Soc. Sci. Med Vol. 25, No. 10, pp.

1163-1173, 1987

Printed in Great Britain. All rights reserved

0277-9536/87 $3.00+ 0.00 Copyright 1987 Pergamon Journals Ltd

W O M E N AND HEALTH CARE ON A G U A T E M A L A N PLANTATION

SHEILA COSMINSKY Rutgers University, Camden College, NJ 08102, U.S.A. Abstract--Women on a Guatemala plantation are responsible for the health care of their families and are the primary therapeutic decision makers. This study focuses on women as lay health care providers. They provide medical care directly through home treatment and indirectly through strategies which increase their access to resources which enable them to utilize various illness treatment options.
Key words--women, health care, Guatemala, decision-making

INTRODUCTION Studies of women and health care have focused either on their roles as specialized healers or as clients or consumers, especially in the domain of reproduction [1]. Women are health care providers, however, both on the specialist and lay levels. Less attention has been paid to the lay sector and to the participation of women in family health care [2, 3]. Kleinman refers to this sector as the popular arena which includes the family context of sickness, and estimates that 70-90% of sickness is managed solely within this domain. Most decisions concerning other health care options are also made in the popular domain [4]. This paper examines the role of women as family health care providers and decision makers on Finca San Felipe (a pseudonym), a Guatemalan sugar and coffee plantation. Planta'don women have the primary responsibility for family care and health care decisions. They employ a variety of strategies in providing health care for their families. These activities and the available therapeutic options must be viewed within the constraints set by the women's position in the plantation socioeconomic system and their poverty, which influence both their disease burden and economic resources. These strategies involve the manipulation and management of resources, opportunities and situations aimed at increasing their access to resources and maxiniizing those that they have [5]. In this way, women provide the means for obtaining access to other sources of treatment, as well as directly providing health care. The paper delineates the way women extend their resource base and increase their access to cash and other means in order to obtain medical services. These resources are among the factors that influence women's health care decisions and also enable them to implement these decisions. The available options entail differential costs and benefits, which are weighed by women in the process of choosing among treatment alternatives. Financial costs, time and energy costs, including distance, social and psychological costs, and household organization and social support are examined with respect to the role they play as factors influencing women's health care decisions. Although these are only some of the variables that have been considered in health care

decision making studies [6-10] they are ones that plantation women have expressed influenced their decisions. These factors must be considered in relationship to each other and in terms of their impact on women in order to understand their therapeutic decisions and improve health care delivery. The approach used in this study views women as active participants and actors, not passive or fatalistic recipients or resistant conservatives. No attempt, however, is made here to develop a formal decisionmaking model, such as Young has done [7]. Rather, the emphasis is on utilization of health care services, the strategies used in obtaining resources with which to implement their health care decisions, and factors that the plantation women have mentioned have influenced their decisions. METHODOLOGY Research into health practices on the plantation has been carded out at various periods between 1970 and 1979. Data in this paper were obtained primarily during research concerning the allocation of resources for food and medicine during 1978. A sample of 35 households was selected to represent a range of nutritional and health status as measured in previous studies on the fmca. Each household had at least two children, one of whom was under two years of age. Information on illness episodes, health seeking behavior, and household expenditures was obtained for at least two or three different 2 week periods. The 2 week period was chosen to coincide with the plantation's 2-week pay schedule. Visits, observations and interviews were conducted with folk healers, spiritists, hospital staff and other health care personnel consulted by the local population. SETTING ' Finca San Felipe is a coffee and sugar plantation located in the Department of Retalhuleu on the Pacific coast of Guatemala. Although a significant proportion of the Guatemalan population five and/or work on plantations, few anthropological studies have been made [11, 12]. The plantation of this study differs in several ways from La Cafiaveral, the one studied by Bossen. One of the most important

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differences is that on Finca San Felipe women are employed during the coffee season and have control of the cash they earn. In contrast, on E1 Cafiaveral, most of the land is in sugarcane and only 5% in coffee. Only a very small percentage of the women are employed by the plantation, and they do not pick coffee for wages. E1 Cafiaveral, however is much larger, more modern and employs a large number of migrant workers. Most permanent workers have running water and electricity, and the standards of living for the permanent workers or colonos are higher than in Finca San Felipe, where water is provided by a couple of public water taps. Whereas, E1 Cafiaveral has its own health center, no medical services are currently provided on Finca San Felipe [13], except for a very small first aid station in the plantation office, which is required by law, and which very sparingly dispenses patent medicines such as aspirin, malaria tablets, cough remedies and vermifuges. E1 Pilar, the plantation studied by Pansini, provides a plantation paid medical program which includes the services of a visiting physician, a resident paramedic, and a first-aid station [12]. The plantation covers an area of about 1384 acres with a resident community of approx. 700 persons in 125 households. The population is mixed Indian and Ladino [14], consisting mainly of second and third generation Indian migrants, from the Western Highlands. There does not seem to be any difference in utilization of health care resources according to ethnicity. Land, labor and housing are controlled and allocated by the plantation owner. This has resulted in a relative homogeneity in salaries, living conditions, and housing. Although there is some economic micro-differentiation, almost all the workers (excluding the few salaried employees) exist at a marginal poverty level of subsistence [15]. Housing is poor and overcrowded. Most, though not all, houses are in long rectangular buildings or galeras that are divided into single large rooms to which a family is assigned. These may be further subdivided into partitions by their inhabitants. Other units are one-room free standing houses. Structures are composed of wood walls, earthen floors, and tin roofs. Many houses have lean-to additions used as a kitchen area or as space for a married child. Most of the households are comprised of nuclear families although several have extended families. The average household size is 5.6 persons, ranging from thirteen members at one extreme, to single person households, usually a widow or widower, at the other [16]. Environmental sanitation is very poor. With the exception of a few salaried workers who have installed private water taps and constructed latrines, most of the population do not have their own water or latrines. People use the fields for defecation. They obtain drinking water from one of two public taps or pilas, and bathe and wash dishes and clothes in one of the local streams. HEALTH AND NUTRITIONAL STATUS Health conditions on Guatemalan plantations in general have been reported to be among the worst in

