the Dead: The Modernization of a Mayan Community in the Highlands of Guatemala (New York: Gordon and Breach, 1979); Ricardo Falla, Quiché rebelde: estudio de un movimiento de conversión religiosa, rebelde a las creencias tradicionales, en San Antonio Ilotenanga, Quiché (1948-1970) (Ciudad Universitaria, Guatemala: Editorial Universitaria de Guatemala, 1978). Kay B. Warren, The Symbolism of Subordination: Indian Identity in a Guatemalan Town (Austin: University of Texas Press, 1978); John Watanabe, Maya Saints and Souls in a Changing World (Austin: University of Texas Press, 1992).
(17.) David Carey, Our Elders Teach Us Maya–Kaqchikel Historical Perspectives: xkib’ij kan qate’ qatata’ (Tuscaloosa: University of Alabama Press, 2001); Martha Few, For All of Humanity: Mesoamerican and Colonial Medicine in Enlightenment Guatemala (Tucson: University of Arizona Press, 2015); Sandra Orellana, Indian Medicine in Highland Guatemala: The Pre-Hispanic and Colonial Periods, (Albuquerque: University of New Mexico Press, 1987); Lois Paul and Benjamin D. Paul, “The Maya Midwife as Sacred Specialist: A Guatemalan Case,” American Ethnologist 2.4 (1975): 707–726.
(73.) El Informador series logo for ASECSA.
(18.) Cabrera, Otra historia por contar, 27.
(19.) Philip Berryman, Christians in Guatemala’s Struggle (London: Catholic Institute for International Relations, 1984).
(20.) M. M. Coady, Masters of their own Destiny: The Story of the Antigonish Movement of Adult Education through Economic Cooperation (New York: Harper & Row, 1939).
(21.) Although these ideas are associated with the era following the Second Vatican Council and the advent of liberation theology, they had much earlier roots in the United States in the National Catholic Rural Life Conference and in Canada in the Antigonish Movement. See David S. Bovée, The Church and the Land (Washington, DC: Catholic University of America Press, 2010); Catherine LeGrand, “The Antigonish Movement of Canada and Latin America: Catholic Co-operatives, Christian Communities, and Transnational Development in the Great Depression and the Cold War,” in Local Church, Global Church: Catholic Activism in the Americas before Vatican II, edited by Stephen J. C. Andes and Julia G. Young (Washington, DC: Catholic University of America Press, 2016).
(22.) Deborah Levenson-Estrada, Trade Unionists against Terror: Guatemala City 1954–1985 (Chapel Hill: University of North Carolina Press, 1994), 80–91, demonstrates that Cardijn, who visited Guatemala in the 1950s, had a profound impact in the country.
(23.) Paulo Freire, Pedagogy of the Oppressed (15th ed., New York: Continuum, 2000).
(24.) Mary Roldán, “Acción Cultural Popular (ACPO), ‘Responsible Procreation,’ and the Roots of Social Activism in Rural Colombia,” Latin American Research Review 49 (2014): 27–44.
(25.) Keaty and Keaty, Study of Health-Related Private Voluntary Organizations, Introduction by Gabriel Evans, Office of the Coordinator of International Affairs, Ministry of Public Health and Social Services.
(26.) In 1971, the government of Guatemala’s Ministry of Health recognized the Maryknoll sisters’ health promoter programs. In 1975, Andrew Weisenthal undertook a study of health for USAID, which included visits to a number of the core health programs established by HPVOs at the time, including David Iven, Casa Parroquial, Santiago Atitlán, Sololá, Sister M. Immaculata Burke, Centro de Salud, El Novillero, Santa Lucia Utatlán, Sololá, Miss Ruth Wardell, Clínica Evangélica MAM, Centro Evangélico MAM, San Juan Ostuncalco, Quezaltenango, Madres Maryknoll, Jacaltenango, and Huehuetenango. Andrew Weisenthal, “Report Field Trip, 1/28/75–1/31/75” NARA, Box 2 of 3 RG286-81-10, Subject FY75 Public Health. National Archives and Records Administration (NARA).
