Climate change directly affects the health of hundreds of thousands of Guatemalans on an annual basis through uncertain rainfall and flooding. The knock-on effects of issues such as contamination of water and food supplies causes the national health system millions of dollars per year treating cases of diarrhea—one of the biggest killers in the country—and other intestinal infections. As of May 2017, 721 children under five had already died of diarrhea or pneumonia this year.
Even when there are no major natural disasters, climate change increases the risk of vector-borne disease transmissions. The start of the 2017 rainy season has been heavier than previous years. The more standing water that is available, the longer mosquito eggs can survive and flourish. The longer a mosquito can live, the more chance it has of being able to pass on diseases that imperil humans.
Mosquito “migration” to areas previously too cold for them or in too-high altitude to sustain them previously is already occurring in Guatemala. The World Health Organization (WHO) now warns about mosquito diseases in Guatemala up to 6,500 feet—though, already the country’s second city, Quetzaltenango at 7,700 feet above sea level, is seeing an unparalleled increase in mosquito numbers. This will inevitably end up with more mosquito-borne diseases being reported in the region with doctors awaiting vector diseases like zika, dengue, malaria, chikungunya, and leptospirosis. Ninety percent of all malaria cases in Guatemala are limited to two of its departments—81.81% of the cases in Escuintla and Alta Verapaz with 8.28%. With the changes in climate and temperature, malaria is likely now to spread to other departments.
Other vector and communicable diseases and illnesses are also spreading across the country at a rapid rate as well. The potentially fatal chagas (American trypanosomiasis) is passed on to humans by triatomine bugs (“kissing bugs”) and has infected about seven million people worldwide, mainly in Latin America. There are also skin diseases, cardiovascular infections and respiratory infections. And contaminated food or water linked to flooding has led to diarrhea, viral hepatitis, rotavirus, typhoid, shigellosis, or dysentery. In all, in 2015, the principal illnesses caused by environmental factors were: diarrhea, tonsillitis, rhinopharyngitis, bronchitis, the common cold, intestinal infections, ear infections, amoebas, upper respiratory infections, and intestinal parasites.
Although there have been significant decreases in cases of dengue, chikungunya and zika up to June 2017 compared to 2016 (61.87%, 91.01% and 82.91% respectively compared to the same six-month period in 2016) the rains that began in May could see levels return to or even exceed those of 2016. Doctor Arturo Sánchez López M.Sc. head of health and social security at the Instituto de Problemas Nacionales ( Insitute of National Issues—IPNUSAC) and in charge of the zika program said, “I believe that this year we could easily reach the same number of dengue cases from last year, there has been an epidemiological ‘silence’ of the Arbovirus throughout the region of the Americas. [And] an event like [Hurricane] Mitch would be catastrophic, with an increase in malaria, dengue, chikungunya, and leptospirosis.”
Access to clean water is another way climate change is affecting Guatemalan health through food-borne diseases, especially unregulated street food. Water and food sources can become contaminated during excess rainfall and flooding. By using contaminated food or water or implements in the preparation of the food, harmful organisms enter the food cycle. There were over 100,000 food-borne cases reported in the country in 2015 with the most—24,148—in the Guatemala City metropolis. The top four was rounded out by border departments with Mexico—San Marcos, Huehuetenango and Quiché. Three of these four departments—Guatemala, Quiché and Huehuetenango—also suffered the highest rate of diarrhea.
And yet the state has done nothing to prepare from the likely spike in health issues. According to Dr. Sánchez López, “The Guatemalan health system has made very little effort to address the effects of climate change. It [the responsibility for responding] is part of the disaster reduction council (CONRED) [which] has a risk assessment program but there’s no budget for this issue. Everything is seen and handled as an emergency and its aftermath, not on prevention.”