the country [17, 18]. Earlier surveys done on Finca San Felipe show that the population has poor general health and nutritional status [19]. Diarrheal and respiratory infections are common with the highest incidence occurring in young children. Communicable childhood diseases, such as measles and whooping cough occur epidemically. These infections act synergistically with malnutrition, in an already poorly nourished population. Forty-one percent of children between 1 and 5 yr of age were moderately to severely malnourished (less than 75% standard wt/age). An additional 40% had mild malnutrition (75-89% standard wt/age) [20]. There is also a high prevalence of anemia. Fiftythree percent of the population had hematocrit values more than 10% below the lower limit of normal. Anemia was most common among young men, which has serious negative implications for work performance [19]. The prevalence of acute diseases is high and varies seasonally. Diarrheal diseases increase with the onset of the rainy season (April-May) and respiratory diseases are most common d u r i n g the dry season although both are hyperendemic. Almost everyone has heavy burdens of intestinal parasites. The nutritional and health status of a woman influences her ability to provide health care for her family: At least 70% of the plantation women between 20 and 30yr of age are either pregnant, lactating, or both [16]. Lactation often continues for 2 yr, placing a heavy biological demand on mothers. In a 1976 survey only 8% of pregnant women and none of the lactating women were meeting the recommended dietary level for calories [21]. Such low nutrient intake may precipitate more illness episodes. The reproductive stress of pregnancy and lactation are compounded by frequent infections and by the nutritional stress of an inadequate diet. The resulting poor health may reduce a woman's energy levels and limit her activities, such as traveling long distances for treatment and her ability to extend her cash and food resources to satisfy the costs of medical care.
HEALTH CARE RESOURCES

A wide variety of health care resources and services, both on and off the plantation are utilized by the local population. These alternatives include home treatment, folk eurers, herbalists, midwives, spiritists, shamans, injectionists, stores, pharmacies, traveling vendors, public and private clinics, hospitals and private physicians. These treatment resources incorporate components derived from Mayan Indian, folk Ladino, spiritism and cosmopolitan or Western medical traditions and have been described elsewhere [22]. Home treatment is the most common initial resort (39% of 246 illness episodes), especially for episodes of gastrointestinal and respiratory disorders. In addition, home treatment was used at some point in the treatment sequence, often repeatedly, for more than 47% of illness episodes. Home treatment includes self-treatment and home remedies. Home remedies are composed of herbs and simple commercial patent medicines or a combination of these. Several different herbal and patent remedies might be tried in the course of an illness. It is the least expensive and most

Women and health care on a Guatemalan plantation convenient form of care available. In this capacity, women are the first line of medical care providers. The majority of women identified several common medicinal plants, such as yerba buena (mint) and ruda (rue), which are grown locally or bought for a few cents in the stores or town market. Older women tend to know a greater variety of herbs. Other women, like Marina, who sells medicines from her local store and gives injections, have a wider knowledge of both herbs and commercial medications and are frequently consulted for medical advice. Herbal remedies are also prescribed by specialists, such as midwives and herbalists, who have a more extensive knowledge of herbs and prescribe more complex combinations of plants. All herbs, medicines, foods and illnesses are classified according to their qualities of hot and cold. On the basis of the humoral principle of hot-cold opposition, illnesses are treated with medicines of the opposite quality. Both new pharmaceuticals and biomedical disease labels have been classifed into hot or cold categories and have become incorporated into the humoral system. The female household head is responsible for procuring (whether gathered or bought), preparing and administering herbs to the patient. This is true in almost all cases of the use of herbal remedies, whether as teas, baths, or poultices, and regardless of who prescribes them. The exception is the midwife, who will sometimes prepare the herbal mixture herself. Patent remedies, such as Alka Seltzer, aspirin and Santemesina (a powdered tetracycline compound), are available at the stores located on the finca and can be bought in small amounts. These stores are convenient and credit can be extended if necessary. If home treatment is unsuccessful, individuals may purchase medications from local stores, lay practitioners, injectionists, or pharmacies. If money is available, individuals may initiate treatment with pharmaceuticals rather than use home treatment. Several stores on the plantation sell patent remedies, but the primary one is Marina's [23] because she also sells and administers injections. The other main source of pharmaceuticals is Don Max, the ambulatory medicine vendor and injectionist. The main pharmacies that are utilized are in Retalhuleu but there are also some in the neighboring towns of San Sebastian and San Felipe. Alternatively, patients may go to one of three health centers or clinics in the town of San Felipe or Retalhuleu. San Felipe, which is 8.5 kin from the plantation, has a public health clinic and a private clinic. The latter is attached to a hospital, Hilario Galindo, popularly called San Cayetano. The hospital is limited with about 30 beds, no X-ray laboratory, and does only minor surgery. However, they "have a child feeding program that serves about 200 children, the most malnourished of whom stay at l the hospital. There is also a public health clinic, a national government hospital, and a Guatemalan Social Security Hospital (IGSS) in Retalhuleu, about 12 km away. The plantation workers are covered by law under the Guatemalan Social Security Institute [24]. This hospital admits only workers and treats primarily accidents, such as fractures, machete cuts, and insecticide poisonings. There are several private physicians who have offices in Retalhuleu, one of

