In June 2024, the University of Colorado College of Nursing invited eight students from the UCAN accelerated nursing program to join Guatemalan nurses at a CU partner clinic in the Trifinio region to experience healthcare in a rural area of southwest Guatemala. At the intersection of three municipalities and situated in the middle of a large banana plantation owned by Banasa and a Palm Oil Plantation owned by AgroAceite, the Trifinio clinic offers free health care to the Agro workers and the surrounding community. Included on the site are an open air clinic with exam rooms and a birthing unit soon to open, a pharmacy, a fully equipped laboratory, a housing unit, and a meeting house for health care workers and students. Pam Prag, Director of Global Health Programs at CU, who has traveled with immersion programs all over the world, said she’s never seen a program so well equipped as this to meet the people’s needs in a one-stop shop service center model. This was the first time students in the accelerated program were invited to participate and Pam looks forward to inviting more UCAN students to participate in the future.
CU Students joined Guatemalan nurses who travel many miles daily to rural homes to deliver care via tuk-tuk, a small four-wheeled open-air car, or via motorcycle, which can both get down the narrow dirt paths between conglomerations of makeshift homes. Greeted by eager children and a menagerie of dogs, cats, chickens, pigs, goats, ducks, English hens, and the occasional flock of turkeys, the undaunted Guatemalan nurses dodge tropical rainstorms and leap across the ponds that quickly form around many of the hand built indoor/outdoor style shelters many Guatemalans call home in this area. With no running water, industrious families build makeshift collection water reservoirs and cook over gathered wood fires built in cement block stoves while younger children play in the water puddles, wrestle with the animals, and care for the babies and younger children.
The standing water, inevitable in an area with poor drainage, heavy rains, and no septic system, results in mosquito breeding grounds and the spread of diseases like malaria and dengue fever, which the clinic sees daily. The constant interaction between humans and farm animals along with the tropical climate breeds parasites and many of the clients the nurses visit are offered anti-parasite medicines. Both lack of education and lack of resources result in malnutrition in two out of three Guatemalans, and Guatemala has the highest rate of growth stunting in Central America due to malnutrition. Pregnant mothers and young babies are particularly vulnerable to the negative effects of malnutrition and infection so the nurses assess the patients during home visits and bring medications, iron and zinc supplements, vitamins and bananas, and one could say most importantly, they bring education. They spend several hours with each family, measuring babies’ height, weight, and head circumference, listening with a mobile doppler unit to pregnant women’s babies’ heart rates, and testing the pregnant women’s blood for low iron which is common when meat and iron rich vegetable consumption are limited. They also test blood sugars and urine pH and educate women on nutrition and answer questions. They are master listeners and when prompted, try to dispel rumors that using birth control makes one sterile forever, or encourage women to eat plantains and beans during pregnancy for the nutrition instead of avoiding them due to the widespread belief these foods will cause them to lose the baby.
CU Nursing student Erin Newton smiles with baby. |
Since the clinic opened in 2011, local nurses working with interdisciplinary medical teams have identified community needs and developed specific programs to address those needs. The programs include Creciendo Sanos which includes Madre Sanas and Nino Sanos, or Healthy Mothers and Healthy Children in which babies are followed for 24 months after birth, and mothers are supported through the “Alma” program meaning “soul” in which mental health is supported. Over 350 children are in the program and 220 women participate each year. They specifically support adolescent mothers and also offer a sex education program in secondary schools called “Gran Decisiones” which aims to educate children between 10 and 15 years old on healthy relationships and encourages abstinence or use of birth control and setting goals. The nutritional program nurse typically visits seven families per day, assesses their baby’s intake, monitors growth charts, encourages supplementation with vitamins for malnourished infants, and offers education on family planning, stages of childhood development, and support for adolescent moms. The Creciendo Sanos, or family planning, program offers the Jadelle injection at 1 and 3 months at no cost to prevent unintended pregnancies, and young women are more receptive to this form of birth control over the more invasive IUD option or the more visible birth control pill option, which their family may not support.