Dr. Soto’s colleague, Doctor Juan Antonio Villeda, former director of San Juan de Dios Hospital also in Guatemala City and the country’s second largest, was sacked last month. Dr. Villeda had admitted in a national newspaper interview that Guatemala’s public health system wasn’t prepared to deal with the tragic fire at Hogar Seguro that killed 41 teenage girls nor the El Cambray Dos landslide that killed over 280 in 2015.
Interplay of Extreme Weather and Policy
Hurricane Stan, 2005
According to the UN Economic Commission on Latin America and the Caribbean (ECLAC) Hurricane Stan in 2005 placed millions of Guatemalans’ at health risk, beyond the destructive impact of the natural disaster, specially in Escuintla (445,515 inhabitants), Quetzaltenango (443,246 inhabitants) and San Marcos (429,401 inhabitants). As a result of the destruction left behind by Stan, Guatemala’s Unidad de Respuesta Rápida y Asistencia Técnica del Sistema Integral de Atención en Salud (Rapid Response and Technical Assistance Unit of the Integrated System of Health Care—SIAS) had to respond to 5,431 cases of prenatal care, and hand out 20,563 micronutrient supplements to families and individuals affected by the hurricane.
Stan also caused more than $24 million in damage to the food system, primarily through the death of 3,300 cattle and the resulting loss of milk that affected tens of thousands of families. And Guatemala’s Health Ministry reported damage caused to 87 health posts and 31 health centers, most affecting those who needed treatment in the wake of the hurricane.
Hurricane Mitch, 1998
Over the course of a week after Hurricane Mitch, ECLAC and Fondo de Inversión Social/World Food program noted a 39% increase in acute respiratory infections, a 44% increase in diarrhea, a 45% increase in pneumonia, and a 53% increase in cholera. There was no data collected on damage to health infrastructure in the aftermath of the hurricane.
Child malnutrition, ongoing
In 1965 the rate of chronic malnutrition in Guatemala was 63.5%; as of 2015 it was 46.5%.
The “Strategic Review of the Food and Nutrition Security Situation in Guatemala,” a report published by Asociación de Investigación y Estudios Sociales (Social Studies and Research Association—ASIES) and the World Food Program claims that if current rates of chronic malnutrition over the past 50 years continues, it will take 63 years for Guatemala to catch up to Honduras, 90 years to catch up to El Salvador, and over 125 years to eradicate chronic malnutrition. According to the report, “Studies that address the manifestations and effects of undernutrition on individuals and societies show that acute malnutrition is expressed in a manner similar to a death sentence, while chronic malnutrition is the equivalent of a life sentence.”
As of May 2017, 16 children under five had died in Guatemala because of acute malnutrition, with over 3,900 cases reported.
Preparations for the Future
In 2013, the administration of President Otto Pérez Molina passed Decreto 7-2013, seeking to regulate climate change and reduce greenhouse gases. This led to the formation of the Consejo Nacional de Cambio Climático (Climate Change National Council—CNCC), headed by the president. It was the second specialized climate-change law in Latin America. Its responsibilities are human health, coastal areas, agriculture, forestry resources and protected areas, infrastructure, and water management.
By October 2016, the first Nation Climate Change Plan (Plan Nacional de Cambio Climático—PANCC) was drafted. It provides a legal framework to establish government responsibilities for climate change. PANCC was, in theory, a mechanism to coordinate activities among government ministries, the private sector, experts, indigenous groups and NGOs. Multilaterals assisted in the draft with the German Corporation for International Cooperation (GIZ)—through its Program of Rural Development and Adaptation to Climate Change—the Inter-American Development Bank (IDB)—through the Project “Technical Cooperation Supporting the Climate Change Group in Segeplán”—and USAID’s “Development with Low Emissions” program all lending a hand.
The Guatemala Ministry of Health is part of the country’s overall disaster reduction process. The National Coordination Office for Disaster Reduction (Coordinadora Nacional para la Reducción de Desastres—CONRED) coordinates with the Ministerio de Salud Pública y Asistencia Social (Public Health and Social Assistance Ministry—MSPAS) during a natural disaster and the Health Ministry has a risk department to analyze issues. However, the department remains underfunded and high level planning remains to be a “wait for an emergency, then deal with it.”
