Carosella E. Guatemala makes COVID-19 the responsibility of the people. Harvard Public Health Review. 2021; 27.
It’s a muggy August evening and a thundershower is forming over the hilly treescape that frames Guatemala City’s urban center. I am rushing home from the supermarket, hoping to beat the storm. I’ve lived in Guatemala since 2018, though, recently, going to the supermarket is the only time I leave my apartment, as COVID-19 cases rise across the country. Driving through the city, neon-lit signs flicker on for restaurants and cafes that had, at one point, been under nationally mandated closure. At a stop light, I get a clear view into a well-known restaurant that had been one of my favorites, pre-COVID. Several clusters of people are seated inside a closed indoor space. None of them are wearing masks- a dramatic shift in the panorama from just months ago.
In March, Guatemalan President Alejandro Giammattei announced strict COVID-19 containment measures across the country- shuttering national borders, suspending schools and public services, and mandating the closure of non-essential industries. Gatherings of over 10 people and interdepartmental travel were banned, daily curfews established, and a national mask requirement was imposed- even inside personal vehicles. As an American, I saw this as a striking contrast with the situation in the US, which was floundering under the ineptitude of a president who first refused to recognize the crisis and has since failed to mount a national response. I was impressed by how swiftly Guatemala’s government acted and how seriously they seemed to be taking this pandemic, imposing these measures while the number of cases was still in the single digits.
Since then, cases have continued to rise: Guatemala’s Ministry of Health (MPSAS) currently reports 74,000 total cases and over 2,700 deaths. However, with limited testing capacity, the real number is likely much higher (the head of the Presidential COVID-19 Response Commission- COPRECOVID- projected that the number is “easily 10 times higher than what we’re reporting”). Guatemala’s public health system was already strained prior to the pandemic, already notorious for the de facto exclusion of indigenous people due to discrimination and one of the lowest levels of national investment in the public health system in the region. When newly appointed health minister Amelia Flores (her predecessor was removed in June after accusations of financial mismanagement, hiding data, and failure to secure PPE for health workers) was asked whether an observed increase in COVID-19 deaths was due to the collapse of the public health system, she replied, “Definitely, our hospitals had already filled their capacity before the presence of the first case of coronavirus….” In response to capacity gaps, the government set-up new temporary hospitals specifically to handle COVID-19 cases. Yet, execution of public emergency funds remains low and there are questions as to whether funds are reaching these hospitals at all.
The MSPAS does not track data by ethnic status, meaning that there is no official record of the toll on indigenous people. However, historic disenfranchisement and marginalization puts these groups at higher risk for COVID-19 and the worse of its outcomes. Already before COVID-19’s global economic downturn, nearly two thirds of Guatemalans were living in poverty. Among indigenous communities, the poverty rate is 1.7 times higher than it is among nonindigenous people. Extreme poverty among indigenous groups, meanwhile, is three times as high. Poverty, food insecurity, and violence continue prompting waves of forced migration toward the US. COVID-19 has since led to sharp reductions in remittances and casual labor, on which poor families rely. To help families through worsening economic hardship because of the pandemic, the government instituted the “Bono Familia” to provide $130 per month for three months. However, a recent investigation found that funds were given to families who were not poor; only half of those who qualify received the benefit; and, in many areas, no beneficiaries were registered at all. The impact of this mismanagement is largely on the indigenous poor, whose reliance on the informal economy and historically lack of access to public services, puts them particularly in need of social protection.
Now, the number of families facing a food security crisis has doubled,, with rising acute malnutrition rates. Already, Guatemala has the highest chronic malnutrition rates among children under 5 in Latin America, and the sixth highest in the world., Although the literature on nutrition and COVID-19 is evolving, we know that undernourishment weakens the immune system and increases susceptibility to infectious diseases and severe illness. Respiratory illness remains among the leading causes of death among Guatemalan children, while there are huge access gaps to clean water and sanitation for all segments of the population. At the same time, Guatemala faces the dual burden of a growing obesity epidemic. According to PAHO, 7.5% of the population has diabetes, 48% of people are overweight, and 14% of all deaths are due to cardiovascular disease. Obesity-linked metabolic conditions are strongly associated with worse COVID-19 outcomes, including hospitalization and death.
As of late August, COPRECOVID’s color-coded alert system (based on the daily new number of cases) classifies most of the country is in the two highest alert tiers: orange and red, with a growing number of municipalities in red. For now, which ministry has what responsibilities for enforcing the measures associated with each tier is still unclear. Nonetheless, the government has been under intense pressure from business interests to reopen the economy. Groups like CACIF (the Coordinating Committee of Agricultural, Commercial, Industrial, and Financial Associations), a conglomeration of private sector interests which represents associations from various sectors, has been unequivocal in their push to reopen. In late July, they got their wish as Guatemala officially eased restrictions on multiple industries, despite the ongoing rise in cases across the country. In practical terms, though, many restrictions were relaxed months ago. Although nonessential businesses were required to remain closed until late July, construction sites were up and running in April, building luxury high rises and finishing mall renovations in Guatemala City. It may be no surprise that the construction industry here is widely associated with corruption and money laundering.
Soon after, President Giammattei abruptly reversed his tone, despite several months of impassioned televised speeches where he had pleaded with Guatemalans to stay at home to avoid spreading the virus. On August 6th he proclaimed, “we have wasted time… because we have been kept occupied all this time with the coronavirus. I, thank God, will be leaving this topic behind.” The former doctor who had previously boasted about his unique medical qualifications to lead his country through the pandemic, went on to say, “We now hand this responsibility over to the people. If the people want to take care of themselves, they’ll take care… From now on this is the responsibility of the people.”
Whatever Guatemala might have gained from its quick, initially comprehensive response in the early days of the pandemic, will soon be lost. Decades of systemic anti-indigenous racism, corruption, and political apathy have put the majority of people in this country at higher risk of the worst outcomes from this virus. A significant percentage of the population has underlying comorbidities due to malnutrition and other conditions that stem from poverty – especially in poor and indigenous communities. Meanwhile, with the health system on the verge of collapse, emergency funding for temporary hospitals and social protection has been riddled by mismanagement and fraud. Despite efforts by organizations like Acción Ciudadana and Justicia Ya, which, following President Giammattei’s comments, are calling for an investigation into breach of duties, I am not optimistic that much will change. The president has made clear that, like so many of his predecessors, the large-scale suffering that looms on the horizon for Guatemala’s poor and indigenous people falls below special interests on his priority list.
I observe the people in the restaurant, seated closely together and without masks- a privileged segment of this extremely unequal society in the most expensive area of the most expensive city in this country. Although masks are, in fact, still mandatory, people seem less and less concerned about enforcement here. Beyond the city, the sky grows darker, as storm clouds roll over the hills that separate the Guatemala’s capital from its rural, indigenous communities. As the virus continues to spread, those communities will bear the brunt.