(27.) Development Assistance Programs of U.S. Non-Profit Organizations, Guatemala, 1976—TAICH (Technical Assistance Information Clearing Report) Country Report, in Rachel McCleary, Global Compassion: Private Voluntary Organizations and U.S. Foreign Policy since 1939 (Oxford: Oxford University Press, 2009), 78. The Advisory Committee on Voluntary Foreign Aid established TAICH to provide a global listing of all private voluntary organizations.
(28.) United States Agency for International Development (USAID) “Extension of Health Services to Finca Workers,” Guatemala Health Sector Assessment (November 1977) PN-AAH-398, 5.7‐3.
(29.) Linda Buckley Green, “Consensus and Coercion: Primary Health Care and the Guatemalan State,” Medical Anthropology Quarterly, new ser., 3.3 (1989): 246–257. This effort was part of a global push to provide healthcare to the world’s poor signified by the World Health Organization’s (WHO) slogan adopted at the 1978 Alma Ata Conference, “Health for all by the year 2000,” which contributed to USAID expenditures to achieve this end.
(30.) It appears that USAID’s greatest early engagement with health in Guatemala came in relation to efforts to promote birth control. See “Noncapital Project Paper: Details a study by the University of San Carlos critiquing efforts to control population growth,” Project N520-11-580-189 AID873/State Department, 12-13-68, ACC286-76-069 Folder Pop Growth Ctrl #1 1969. It indicates: “Family Health Project was initiated in 1967 to create awareness of the population problem and encourage family planning in Guatemala … The family planning program within the Ministry of Health has not been given the high level of priority necessary for rapid expansion of services. In spite of this the number of active users increased by 10% from Sept. 73 to Sept. 74. The Directors of the Program have been reluctant to order large quantities of the currently contracted oral contraceptive because of the problems encountered with side effects, e.g. hemorrhage and amenorrehea. Their reluctance has been overcome and sufficient stocks have been ordered to fill the country's needs.” “Letter to Edward W. Coy, Director, November 21, 1974,” AL286-81-10 Subj. 75, Pub Health Folder: Pop. National Archives and Records Administration. In 1972, a $3,400,000 loan was approved for the second phase of a program for “improvement of rural health services.” USAID-DLC/P-1045, June 23, 1972, Subject: Guatemala—Rural Health II.
(31.) Interview by author with HPVO agent who worked in these programs at the time, April 12, 2009, Petén, Guatemala. At the time, the health program initiated by the HPVO affiliated with the parish of Lake Atitlán represented virtually the only external influence on the closed fincas, which were notorious for their violent exploitation of workers and devastating conditions. The speaker believed that USAID took over the program because it did not want the presence of outsiders on the fincas, where there was tremendous potential for labor unrest, which would be realized in 1980 in the largest strike by sugar workers in Guatemala’s history.
(32.) Susan Fitzpatrick-Behrens, “Maryknoll Sisters, Faith, Healing, and the Maya Construction of Catholic Communities in Guatemala,” Latin American Research Review 44.3 (2009): 27–49.
(33.) Contacto 19: Christian Medical Commission World Council of Churches, 150 Route de Ferney, 1211 Geneva 20, Switzerland, “The Chimaltenango Development Project, Guatemala, Carroll Behrhorst, MD,” 1973, CIRMA 3848; online at http://www.popline.org/node/517239.
(34.) Carroll Behrhorst, “The Chimaltenango Development Project in Guatemala,” in collaboration with E. P. Mach, M.D., Division of Strengthening of Health Services, World Health Organization, and published in Health by The People (Geneva, Switzerland: World Health Organization, 1975), 3.
(36.) Carroll Behrhorst, “A Design for the Expansion of the Chimaltenango Development Program in Uspantan, Quiché, Guatemala” (Guatemala City: CIRMA D-2044, n.d.). Among the people trained as health promoters at the Uspantán extension program was Vicente Menchú Tum, father of Nobel laureate Rigoberta Menchú Tum.
