A Discussion with Andrea Santos, Project Coordinator, ALIANMISAR Guatemala

With: Andrea Santos Berkley Center Profile

February 27, 2016

Background: Andrea Santos, the first woman in her family to pursue higher level education, works with the National Alliance of Indigenous Women’s Organizations for Health, Education, and Nutrition (Alianza Nacional de Organizaciones de Mujeres Indígenas para la Salud, Educación, y Nutrición, ALIANMISAR). In this interview she describes the advocacy work of this network and its grounding in human rights and other legal instruments, pressing for better access for indigenous women to health services. They focus especially on family planning and vaccination services. Challenges include weak political will, language barriers, and poor understanding of cultural differences among the indigenous communities. This interview reflects a discussion on February 27, 2016 with Carlos Martinez Ruiz in Guatemala. The discussion focused on the work of ALIANMISAR and on the challenges facing indigenous women in Guatemala, including the roles that churches play. She focuses particularly on the challenges facing expectant mothers and changes that need to be made to allow for safe and culturally sensitive maternal health.
Could you tell me about your background and the organization for which you work?

I work for the National Alliance of Indigenous Women’s Organizations for Health, Education, and Nutrition. It’s a national organization that focuses on eight departments: Totonicapán, Quetzaltenango, San Marcos, Huehuetenango, Quiché, Sololá, Chimaltenango, and Alta Verapaz. I am from the Esperanza municipality in the department of Quetzaltenango, in the Quiché area. I can understand Quiché and Mam, but I can’t speak them since I belong to a generation that lost the language. Neither of my parents taught me their languages for fear of discrimination. They were discriminated against when they were growing up because they couldn’t speak Spanish, so it was hard for them to communicate. So that’s a personal goal: to motivate myself to learn my native languages. I used to think it wasn’t that important, but the more you get involved, the more you see the need to take the issue seriously and how we have lost our identity.

I grew up in Xela and studied at a school in Esperanza. My studies were a point of contention between my mother and father because I am a woman. My father said that school was not a practical investment since I was just going to get married. My mother convinced him to let me go to school under the condition that I could not have a boyfriend or get married right away, since that would validate my father’s concerns. I finished the basic level and wanted to keep studying, so my mother supported me and I graduated. I am the first woman in my family to study beyond the sixth grade.

We were originally Catholic, but then my mother decided to convert herself and us children to evangelicalism. Because of this religious affiliation, I was able to get a part-time job working for an organization that helped children with their homework and monitored their health. That was how I got involved in social work and slowly developed awareness. I used to see the living conditions of others and feel grateful to God that I wasn’t provided too much or too little.

My plan was always to go to college. When I was 15, my mother took my siblings and me out to work in the fields and taught us how to cultivate corn. She told us that we needed to learn how to work, because my parents are farmers. But I started to think that we wouldn’t be able to live off of farming forever, because it’s very hard work. I managed to finance my college education through my earnings with the children’s organization. I was studying auditing in Xela when economics caught my eye. I ended up studying both auditing and economics at the same time, but financial reasons slowed down my economics major, so I am currently writing my thesis to complete it.

In reality, all of this was made possible by the organization where I worked. It was a student center funded by Compassion International and run by evangelicals. It was through this process that I got involved with evangelical groups, which gave me a new perspective.

After that, I became involved with the Community Development Council [Consejo Comunitarios de Desarrollo, COCODE], which is the urban development board that handles improvement projects for drainage, streets, public lighting, and so on. I started off by covering for my father when he couldn’t go to the meetings. The groups consisted of only men, so they didn’t take well to the involvement of a young woman at first. Since I had been in charge of accounting for a children’s organization for five years, they eventually made me treasurer.

I got the opportunity to work with a group of women in tomato production and to help them organize meetings. Through the Women's Bureau [Oficina de la Mujer], we were able to form the first women’s committee ever in the municipality, and I was elected committee president. So I thought that was the right moment to not necessarily change the system, but to contribute to the change at least a little bit. Through this organization I eventually came to ALIANMISAR.

Could you tell me about the history of ALIANMISAR?

ALIANMISAR, whose headquarters is in Guatemala City, began in 2006 to bring together many organizations from eight departments and to respond to the need to examine the healthcare system and its cultural appropriateness. The members do not receive a salary, so it is volunteer work, which is not well understood in our country. If someone does volunteer work, they are thought to be wasting their time. People have not accepted it.

Our objective is to influence and generate political dialogue. We develop strategies to strengthen civil society and foster nonviolent dialogue with authorities in a way that everyone reaps the benefits. We monitor and collect data through alliances and departmental networks. We visit the health centers and examine physical conditions, such as the availability of medication and family planning methods, which the law says have to be made available. When a woman goes to the health center, she should be offered the method that is most appropriate for her. However, we have seen that health centers often pressure women into using methods they don’t like. You have to keep in mind that there is a machista mentality in the communities, so women have to go behind their husbands’ backs. Sometimes a husband might not let his wife go to the health center. Therefore, when we go, we collect evidence, take pictures, and interview patients and the director of the center or clinic.

