Stories from the Field: Clínica Tzanabaj (San Pablo, Guatemala)

by Deborah Flores, RN, Ed.D, MBA E-mail

Lake Atitlan is a large lake approximately 340 meters deep, situated in the Guatemalan highlands. It is flanked by several volcanoes and surrounded by towns and villages inhabited by descendents of Mayan people. They are proud and strong people. The lake itself is one of the most beautiful in the world.

This lake supports coffee and farm crops. Most of the indigenous population survives on very little money as they make a living from the land. The lake is a major life force in their lives. There is cyclical contamination from fertilizer run off, etc. which leads to bouts of cyanobacteria in the lake.

Although the weather is temperate, the rainy season brings mudslides and flooding, which has been known to destroy homes, commercial property and lives.

There are several small hospitals around the lake; one is public, and the others are private. There are also many clinics which provide basic medical and dental care. These are supported by churches and/or by locals, and some of these are private as well. Providers are predominately volunteers who either come in to the area from Guatemala City or are on short assignments from US, Europe or other parts of Central or South America. Much of the equipment is donated either through medical companies or churches. This in itself can be a challenge.

In December 2010, my husband, a general surgeon practicing in the US, decided to retire from medicine. He is from Guatemala, and for many years has desired to return there. He has always been drawn to the lake area, as so many people are. He decided we could contribute if we opened a health center to care for the people, because basic healthcare needs are difficult to meet. For example, basic dental care is in great need, infants suffer from dehydration and the women suffer from early respiratory disease due to cooking over an open fire that often is not vented properly.

After much deliberation and planning, the clinic is now being built in San Pablo, a town with inadequate water and sewage systems.

Most children get a basic education but seldom leave the lake area. It is a closed community and very difficult to earn people’s trust.

We hired approximately 50 local workers and, with the help of a family member who is an engineer and architect, the workers were taught how to create and build using the earth underneath them. All of the materials are made on site, and rock is hauled from the riverbed to use for the rest of the structures. These men have acquired skills that they will now be able to use for the rest of their lives, hopefully to gain future employment after the project is complete. At this writing, this site has been under construction for over two years. The project itself has had an economic impact on the community, as it is the largest construction project that has ever been implemented in San Pablo.

Before breaking ground, a shaman blessed the land, as this was very important to the local workers. We then joined a local parade to advertise the coming clinic. Our workers started a soccer team for “Clínica Tzanabaj” and wear special shirts to denote who they are. We will continue to find ways to advertise the facility, but in reality, you cannot miss it driving through the area between San Pablo and San Marcos.

Until the clinic is finished, my husband travels from town to town to assist with surgeries as needed. When the clinic is complete, I will join him there to provide primary care. We hope in this way we have been able to impact our world far more than if we had stayed in the US and continued to provide care.

Deborah Flores will be joining the faculty of Research School of Nursing, which is affiliated with Rockhurst Univerisity.  Her husband is a general surgeon who retired early and is providing free care in Central America, and she joins him every few months to assist.

Health Care as a Means to Peace

By Courtney Cawthon

Attending the Community-Based Primary Health Care (CBPHC) workshop on Saturday, October 25 at the 136th annual APHA conference, I was reminded of how there truly can be “power in numbers”.

Having worked in domestically in tertiary care at a well-funded institution (basically the opposite of CBPHC) for almost a year now, I searched for common ground with the international community-based primary care group, relying on my relatively brief but highly educative experiences in international public health. I of course am still interested in community health and primary care, but as others noted in an earlier blog entry from this conference, the funding for positions in that field is minimal.
At the workshop on Saturday, I realized just how many dedicated people there are focused on this area, and that our strength is in combining efforts to accomplish our goals. I often witnessed how a group’s synergy can greatly improve its effectiveness and creativity. At the workshop, we split into 3 groups, each one discussing the major actions needed to further the field of CBPHC, including, documentation and dissemination, raising awareness, and finding funding. My group was charged with discussing how to create or find more resources to implement programs in CBPHC. Continue reading “Health Care as a Means to Peace”

Community-Based PHC: So What’s New??

