Breastfeeding paper

Here is something we have been working on. I'm attaching a part of it because I'm bored

Introduction

I would just give her a cup of coffee. When I had rice, atol, I would give it, but when I don’t have it, I can’t. When I don’t have a way to give it, I don’t give it. I don’t have a way to give it, as much as my heart would like to, but I just don’t have a way.

Sitting on a broken plastic stool in the heat of her parents’ one-room house, Flora explained how difficult it was to provide for her daughter, Marisa, throughout her infancy. Flora’s eyes were infused with the intensity of her memories—of how thin Marisa became, how her stomach swelled up and all her ribs became visible, and how everyone feared she would die. Yet she described her helplessness to feed and cure Marisa with calm; Flora, like many of Guatemala’s rural poor, is long accustomed to the daily struggles of hunger and sickness.

Flora is twenty years old. She feels that her life has improved since her childhood, when her family was far worse off than they are now. She recalls how the dirt floors used to turn to pure mud when the house would flood during the rainy season; how so often, she ate nothing but tortillas with salt and drank bitter coffee since her parents could not afford sugar; how she used to feel her heart flutter with exhaustion every time she walked, but nevertheless went to work as a maid at the young age of fourteen to help feed the family. At least now, she says, they have a cement floor. At least now, they sometimes have more food than just tortillas. At least now, she receives free vitamins through a foreign health project and no longer feels tired throughout the day.

Even though Flora feels that she is better off today than she was twenty years ago, she and her husband Ramon rarely have enough food for themselves and their two children—Marisa, now two years old, and Angelica, a baby of eight months. Ramon, who has worked in cattle ranching, meat sales, and construction, rarely finds more than a temporary job, which draws him away from home for one or two weeks. Upon his return, he gives Flora gastos, a portion of his salary he allots for her to buy the family’s food supply. The amount is variable, depending on how much Ramon is paid, how much debt he accumulates from food and lodging at his worksite, and whether he lapses into alcoholism and spends his salary at bars. Flora must spend the money wisely in the Sunday market, using every centavo to its maximum potential.

Flora and Ramon, too poor to afford their own house, used to live in a rented room with Ramon’s two parents, seven siblings, and eight nieces and nephews. Cramped, crowded, and suffering to help bring enough food to the table for all, the couple eventually moved to Flora’s parents’ house, where there were fewer people—ten in total, as opposed to nineteen. There, they have a little bit more space and a better chance of having enough to eat. When Ramon does not have work, Flora’s parents provide the food for both families. When Flora’s father does not have work, she stretches her gastos to feed her parents and younger siblings in addition to her own nuclear family of four. More often than not, both Ramon and Flora’s father are unemployed, and the family eats the cheapest meals possible: tortillas with salt and coffee with sugar.

For a woman like Flora, it is almost impossible to follow the common biomedical recommendation that mothers introduce solid foods into infants’ diets at six months of age². At this point, breast milk is no longer a sufficient source of nourishment for infants, who require early complementary foods for proper growth and nutrition³. But Flora has inconsistent access to food, and her opportunities to obtain more food are few and far between. She has already taken one step--the move to her parents’ house--to guarantee more food per family member. However, finding more money for food is impossible. Flora, who cannot work because she has two young children to care for, is economically dependent on Ramon. Ramon snatches any chance to work, but those chances come with unjustly low wages and do not come often enough. Planting and growing the family’s food is also infeasible. Inequalities in land distribution, land loss, an increased gang presence in rural areas, and rampant thievery of crops prevent families from participating in subsistence agriculture even when they have money to buy seeds and plants.

Even if a doctor had told Flora to give Marisa early complementary foods when she was six months old, Flora would not have been able to do so. Ramon did not have enough work to expand the family’s food budget. Rather than dipping into the family’s limited food supply to feed Marisa, it made more sense to Flora to give her daughter the most readily available calories: those of breast milk. She continued to exclusively breastfeed Marisa until she was eight months old, when Ramon found a job that provided Flora with gastos to buy and cook vegetables for her infant daughter. Soon thereafter, Marisa became sick with extensive diarrhea and her father entered a long period of unemployment. Flora could no longer offer Marisa anything but tortillas, salt, and coffee, aside from a diminishing supply of breast milk, due to another pregnancy and subsequent decision to wean Marisa from the breast. Without food or medicines for her diarrhea, Marisa’s health declined until she was severely malnourished⁴.