How do you get access to the health centers?

We have support in our constitution and in the law for access to public information in the municipal code. We have a letter of understanding from the Ministry of Health with information on our ability to access the health centers. We also have agreement letters with Human Rights, the Indigenous Peoples’ Commission, the Commission for Women, and even with SESAN.

What is SESAN?

It’s the secretariat for food security [Secretaría de Seguridad Alimentaria y Nutricional], and strictly speaking, the ministries that work on food security, which include the Ministry of Agriculture and the Ministry of Social Development. When we visit the health centers, we show letters from these institutions. There was one case in Totonicapán where they didn’t want to allow my colleagues to enter, so they showed them the letter of understanding. Because of this letter, none of the directors could do anything to prevent their entry. When we conduct a quick visit at the hospital, we simply tell the policemen that we are from the Organization of Indigenous Women and they let us in, since they recognize the organization and its work.

Is there ALIANMISAR staff with medical training or experience that can determine if the equipment or the medicine in the hospitals is adequate?

Before the volunteers can conduct a visit, they must receive training on what to look for. They have to know what to ask. Otherwise, they simply ask questions and don’t know anything. So we prepare them, and they learn the technical names of medications. Basically, the volunteers are spoon-fed the information. We have all been trained specifically for this.

Do you address all areas of the hospital or just those that have to do with reproductive health?

We also oversee vaccine administration. We observe the cold chain, the conditions, and if the staff is offering treatment in a pertinent manner.

Do you encounter resistance from the doctors, nurses, and other staff?

Sometimes at first, they question who we are. On one occasion, the health center director told us that we seemed worse than the health comptroller, since not even the health comptroller requests everything that we request. We ask to see the prex, which is like a cardex, where they index all of the medicines. We ask them how much they had during a certain month, how much they have now, and how much they will need for the next month. We do a comparison of the last three months on the availability of contraceptives, medications for malnutrition, vaccines, zinc, iron, and folic acid. We do this to see if they are truly meeting community demand. These are things that seem easy, but they exert a huge influence on the lives of those in the community.

How do you choose which hospitals to audit?

We only audit public hospitals. We take samples from departments that have a high incidence of malnutrition. We also take advantage of the Maternal-Child Health Survey [Encuestra de Salud Materno Infantil]. This gives us an idea of the situation in each department, and then we try to determine where there is the most need. The situation in the departments with the highest rates of malnutrition is a reflection on the nation as a whole. Once we have collected data, interviews, and irrefutable evidence, we act. We go to the municipal authorities and show them the state of their health center and the importance of intervention. The first level of care is important, because if the first level is functioning as it should, then it will relieve congestion in the third level. The first and second levels are for prevention, while the third level is for treatment. If both of the first two levels are covered, it will ease the congestion in the hospitals.

What are the primary problems or deficiencies that you have identified in the work you do?

Political willingness. The people in our networks need to be able to get young people involved in our network in order to strengthen us.

From your perspective, what are the problems that women and children face?

The nurses do not treat the women with cultural propriety, or offer them proper explanations. For example, they don’t explain if a child’s weight corresponds with their height. They just weigh them and tell them to leave. If you go to a center a bit further away, you find that language is a barrier. They don’t provide patients with the service that they should. Around six months ago, we published the stories of the women we spoke with during our monitoring. It’s all on ALIANMISAR’s web page, along with the report of the last monitoring we did.

How many volunteers do you have in the eight departments?

It varies by department. There are around 3,000 subdivided organizations. There are even some who do not live in the priority municipalities but still participate. Our vision is to expand and get more people involved.

What type of organizations have you formed alliances with? Are any of them church groups?

There are women’s organizations, COCODEs, and NGOs involved. The only church-related groups are the student centers, but they aren’t directly linked to Catholic schools.

Can you tell me more about these student centers?

They are financed by the churches. But within these organizations, you find the same women. One woman who is on the Cantel Health Commission is also known as a church leader in her community. She belongs to a Presbyterian church, where she has been able to make a lot of things happen. She has even managed to benefit her community with health fairs. Thus, there are people that are part of an organization but are also church leaders.

On a personal level, are you committed to the reproductive health and the right of women to make their own decisions? How do you negotiate that with your religious beliefs?

I have always thought that one person can propel change, even by affecting one person. One can ask a woman how she is, if she’s going to the health center, if she’s having her children checked. Sometimes they demand their rights, but they never follow through with their obligations. However, we’ve never seen this as an obligation, but rather a social commitment that we have. And even if I go to a church and the pastor tells me that he doesn’t agree with family planning, I know it’s important for improving the socioeconomic conditions of a person. I can go and speak with people and make them see. Perhaps I can do that by attending a group and raising awareness about the importance of going to the health center, and of family planning, since social norms don’t allow us to do so.

