Neo-Colonial Epidemiology in Guatemala: An Interview with Alejandro Cerón

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David Flood
David Flood, MD, MSc, is a physician with the Guatemalan NGO Wuqu' Kawoq | Maya Health Alliance and resident in Medicine-Pediatrics at the University of Minnesota. He received his medical degree from Harvard Medical School and an MSc in international health policy from the London School of Economics.

I recently had a chance to talk with Alejandro Cerón, an Assistant Professor of Anthropology at the University of Denver. Cerón trained as a physician and epidemiologist in Guatemala before completing his PhD in anthropology in the U.S. at the University of Washington. He has written broadly on health in Guatemala, and in 2013, he completed his dissertation on the practice of epidemiology in Guatemala, entitled “Neo-Colonial Epidemiology: Public health practice and the right to health in Guatemala.”

Alejandro Cerón carrying out participant observation. Monterrico, Santa Rosa, Guatemala

Alejandro Cerón carrying out participant observation. Monterrico, Santa Rosa, Guatemala

You use the phrase “neo-colonial epidemiology” to describe to the practice of epidemiology in Guatemala. What makes epidemiology “neo-colonial” in this setting?

When I was in grad school, I was trying to figure out what “tribe” to study. If you think of anthropologists, we study tribes. I ended up deciding to study people doing public health work because that was something I was very close to. I was not expecting to find what I later called “neo-colonial epidemiology.” I was trying to move away from saying “there’s racism” and “there’s social inequality” in Guatemala, and that’s the problem. I was more interested in trying to find the mechanisms of how inequality gets reproduced.

With neo-colonial epidemiology, I am trying to encapsulate through my ethnographic work with Guatemalan epidemiologists how inequality expresses itself through public health work. I had a hard time deciding what term to use in describing these epidemiologists; some people with European backgrounds working in Africa, for example, have a different understanding of the concept of “neo-colonial.” In my use of the phrase, I am highlighting how unequal relations between the Global North and Global South influence the practice of epidemiology in Guatemala.

We often complain about the weaknesses of health institutions in Guatemala—how much better everything could be if the institutions were stronger, more efficient, less corrupt. Through my ethnographic research with Guatemalan-trained epidemiologists, I began to view the weakness of epidemiological work in Guatemala from a post-colonial reality.

The tribe you picked to study was “epidemiologists,” which is a tribe you could have belonged to.

I was very influenced by my experience in medical school when I did emergency work after Hurricane Mitch in 1998. After that, I thought, wow, this epidemiology thing is awesome—this is what I want to do, this is how you get to the root causes of things. If we have more people trying to focus on our main health problems and their real causes, then we can really improve the health system. That’s how I started my post-medical school life, thinking that epidemiology was something that could do a lot of wonderful things, that epidemiology had “emancipatory potential.”

I learned that a similar process happens to all Guatemalan epidemiologists. They all have had other ideas of what they wanted to do, and at some point they saw the light and decided to follow the epidemiological path. If things had worked out differently, maybe I would be an epidemiologist working in the Ministry of Health in Guatemala. As I was talking to all of these epidemiologists, I was always reflecting on my own professional path; in a way, I still want to be an epidemiologist, just a different kind.

Alejandro Cerón at a Health Post inauguration in Tzamab'aj, Sololá, Guatemala

Alejandro Cerón at a Health Post inauguration in Tzamab’aj, Sololá, Guatemala

You describe “neo-colonial epidemiology” in part by contrasting it with Latin American Social Medicine, which hasn’t had as much of an influence in Guatemala compared with other Latin American countries.

Latin American Social Medicine has been around for 50-60 years at least. I would say that the main difference between Latin American Social Medicine and mainstream public health is the former’s commitment to social justice and health inequity. From there, you start questioning the methods that you use and start trying to figure out the causes of social inequity. You end up engaging with other disciplines and other methods. You come closer to addressing how to deal with a system that has produced and keeps reproducing social inequality.

Guatemala and especially Guatemalan elites have tended to not want to look at the reality of the situation for the majority of people in Guatemala. This has influenced many areas of life in Guatemala, such as the weak education system and weak public health system.