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whom has his own small hospital. One woman said that the doctors in Retalhuleu are older and have more knowledge than the doctors in San Cayetano, who are young and keep changing. No formal or cosmopolitan health care facilities exist on the plantation, except for minor first aid and patent remedies occasionally dispensed by the office. A variety of folk practitioners are located on the plantation. These include five curers (four of whom are female), who treat children's illnesses, such as the evil eye (mal ojo), fallen fontanelle (mollera), worms and diarrhea, two quemaderos or burners (both male), two bonesetters (one male and one female) and one female midwife, who is also a shaman and a spiritist [25, 26]. Two spiritists (one male and one female) live in the village adjacent to the plantation and are the ones most frequently used by people from the plantation. Several other healers, used by plantation clients live and practice in various towns, some of which are quite far from the plantation. These practitioners often prescribe drugs which must be purchased from the pharmacy or from one of the local vendors. The perceived severity and/or the persistence of an illness are major determinants of medical choices. A simple cough, colds, and diarrheas may receive no treatment, or they may be treated with herbal remedies or inexpensive patent remedies. The continuation or increased severity of an illness or symptoms, such as a high fever, usually precipitates treatment with a pharmacy or a clinic. If that is not effective than the patient may go to a physician or hospital or a folk specialist. This tendency to use the least costly treatment initially, relative to one's resources is illustrated by the example of Luisa. Luisa specified that she was using Alka Seltzer for her child's diarrhea because she had insufficient money to purchase a more effective remedy. She eventually went to the clinic for her baby's diarrhea because the home treatment was ineffective, but she did not have the money to buy the prescribed medications. She said she would have preferred to go to a physician but had gone to the clinic because she did not have enough money to consult a physician and hoped the clinic would provide medication. The persistence and severity of an illness influences the specific resource employed, as well as the complexity of care. The tendency to begin with low cost or home remedies and move to more expensive resources if the illness continues or becomes more severe, is subject to a number of constraints, so that there is not a clear sequence of resort. Utilization of therapeutic alternatives by the plantation population is highly pluralistic, with multiple usage being common. Therapeutic services may be used sequentially or simultaneously. F o r example, an infant may be given patent remedies for diarrhea and undergo treatment for the evil eye by a local curer at the same time. The sequential and simultaneous usage can present certain methodological problems in recording and analyzing the data. In addition, specialists such as physicians or spiritists may prescribe a series of injections. These are bought in the pharmacy and then administered by one of the lay injectionists. Thus three resources are used for the one treatment. Each resource also entails additional cost. However,

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it is misleading to record these consultations sequentially or as separate treatments, as is frequently done, since they are part of the same treatment procedure. Plantation women are responsible for making most of the health care decisions in a family. They evaluate the relative costs and benefits of alternative therapies in relation to their own assets and constraints, such as availability of cash, distance, time, severity of illness, and household composition, and with respect to the expectations they have of the different services and treatments. These different factors and their interactions are examined below.
COSTS

Financial costs and access to cash

Public and private clinics both charge 25 centavos [27] for a consultation. A physician's fee is Q4 (which was the equivalent of 4 day's wages in 1978). Most of the folk practitioners charge 25 cvos for a consultation and a minimum of Q4 if a ritual or "invisible operation" must be performed. Financial cost, however, includes not only the price of the medical service but also the transport costs to the facility or practitioner, consultation fees and additional travel costs to the pharmacy or market to obtain medicines prescribed for treatment. Cost may be a more important criterion with respect to treatment compliance than it is in shaping the initial consultation decision. Many of the 'mode m ' and 'traditional' or 'folk' specialists, prescribe pharmaceuticals, especially injections. A client's purchase of some or all of the drugs may depend upon the availability of money. Several women reported that they could not buy the prescribed medication or could purchase only a portion of it because they did not have enough money. Even use of health services that are supposedly free or nominally free may entail costs. For example, the use of free care at the national government hospital in Retalhuleu may incur hidden costs. People believe that to receive attention in the hospital, patients must be referred by a private physician, rather than a clinic. Thus the family must pay for the physician's fee for a referral. In addition a hospital stay might entail other costs, such as payment for X-rays, lab tests, serum, blood, ice and medications. These costs must be placed in the context of the severe economic constraints faced by the plantation population and their limited access to cash resources. Wage labor provides the most important source of cash [28]. Permanent male plantation workers earned an average in 1978 of Ql8.00/quincena (2 week period). Men are expected to provide corn for their families either from their milpa (a small plot of land provided by the plantation owner to grow subsistence crops) or by cash purchase. They are also expected to give part of their salary to their wives or mothers for additional food and household supplies. Sometimes they give money to women to purchase medicines and sometimes buy remedies themselves. Frequently, however, a significant amount of a man's salary is used to buy alcohol and to pay debts for purchases of items such as radios. Women work seasonally, primarily as coffee pickers during the coffee season, from mid-August

through November. Children help their mothers pick coffee. Adolescents (above 14 yr of age) either work on the plantation if jobs are available or, more frequently, they find jobs on neighboring plantations. They are expected to give most of their earnings to their mother. A woman keeps and controls the cash she earns and money that is given to her by her children and husband, or other family members. The amount of cash she has control of is a major factor influencing her health care decisions. The importance of financial cost as a determinant of medical choice is relative to one's resources. Resources are scarce for the plantation families, especially during the lean season. During this period most people must buy corn since their harvested supplies are finished, and because women are not earning cash from coffee picking. Both less cash and less food is available to families at this time of year. For example, one woman who wanted to purchase injections for her daughter suffering from diarrhea, said she had to wait to buy remedies until after the corn harvest. This family had also borrowed money for medicines from the plantation administrator and would have to repay him after the corn harvest. The lack of access to cash is an important constraint in obtaining medical treatment. When a husband is unable to provide cash for medicines, responsibility falls on the woman. She must resort to strategies to supplement the wages and find ways to increase her resources. Men are tightly constrained by the mandatory labor system on the plantation. Most of the strategies for extending the resource base, therefore, are carried out by women. Women have a more flexible work schedule except for their obligations during the coffee season, and can carry on more outside activities.
Strategies to increase resources

Strategies used by women to increase the amount of cash available for health care include borrowing money, selling animals, and pawning items. These are means of obtaining money quickly for specific purposes, such as medical emergencies. Strategies to extend the value of cash for health care include credit, buying in small amounts, and utilization of multiple treatments [22]. These strategies enable a woman to obtain medical treatment quickly when no or little cash is available. However, this short-term benefit often incurs long term costs, such as higher prices for medicines. These strategies differ from the more regular and longer term economic or survival strategies that women employ to increase their cash flow, such as increased wage labor, petty trading, vending fruit or foodstuffs, sewing, cooking, and various business ventures [28]. Borrowing money is usually resorted to only in emergencies. Small amounts of money may be borrowed from kin, godparents or neighbors. Larger loans may be obtained from the plantation owner, the administrator, or from nearby plantation owners. The debt must be repaid during the peak coffee season or after the corn harvest, when the family no longer has to buy corn. Individuals can also borrow from a local moneylender. In such cases high interest is charged on the loan. Money from the plantation owner or from moneylenders is borrowed by men,

