on hunger, miracles, and the double burden of malnutrition

Everything is Diabetes: 🫡 hi from the Nelsons in Guatemala

Dear friends,

We have been back in the swing of life in Guatemala for a few months, and the time has come for a proper update. Kids first: school is going really well this year, with Cora and Lucie both in high school and Hazel in her last year of elementary school. Everyone is playing soccer, play auditions just happened, and Cora and Lucie are both really busy with student council and model UN responsibilities. We love our little international school— class sizes are small, a majority of the kids are Guatemalan (or at least Latino) and Spanish is the dominant social language spoken. Our teachers are from a mix of international and national backgrounds, and they are really involved in the lives of our kids in ways that feel unique to our setting.

With friends at the beach a couple of weekends ago.

All that said, it was still a rough transition back into Guatemala for the girls this school year. After a summer in the US, being really American and enjoying lots of ways that life in the US is just easier, there was a real emotional ditch waiting when they returned. It took some working through, and everyone is in a better place, but it is a good reminder that this life we are called to involves real heartache for our kids, particularly around goodbyes and big transitions.

Cutest mechanic/worst car in Central America.

Jeff is busy fixing things (as ever) AND in his therapy practice. Without being specific, he has done quite a lot of work lately with people struggling with depression and vicarious trauma and all the tentacled ways that affects their lives and the lives of the people around them. It is good work that bears fruit we often don’t see, and he is grateful to be back in a regular rhythm of referrals and intakes, working through a therapy process and seeing people progress out of acute crisis.

the scene just outside the clinic in Zona 3: metaphorically and literally accurate.

As for me, the return to clinic was unusually tough after a few months away. Traffic was unaccountably much worse, taking 2-3 hours to get into town in the mornings (the commute is normally about an hour and a half). We have had a lot of complex problems with our pharmacy process, and it turns out that many of my patients had not been getting any medications in my absence over the summer, catastrophically in one or two cases. After a lot of conversations with Dr. Layla, the pharmacy staff and the front desk, it became clear that the way we had built and run the program for the last 6 years is just no longer tenable. Their preference is that each patient has a brief consulta with a doctor/provider every month before each medication refill, which would have easily quadrupled my time and work demand in the clinic. Layla expressed willingness to take over the diabetes program entirely, and so I am handing it back to her, with a promise to stay connected and continue to provide support without actually being the primary care provider for the program going forward.

I have been so conflicted (heartbroken) about this whole thing, but I don’t doubt that it’s time to work on something new. My work at Johns Hopkins over the last few years has focused on the ways the food choices available to people (i.e. their “food environment”) influence their health, and I have been studying the myriad policy levers governments and civil society have available to improve the food environment. I’ll finish the policy projects I’m working on this spring, and my plan is to build a new health project in a village close to our house where our team runs a small farm and chicken project with single moms and widows. A needs assessment in the village will come first, and then hopefully a health program that eventually is a bridge providing healthy food to both the Magdalena patients and the folks in Zone 3. I have dreamed for YEARS about how to use more than just medications to treat diabetes and hypertension in communities like Zone 3, and it is exciting to finally have some schedule space and bandwidth on the horizon to start working on it.

A common tienda in Zone 3, Guatemala City. No fresh food in sight.

The small farm at Project for Hope, Magdalena Milpas Altas

Guatemala has one of the worst rates of chronic malnutrition in the western hemisphere, but increasingly the problem is not a lack of calories so much as a substitution of food-like sugar and chemicals for actual food. The patients I take care of in the garbage dump community do not have running water in most cases, much less a water filter, but they can buy a 3 liter bottle of Orange Crush or Pepsi for about $2. They are so poor there is often neither a stove nor a refrigerator, rendering fresh vegetables or home-cooked eggs and beans out of reach, but the tienda on the corner sells tasty, salty chips and cookies for just a couple quetzales. Diabetes and heart disease are without question the leading causes of death both in Guatemala and the rest of the low and middle income world. The double burden of malnutrition kills more people every year than tuberculosis, than famine, than wars or interpersonal violence.

I have spent SO much time thinking about hunger, the nature of need, and all the places in scripture where God talks about feeding people. I read a wonderful book this summer called the Covenant of Water and there is a line in one part of the story (about a feeding center opened during a time of famine) that said, “There are people in the world so hungry, that God cannot appear to them except in the form of food.” Some of you, skeptical of any scent of social justice in missionary doings, will say Hang ON, that’s not the gospel, but I’d challenge you to think again? Jesus literally said, this bread is my body broken for you, take and eat; this cup is my blood, spilled for you, take it and drink.

It feels daunting to contemplate building something that provides food alongside medication to treat patients with diabetes and cardiovascular disease, but it’s encouraging to remember that Jesus made lunch for thousands of people from the fish and bread in a child’s basket. It’s also encouraging to remember that there were a dozen baskets of leftovers that couldn’t be finished, that Jesus didn’t just meet survival needs. I’m going to put Isaiah 55 below for your edification and enjoyment, and in the meantime would you just pray for me to have wisdom and perseverance and clarity as I figure out this next thing?

Otherwise: pray for us as a family, for the fruits of the Spirit to be manifest in our family culture and for wisdom as we are parenting in what feels like a dark, secular age. Pray for the patients in Zone 3 who may struggle with access to the clinic in the new era of different physicians running the diabetes program, and for the staff in the clinic to see them clearly, and with compassion.

So much love,

Abbie & Jeff and the girls

The Compassion of the Lord

55 “Come, everyone who thirsts,

come to the waters;

and he who has no money,

come, buy and eat!

Come, buy wine and milk

without money and without price.

² Why do you spend your money for that which is not bread,

and your labor for that which does not satisfy?

Listen diligently to me, and eat what is good,

and delight yourselves in rich food.

³ Incline your ear, and come to me;

hear, that your soul may live;

and I will make with you an everlasting covenant,

my steadfast, sure love for David.

⁴ Behold, I made him a witness to the peoples,

a leader and commander for the peoples.

⁵ Behold, you shall call a nation that you do not know,

and a nation that did not know you shall run to you,

because of the LORD your God, and of the Holy One of Israel,

for he has glorified you.

⁶ “Seek the LORD while he may be found;

call upon him while he is near;

⁷ let the wicked forsake his way,

and the unrighteous man his thoughts;

let him return to the LORD, that he may have compassion on him,

and to our God, for he will abundantly pardon.

⁸ For my thoughts are not your thoughts,

neither are your ways my ways, declares the LORD.

⁹ For as the heavens are higher than the earth,

so are my ways higher than your ways

and my thoughts than your thoughts.

¹⁰ “For as the rain and the snow come down from heaven

and do not return there but water the earth,

making it bring forth and sprout,

giving seed to the sower and bread to the eater,

¹¹ so shall my word be that goes out from my mouth;

it shall not return to me empty,

but it shall accomplish that which I purpose,

and shall succeed in the thing for which I sent it.

¹² “For you shall go out in joy

and be led forth in peace;

the mountains and the hills before you

shall break forth into singing,

and all the trees of the field shall clap their hands.

¹³ Instead of the thorn shall come up the cypress;

instead of the brier shall come up the myrtle;

and it shall make a name for the LORD,

an everlasting sign that shall not be cut off.”