There is within Guatemala a frame of mind that there are different levels of citizenship, that there are second-class human beings in the country. You, as an elite, do not see yourself as being part of the same group as the rest of the country, so you don’t care about things like social inequity. I think this is part of the reason that addressing health inequality is still not a goal of the Guatemalan health system.

One of your informants said, “I can’t understand what a Guatemalan epidemiologist does if it’s not addressing the problem of inequality.” At the same time, you show how the training of national epidemiologist doesn’t prepare people to analyze inequality.

I know that we need to do more than just change the training that epidemiologists receive in Guatemala. But that’s one of the ways where I found specific mechanisms in place that prevent people from paying attention to what really matters—even those of us who decide to follow the epidemiological route because of its emancipatory potential.

When I have worked with public health students in Guatemala, I am struck by how they don’t have the tools or mindset that allows them to ask questions about what they observe. When you learn a craft such as medicine, you learn to look at the chaos of the messy world, try to select some pieces, put order to them, say something about them, and then try to come up with solutions. When I ask public health students to generate research questions from their reading of health-related material relevant in Guatemala, they are unable to do so. They haven’t been trained to ask questions, especially questions about inequality.

Alejandro Cerón in a qualitative methods class in Guatemala City, Guatemala

Alejandro Cerón in a qualitative methods class in Guatemala City, Guatemala

You argue that the brain drain is partially a product of “neo-colonial epidemiology.” What do you mean?

As I was analyzing the data, I realized that all these epidemiologists ended up working outside of the government health system. I also realized that this described my own personal trajectory.

There are different ways that the brain drain happens for Guatemalan epidemiologists. You have foreign institutions with money and an agenda that want to hire Guatemalans with epidemiological training. They know that these people can write reports and collect data. These institutions usually work on short-term projects, but they have their own agendas. It does not mean that USAID, the World Bank, and different United Nations organizations have evil agendas. But they offer money, prestige, and an uncomplicated and uncontroversial job that you can do without getting in trouble.

On the other hand, if you want to do epidemiological work in the public sector, you basically work in a context where if you do your work well, you show all of the things that the Ministry of Health does poorly and you are very likely to get fired. In addition, you lack the resources to do rigorous epidemiological research and analysis. For Guatemalan epidemiologists, working in the public system is very frustrating, you can get in trouble, you don’t get paid well, and you don’t get any prestige out of it. In the end, it doesn’t matter how committed you are in the start, you will always end up working somewhere outside the public system.

Talk about what the word “outbreakologists” has to do with epidemiology in Guatemala.

If you study epidemiology in university programs in Guatemala, you end up seeing epidemiology as connected to public health. You learn that epidemiologists have several roles including outbreak control. But there are other forms of epidemiology that have more to do with studying the underlying causes of health problems, evaluating health programs, and researching clinical care. Outbreak control is just one little piece of what epidemiologists should do.

In Guatemala, there is a field epidemiology training program with the CDC. In this program, people end up primarily learning how to do outbreak control. This is not a bad thing; it’s something you want the Ministry of Health to be able to do. But it becomes frustrating to epidemiologists when they only see themselves as attempting to do outbreak control.

In addition, due to the lack of resources and support in the Ministry of Health, epidemiologists end up doing more emergency-like actions that are highly influenced by the agendas of the WHO, the CDC, or PAHO. Many of the epidemiologists I interviewed talked about how they were unsatisfied working primarily as “outbreakologists.”

In addition to your training as an anthropologist, you are also a physician and a public health practitioner. How have these other fields influenced your anthropological work?

Up until very recently, I thought of myself as a rural health worker because most of my professional life was devoted to taking care of patients in rural Guatemala. It was through that work that I ended up being interested in anthropology and, eventually, pursuing a PhD in anthropology.

To be honest, maybe my frustration as a rural health worker is what drove things for me. When I was a first-year medical student, I was part of a student organization that would do medical trips to different rural villages in Guatemala. The way it worked is that younger students like me were paired with a medical student in their final-year so we could learn from those who had more experience. Very early on, during these trips, I realized how much of a lack of communication there was between physicians and rural patients. Without really noticing, I found myself reading medical anthropology.

