Situating Knowledges of Stunting in Sololá, Guatemala

THE SHAPE OF A CHILD: SITUATING KNOWLEDGES OF STUNTING IN SOLOLÁ, GUATEMALA

CAITLIN BAIRD PETERSON

A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

2017

to peter, for teaching

ACKNOWLEDGMENTS

I would like to thank the members of Kixok, who surely recognize themselves in the text despite the care I took in crafting pseudonyms. Long-term fieldwork is never easy, and I want them to know that the time I spent with their organization was a balm I smoothed over the rough patches in my heart and mind, a tool I used to remind myself, daily, of why I was doing what I was doing. It kept me going. They kept me going. The work they do still keeps me going.

To the friends— now colleagues—who kept me supplied with laughter and sanity during graduate school, thank you. These wonderful humans are by no means limited to, but certainly include, Nick Kawa, Lizzy Hare, Ellen Lofaro, Raina Heaton, John Anderson, Camee Maddox,

Jessica Jean Cassler, Jesse and Melissa Kreye, Jamie Lee Robinson (neé Marks), Noelle Sulli- van, Judy Anderson, Meghan Farley Webb, Heather Wehr, E. Anderson, and Alan Schultz, Jef- frey Vadala, June Carrington, Kate Kolpan, and Timateo Mesh. God bless you all, my brothers and sisters in the trenches.

Álvaro, Diego, and José de Castro; thank you for being my home away from home and my family away from family. I doubt there will ever be a time I don’t miss our little nest in San- tiago. To my much-needed release valve in the cobbled wonderland of Antigua; thank you. Espe- cially Annie and Mike Vanderboom, Mercedes Escobar, and Mike Tallon, without whose company I would have become a much paler version of the person I am now.

I would like to thank Mary Norman, who fed me while I was writing, and kept me well supplied in Earl Grey tea (hot), and Lisa Baird, who was the best and most supportive coach anyone could ask for. Fred and Carol Schober gave me a cozy place to hole up as I finished the last of my revisions, and I’d like to thank them, as well (and Sophia and Pancho for keeping me company.) Liz Guthrie, Dr. Lisa Munro, Dr. Daniel Godwin, Jessica Voloch, and Rosa Sofía Nylund provided the friendship, love, and support I needed to make it through the painful process of

turning painful memories about painful things into something useful. I would also like to thank

Dr. Ryan Morini, who, in addition to being a walking library of anthropological theory, is my port in a storm and my dearest friend. I would like to thank my chair, Dr. Richard Kernaghan, who taught me that the deepest insights are likely, often, to come from a place of kindness. In that vein, I would like to thank Diane and Ralph Morini, who are perhaps the kindest people I’ve ever had the privilege of knowing. I consider myself blessed to be the first of your strays. To my dissertating buddies and sisters-in-arms, Dr. Anita Chary and Dr. Eshe Lewis—you remain my inspiration every single day.

I don’t know how to thank the truly wonderful and indomitable Blake Zook, except to say, with all honesty, that I would not have made it through 2017 without you. Without your undying faith and support, I would most likely still be bussing tables.

I would like to thank my Kaqchikel teachers, who were more patient with my clumsy pronunciation and often deeply embarrassing linguistic faux pas than I know I would have been, had our circumstances been reversed. To everyone in the department of anthropology at the Uni- versity of Florida who played a hand in any of the grants I’ve received since 2009, especially

Alyson Young and Faye Harrison, and all my other readers and recommenders and anyone and everyone who raised their hand when my name came up; thank you. You fed me and kept a roof over my head. Todd Dickinson, Sam Droke-Dickinson, Amy Loyd and Dr. Danielle Watts; thank you for giving me work when I found myself stranded and poorer even than usual this past year.

(And thank you also for all the free baked goods, coffee, and books…have I mentioned how much I love Lititz?)

I would also like to thank the InterAmerican Foundation for Grassroots Development, which funded this research, and all of the brilliant scholars and thinkers I met as a member of

that cohort, especially Dr. Elizabeth Cartwright and soon-to-be-Dr. Sebastian Ramirez. To all of my advisors and fellow fellows: thank you. I am honored to count myself among your number.

This needs to go acknowledged as much as anything else: no one—not a single one of us—would have made it through all the hoops and rings and red tape of graduate school had it not been for our own embroidering angel, our graduate program assistant, Juanita Bagnall. Nita, you are as you have ever been: a lifesaver.