Trying to keep up with the flow of ideas
Participants Trying to keep up with the flow of ideas

By Janine Schooley

Sometimes I get the question, “So what’s new and innovative in CBPHC?”  The answer is that there isn’t anything new, and that’s the point!  We already know what we need to do.  We have the bullets, as someone said, but the gun seems to be elsewhere or malfunctioning.  I think it isn’t that we don’t have the gun.  I just think we have misplaced it, or it needs some tinkering to get to work, or we need to remind ourselves how to pull the trigger.  I really dislike this analogy for it’s militaristic and violent connotations, but I couldn’t come up with anything better….So, to continue this horrible analogy, we have several bullets and they are inexpensive, tried and true.  We know the power of exclusive breastfeeding, good antenatal care, immunizations, long lasting insecticidal nets, good nutrition, and other low cost, low tech interventions in terms of saving lives and improving quality of life.  We’ve been talking about this for decades, not just amongst ourselves, the practitioners in the field, but at the highest policy levels.  As the September 13-19, 2008 Lancet reminds us, a major milestone, the Alma-Ata Declaration, was issued 30 years ago.  So what’s new isn’t the need for what the Alma-Ata Declaration so eloquently calls for, but perhaps it’s the realization that we still haven’t gotten there.  In other words, we don’t need innovation.  What we need is inspiration and, as Nike so aptly puts it “Just do it!”.  Continue reading “Community-Based PHC: So What’s New??”

APHA San Diego: A passion for Primary Health Care

By Monica Dyer

WHO World Health Report 2008
WHO World Health Report 2008

Attending the Community-Based Primary Health Care workshop yesterday was one of the most invigorating experiences I have had in quite a long time. It was so fantastic to meet people carrying out work that I have been constantly thinking and talking about the need for. As my colleagues and I struggle to establish a comprehensive community health center in Gatineau, Haiti we are constantly trying to figure out whether or not we are actually implementing best practices. While we all value the importance of making decisions based on evidence and learning from others’ mistakes, it is incredibly challenging to find detailed information. Through this process and past research, I have been made especially aware of the need for more accessible and thorough documentation of both effective and ineffective practices and implementation experiences in global health.

This is not to be unexpected as organizations carrying out this work are usually so over-extended and resource constrained that documenting their processes and practices often becomes low-priority unless it is to meet the requirements of funders. However, when this is the purpose of such documentation the tone changes from factual reporting of successes and failures to trying to demonstrate efficacy so that a donors will keep sending money, so financial survival is not the best motivating factor for the objective documentation needed. In my own experience so far, although we have said that documenting and sharing the entire process of establishing a community health center would be a very useful activity that we would like to do, we have thus far been unable to follow through while dealing with all of the day-to-day logistics of running a clinic, seeking/maintaining funding and the planning of future programs and community organizing. If we had a volunteer historian or could work with students to take the documentation process on as a project for course credit, it might be much more feasible. However, with limited time to coordinate such efforts and so many critical activities competing for our resources, this honestly falls relatively low on our hierarchy of needs. 

I was encouraged when I recently heard about the Global Health Delivery Online but somewhat disappointed that it thus far only includes HIV, TB and Technology discussion communities. Understandably, these are in the scope of the founding collaborators’ chief interests but I hope they will continue to expand this venue into other important realms in need of increased attention. Continue reading “APHA San Diego: A passion for Primary Health Care”

APHA San Diego: notes from a CBPHC workshop

By Corinne Cohen

TB can be fatal. It is a worldwide epidemic that knows no borders.
TB can be fatal. It is a worldwide epidemic that knows no borders.

I am a resident in Family and Preventive Medicine, concurrently working towards getting my MPH.  I attended the Community Based Primary Health Care (CBPHC) workshop at the American Public Health Association National Conference, which was organized by APHA’s International Health Section on October 25, 2008. Project Concern International (PCI) facilitated the workshop. 

We opened by discussing the principles of the 1978 Alma-Ata Conference, which include health as a fundamental human right, equity, and the emphasis on community participation. 

We engaged in several spirited group discussions about the role of CBPHC in our own work and ideas for effective behavior change.  A highlight was a presentation on the use of TB-Photovoice (, a powerful means for creating effective messages of change from those who are most affected by the disease.  At the end of the workshop we broke into groups to discuss either the documentation and dissemination of work, how to increase funding, and how to advance knowledge of CBPHC.  My group was comprised of documenters and disseminatorsand we discussed starting a new journal that is a forum for talking about projects that are in the works or have been completed — this would allow newcomers to avoid reinventing the wheel, would serve as a forum for old hats to bounce ideas off each other around what did and didn’t work in their projects, and would also provide powerful individual stories, photos, videos, etc. that would assist with funding.  The forum would be online, open access and free.  Start up funding for such a new journal  is actively pursued and hopefully we can capitalize on that.  Wikipedia sounded like an option as well.  Also, we want to try to connect students and young professionals with project managers so that we can recruit writers!  Community-Campus listserv may be the way to go for that connection.
Overall, the workshop was stimulating and exciting – an opportunity to gather a collection of dedicated and passionate professionals to share ideas and projects that serve a common goal.