(37.) David Werner, Donde no hay doctor: Una guia para los campesinos que viven lejos de los centros medicos (Mexico City: Pax-Mexico, 1975). David Werner was cofounder of the international Hesperian Foundation, which published his book, Donde no hay doctor. In 1991 he received a MacArthur Genius Award recognizing his contributions to communitarian health and the particular health needs of developmentally disabled children. Additional information about Werner can be found at the Hesperian Foundation.
(38.) Intervew by author with David Werner, June 1, 2014, Silver Lake, New Hampshire.
(39.) Interview by author with secular HPVO agent, April 12, 2009, Petén, Guatemala.
(40.) El Informador, 3. 10, November 1978, 1.
(41.) Cabrera, Otra historia por contar, 29.
(42.) El Informador Comunitario, 4.5, May 1979, 1. Competition between medical “professionals” and empirics has been a common feature of the development of public health in Latin America. See Steven Palmer, From Popular Medicine to Medical Populism: Doctors, Healers, and Public Power in Costa Rica, 1800–1940 (Durham, NC: Duke University Press, 2003); Ann Zulawski, Unequal Cures: Public Health and Political Change in Bolivia, 1900–1950 (Durham, NC: Duke University Press, 2007).
(43.) Skype interview by author with HPVO agent from Huehuetenango, July 6, 2012. See Edgar Esquit, “Nationalist Contradictions: Pan-Mayanism, Representations of the Past, and the Reproduction of Inequalities in Guatemala,” in Decolonizing Native Histories: Collaboration, Knowledge, and Language in the Americas, edited by Florencia Mallon (Durham, NC: eDuke, 2012), 196–218.
(44.) Interview by author with secular HPVO agent, April 12, 2009, Petén, Guatemala.
(46.) Mary Hamlin de Zúniga, “Apuntes Editoriales” El Informador Comunitario 4.9 (September 1979): 1.
(47.) Interview by author with secular HPVO agent, April 12, 2009, Petén, Guatemala.
(48.) Skype interview by author with HPVO agent from Huehuetenango, July 6, 2012.
(49.) El Informador 4.11 (November 1979): 6.
(50.) Steltzer, Health in Guatemala’s Highlands, 24.
(51.) Palmer, From Popular Medicine to Medical Populism.
(52.) Marcos Cueto, El regreso de las epidémias: Salud y sociedad en el Perú del siglo XX (Lima: Instituto de Estudios Peruanos, 1997); Mariola Espinosa, Epidemic Invasions: Yellow Fever and the Limits of Cuban Independence, 1878–1930 (Chicago: University of Chicago Press, 2009); Gabriela Soto-Laveaga, Jungle Laboratories: Mexican Peasants, National Projects, and the Making of the Pill (Durham, NC: Duke University Press, 2009).
(53.) Marcos Cueto, “Tifus, viruela e indigenismo: Manuel Núñez Butrón y la Medicina Rural en Puno,” in Cueto, El regreso de las epidemias, 87–126.
(54.) Birns and Necochea, “Footprints on the Future,” p. 511. Raúl Nechochea López, “Priests and Pills: Catholic Family Planning in Peru, 1967–1976,” in Latin American Research Review, Vol. 43, No. 2 (2008), pp. 34–56 provides important insight into the sometimes surprising role of Catholic clergy in contemporary health issues in Latin America.
(55.) Cueto, “Tifus, viruela, y indigenismo,” presents one exception.
(56.) Birns and Nechochea, “Footprints on the Future,” 525.
(57.) Palmer, From Popular Medicine to Medical Populism; Steven Palmer, Launching Global Health: the Caribbean Odyssey of the Rockefeller Foundation (Ann Arbor: University of Michigan Press, 2013). For more contemporary studies see Walter Randolph Adams and John Palmer Hawkins, Health care in Maya Guatemala: Confronting Medical Pluralism in a Developing Country (Norman: University of Oklahoma Press, 2007); Sandy Smith-Nonini, Healing the Body Politic: El Salvador’s Popular Struggle for Health Rights from Civil War to Neoliberal Peace (New Brunswick: Rutgers University Press, 2009); Luisa Cabrera, Otra Historia por contar: Promotores de salud en Guatemala (Guatemala City: Asociación de Servicios Comunitarios de Salud, 1995);
(58.) Espinoza, Epidemic Invasions; Alexandra Stern, “The Public Health Service in the Panama Canal: A Forgotten Chapter of U.S. Public Health,” Public Health Reports 120.6 (2005): 675–679.
