I’m sitting on the edge of Lake Atitlan looking out over the sparkling water. San Pedro volcano stands proudly before me. The energy of the volcano feels alive and this lake is magic. I come here when I need to slow down. It’s only a few hours from Concepción, where I live. This week my dear friend Cheryl is here in Guatemala visiting me. We spent the last five days at ACAM so she could see where I work and what we do. Now we have six days at the lake to relax, share, write, play our ukuleles, and do yoga.
Cheryl’s visit has been wonderful for me because I am seeing my whole scene through her eyes. I’ve been in Guatemala for five months now. Because things now feel routine, sometimes I need a reminder of the beauty and absolute WONDER of the work that I have come to find myself doing, which was so clear to her. Lately I have been moved to tears because of how much I care about the people here and I am softening and falling in love with Guatemala.
Earlier this month, 8 of the ACAM midwives, myself, Mary Ellen (another midwife from the states) and ACAM’s family practice doctor Valeria did a grueling week-long course on cervical cancer screening using visualization with acetic acid (VIA) and treatment with cryotherapy. We prepared for MONTHS for this course, which took place in Xela. My part was to train the midwives in how to do pelvic exams, mainly finding the cervix using speculums. For the last several months, I heard many a familiar call up to me in my apartment saying “Maaaaariiiiii, un examen pelvico!!!!” and I would hurry down to supervise and assist whichever midwife was performing her exam. Each of them had to complete a minimum of 8 exams prior to starting the course, and they worked hard to recruit their friends, sisters, cousins, and generally whoever was willing to let them practice on them.
Our amazing doctor, Valeria, prepared in-depth trainings on the theoretical part of the course and made the midwives practice exams to help them master all the written material before the course began. These women never cease to amaze me. They were assigned a book FULL of technical medical information about cervical cancer, human papilloma virus, statistics including terms like sensitivity and specificity, not to mention chapters on disinfecting and sterilizing materials, formulas for calculating concentrations and dilutions of different cleaning solutions, etc. Keep in mind that most of these women have very little formal education so imagine studying a medical textbook and then being tested on it when you have never had a basic science class that explains to you what a cell, virus, or bacteria actually is.
They studied and studied and practiced and practiced and finally the week of the course came. The midwives were incredibly nervous. They were the first midwives ever to be included in the training, which is usually just reserved for doctors and nurses. Bear in mind that midwives are looked down upon by most of the healthcare establishment in Guatemala and treated horribly by the majority of physicians.
The first few days were tough as they felt discrimination and doubt from some of the course trainers. But Maya women are no strangers to discrimination and they know how to hold their heads up high and keep fighting. A large part of the course was the practical part, which involved doing speculum exams on patients and putting acetic acid (vinegar) on the cervix and assessing for white lesions, which are indicative of precancerous cells. The midwives did AMAZING. I was bursting with pride. Their instructors were surprised, some visibly shocked. They were trembling on the inside, but they did their exams like the experts that they are and even ended up translating for the instructors, as many of the patients were Mam-speaking. Over and over, they show me how powerful and important the traditional Maya midwife is. Women trust them, they are their sisters, and they understand the complexity of the challenges that poor indigenous Guatemalan women face because they are deeply integrated into the community.
There were about 28 people in the course, 8 of whom were our midwives and the rest of whom were medical professionals including a few doctors and mostly nurses (our midwives were much more skilled at their exams than the majority of the people in the course!). Of the 28 people total, only a few had the chance to become certified in cryotherapy, the treatment used to treat pre-cancerous lesions. In order to be certified, a person has to complete 5 cryotherapy treatments. Since there are only a limited number of patients who showed up who tested positive, only a few people in the course had the opportunity to be certified. We desperately wanted one of our midwives to become certified so we can treat women out in the communities who test positive. We know all too well how unlikely it is for women in rural communities who test positive for pre-cancerous lesions to actually follow up with an appointment in Xela for cryotherapy or colposcopy, so we felt strongly that we should know how to provide this service since we work out in hard to reach communities.
Over the course of several days, 15 patients tested positive, meaning 3 students in the course could be certified. The first person to be selected to be certified in cryo was a MALE DOCTOR who doesn’t even work in a clinic with cryotherapy, he works in eye care!!! He took this life-saving and precious opportunity and wasted it as he won’t be putting it into practice. We were furious and frustrated, but unsurprised that the male MD was given preferential treatment. Myself and Mary Ellen started speaking with all the course trainers about how much we wanted a midwife to be certified. We explained about our communities, some of which take 2-3 hours to reach form Xela on rough roads requiring four-wheel drive vehicles. Our pleas seemed to fall on deaf ears, but on the final day of the course we were pleasantly surprised.
The Guatemalan doctor running the course approached us to say “Ok, which midwife will it be. Hurry up and let us know, we don’t have all day. We have a few positives”.
My stomach leapt with joy. “Imelda!!” we both decided. Our lead midwife, Imelda, was a natural choice. She is an inspiration- incredibly intelligent and the heart and soul of ACAM. We went to tell her she was up. She would start doing cryo treatments under the supervision of the doctor. Her eyes got wide and she mouthed to me “Tengo miedo” (I’m scared). I know, I told her, but you can totally do this. You know you have to do this. We’re all here with you.
So, she did it. She sat there for several hours, performing the treatment on patient after patient, the doctor waiting to criticize any misstep. She did beautifully. I am so SO very proud to say that as far as we know, she is the first midwife in Guatemala to ever be certified in cryotherapy.
We finished the course that day and I am thrilled to say that most of our midwives passed both the practical and written exams and are now certified in VIA screening. In a country where pap smears are not possible in poor areas due to costs and scarcity of labs/cytology, the impact of ACAM midwives doing cervical cancer screening is huge. I am tearing up as I write this because I can’t really put into words what a joy and honor it is to be part of these women’s lives and to be involved in what they’re achieving. When we left the course that evening Imelda burst into tears. They were tears of exhaustion and joy. “I never thought I would have this kind of opportunity,” she said hugging me hard, “thank you for all your support”.
I am exactly where I want to be. I am following the path of my heart and I feel like that path is getting a little clearer and more illuminated. People are coming into my life for important reasons and teaching me what I need to learn, which is sometimes joyful and sometimes painful. I’m making lots of mistakes. I’ve opened my heart and I’ve been hurt and I have hurt. I’m trying to be at ease with all the questions and uncertainty of where I’ll end up and what I’ll do next and right now focusing on being here. There is a strong spiritual energy in Guatemala and it’s making me much more sensitive to the subtle signs that the universe sends my way. My dreams here are vivid, my connections deep and intense. Life here is in your face- the pain and the beauty. It cracks you open.
On that note, here is a poem Mary Ellen shared with me:
“Be patient toward all that is unsolved in your heart and try to love the questions themselves, like locked rooms and like books that are now written in a very foreign tongue. Do not now seek the answers, which cannot be given you because you would not be able to live them. And the point is, to live everything. Live the questions now. Perhaps you will then gradually, without noticing it, live along some distant day into the answer.”
-Rainer Maria Rilke
Peace and love y’all.