As weird as this might be, I would also like to thank the artists, who, since childhood, have "comforted me when I was disturbed and disturbed me when I was comfortable.” To the lives and memories of Erik Peterson, N.C. Wyeth, C.S. Lewis, Nikki Giovanni, Elie Weisel, Lois

Lowry, Madeline L’Engle, Audre Lourde, Ray Bradbury, Frank Herbert, Neil Gaiman, Karen

Russell, Kazuo Ishiguro, N.K. Jemison, Margaret Atwood, Richard Matheson, Roald Dahl, Har- per Lee, Douglas Adams, and so many, many more, thank you. Your words are the scaffolding upon which I’ve built everything that I am.

There are so many more people I would still like to thank, but can’t, for reasons of anonymity. However, they know who they are, and probably recognize themselves in the text. I hope they know that their role in my life, and mine in theirs, has not ended simply because this dissertation has to. I am as much a friend as ever.

TABLE OF CONTENTS

page

ACKNOWLEDGMENTS ...... 4

LIST OF ABBREVIATIONS ...... 9

LIST OF KAQCHIKEL TERMS AND PHRASES ...... 11

LIST OF SPANISH TERMS AND PHRASES ...... 12

ABSTRACT ...... 15

INTRODUCTION ...... 18

What to Expect ...... 20 Fieldwork ...... 21 Guideposts ...... 23 Part I: Stunting ...... 26 Pathophysiology ...... 28 Setting ...... 29 The Myth of “Zero Cost” Adaptation ...... 30 Long Term Costs ...... 33 Cognitive ...... 33 Metabolic ...... 35 Cardiovascular/vascular ...... 37 Maternal Mortality ...... 38 Catch-Up Growth? ...... 38 The Cycle of Poverty ...... 38 Part II: Violence ...... 39 Part III: Theoretical and Practical Framework ...... 49

INVISIBILITY ...... 58

Opening Remarks ...... 60 Sight Unseen ...... 62 If Everyone Is Ill, Then No One Is ...... 67 Aquí, Pero No Aquí Mismo ...... 72 Clinical Encounters of the Third Kind ...... 85 The Pathologies of Profit ...... 95 Crisis and Affect ...... 99

SERENDIPITY ...... 105

Part I: Serendipitous Care ...... 108 Non-Governmental (dis)Organizations ...... 108 The “Business of Social Suffering” ...... 109 No Se Atiende ...... 116

The Right Kind of Mayan ...... 123 Part II: Lost in “the Jagged Landscapes of Aid” ...... 130 Between the Cracks ...... 132 Paved with Good Intentions ...... 138 “Privately Organized Bureaucratic Failure” ...... 142 Where There Are No Patients ...... 146

INDIVISIBILITY ...... 149

Young, Poor, Mother, Child ...... 153 Good Mothers, Bad Mothers ...... 166 Adaptation ...... 175 Palliative Feeding ...... 181 Choosing Empathy Over Authority ...... 184

CONCLUSION ...... 189

Cuéntame, Nan ...... 189 Death, Fast and Slow ...... 196 The Chronicity of Chronic Disease ...... 198

LIST OF REFERENCES ...... 203

BIOGRAPHICAL SKETCH ...... 228

LIST OF ABBREVIATIONS

AUC United Self-Defense Forces of Colombia

CAFTA Central American Free Trade Agreement

CCT Conditional Cash-Transfer

CEDAW Convention on the Elimination on All Forms of Discrimination Against Women

CIA Central Intelligence Agency

IMF International Monetary Fund

INCAP Institute of Nutrition of Central America and Panama

INE Instituto Nacional de Estadística

JAMA Journal of the American Medical Association

LMIC Lower Middle Income Country

LPN Licensed Practical Nurse

MDRTB Multi-Drug Resistant Tuberculosis

MFP Mi Familia Progresa

MOH Ministry of Health

NGO Non-Governmental Organization

PCP Primary Care Physician

PEC Program for Expansion of Coverage

PEP Post-Exposure Prophylaxis

PI Principle Investigator

RN Registered Nurse

SIVIM Sistema de Vigilancia de la Malnutrición en Guatemala

SFAA Society for Applied Anthropology

STMM Short-Term Medical Mission

WTO World Trade Organization

UN CRC United Nations Convention on the Rights of the Child

UNDP United Nations Development Programme

UNICEF United Nations Children’s Fund

LIST OF KAQCHIKEL TERMS AND PHRASES

ja yes kaxlan ya’ Kaxlan is Kaqchikel for “foreign”, but often means in context, “Spanish”, or “gringo”; ya’ = water, kaxlan ya’ = “Spanish water”, or foreign water, or, in this case, soda. To give another example, “wey” = tortilla, while “kaxlan wey” = sliced bread nan grandmother. also a term of respect, similar to Spanish’s “doña” qa’chab’al literally, “our language” qanchi’ English qanchita slang for English-speaking white lady foreigner, with the diminuitive toycoyal a ribbon-like head wrap worn by some indigenous women in the highlands