The nutritional guideline of offering the first nonmilk foods (beikost) at six months is offered from a context divorced from food insecurity and economic pressures. The conditions of Flora’s life complicate the idea of using such metrics and placing value upon certain behaviors as the “best” health practices without regard to their setting. It also complicates the use of health education, often an important measure in improving health outcomes, as a way to influence or change a patient’s behaviors. How can we hope that patients will adopt what we deem as biomedically-appropriate behaviors when our suggestions are economically infeasible?

By examining case studies such as Flora’s, this paper explores how economic pressures and gender inequalities significantly constrain poor mothers’ decisions to give infants early complementary foods in rural Guatemala. We argue that because of scarcity and food insecurities, these women are unable to follow biomedical recommendations of “best practices” regarding breastfeeding. They too often cannot begin to provide solid foods at six months, nor can they provide infants with consistent or diverse diets of solid foods. We suggest that health education with regard to the introduction of solid foods must be coupled with efforts that alleviate the financial burden of changing nutritional behaviors. As such, we offer recommendations about maintaining healthy infant growth. We also discuss the implications of applying metrics developed for economically secure, first-world communities to the marginalized poor, and reflect upon the idea of “best practices.”

Thoughts from afar

We are helpless there, we are helpless here.

My initial motivation to spend a year working in Guatemala was a vague sense of wanting to help people. Perhaps many of us who are attracted to the disciplines of medicine, public health, social work, and medical anthropology have this intention. And then when we begin our projects or practices in a poverty-stricken, developing country whose people are oppressed, we question our goal of "helping" people. In the face of unjust suffering and continual misery that is all too often unacknowledged and perpetuated by those who have the power to effect change, we find ourselves wondering if we are able to truly "help" anyone at all.

In Guatemala, I felt helpless more often than I felt helpful. There was no way for me to intervene when Paulino's corrupt bosses didn't pay him after weeks of work. I could do nothing for women like D. Celestina, who went to the hospital with obstetrical emergencies and were ignored until they died. I could not help battered women like VQ find safe places to take refuge when their drunk husbands flew into fits of rage. Even when we did give out Incaparina, de-wormers, and medicines, they were merely palliative measures that couldn't fix any of the underlying political and economic inequalities that would further the malnutrition and sickness we were trying to combat.

I am helpless in the US, as well. In the past few months, bad news from Socorro has punctuated my comfortable life in St. Louis. The death of little Selvin to appendicitis. The pregnancies of women who wished they were on birth control, which their alcoholic husbands objected to. The infants falling off their growth curves.

I know that there is little I could do if I were there. I have to keep reminding myself of that vague motivation to help, the whole reason I embarked upon this long academic journey, and hope that it will make me a more useful member of society than what I am now. And I know that even with an MD, I will not be able to solve a lot of problems. But I would rather be helpless and be there. Trying.

Little old people, monte, and chichas

I just went to the market in San Antonio to try to find some eneldo, a plant which helps milk come down for mothers who are having trouble producing. Unfortunately, eneldo is not available here, as I found out from the traje-wearing little old man who sells monte, or medicinal plants. To determine this, though, I asked the old man if he sold eneldo, to which he scrunched up his wrinkly face, looking very confused, and asked me to repeat the name of the plant four times before saying he didn´t have any. He asked me what it was for, and I said, ¨You know, to bajar la leche.¨ Ahh, he responded, no, he did not have any. Then I was tapped on the shoulder by an equally wrinkly little old lady who appeared out of nowhere--but who had apparently overheard us--and started telling me about other plants I could use to make my milk come down. I didn´t bother explaining that it wasn´t for me, and she told me I ought to come to her spot in the market by the meat vendors tomorrow morning. She said she would bring me a plant that would make my boobs so big that my baby wouldn´t even be able to suckle. Then she called me a little doll and commented on how my breasts are too small to feed anything. Again, she talked about the plant and gestured with her hands to show how much milk there would be, reiterating that my baby wouldn´t be able to hold on.

It was a fun moment. It was also a moment of personal progress for me--I now no longer care as much when people state the obvious about my body, while I certainly would have been much more self-conscious about those comments a year ago. After the kids´ (and adults´) constant ¨You have a mole on your face,¨ ¨You have hairs on your arms,¨¨You have pimples,¨and ¨You went to the US and got fat and white,¨¨Your boobs are small,¨and now this, I think I´m getting more accustomed to what would be offensive comments in the US.

Too bad I didn´t actually find the plant I needed.

Internalized racism

A few anecdotes.