The World Bank granted a $100 million loan in March 2017 to combat chronic malnutrition in Guatemala. In 2015 that represented 46.5% of the population with 41.7% of children under two suffering chronic malnutrition according to statistics from the Procuraduría de los Derechos Humanos (Human Rights Attorney Office—PDH) and Secretaría de Seguridad Alimentaria y Nutricional (Food Security and Nutriton Ministry—SESAN). According to the same statistics, these levels of malnutrition rises to 47.3% of children when you raise the age to those under five.
USAID is providing funding to projects to reduce zika and improve child malnutrition and maternal health. The World Bank has assisted during climate emergencies with loans. The IDB has provided some help under its umbrella of establishing better institutional conditions to deal with climate change. At the same time, Guatemala’s Ministry of Finance is exploring “green taxes” but is still in the planning phase. Guatemala’s Congress has proposed financing health programs with taxes on guns and drinks, but nothing has resulted yet.
In short, international and domestic assistance in this critical area that will affect millions of Guatemalans’ health over the next decade has been spotty, too narrow, haphazard, or simply failed to match action with promise.
Although there is a framework law in place, discussions are still going on at an academic level on how to proceed with legislation in Guatemala. The disaster reduction council is a positive move but its budget is limited. Events are still treated as emergencies and there’s little to no attempts at prevention. CONRED admits there is no budget for preventative measures on their part.
The public health system has no standards, guides or manuals focusing on prevention. This feeds into the cycle of disaster-reaction-disaster.
According to Dr. Karin Slowing, Guatemala public health expert and assistant director of Catholic Relief Services’ project, “Communities Leading Development,” the existing policies and the climate change legal framework have had little implementation or financial support. The integration of environmental issues into national planning has been slow and equipment and infrastructure is lacking. Guatemala’s response to the zika crisis was underwhelming, with the headquarters relying on equipment from the 1970s and delays to spray infected areas. What budget is available for climate change is not sufficient nor is it binding in the national budget, which means it is unlikely the Health Ministry will ever see it. This fits into the pattern of regional governments that do not have prevention schemes nor the budget to execute them.
As Dr. Slowing said, “It seems to me that Guatemala and its public entities are doing very little to prepare themselves to cope with climate change, both in terms of mitigation and adaptation. The main studies on the subject have been supported and promoted mainly by international organizations, where the national entities do not have a strong leadership in how they are carried out, but rather see themselves as collaborators of these analyses.
There is no anticipation or preparation to anticipate and/or prevent events and they are still acting reactively. The local units of CONRED have been weakened in recent years.”
At the same time, there is little environmental management within the Health Ministry, much less of the caliber of interdepartmental collaboration and staff required for effective climate change policy. At best, climate change is considered as a variable or factor to be taken into account when explaining epidemiology. As such statistics on climate change factors are collected in a non-uniform process, especially in areas such as respiratory diseases, child malnutrition and maternal health. For instance the recent 750+ page ENSMI report (Maternal and Child Health National Survey), the Ministry of Health’s largest undertaking that focuses on maternal health and malnutrition, mentions climate change once and in relation to HIV/AIDS.
Last there is also the problem of excessive centralization. Over 80% of Guatemala’s doctors work in Guatemala City and the only effort to rectify this so far has been mandating student doctors to work in rural areas. Although this improves student doctors’ experiences, there is currently no policy to decentralize where doctors practice to serve most-at-need rural populations.
Projected Consequences of Inaction
Inaction would affect the millions of Guatemalans’ health from increased communicable and infectious diseases to vector-related diseases like malaria and dengue, and overwhelm the country’s already-strapped health care system.
The financial cost of these environmentally-induced effects to Guatemala’s health system is estimated in the tens of millions of dollars annually.