Another important decision point in my life was when I was in my fifth year of medical school. At that time, I was the president of the medical student organization at the San Carlos University when Hurricane Mitch struck Guatemala in 1998. I ended up being involved in the university emergency response. That experience made me realize that I wanted to work more on the social aspects of health. I started realizing how little I was able to do with my medical craft.

Alejandro Cerón serving at a community health house. San Miguelito, Guineales, Sololá

Alejandro Cerón serving at a community health house. San Miguelito, Guineales, Sololá

Throughout your career, you’ve been devoted to thoughtful, comprehensive approaches to rural health care in Guatemala. What are your thoughts as the main rural health mechanism in Guatemala, the Program of Coverage Expansion (PEC), has recently been dismantled?

I am glad that finally PEC is going to die. I hope that the Ministry of Health will be able to institutionalize something that will not make the same mistakes that were made with PEC. I worked with PEC for a little less than two years, and when I started I was already aware of some of the criticisms of the health sector reform in Guatemala.

One good thing about PEC, at least at the beginning, was that it brought some care to communities that did not previously have any access to health care services. At least in the beginning, that was how it happened in most places. But then PEC was often implemented with public money being used to contract NGOs to deliver rural health care, which created a system with the wrong incentives at many levels. NGOs who were not really committed to doing work in rural areas would market themselves to try to get a piece of the public money. And then politicians started using PEC as part of a patronage arrangement. For example, if you are running for Congress, you promise that a certain group will get the PEC contract in exchange for their political support. Another problem had to do with how PEC only consisted of a very basic set of health services.

So, I am happy that rural health care is going to change, but I am concerned and sad about the way PEC died. I am hoping that something good will come of this. Some people in the Ministry of Health are working to implement some of the more comprehensive rural health models, which will mean there would be better-trained and more available health providers in rural areas. But who knows what will happen.

You write how you were unable to incorporate indigenous models of well-being into a study of Guatemalan epidemiology. Why?

I had to humbly accept that with my focus on epidemiology and the right to health, I was already medicalizing my research project. I have learned from indigenous rights activists about how indigenous health is connected to land, which is itself connected with land autonomy and land rights. Thinking about indigenous notions of health was going in such a different direction that I decided I couldn’t follow that thread completely. It made me realize the limitations of our Western focus on “health.”

In other words, most of us working in health-related fields like to think that health is fundamental to everything. However, the notions of health in indigenous communities may be very different than how we’ve traditionally thought about health in anthropology, public health, or medicine. There’s a reason why many languages did not have a word for health. The very notion of “health” as we end up using it, or salud in Spanish, is something that is not as natural as we may presume.

Do you think that neo-colonial epidemiology exists in other countries, and to what extent?

When I observe health crises like the H1N1 epidemic or the Ebola outbreak, I see a similar lack of attention from international institutions and international health care workers from the Global North in strengthening health care systems at the local and national levels. But this lack of attention doesn’t just come from Global North institutions and people, but also from the chaos of the national system and the lack of priority we give to public health in our countries.

I suspect that the disciplinary “conformism” I observe in Guatemalan epidemiology also is relevant in other global health settings. For example, there are wonderful people doing wonderful work at the CDC. But the CDC’s priorities do not necessarily align with national priorities in Guatemala, or any other country. However, the CDC has all these resources, and, perhaps unconsciously, they end up driving the epidemiologic agenda.

What suggestions do you have to “de-colonize” epidemiology in Guatemala?

First, I think about how social exclusion needs to change, and we need to build a more just Guatemalan society everywhere—schools, universities, private businesses. And we also have to do it in the public health system. Solutions can be really complex, right? But also sometimes really straightforward. The two things that the public health system in Guatemala needs to do are: (1) to make a political decision that addressing health inequalities is a goal, and (2) to understand that this can only be done by promoting social participation. I hope for this opportunity to construct a more equal, more inclusive health system in Guatemala.

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