1. Sarah and I were talking to one of the mothers who is on the local school board (which is largely ignored by school teachers and administrators) about the poor quality of education in the local school. The government sends money to the school every year to buy school supplies for the children, but the teachers often take this money and spend it on themselves. The mother was trying to speak out against this, and the teachers told her to be grateful of the service they were doing for her kids. She told them that they ought to be grateful that she had kids, otherwise they would be out of jobs. Sarah and I were impressed at her spunkiness, considering that few women are so outspoken about standing up for their rights here. But then this woman went on to explain what she had told them word for word: "Aunque son negritos, tienen que valorarlos," she said. To translate, she told these teachers--almost all of whom are ladinos, lighter-skinned non-Mayans who are higher up in the racial hierarchy--"Although they are little black kids, you have to value them."

2. We were having a few issues with a family who wasn't coming to pick up their incaparina (the food supplement we are giving out). I started talking about why they wouldn't want to come with Paulino, one of our friends in Socorro who has been helping us throughout the year, and in explaining their behavior he said, "Pero somos indios, somos indigenas. A veces no entendemos." Basically, he said that the reason these people didn't understand the project and didn't understand why it was important to pick up their medicines was that they are "Indians." They are "indigenous." And that's why they sometimes don't understand.

The sad thing is that these types of sentiments are not uncommon in Socorro. People have absorbed the racism they have been fed for generations and learn those values--that a "little black" child (used to mean dark-skinned) is worth less than a white one. That indigenous people just don't understand because after all, they are Indians.

Glazed-Eye Technique: Getting Your Way in Guatemala

Anyone who spends enough time working in the Suchitepéquez area, riding buses, or shopping in the market will quickly become familiar with glazed eyes. In Guatemala, the ATM's deliver your cash in 100's, but unless you are in a big enough city, it can be a pretty useless bill. You can try to hand it to a woman in the market, and she will quickly return it to you with glazed eyes--meaning that she does not have change for it, and expects you to come up with the "sencillo" yourself. You can hand it to the fare collector on the bus, and he will ask you for sencillo and glaze his eyes as soon as you start protesting that you have none--thus making it your responsibility to come up with the smaller bills. Even if money is not involved, but rather some medical tidbit about how it is best to wait more than a day before giving kids medicine for diarrhea, you can expect some glazed-eyes. The glazed-eye is basically a signal that one is choosing not to listen to you because you are either not giving them what they want to receive or telling them what they want to hear. And once you see that cloud of disinterest floating across the pupil, you are doomed to remain unheard--and most likely with your 100.

Peter has encouraged us both to adopt the glazed-eye strategy ourselves, but normally chapines are too quick. They glaze their eyes the fraction of a second before you try, and you're stuck. However, yesterday when my mom came to visit us in Guatemala City, we had a great opportunity to practice. We went to the Museo de Etnología y Arqueología, one of the most famous, and were disturbed to find that the price for nationals is a measley 5Q, while for "extranjeros," or foreigners, they charge 60Q. Sarah and I joked with each other about how we ought to try to pass for Guatemalans, so that we would only have to pay 70Q rather than 180Q.

When we got to the front desk and I told the receptionist that there were three of us, he asked where we were coming from. I decided to try my luck and told him that Sarah and I lived in Guatemala, but that my mom was from the US. "Are you guatemaltecas?" he wanted to know, and Sarah said that we were not, but that we worked in Guatemala. He asked if we had any papers or documents to prove where we were from, and we said no. At this point, I pulled 100 out of my nature's wallet and handed him the bill. Without realizing it, I cut off eye-contact and glazed away, meanwhile hearing him murmur to himself that he would have to charge us 70Q.

When he handed me back 30Q in sencillo and two national tickets, I rejoiced and joked with Sarah about how we had passed off as Guatemalans. She said, "No, we definitely didn't. I'm pretty sure that since you only handed him a hundred, he didn't really know what else he could do."

So, in the end, I unconsciously glazed my eyes to manipulate my way into saving 110Q, which on a volunteer's budget, is great news. And perhaps the greater success: now that we've done it once before, I may have more courage with the ayudantes and vendedoras. If I can glaze my eyes first--in that deciding duel of a moment--maybe they will have to give me sencillo?

The Fine Art of Preparing True Guatemalan Coffee

When strolling the streets (or in my case, more often the airports) of US cities, you are bombarded with coffee shops: Starbucks, Espresso Royale, Caribou Coffee, you name it. Plastered in display windows or scrawled on signs in multi-colored chalk, these shops boast that they use nothing but the finest imported coffee—often from Guatemala.