Women and health care on a Guatemalan plantation whereas in other situations w o m e n m a y do the borrowing. W h e n w o m e n borrow from neighboring plantations, they must work on that plantation to repay the loan. Items such as radios or watches m a y be pawned or sold to obtain needed cash. Such items are usually the male's and thus the decision to sell or pawn those items are made by him. If the family has any maize, they m a y sellsome for cash and buy medicines. One woman, Elena, whose whole family was sick, including herself, sold 8-10 pound quantities of corn for Q0.08/lb at various times to wealthier individuals, such as the midwife or a storeowner, to pay for medical treatment. This strategy enabled her to obtain immediate cash for needed treatment. However, the short term benefit was obtained at a disadvantage since she had to sell below the market price of Q0.10/lb. and because she ran out of corn more quickly. The decision to sell corn is usually made jointly by the husband and wife, although the woman may do the actual selling herself, especially for small amounts. Elena stated that she had to ask her husband for permission to sell some corn, since he could calculate how much corn the family would use and how much would be left. Women are responsible for raising small animals, such as pigs, chickens, turkeys, and ducks. This provides a means for women to expand both their food and cash. Selling animals and/or their products is an important method for obtaining ready cash. Most families own only a few animals. Pigs are regarded as an especially important investment which can be converted to cash when needed. A piglet costs $10 and may be sold for $40 or $50 depending on the size and health of the animal. Once a family has sold their animals, it may take them time to recoup funds to purchase more animals and the resources for feeding time. All the strategies for increasing resources mentioned above are illustrated by the following case of Luisa and Jose, a young couple who had a 1-yr-old child suffering from chronic diarrhea and malnutrition. They used multiple resources to treat him, including two different physicians, a clinic, a spiritist, curanderas, and a traveling curer-diviner. In order to pay for these services, they sold their two pigs, pawned their radio and watch, and borrowed from relatives. At various times, the family was reduced to eating just tortillas and greens. At the end of our study they were still in debt, owing at least $54 to several sources. During the following coffee season, Luisa was able to work off this debt. F o r several weeks all her wages went to repay the loans [22]. Buying on credit is a critical strategy for obtaining health care when cash is unavailable. Medicines or injections may be obtained from vendors who extend credit, rather than pay cash for remedies at the pharmacy. The two main sources which allow customers to buy on credit are Marina's store and the ambulatory vendor-injectionist, Don Max. Two local schoolteachers also give injections, but they are not used as frequently. Credit may result in purchases of more expensive medicine. Don Max usually charges more than the pharmacy for the same medicine. A woman may also try to spread out debts by obtaining credit from different stores or practitioners. F o r
S.S.M 25]10---G

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example, she may buy some medicines or injections from Marina and once she has reached her credit limit there, will buy other medications from Don Max. A woman must balance the amount and duration of the debts, repaying as much as possible on payday. The size of debts accumulated for medicines is weighed against expenditures and debts for food, which usually takes priority. Buying in small quantities is another strategy for maximizing the amount of medicine which can be obtained with available cash. This is common practice with patent remedies such as aspirins, and antibiotic pills, such as terramiacin, which are bought a couple at a time for 5 or 10 eros. Even injections may be bought one at a time. Often the family cannot afford to purchase an entire prescription provided by a physician or other practitioner and will buy the medications in smaller quantities. This may be more costly in the long run, but is affordable in the short term. Although the person may obtain some temporary relief, the symptoms may return because the full course of treatment was not taken, and drug resistence may build up. Multiple treatments are another strategy for obtaining treatment despite lack of money. Although many treatment sequences begin with home care, once more expensive therapies have been used without success, the woman may resort again to home treatment. Other women may not seek care until they are able to regain some assets. Time and energy costs The element of time includes several components: the time spent waiting, the transport time (bus vs walking), the time or duration of the treatment and the time lost from other activities, such as wage labor, cooking, farming, fetching water, marketing, and child care. Since the majority of health care activities involve the participation of the mother, her time constraints must be considered. These are rarely taken into account in the delivery of health care services, especially in the structuring of the clinic schedule or in the care given by the medical personnel. The usual procedure at a clinic is for patients to receive a number when they arrive and they are seen in that order. If a person arrives too late, all the aUoted numbers may have already been given out and she may be told to come back the next day. Even if the person has received a number, she might not be seen that day and would have to return. One woman said she prefers the clinic in San Felipe to the one in Retalhuleu because there are fewer people there so the wait isn't as long. According to the nursing supervisor, the outpatient clinic at the national hospital in Retalhuleu distributes appointments into three time periods, 8-10 a.m., 10-12 a.m. and 4 - 6 p.m. with 10-12 patients per period. Patients must arrive no later than 7 a.m., 9 a.m. and 3 p.m. to be seen during the closest period. If all the slots for any time period are filled, the patient must wait for the subsequent period, except for emergency cases which are seen at any time. Because of the transportation problems and bus schedules most of the patients arrive between 9 and 10, and therefore might have to wait for the afternoon period, with a waiting period of 6 or 7 hr. The San Cayetano clinic, attached to the