From 1930-2008, major natural disasters such as floods, earthquakes, forest fires and drought have occurred in Guatemala at an average of 3.17 per year. About 85% of these are hydrometeorological (floods, tropical storms, landslides and mudslides) in nature. Food security is extremely vulnerable to climate variability. In 2015, Guatemala ranked tenth according to the Climate Risk Index of the poorest countries affected during the period 1994 to 2013 by climate change.
Again, according to Dr. Slowing, “It seems to me that Guatemala is very, very far from passing the discourse on the recognition of climate change as a threat and a real risk for the country, to the realms of concrete actions. Its instruments of policies, plans, laws, etc. may recognize climate change but the real action of its institutions is still a long way from translating these elements into programs, projects and new practices and regulations that contribute to mitigate the effects and adapt the economy and society to climate change.”
What should be done?
Here are some preliminary suggestions based on our analysis:
- The world over, especially the major polluters, must comply with international climate change agreements;
- Guatemala needs to ensure it has the budget to confront climate change emergencies and to implement laws it has already passed or is in the process of passing;
- Although Guatemala has supposedly launched a national climate change plan and in theory is participatory, the reality is that there are still silos of information that do not filter down to public level. After five years, the development of a national plan is still being discussed by politicians and academics; it needs a budget and action plan that allows implementation;
- As part of the climate change policy, the Guatemalan Health Ministry must provide fundamental support to national, regional, local and hyperlocal units. This includes standards, best practice policies, establishing and ensuring that extreme crises are handled uniformly to meet pre-established standards, and creating the guides and manuals to ease that process. Specifically, the focus has to be on predicting and preparing its staffs and offices for these events and needs;
- The Guatemala Health Ministry needs to do better at collecting and reporting environmental disease statistics. By its own admission, the PANCC could not rely on respiratory disease statistics despite pneumonia being the country’s biggest killer. According to Doctor Ricardo Menéndez, pediatric unit head of Roosevelt Hospital, Guatemala’s largest public facility, every day in 2017 five children suffering respiratory illnesses need to be ventilated. An increase, year-on-year of 15-16% because of augmented rainfall and damp in houses.;
- Internally, the Guatemalan Health Ministry needs to free up funds for medicines and personnel by renegotiating union collective bargaining agreements. Currently staff salaries and regularized increases account for over 90% of MSPAS’s budget. In addition, a census of the ministry employees—like the one proposed for public officials—is needed to expose “no-show employees” in this critical public function;
- The government has to finish the four hospitals started under previous administrations and conduct a nationwide assessment of the health service. A the same time, given the growing challenges outside the capital it has to increase the number of local health centers to provide for smaller communities and boost resources to regional hospitals;
- It should be a state responsibility to increase public education of health risks from climate change. This should involve identifying and clarifying which governmental bodies are responsible for such a public-education campaign and ensuring they liaise with local municipalities and auxiliary representatives at a neighborhood level;
- To help combat climate change, other ministries need to play a bigger part, especially the Agricultural Ministry (MAGA), the Environment Ministry (MARN), Social Development Ministry (MIDES) and the municipal development institute (INFOM). The Health Ministry is essentially the end recipient of failures on the part of environmental management;
- The national government and congress need to force municipalities to invest In water and sanitation in a systematic way and change the incentive scheme for transfers of funds from the central government to the municipalities. Currently, they receive resources regardless of whether they succeed or fail with their work; and
Perhaps most important the government, as it confronts this looming crisis, needs to streamline and improve the efficiency of public expenditures. As of June 2017, MIDES has only spent 9.4% of its budget. The ministry blamed the lack of spending on the need for a census to see if state aid was helping the most vulnerable families. Internal MIDES data suggested that those receiving state aid did not escape poverty. However, this delay has led to programs preventing chronic malnutrition and monetary transfers to families that require health assistance having a zero percent execution rate.