Many families who do not have income adequate to boil all drinking water or purchase purified water suffer from constant GI distress, and nurses do their best to educate on risks while recognizing many families are functioning at a basic subsistence level, focused on providing food, clothing, and shelter, so many diseases are recurrent and nurses must refer critically ill patients to the free clinic, hoping they can get there. With most of the men working in the fields or traveling to find work in other countries and sending money home, women often have limited transportation and can only travel to places they can walk with young children in their arms. To supplement income, women often spend all day making food like tamales or tortillas to support their families. Many families live in shelters with corrugated roofs held up by branches they cut from trees and cement blocks. One student said, “It’s more than a little disconcerting as a mom to see just how vulnerable these families are, truly living on the edge of life and death, but the innovative ways they find to survive are a true testament to the resiliency and ingenuity of these families and the Guatemalan people.”
Director of Global Health Programs Pam Prag (L) with CU Nursing UCAN students. |
Among the group of eight students in the program, one grew up in Cuba under an oppressive regime, one grew up in America born to financially disadvantaged parents from Mexico, one grew up in the central valley of California with a large migrant of farmers who harvest thousands of acres of produce, and many in the program had traveled extensively in Spanish speaking countries so we're able to employ their Spanish to interact with the rural low income community. Though their perspectives are all different given their varied life experiences, the students reported this experience will shape each one’s future understanding of care for disadvantaged populations wherever they end up in health care.
The CU students appreciated the fully immersive opportunity to go into the community with the Guatemalan nurses performing assessments of pregnant young women, new moms, and their babies. The students toured the banana packing plant nearby to better understand the working environment of the community and human power involved in moving bananas from the plantations in the area across the world. Their translator commented, “The bananas with imperfections are called “rechaza” or rejects and they get cut off and thrown in a pile in the truck, but I don’t like that term Rechaza. Do you know why? Because those are the bananas that go to my people. The so called rejects.” The workers who pick, sort, clean, and box the bananas make just over $10 per day, and in recent years, with rising temperatures, workers have to drink electrolytes as they were losing too much fluid and nutrients in the hot packing houses. Renal problems are common in this area where people often choose coke over water to try to keep energy levels up for long days in the heat.
The students spent time in the onsite well equipped clinic lab looking at pathogens under the microscope which cause tropical diseases such as Dengue Fever which is making a resurgence in the area, parasites causing gastrointestinal distress for which many in the community are treated due to the poor water quality, and Tuberculosis, which is common in financially disadvantaged communities. The students attended trainings with the “comadronas” or midwives in the community who are highly respected and skilled and are often the only bedside care provider in home Guatemalan births. They were trained on new mobile ultrasound equipment the clinic will utilize with the aim of improving pregnancy monitoring in this area since there is a very high rate of premature births and mortality. Amongst all of these impactful experiences, the students reported seeing the delivery of care provided by the Guatemalan nurses who listened quietly to their patients, took time to educate and help problem solve, and were highly respected by their community, was the most pivotal for their future practice.
CU Nursing students spend time in the clinic lab. |
Gathering each evening to debrief with a small staff of Guatemalan women providing home cooked meals daily, the students shared their experiences out in the field, their insights, and their discomforts with the conditions they saw, being in close contact with families living in destitute poverty. They talked about how they could use informed practice when they are working in healthcare settings worldwide and shared lessons learned for improving community healthcare. At their last debrief following their community immersion, the book “The Bottom Billion” was referenced and as students grappled with the weight of finding ways to make changes in a system that does not support change for the poorest one billion people on earth, including the fifty failed states, one student read that the author Collier’s proposal is that a struggle rages within each of these nations between reformers and corrupt leaders, stating that the corrupt leaders are winning. Collier analyzes the causes of failure including traps these countries fall into like civil war, a dependence on the extraction and export of natural resources, and bad governance. He proposes a bold new plan is needed, supported by the Eight industrialized nations, or G8, including adopting preferential trade policies, new laws against corruption, new internal charters, and carefully calibrated military interventions. As the student group dispersed to work on educational presentations the Guatemalan nurses requested for their home visits, one student said, “It’s all so overwhelming, you don’t even know where to start to make things better. But if I can be a voice and a witness to the suffering we have seen here, then I can make small changes to my practice which hopefully will have a ripple effect wherever I land.”