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Hilario Galindo hospital, does not limit the number of patients they will accept and appointments are given from 7-9:30 a.m. and. 2-3 p.m. The time spent waiting which is often several hours, is one of the most common complaints concerning the clinic. The long waiting time is contrasted with the brief consultation or examination time which is usually only a few minutes. Although the waiting time may be the same or even longer at some of the spiritists or healers, people do not complain about the wait. For example, clients wait several hours for consultation with one of the very popular herbalists about 15 km from the plantation. His consultations are usually just as brief as the physician's but people do not complain either about the waiting nor about the brief consultations. The negativity of waiting may be mitigated by the friendly atmosphere and socializing that takes place among the clients, who are from all over the country, while they wait in the patio. While waiting, people drink and eat refreshments, some of which they have brought with them and some of which are bought from a stand run by the herbalist's wife. The impersonality and silence of the clinic waiting room provides a sharp contrast. In the public health clinic, certain activities, such as prenatal examinations, distribution of free food from the maternal and infant program (which also entails attending a nutrition class), immunizations, patient consultations and examinations, are scheduled on separate days. This can result in unrealistic demands on rural women. For example, Elena (mentioned above), was pregnant and went to the prenatal clinic to be examined because she was not feeling well. Pregnant women also have to be examined in order to be registered for the supplementary food distribution program. At the same time, Elena brought in her sick 1-Yr-old child to be examined, but was told they could not examine the boy that day because it was prenatal clinic day. She was told to come back the next day, which would require another 3 hr walk round trip carrying the sick child. She could also get caught in the rain, might have to wait most of the day to be seen and would increase the chances of worsening her own illness. Other cases involved complications over immunizations. The public health center runs a mobile clinic which periodically visits the different plantations to vaccinate the children. However, if a child is sick that day he should not be vaccinated and the mother should go to the clinic when the child recovers. One mother took her baby to the clinic to be vaccinated but the clinic was closed that day. A couple of months later she went back on a different day of the week and was told that they had run out of the vaccines and she would have to come back the following week. Several such cases were mentioned by informants, indicating problems of obtaining sufficient vaccine supplies as well as scheduling. No consideration is given to the woman's constraints vs the rigid clinic schedule. The clinic is oriented toward the local town population. Although the scheduling problems are partially due to personnel shortages, a more flexible clinic schedule, more considerate and respectful attitudes of the staff and greater recognition of the difficulties faced by these women would improve utilization of the facilities and

quality of the services. Because of the long wait and their time constraints, women often go directly to the pharmacy, where there is no waiting. They either request a medicine with which they are already familiar or ask advice from the pharmacist. Some of the folk healers also do not consider women's time constraints and work burdens. Elena, in addition to going to the clinic, went to consult with her brother who is a quemadero, or burner and healer. He said that the reason she and her family were still suffering various illnesses and not recovering was because of the bad influences (real influencias) from the recent death of her sister-in-law, who had lived next door. In order to get rid of those influences, she had to pray and burn candles in nine different churches. Her faith in her brother's abilities, the kinship obligations, and the attribution of a supernatural cause to the family's continuing illnesses were all factors which exerted pressure on her to comply and fulfill this demand. This was a very large investment in time, energy and money since the churches were in several different towns, some quite a distance away. Time constraints vary seasonally, as do other variables such as income, availability of cash, and food supply, and affect the use of medical services. During the lean season, from April-July both cash and corn are scarce but women have more time. This season also marks the beginning of the rainy season, which other studies have shown is the season when diarrheal diseases are most prevalent [29]. Several families said they lacked the money to get treatment during this period. As one woman stated "if we have money, we're cured; if not, we die." The alternatives are: (1) to utilize less costly therapies such as home treatment; (2) put off more costly treatment until illness is perceived as severe and resort to one of the strategies to obtain cash discussed above; (3) delay treatment until the corn harvest when families do not have to buy corn or until the coffee harvest when women are earning money picking coffee. However, at harvest time although more cash is available, women's time constraints are greater. Some women specifically stated that they did not go for health care because they did not want to lose time from coffee picking. They could not spare the time to spend the day at either a clinic or with a spiritist or practitioner. Also, the peak coffee season coincides with the peak rainy season in October, and some women said it was difficult to go to either of the clinics in San Felipe because of the rains. Thus one might choose more convenient although more expensive methods, such as buying directly from the pharmacy or from the traveling vendor, or going to a local practitioner, who hold their consultations in the evening.

Distance
Time and energy costs are also related to the distance of the health care service. Distance has been emphasized in the literature as an important deterrent to utilization of health services [30]. Akin et al. suggest that distance may be an inappropriate proxy for transport cost and transport time, which are the true items of interest. Young stresses that accessibility includes not only distance but cost and transportation and inaccessibility is a significant determinant

Women and health care on a Guatemalan plantation of the non-use of physicians [7]. Accessibility (distance, transport costs, time) does tend to influence initial treatment choice made by plantation women. They tend to choose those options that are most convenient with the least cost, such as home treatment, remedies from the local stores, or the traveling vendor. Of these, the last one, Don Max, is clearly the most costly in monetary terms but since all of these are on the plantation, no transport costs nor waiting time is involved. However, in choosing among the alternatives of the clinics, the pharmacy, the physician, the hospital, and traditional healers, physical distance does not seem to be as important as other factors such as age of the patient, household composition, transportation cost, travel time, severity of the illness, illness beliefs, and the quality of the health care service. F o r example, people usually prefer to use the public health clinic or the private San Cayetano clinic in the town of San Felipe, which is 8.5 km despite the difficulties of bus transportation, because they can walk to these facilities in an hour and a half. The benefit of saving transport costs outweighs the cost in time and energy. By contrast, the public health clinic in Retalhuleu is 12.5 km away and patients usually take the bus to this clinic at a cost of Q0.50 round trip for transportation. A woman who is sick and lacks the energy to walk to San Felipe may take the bus to the clinic in Retalhuleu instead, despite the higher transportation cost or consult one of the physicians who are located in Retalhuleu if she has the money. During the rainy season, some women expressed reluctance to go to San Felipe because they would have to cross an unstable plank bridge over the River Samala. They believe that the "brisas" or winds from the river are dangerous for a sick person, especially for an infant with fever, and that these winds can make the illness worse. The benefit of not being exposed to these dangers outweighs the transport costs. Women also expressed fear of walking there by themselves because of rumors of kidnappings and killings on the paths. They feel more comfortable going there on market day (Sunday) when many people are on the road. The clinic would benefit from opening on market day but since the market is held on Sundays, it is closed. Other factors are considered in treatment decisions if the patient is an infant. F o r example, if the mother suspects that her baby will be hospitalized, she may prefer to take the child to the public health clinic or the national hospital in Retalhuleu rather than the San Cayetano hospital in San Felipe since she cannot stay overnight with her baby in San Cayetano. A mother can stay in the Retalhuleu hospital portal (vestibule) overnight. However, as noted earlier, a physician's referral is thought to be necessary to receive care and the family must pay a fee for the physician's referral. The consultation fee is weighed against the time and energy that would be spent going to the San Cayetano hospital, even though the actual distance to San Cayetano is less. Priority is placed on the mother-child relationship and the reluctance of the mother to leave her child in the hospital. Decisions to leave a baby in the hospital are also influenced by the availability of an older child, a grandmother, or other relative to take care of the

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rest of the family while the mother is visiting her hospitalized child. If different services are located approximately the same distance, as are the public health clinic and the private clinic San Cayetano, both in the town of San Felipe, then other factors are more salient. Several women remarked that they would prefer to visit San Cayetano because there is always a doctor there. By contrast a doctor is present only once a week at the public health clinic. The perceived value and expected effectiveness of the service is increased by the doctor's presence. According to informants, while physical access can be a problem, it is less important than other factors. This data supports Annis' findings that utilization of health services in Guatemala depends more on the quality of services than on distance or travel time [31].

