the long game

faithfulness in the daily grind.

Dear friends,

Come on a journey with me, for a thousand words or so, into the world of a diabetes clinic on the edge of the largest urban landfill in Latin America.  Guatemala City is at the same elevation as Denver, situated in the northern part of an unusually active ridge of volcanoes, and home to nearly 4 million people.  Our house is a 45 minute drive up and over the hill, blessedly far from the city chaos (and close to our girls’ school). On clinic days I get up with the sun around 5:30, drink a half a pot of coffee, put on scrubs and throw an orange, a granola bar and a liter of water into my medical bag.  I drive down the valley into town along with the other half a trillion people that come into city to sell produce at the market and work as maids and security guards and cooks and gardeners.  There’s a lot of traffic.  

I wind my way past the entrance to the actual dump (el basurero, translates literally as trashcan and is shorthand for being the armpit of the city) and turn onto a narrow street crowded with diseased dogs, piles of garbage higher than my land cruiser, children playing in the street, legs of men sticking out from under dilapidated cars.  At the end of the block there is a large maroon metal gate, usually with half a dozen patients hanging around outside who recognize me as I get out of the car to ring the bell and bombard me with questions about whether they can be seen without a number¹.  Eventually Mynor opens the gate, and I drive into the courtyard, park my car, say hello to the crowd of patients waiting outside the clinic entrance, and make it inside to my exam room to start the day.  

When I started coming to clinic in the spring of 2019, Dra. Layla Chanquin was running the place largely on her own.  She is the wife of Pastor Saúl, and together they lead a large Baptist church in a neighboring community.  The clinic has been open for about 10 years at this point, and has slowly grown both in physical and professional capacity.  There is now a lab, a hospital-grade ultrasound machine, a physical therapist and a dentist that donate their time to see patients on a weekly basis, and me, running the diabetes program.  

Diabetes is (arguably— numbers are hard to nail down here) the leading cause of death in this country.  It is a key part of the “double burden of malnutrition”, the downward spiral whereby poverty creates infirmity which contributes to more poverty.  It is also the most unsexy, hopeless disease to work on… most Guatemalan physicians have an understandable degree of diabetes burnout, given the lack of resources² to manage this long-term.  When I showed up, Dra. Layla asked if I could “do something” with the diabetics, and after about 6 months of working in clinic, teaching diabetes classes, making home visits and reading research, I put together a program: a medication formulary, purchased a hemoglobin A1c machine, hired and trained a diabetes educator from the community, instituted an appointment system to get people out of the early morning line, and launched the thing.  Just 2 months shy of Covid’s arrival and everything (including the clinic, temporarily) shutting down.  

During my years as a primary care provider in Oregon, nearly all of my diabetic patients had medicaid.  Their office visits and labs were free, and meds cost less than $30/month most of the time.  I could count on being able to refer them to a dietician, order labs to check renal function, glucose levels and cholesterol a couple of times a year, and know with certainty that they would be able to pick up a full months’ supply of the same medication regimen each month between office visits.  All of that is a laughable luxury here— diabetes is managed as an urgent care problem, as is everything else— patients go to the doctor when they’re sick, they buy their medicines off of open tables in the market or at the corner pharmacy when they feel ill and/or can afford it, and generally regard diabetes as a diagnosis similar to cancer: everyone knows someone who has died of it, often someone in their family.  

There is a paucity of research about how to treat this disease in this setting.  A review of the literature turned up studies done in Africa, rural parts of Latin America, Cambodia, India, and urban cross-cultural communities in developed countries, but nothing accurate to my setting.  I was looking for something like a recipe: a replicable study that documented some specific strategies and interventions that would produce decent outcomes.  I ended up putting together my own recipe from a hodgepodge of sources, and the cake is now in the oven.  To drive the analogy into the ground, the Covid shutdown amounted to a power-outage.  The lights are back on, but I have no idea if what is coming out of the oven will be edible or not.  

When I rolled up to clinic last Monday, a woman named Wendy (that’s her, just above) was one of the first patients in my exam room.  She’s about my age, and we have gotten to know each other over the last couple of years.  She was diagnosed with diabetes in her early-30’s after her last pregnancy, and already has several grandkids.  Her life is difficult— she and her kids all work in the basurero, money is scarce, anxiety and fear are high.  Her initial HgA1c³ was 11%, and we chatted about how she had been doing over the past 12 months.  I had started her on insulin a year ago, and she had been pretty consistent with picking it up and taking it, along with the metformin and blood pressure medicine.  She said she’d been drinking more water, trying to get some exercise when she could, and paying attention to eating less sweets.  I sent her upstairs to the lab for a repeat HgA1c, and was totally floored when she returned to the exam room with 8.3% written on her lab card.  What ensued was the most beautiful conversation: I confessed how pessimistic I’d been, and praised her for incredible hard work and fortitude in what has arguably been the worst year ever.  She gave all the credit to God, who cares for her, walks with her, lifts her up and binds up her wounds.  