(59.) Howard Waitzkin, Celia Irart, Alfredo Estrada, and Silvia Lamadrid, “Social Medicine Then and Now: Lessons from Latin America,” American Journal of Public Health 91.1 (2001): 1592–1601; Angela Vergara, “The Recognition of Silicosis: Labor Unions and Physicians in the Chilean Copper Industry, 1930s–1960s,” Bulletin of the History of Medicine 79.4 (2005): 723–748. In 2010 Naomi Rogers, Mandisa Mbali, and Esylit Jones organized a symposium “Health Activism in the Twentieth Century: A History of Medicine at Yale University,” which sought to introduce a new field of study in global health activism.
(60.) Birns and Necochea, “Footprints on the Future”; Palmer, From Popular Medicine to Medical Populism; Ann Zulawski, Unequal Cures: Public Health and Political Change in Bolivia (Durham, NC: Duke University Press, 2007). All highlight the intersections of “professional” Western medicine and “empiric” practices of health.
(61.) Clyde M. Woods, “Medicine and Culture Change in San Lucas Toliman: A Highland Guatemalan Community” (PhD diss., Stanford University, 1968); Clyde M. Woods and Theodore D. Graves, The Process of Medical Change in a Highland Guatemalan Town (Los Angeles: University of California Press, 1973).
(62.) Sheila Cosminsky, “Decision Making and Medical Care in a Guatemalan Indian Community” (PhD diss., Brandeis University, 1972).
(63.) Paul and Paul, “The Maya Midwife as Sacred Specialist.”
(64.) Carey, Our Elders Teach Us.
(65.) Orellana, Indian Medicine in Highland Guatemala; Few, For All of Humanity.
(66.) Farmer, Pathologies of Power, especially pp. 139–178.
(67.) Smith-Nonini, Healing the Body Politic, especially 75–98.
(68.) Cabrera, Otra historia por contar.
(69.) Edwin Barton, Physician to the Mayas: The Story of Dr. Carroll Behrhorst (Philadelphia: Fortress, 1970);Ulli Steltzer, Health in the Guatemalan Highlands (Vancouver: Douglas & McIntyre, 1983); Richard Luecke, A New Dawn in Guatemala: Toward a Worldwide Health Vision (Prospect Heights, IL: Waveland, 1993); Behrhorst Clinic Foundation. “Go to the People”: A Video Tribute to Dr. Carroll Behrhorst. [S.l.]: Behrhorst Foundation, Behrhorst Clinic Foundation.
(70.) Barton, Physician to the Mayas.
(71.) David Werner, “The Village Health Worker: Lackey or Liberator?” World Health Forum, 2.1 (1981): 46–68; David Werner and Bill Bower, Helping Health Workers Learn: A Book of Methods, Aids, and Ideas for Instructors at the Village Level (Berkeley: Hesperian Foundation, 1982); David Werner, Disabled Village Children: A Guide for Community Health Workers, Rehabilitation Workers, and Families (Berkeley: Hesperian Foundation, 1987); David Werner and David Sanders with Jason Weston, Steve Babb, and Bill Rodriguez, Questioning the Solution: The Politics of Primary Health Care and Child Survival: with an in-depth critique of Oral Rehydration Therapy (Palo Alto, CA: Healthwrights, 1997).
(72.) J. Francisco Cabarrus P., Carlos E. Pomes, Edgar A. Moran, and Roberto Gereda, “Programas de ejercicio professional supervisado y de promotores rurales de salud oral en Guatemala,” Educación Medicina Salud 12.4 (1978): 361–391.