Social and psychological costs

Social and psychological costs refer to such factors as guilt, anxiety, fear, embarrassment, and humiliation. These non-monetary costs are engendered by the attitudes of the medical personnel in the formal health services and are reflected in their interaction with the health seekers. Many of the nurses and doctors act very condescendingly and assume the patient is ignorant. They tend to speak in an authoritarian tone, often scolding the patient, as illustrated by the following example. A young mother, Julia, brought her very marasmic son to the San Cayetano hospital. She had been treating the child with a variety of medicines from the pharmacy but nothing had helped. The nurse, however, did not ask if the child had had any previous treatment or medication, but immediately began yelling at Julia. "Why did you wait so long. Don't you love your child. How could you let him get like this." This type of attitude in turn increases people's ambivalences toward the facility and their reluctance to return in the future. In another case, Sylvia, a l~-year-old was being treated in the national hospital in Retalhuleu. When the mother came in to see the child, she noticed the baby was crying and tossing and was thirsty. She went to breastfeed the baby, and the nurse started yelling at her that she could not nurse the child at that time, only at 12:00. We then noticed that the IV tube was not turned on so the child was not getting any of the liquid she was supposed to be receiving, which is why the child was so thirsty. We showed the tube to the nurse who said that she had so many children to take care of that she couldn't watch them all. Thus in addition to the s~olding, the inattention given to patients by the staff is another problem. This lack of attention is partly due to the overburdening of the staff and lack of personnel, but also because of the tendency to regard poor patients as .unimportant. This was tragically shown in the case of Maria, a woman pregnant with her fifth child who went to the hospital for a delivery because she wanted to get a tubal ligation. She had been suffering from tuberculosis and had been advised to be sterilized and not have any more children. With much trepidation and ambivalence, especially from the fear of surgery, she agreed and went to deliver in the hospital. However, due to the lack of attention, she delivered the baby herself under the sheets, and it wasn't until the nurse

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heard the baby cry that she came to help. Unfortunately, the baby died, and Maria was then afraid to get her tubes tied [32]. The anxiety provoked by the fear of surgery, which is very strong, is another psychological cost. A patient who thinks the doctor may recommend surgery may be reluctant to consult the physician. If surgery is recommended, the patient may delay or refuse. One informant cited this saying, which expresses this fear: "No quiere meter un cuchillo, mejor matar con un tiro." (A person doesn't want a knife inserted, better to be killed with a bullet.) As in other parts of Latin America, modesty is a very important value held by the plantation women and is often ignored by the nurses and doctors [33]. Hardly any privacy is granted to the patient, especially in the hospital wards. Since most physicians are male, women are reluctant to go for examinations, especially for gynecological problems. Several women mentioned having various gynecological problems, such as vaginal bleeding, and "fallen uterus" (decompostura), which interfered with their activities. They prefer to consult the local midwife for such problems. She employs a variety of herbal teas, massages, and baths to relieve these conditions. These methods, as well as other traditional methods of treatment, treat the patient clothed, especially the lower part of the body, and preserve this strongly held value.
Expectations People have different expectations of the different treatment specialists and services and what they can offer. These expectations also influence their health care decisions. F o r example, the private physicians in Retalhuleu, some of whom have lived in the area a long time, are considered as more experienced and knowledgable, and thus more effective than the doctors at the San Cayetano clinic, who are young medical students and transient. People tend to have more confidence in the former than the latter, and thus if they can afford it choose the private physician, even though he is more expensive. However, the cost deters most from choosing that option. People expect quick results and rapid recovery from biomedical treatment, whether by the physician, the clinic, or the pharmacist. The effects people have experienced with antibiotic injections are generalized to virtually all pharmaceuticals, including vitamin injections. People prefer injections to pills and are disappointed if they are not prescribed. Because of people's often unrealistically high expectations, they are discouraged, disappointed, and critical when quick recovery does not occur. Although people use folk practitioners and healers primarily for therapeutic purposes, they also seek them for other reasons. The burning of incense and candles by the shamans is believed by some women to give strength to the patient. In addition, people expect answers to questions of causation from shamans and other healers, who deal with ultimate causes of illnesses, such as witchcraft. The doctor may provide symptomatic relief and "cure" an illness but usually does not attribute a cause. Several people mentioned they go to the spiritist to ask for "protection". In one case, Rosa, a young woman with her

first pregnancy was having nightmares about the birth and dreaming about the hospital. She said she felt she was going to die and would just sit around and sigh during the day. She went to one of the spiritists to ask for "protection". He told her she had been cursed by her mother because of her premarital pregnancy, and the baby would die, but the spirit would save the baby. He did a ceremony for her which cost Q6, and predicted she would have a baby boy. About a month later, she had a healthy baby girl. Other clients would go to ask for spiritual protection for a member of the family who was in the hospital. Several people regularly go to the spiritist to attend the service instead of a mass even when they are not sick. On the other hand, there are several families who never go to the spiritists or Centros and say they don't believe in it or depend only on God's will.
HOUSEHOLD ORGANIZATION AND KINSHIP RELATIONS