Lack of family planning can mean an increase in the incidence of chronic malnutrition in the country. And the country is not committed—it doesn’t have a strong policy to at least be able to fulfill basic needs. From my point of view, everyone should offer their support and raise awareness with others.

What has been the reaction of religious groups to ALIANMISAR’s work?

There is a group of female pastors from Totonicapán that has received training in sexual health. I believe that the religious groups see all of the information that we provide, and when they are interested, they approach us and ask for more information. There has been no national reaction, however.

And when the churches express their specific positions on family planning or maternal health, does your organization react to this?

No. We are in a country that has freedom of expression. But we do not comment on what the churches do. We focus our commentary on health and educational services that are offered to the community. We do not necessarily react even when their positions might be contrary to ours.

What is ALIANMISAR’s take on the situation in Guatemala? Have you seen improvement or deterioration of the status quo in your 10 years?

There are services that have improved. The alliance is working to address the root causes of problems. Therefore, the philosophy is not to fight with the ministries, but rather to raise awareness about the situation, and as a result, to highlight where new health clinics have been built. We have had to fight for these clinics, even for agreements to be signed between the municipality and the healthcare field so that they can assign personnel. It has been a national fight, but also a fight with the communities. There was a teacher who was protesting: “A lot of organizations come here and they do studies on us, they tell us problems, but we never see that they stick around.”

What are your aspirations for the future?

What we would like now is for the entire health budget to be decentralized. That way the municipalities can be in control. Each municipality and each town has its special issues that are priorities for the government. There would be more pressure coming from the community to do social auditing, improve their conditions, and understand that the COCODEs are not supposed to benefit just one group or the political sector. It goes beyond managing gray construction projects. Gray construction refers to street and other infrastructure improvements. But it’s also about improving the schools so that kids can have a quality education, and sharing cultural ideas according to the customs of the community.

What are the challenges that you see for Guatemala in the area in which you work?

Daring to express oneself. Daring to have an opinion. Not to need any longer to have to repress oneself or have a machista mentality, because we see that the women, even though they are not men, have that machista mentality as well. We need to get away from that. We have a television and radio program, and we have been able to exert some influence through them. We have to take advantage of these spaces where we can speak about the issues directly with women. However, some women are afraid to be on television or express what they feel.

In terms of preventative healthcare and maternal health, one of the challenges is having the state commit as it should to the issues. The personnel don’t love what they do. A lot of the positions are political, and that passion is lost.

So you think the state needs to commit to appointing more appropriate personnel?

The personnel should suit the characteristics of every community. Quetzaltenango is not the same as Quiché. We have also tried to promote culturally appropriate labor and delivery. A culturally appropriate birth is done standing and with a midwife. There is a Midwives’ Law, but midwives often have limited access to the hospitals, even when they are simply trying to help the patient. We have been demanding better conditions and that midwives be allowed in, because in many hospitals they no longer tend to patients in the labor and delivery room. Since they don’t have enough beds available, women have had to give birth in the hallways of the hospital. Giving birth is a very special moment for the women, and a very delicate moment, which is why we are trying to pass laws that could benefit the people.

What are the specific challenges for indigenous women, and what do you see as the solutions?

The solution is commitment and increasing access to the local authorities. Changes also need to be made so people don’t have to travel two or three hours to reach the closest health center or hospital, particularly if it’s an emergency. There needs to be a plan for emergencies. In a lot of places, there is no ambulance to transport a patient, or even if there is, no one is able to pay for the gas.

What is the most basic public service that a woman has access to for labor and delivery?

The hospital. The hospitals are located in the main city in each department. The only exception is Xela, where there’s a hospital in Quetzaltenango and also in Coatepeque. Sometimes they can go to a health center, but often health centers are not equipped to handle a birth.

And what is your take on Guatemala in general with all of the changes that have occurred?

We believe that the government can improve and concern itself more with its citizens. We see that there is political willingness for this, but there’s a big difference between saying and doing. We have spoken with the Women’s Commission, and the deputies are willing to contribute. However, when we look at the reality of the situation, there is not a lot of long-term participation. Currently, we are trying to propel the Indigenous Peoples’ Law, which is being run by the Indigenous Peoples’ Commission [Comisionado de los Pueblos Indígena]. This law, which handles food security and cultural appropriateness, has already been presented at a meeting, but it has not yet been submitted to congress.

How do you see the future of ALIANMISAR?

ALIANMISAR has been around for 10 years. The people who work here have the willingness and the desire to improve healthcare and education in the country. I believe that this organization has defined itself because when someone mentions ALIANMISAR, people already know what it is.
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