Three themes were identified through the analysis of the episodes of mistreatment documented in this study. Episodes narrated and discussed by participants pointed to discrimination in access, abusive treatment, and neglect of professional ethics in health care services. Table 2 presents the number of episodes that talked primarily about each of these themes, which are described in the following sections.
Theme 1: Discrimination in access to care
For indigenous people trying to access care in a public health facility, the ability to speak Spanish is a major determinant. Without a good command of the language, patients will not be able to explain their symptoms or to follow conversations laden with medical terms. Participants reported that physicians and nurses might deny care to patients that did not speak Spanish. Healthcare providers would not seek out any interpreters; even when family members were present and willing to help. This led some participants to believe that speaking a Maya language put people in disadvantage, and that only Spanish native speakers will receive the care they seek. One woman reported:
‘When I went to the hospital, I could not explain to the doctors how I felt because I do not speak Spanish very well. The doctors did not understand what I wanted to tell them, and they did not let any of my relatives come in [to the examination room to help me] and explain to them how I felt’. Woman from Solola.
The Guatemalan Ministry of Health has an explicit policy of prioritizing the delivery of maternal and child health services. Although services to other population groups are provided in larger urban facilities, in rural facilites with limited resources mostly target expectant mothers, women who want to avoid pregnancy, and young children. Services for any other age or gender group are usually not provided. People that do not belong to any of these age-groups do not feel welcomed at the facilities. Participants reported that when men go to a health care facility, they get turned away with the explanation that ‘men never really get sick’ and that the resources that exist are only there for women. It was reported that in Huehuetenango, single women and girls that seek healthcare are asked if they are pregnant. If they say no, they are sent away.
In the experience of many of the participants in our study, these barriers can only be overcome through having personal connections to the staff at the health facility. Influential patients and families, routinely receive better attention, have shorter waiting times and are given medicine at the end of the visit. A patient without these connections would routinely be made to wait, or be told that there are no drugs in stock.
‘One day my daughter had an infection in her foot, so I took her to the hospital. I got there and asked if they had medicine for my daughter. ‘Sit over there, I’ll go check’ the doctor told me, and he was angry. Then a lady came and she got care while I waited outside and my daughter was still there. Then another lady came and she also got care pretty quickly. The nurse would say ‘you stay there waiting’ and I would tell them my daughter was very sick. Five people came after us and got care. When they finally saw me they only half-checked my daughter’s foot and we didn’t get any medicine. The other people did get medicine, while we only got a prescription. They only care for the people they know, while I came from far away and the doctor doesn’t care…’ Man from Alta Verapaz
Theme 2: Abusive treatment in care
The cases of abuse we documented ranged from lying to patients and their families, to forcing unwanted and painful procedures on individuals. In many cases, the abuse involved several types of mistreatment. The most commonly reported form of abuse was yelling, which often occurred in combination with other types of mistreatment. According to the participants, belonging to an indigenous ethnic group and being poor were the motivation behind the abusive treatment they receive. Physicians and nurses would yell out disrespectful remarks along with commands or orders. Many of the participants felt powerless after being yelled at by a health care provider. Others added that, in some situations, they were in urgent need of care and felt that they could not defend themselves, so they had to put up with the abuse. One woman told us:
‘It happened to me when I was pregnant. I was in the hospital bed and I had strong pains, so I was moving a lot and screaming. The doctor shouted at me and said ‘do not yell and hold it in. Were you screaming this way when you were making this baby? No, you were going about it slowly and smoothly, right? So now put up with this.’ Woman from Huehuetenango
It was reported that patients and families are frequently lied to during interactions with the staff from health facilities. A patient might be asked to wait for hours, only to later be told that the clinical staff was not in that day. Other times they would be told that a certain diagnostic test could only be done at private laboratories, or that there were no drugs at the health facility. In some severe cases, patients were not told the truth about the gravity of their situation, or were never told their diagnoses. The effects of these lies can range from feelings of desperation or confusion to economic loss through extra out-of-pocket expenditures. One woman recounted:
‘My son had a stomachache and I took him to go get checked, and it turned out his liver was sick. [the doctor] sent us to get blood, feces and urine tests to a private facility because the results come back faster there… I had to pay for the tests, and then went back to the health center with the results. The nurse then told me the doctor was not there, he had gone home for lunch at noon and would not return until 4 pm. I was left there waiting. I was hungry because I used the money [60USD] I had borrowed to pay for the tests… meanwhile the doctor is having lunch at his house. I was there waiting and going back and forth while the nurses were just laughing and not paying any attention to me’. Woman from Totonicapan.
Participants reported that it is common practice for patients to be forced to accept procedures without being properly informed beforehand by the staff in the health facility. In the case of institutional deliveries, women are often forced to undress, made to take cold baths, and shaved without consent. Sometimes, procedures like caesarean sections and even sterilizations are performed without informing the expectant mother or the rest of the family:
‘One day, we traveled to the hospital because my wife was going to deliver, but we had to wait for a long time before someone finally saw her. Then they took her in and very quickly performed a C-section. They did not examine her beforehand… I asked the doctor why he had done this and he said that my wife was in too much pain, and that this was why they also injected her with something to stop her from having more children. I got very upset because they should have asked…’ Man from Solola
It is not only expectant mothers that are forced into procedures without any explanation:
I had a stomachache and could not stand the pain. I went to the hospital and they did not have any medicines to give me, so the doctors… washed my stomach out with cold water. They were very unkind. They forced me to do it. I did not want to…’ Woman from Solola
Theme 3: Neglect of professional ethics
In general, participants thought that having the vocation to become a physician or a nurse was a gift that came with specific duties, and being a healthcare professional meant they had a calling to serve the community. These professions, they expressed, come with a specific set of duties and with a code of ethics that should translate into kindness and polite treatment to patients.
The care that physicians and nurses provide should be personalized, and healthcare professionals should take the time to explain to patients about their illnesses and explain the treatment patiently. This would make people feel cared for and like they were in a place where they could feel better. However, this type of treatment is scarce, as one man recounted:
‘Never did the doctor or the nurse sit down with me and explain what medicine I should buy. They talk to you in a hurry; they just say there is no medicine. The doctor did not even smile at me. They only give you a prescription and they do this while they look somewhere else. They never even look at your face’. Man from Alta Verapaz.
According to the participants, it is not acceptable for physicians and nurses to leave patients alone in their beds, or not to be present to help them take their medicine. Patients wished the health staff would show more interest in how patients feel, as well as have more compassion and empathy. In stark comparison, traditional birth attendants are perceived as kind and as living up to what our participants described as ‘their professional code of conduct’.
As a way to improve the quality of care given out at health facilities, participants expressed the need for healthcare providers to be better supervised. This would lead to more accountability and an improvement in their demeanor and attitudes.