The household organization, composition, kin ties and the social support system have significant influence on both the illness patterns and health care decisions [34]. Relations between household members and those of other households available for support or assistance depends on the existence of consanguineal, affinal, and godparent relationships. A young nuclear family with several small children and no adolescents or other adults has a high 'dependency stress' not only economically, but also with respect to the support available when illness occurs. The mother is constrained by the number of small children that she must care for alone. It is more difficult to take either herself or a sick child any distance or for long periods of time for medical treatment unless she has someone else to take care of her family while she goes for health care (i.e. older siblings, mother or mother-in-law). Some mothers expressed reluctance to leave a child in the hospital. They would be unable to visit the hospitalized child frequently because of household responsibilities and because no one was available to take care of the other children. For similar reasons, women were reluctant to go to the hospital themselves either for illness or for births. One woman said she was able to stay in the hospital with her sick child only because her mother-in-law, who lives with them, took care of the other children. Small children tend to have more sickness episodes, especially diarrheal diseases, malnutrition, and communicable diseases. Thus a family with several small children will experience a greater drain on household resources, especially the mother's time, energy, and cash. As one woman said "when the children are sick, there is no money to buy food", and "I cannot leave the house because the children are sick, so I did not go to market on Sunday." Another mother said that because she is frequently sick and because the children are always sick, she has not been able to work as much as some of the other women who go out and clear the field and gather food. In contrast, a 'middle cycle family' has both young and adolescent children. The older children can take care of their younger siblings if the mother has to seek

Women and health care on a Guatemalan plantation health care for either herself or one of her children. They can relieve her of household duties so that she can care for the sick household member, and they can be an economic resource by earning cash to buy medicines or food. These older children save the mother both time and energy, enabling the mother to expend more of her resources on health care activities. The mature stage household does not sustain the stress from sick infants. The woman is freed from most child-care activities, although she may take care of grandchildren. She may have a higher cash income because she receives a portion of the earnings of her older children and may engage in different entrepreneurial activities. This enables her to help provide health care support for her children and their families in times of illness. However, this situation might be reversed when the elderly parent is sick and the children have to provide support for medical care. F o r example, Caterina, her husband and children, moved into the home of her mother-in-law, Marta, who had become very sick in order to take care of her. She had been sick for over a year and had become worse. She had a pain in her throat and because of the difficulty in eating had become very thin. Caterina said that they had spent a lot of money on curing. Her husband's money was now being spent on corn and that all her single brother-in-law's money was being spent on medicines for his mother. They had tried everything they could think of to cure her including at least three different spiritists, a shaman, three different private physicians, (including a throat specialist), and had gone to the hospital in Quezaltenango which specializes in tuberculosis to examine her lungs. She has also received innumerable injections from the traveling injectionist. The mother was still sick, and a group of evangelicals were trying to cure her by praying for her. Her children's support enabled her to utilize various health care options, although the expenditures were a drain on the household resources.

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CONCLUSION Women are direct health care providers, both in specialist roles, and with respect to home treatment in the lay sector. They also act indirectly as health care providers by finding the means to utilize other treatment alternatives for themselves and their families. A woman's health care decisions are based on the interaction of several factors, such as characteristics of the services (distance, price, time costs) the characteristics of the illness (severity and persistence) and her access to and control over cash, food, time and energy resources. These factors are influenced in turn by her household organization and support system. Although the husband contributes to the household budget, the amount is highly variable. Consequently, the woman's management and allocation of scarce household economic and human resources, and the strategies she uses to extend these resources, often enable her to obtain health care for herself and members of her household. In this respect, the plantation woman is not only a health care consumer but also a significant health care provider.

The ability and persistence of these women to cope with the severe health problems faced by themselves and their families entails a tremendous expenditure of time, energy and money which is spent either on treatment activities or on obtaining the resources for treatment. The employment of these strategies must be seen in the context of the constraints and odds that these families face. Some of these constraints are due to the structure of the plantation system. These include national problems such as land distribution, and international ones, such as the price of sugar and coffee on the world market, and thus are more difficult to change. However, much of the illness and disease burden are due to poverty conditions which could be ameliorated or prevented. Improved living conditions, including potable water, latrines, better sanitation and housing could be provided by both the plantation owner and the government and would reduce the incidence of disease. The drain of time, energy and money spent by women and their families on illness treatment could then be channeled or spent on other productive and income-generating activities, which in the long run would increase the purchasing power and the health of their families [35]. The available health care programs do not take into account the needs of the plantation population, especially the women. They should be more flexible and recognize that women are the primary health care providers and decision makers. Programs are being developed in Guatemala to train health promoters or community health workers [36]. Although health care programs on the plantations have been regarded as the prerogative and responsibility of the plantation owner, government and privately run health promoter programs should include plantation populations. They should train women, as well as men, as health promoters, including those who already provide health care and are sought for advice by the plantation population, such as Marina, and the local midwife, Maria. However, the likelihood of this occurring is slim. During an interview with a doctor from the health center in Retalhuleu, he mentioned that there was a health promoter program, but the promoters were mostly males. When asked why, he answered, "It is because of the custom. Men first, men second, men third, women last, which is a Guatemalan tradition." This statement indicates the lack of recognition of the significant role women play in health care and the need to increase the medical personnel's awareness of that role.

Acknowledgements--Support for this study was provided by

Rutgers University Research Council grants and the International Nutrition Program, Department of Nutrition and Food Science, Massachusetts Institute of Technology. I wish to express my appreciation to Mary Scrimshaw, my co-investigator, for her valuable ideas, suggestions and assistance, and to the owner and people of the plantation for their cooperation and hospitality. This paper is a revised version of a paper presented at the American Anthropologieal Association, Washington, D.C., 1985.