The rest of the morning was not like that— most people have not been able to get meds consistently during the pandemic and mostly numbers have gone in all the wrong directions.  But Wendy’s story gave me a lot of hope, something I’ve mostly avoided the heartache of letting myself feel in the past year.  

Jeff⁴ and I talk a lot about the psychology of disease in Guatemala— my patients often believe that they are being punished by God, and tend to approach treatment in a mystical way.  Like sick people everywhere, they are on the hunt for a cure, for freedom from the malady itself, and the conversation lining every office visit deals with the reality that there is no cure, but for the ultimate healing is found in Jesus.  I put Zephaniah 3:17 on the front of their diabetes program cards, which says

“The Lord your God is with you,
    the Mighty Warrior who saves.
He will take great delight in you;
    in his love he will no longer rebuke you,
    but will rejoice over you with singing.”

I am working on the idea of research as mission— there is so much we don’t understand about how to treat disease and save lives in this part of the world, and as we approach these communities with compassionate curiosity, relationships open up in the most beautiful ways, bringing opportunities for gospel renewal and healing that far exceed numbers on the page.  I’ve got two research interns (both bright young women headed to med school) coming next year, and we are thinking through ways to adapt this modality for use in other ministry settings.    

Briefly: our kids are doing well! We just moved house at the end of the school year, and made the difficult decision to change schools.  It became clear that the missionary school would not serve our needs through high school, and we feel increasingly certain that we want to be here at least that long.  They will start school in August at Antigua International School, and we are all pretty happy with the decision.  The new house is wonderful, we are getting to know our neighbors, and enjoying the change of scenery in home life.  

It is always a pleasure to write these letters, to sit down and reflect on how God has worked, and we are full of gratitude for the ways you all share this work with us, bear our burdens by praying and checking in, support us not just financially but with the substance of your friendships.  Prayer requests and some more pictures below.  Let us know how you are!  We love to hear back when we send these letters, so drop us a line.  

Big Guatemalan hugs to you all,

Abbie (& Jeff and the girls.)  

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Specifics you can be praying for:

• New school for the kids this fall means new friends, new teachers, significantly more Spanish. Pray for brave, kind hearts and encouragement when they need it.

• Our church (Iglesia Reforma) has grown during the pandemic, partly because, as our pastor put it last week, people have realized that the Guatemalan church generally does not have a theology of suffering and the pandemic has revealed that. Growth in numbers is dangerous if it does not come with a growth in depth, so pray for stability and wisdom for our Guatemalan church leaders.

• The Covid-19 pandemic is not receding in Guatemala.  Like the rest of the world without the infrastructure or government capacity to purchase and administer vaccines effectively, the pandemic will smolder along here for years, probably.  Pray for mercy, and for endurance for all the Guatemalans bearing that burden day after day. 

• Pray for Jeff and I to model well what thoughtful, balanced and faithful work looks like in a ministry setting where workaholism is expected and reinforced. 

1. without a number: care at the clinic is first-come, first-serve.  They hand out numbers (usually 30-50) starting at 5 am, so people get up and get in line before that.  Office visits start at 8:30, so it makes for a long day.

2. Lack of resources: patients make 10q a day, roughly $1.25.  All medicine is out of pocket, so people often literally have to choose between food and medicine.   We charge 5q for office visits, never refuse care for people who can’t pay, and that includes medicine.  

3. Hemoglobin A1c is the gold standard for diabetes diagnosis, telling us how saturated red blood cells are with glucose and giving us a pretty good idea of average blood sugar for the previous 3 months.  Major medication changes ideally will be evaluated for efficacy with a repeat hga1c about 3-4 months later.  Diabetes is diagnosed at 6.5%, and the goal for treatment is 8%.  My machine reads levels up to 16% and I’ve had a few critical high’s, but the average starting value for patients in my program is 11-14%.  

4. Dr. Jeff Nelson is going to write a newsletter soon, try to give you a better sense of his end of the work.  He’s just as busy as I am, but it’s obviously hard for me to explain.  Stay tuned!  :)