I am here to tell you, however, that Starbucks (or any of the other above-mentioned coffee peddlers) has absolutely no idea how to prepare a true cup of Guatemalan coffee. If a Guatemalan were to wander into your typical US Starbucks and order a cup of classic, plain old black coffee (if that is even possible to order anymore), he or she would take one sip, gag, and spit it out.

So, you might ask, how does one go about preparing a cup of true Guatemalan-style coffee?

To answer this question, let me tell you a story. While taking a group of patients to Santa Cruz del Quiche for surgery, we spent the night in Antigua. Anita and I made dinner for the patients—your typical tortillas, rice, and tomato sauce—and afterwards, Elida, the mother of one of the patients, asked if we could make some coffee. I noticed that the hotel (a typical backpacker hostel) had a pot of coffee sitting out—fair game—so I grabbed the pot and poured her a cup of US-style coffee—black and steaming.

Elida picked up the cup of coffee, took one sip, and proclaimed it insanely strong. To remedy this, I boiled an entire pot of water—approximately 4 more cups—and added it to the one cup of black coffee. Elida tasted it again and deemed it still a bit too strong, so I added one more cup of water. Pouring a bit into her hand, she tasted it and nodded.

She then proceeded to dump in half a bag of sugar. There—perfect Guatemalan-style coffee.

Anita and I recently stumbled upon a restaurant menu that perfectly displayed the coffee-drinking habits of Guatemalans, and we took a picture for your viewing enjoyment. Note that "Chapin" means "Guatemalan":

Seeing two stripes on a urine-soaked pregnancy test--indicating a positive--will probably cause anxiety anywhere in the world. But among more privileged socioeconomic circles in the US, that anxiety seems to be tied to an anticipated joy of parenthood, while in Socorro, the anxiety often seems to be linked to fear that the family will not be able to make ends meet, or alcanzar, and offer that baby a fair fighting chance in the world.

In the past few months, both Sarah and I have seen stark contrasts between the behavior of our friends, mothers-to-be, living in the US and mothers-to-be (who are almost always already mothers) in Socorro. In the US, upper-middle-class parents hover over a flickering ultrasound and have lists of names prepared, ready to rejoice over little “Lydia” if the technician points to the hamburger bun-shaped labia, or over “Michael” if the sex goes the other way. In Socorro, parents wait to name their kids until three or even four months after birth, because the chances that kids are going to survive are so much lower here that it doesn’t make sense to name them until you know they’re really going to live.

A disturbing comment from a conversation we had today will remain etched at the forefront of my mind for years to come. One of our favorite women in Socorro, a charming matriarch with some of the cutest grandchildren in the village, asked us today about how many brothers and sisters we each have. Sarah and I both responded that we have older brothers, and she seemed interested that our families were so small, consisting of only two parents and two children. “Aren’t there families there with 5, 6, 7 kids like there are here?” Yes, we told her, but it is more common for women to have about two kids where we come from (although I did not qualify that I am referring to upper-middle class families with her, I will do so here). “But if you only have two kids and one of them dies, you just have one left. And if that one dies, then you have nothing,” she said.

Such a comment might seem strange or even morbid in the US. But my heart sank at her comment, thinking of the grave reality of high infant mortality rates here. In several instances, we have done pregnancy tests for women in their forties, already struggling to raise several children, only to find themselves facing those two stripes and expecting another--another mouth to feed, another round of diapers to wash day in and day out, another child to send to school. At these moments, I have often found myself wondering about how important it will be in the future of our project to offer “family planning” to women who want to use it. Women have approached us in secret asking in whispers if we could do pregnancy tests so they could figure out whether they could go to the health centers to get a Depo-shot; they have asked us whether we think it is sinful to use contraception; they have posed heart-rending rhetorical questions to us such as, “Why bring more children into the world just to have them suffer?”

As Sarah and I discussed with Shom a few weeks ago, there abounds a notion that people should responsibly limit their family sizes to “save the world from overpopulation,” which often serves as sort of euphemism for the idea that the world would be better off with fewer sick babies living in poverty--a euphemism which helps us to ignore the “sick babies living in poverty” and concentrate on the “fewer babies,” allowing us to shake off the guilt we (upper-middle classes) ought to feel about the existence of the masses of suffering poor. However, our charming matriarch’s words ought to be a reminder that notions of ideal family size in areas such as Socorro are conditioned by an environment of poverty, suffering, and unnecessary deaths caused by structural inequalities. It is not only our responsibility to offer “family planning” services, but also to begin to remedy those stark disparities in the quality of life between babies who are named before they even see the light outside of their mothers wombs and those who are cautiously named at four months as their five older siblings share three tortillas.