REFERENCES 1. Kay M. Anthropology of Human Birth, Davis, Philadelphia, 1982; MacCorrnack C. Ethnography of Fertility

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SHEILA COSMINSKY nutritional status on a rural Guatemalan lowland plantation. M. Sc. Thesis, Department of Nutrition and Food Science, Massachusetts Institute of Technology, 1977. Scrimshaw M. Patterns of health on a Guatemalan flnca. American Anthropological Association A. Meet., Abstract, 1977. Gilbert D. A dietary survey of Guatemalan women. International Nutrition Program, Massachusetts Institute of Technology. Unpublished manuscript, 1976. Cosminksy C. and Scrimshaw M. Medical pluralism on a Guatemalan plantation. Soc. Sci. Med. 14B, 267-278, 1984. True names are used for healers, who are public figures, but pseudonyms are used for clients' and informants' names. According to Pansini [12, p. 310] for rural coverage, employers pay only 3% of a worker's salary while workers pay on 1%. Whereas Pansini [18], says that plantation owners and their workers had to pay a combined 8~% of the total salaries for IGSS coverage. I do not know what accounts for this disrepancy, unless there was an increase in the required payments between 1975 when the first study was carried out and 1979 when the second report was made. Cosminksy S. Childbirth and midwifery on a Guatemalan finca. Med. Anthrop. 1, 1977. Cosminsky S. Knowledge and body concepts of Guatemalan midwives. In Anthropology of Human Birth (Edited by Kay M.), pp. 233-252. Davis, Philadelphia, 1982. There are 100 centavos to 1 quetzal. At the time of the study the quetzal (Q), the Guatemalan currency, was equivalent to 1 U.S. dollar ($). Although the price has varied in recent years, in 1986 it stabilized at around Q2.50 to $1. However, there has also been very high inflation since the study was done, including increased prices of staple foods of corn and beans which has placed even worse economic constraints on the people, and worsened the health and nutrition status of the population. Scrimshaw M. and Cosminsky S. Family and food: strategies of food procurement on a Guatemalan plantation. 80th A. Meet. American Anthropological Association, Abstracts, Los Angeles, 19~1. A revised and expanded version, Impact of healtl~on women's food procurement strategies, will appear in Diet and Dorh~estic Life in Society (Edited by Sharman A. et al.), forthcoming. These sources of cash, and the strategies employed to obtain cash, are described in more detail, especially with respect to procuring food.' Valverde V. Nutrition and health consequences of seasonal fluctuations in household food availability. Workshop on the Impact o f Agriculture and Food Supply Policies on Nutrition and Health Status, Bellagio, Italy, March 1985. Akin J., Guilkey D.," Griffin C. and Popkin B. The Demand for Primary Health Services in the Third World, p. 59. Rowman & Allenheld, Totowa, N.J., 1985. Annis S. Physical access and utilization of health services in rural Guatemala. Soc. Sci. Med. 15D, 515--523, 1981. Several months later Maria did get a tubal ligation. Scrimshaw S. Women's modesty: one barrier to the use of family planning clinics in Ecuador. In Culture, Natality and Family Planning (Edited by Marshall J. and Polgar S.). University of North Carolina Press, Chapel Hill, 1976. Browner C. Women, household, and health in Latin America. Social Science Research Council Conf. Political Economy o f Health and Disease in Africa and Latin America, Toluca, Mexico, 8-12 January 1985.

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and Birth, Academic Press, London, 1982; and Jordan B. Birth in Four Cultures, Eden Press, Montreal, 1978, are examples of such studies. Finerman R. The forgotten healers: women's contribution to family health in an Andean Indian Community. Unpublished manuscript. Bender D. and Cantlay C. Mothers as resources for community health in the Third World: a Bolivian example. In Third World Medicine and Social Change (Edited by Morgan J. H). University Press of America, Lanham, Md, 1983. Kleinman A. Concepts and a model for the comparison of medical systems as cultural systems. Soc. Sci. Med. 12, 85-93, 1978. Bolles A. L. Household economic strategies in Kingston, Jamaica. In Women and World Change (Edited by Black N. and Cottrell A.). Sage, Beverly Hills, Calif., 1981. Cosminksy S. Decision making and medical care in a Guatemalan Indian community. Doctoral Dissertation, Brandeis University, 1972. Young J. Medical Choice in a Mexican Village. Rutgers University Press, New Brunswick, N.J., 1981. Kroeger A. Anthropological and socio-medical health care research in developing countries. Soc. Sci. Med. 17, 147-161. Stone B. Formal modeling of health care decisions: some applications and limitations. Med. Anthrop. Q. 16, 41-45, 1985. Sargent c. F. The Cultural Context o f Therapeutic Choice: Obstetrical Care Decisions among the Bariba o f Benin. Reidel, Dordrecht, 1982. Bossen L. The Redivision o f Labor. State University of New York Press, Albany, N.Y., 1984. Pansini J. "El Pilar": a plantation microcosm of Guatemalan ethnicity. Ph.D. Dissertation, Department of Anthropology, University of Rochester, 1977. For a period of a few years, 1971-1974, the plantation owner had provided a medical program which included monthly visits by a private physician, but was then discontinued. The term Ladino refers to people of Spanish or Western culture in contrast to people of Indian culture, including people who are descendants of Spanish or European, mixed European-Indian ancestry, and those who may be genetically Indian but who do not identify themselves as Indian culturally. The plantation workers are divided into three categories: meseros, who are salaried employees such as the chauffeur, tractor driver, teachers, and oflice manager and who are not included in this study; colonos, who are permanent workers and ganadores who are temporary workers, often the sons of colonos, and may be laid off during the slack season. Cosminsky S. and Scrimshaw M. Sex roles and subsistence: a comparative analysis of three Central American communities. In Sex Roles and Social Change in Native Lower Central American Societies (Edited by Loveland C. and Loveland F.). University of Illinois Press, Urbana, 1981. This article contains information on the frequency of different household types on the plantation. Guatemala-AID. Extension of Health Services to Finca Workers. In Guatemala Health Sector Assessment, Annex 5.7. Academia de Ciencias Medicas and USAID, Guatemala, 1977. Pansini J. Plantation Health-Care in Guatemala: Aspects of the Problem. A study prepared for the U.S. Agency for International Development Mission in Guatemala by the Patronato Para el Mejoramiento de la Salud de Trabajadores Agricolas (AGROSALUD) under contract No. AID 520-470. Sobel R. Longitudinal ecological assessment of the

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Women and health care on a Guatemalan plantation 35. Since 1980, after the fieldwork on which this paper is based was carried out, the Guatemalan situation deteriorated with political violence and an economic crisis. From reports that I have had and communication with people from the plantation, the inflation and disruption have, if anything, increased the poverty and worsened the health and nutritional status of the plantation population.

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36. It should be noted that after 1980, especially 1980-1983, during the period known as "La Violencia", many health-care promoters were killed or were the target of military attacks, especially in the highlands, because they were regarded as community organizers, and many programs were terminated. At the same time the government was organizing other health programs especially in the eastern part of the country.