ütz good xocomil the name for the waves that hit Lake Atitlán every afternoon between 1pm and 4pm. Also the name of the sea monster that supposedly lives on the bottom of the lake

LIST OF SPANISH TERMS AND PHRASES

aldea village así, me duele, la verdad honestly, this hurts me atol thin porridge made with corn or rice, sometimes fortified ayudame por favor/soy please help me/I’m blind/I can’t work/god bless you ciego/no puedo trabajar/dios le bendiga bloque concrete block, a common building material in the highlands following the 1977 earthquake cadejo a supernatural beast native to Central America, takes the shape of a dog. The black cadejo is evil; the white, good. caldo de pollo chicken soup chipillin a bitter leafy herb often boiled and eaten chisme gossip corte the large rectangle of patterned fabric worn as a skirt by indigenous Guatemalan women. Often considered a marker of identity in the ladina/indigena divide. (Overheard on a bus from a mother chiding her daughter: “are you wearing pants or are you wearing a corte?”) desconocido unknown desnutrición malnutrition doña doña is an honorific used for older, or married, women in Span- ish. “Don” is the male equivalent. dónde no hay doctor where there is no doctor

gringo foreigner, someone who doesn’t belong guacal a guacal is a deep plastic dish used for various household tasks, as storage containers, food service and preparation vessels, and to aid in washing clothing, dishes and hair in the pila jarabe syrup; can be medicinal jornadas literally “journey”, but used here as slang for STMMs junta a governing body, sometimes said with sarcasm or fear, as in reference to military juntas or mob-boss like behavior lamina corrugated roofing, sometimes tin, sometimes plastic lantal an apron made from discarded/worn corte fabric. Often richly embroidered and/or decorated to cover up stains or tears los que ya tienen “those who already have” machismo an exaggerated sense of masculinity machisto sexist malditas gringas damn gringas mira pues can be translated loosely to “well, look at that” muestra sillas a form of occupation consisting of beading muñeca doll pan francés “french bread”, but not as English-speakers would understand it. More of a soft dinner roll made with processed bleach wheat flour. perraje a large square of tightly-woven fabric used to carry babies and small children on the back or at the hip

pila a deep double-sided basin present in most rural Guatemalan homes that is used for washing pretty much everything poquito little que pica bastante that really itches quetzal/quetzalito a “quetzal” is the main unit of Guatemalan currency, named after the Guatemalan national bird. reina de mi corazón queen of my heart refresco sugary drink served cold

Santa María, ruega por no- Saint Maria, pray for us sinners, now and in the hour of our sotros pecadores, ahora y en deaths la hora de nuestra muerte seño “miss”, an appellation/honorific talimetro stadiometer tan chula so cute tapada stuffed-up traje típico typical dress; each town and region of Guatemala has a traditional indigenous traje, or suit, particular to that region. With a few exceptions, traje is worn more by women now than it is by men. tepache a refresco made from fermented pineapple un buen corazón a good heart vete go vieja old (feminine)

Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy

THE SHAPE OF A CHILD: SITUATING KNOWLEDGES OF STUNTING IN SOLOLÁ, GUATEMALA

Caitlin Baird Peterson

May 2018

Chair: Richard Kernaghan Major: Anthropology

Stunting, the world's most common pediatric growth disorder, is associated with higher mortality rates from infectious disease during childhood and a host of later-life co-morbidities that result in a theft of biological capital and individual potential that is cemented in the first years of life and plays an immense role in the intergenerational transmission of poverty. This dissertation uses the condition of endemic child stunting in rural Guatemala as a coordinating matrix to organize, examine, and make clear the broader structural issues at play in the diagnosis and management of chronic disease in a context of extreme poverty and increasingly pluralized and privatized healthcare systems. It addresses the multiple invisibilities of the condition's life- long effects, including its hidden pathophysiological progression and the parallel but disparate understandings of what constitutes “desnutrición" among the main actors in stunting's identification and treatment; the indivisibility of the learned body praxes of “mothering" in a context of embedded structural and interpersonal violence; and the serendipitous nature of NGO programming and enrollment in a country that has outsourced much of its social services to the affect economy. It makes the argument that stunting's very endemicity and its slow-to-manifest long- term physiological costs are at odds with both the day-to-day immediacies of poverty and the acts of "crisis" necessary to generate an affective response. The dissertation argues that there is a

historicity to chronic disease that is currently ill-addressed in Guatemala's patchy, pluralized, and often transient primary care systems and makes the argument for a brand of liberation medicine rooted in an intergenerational and community-based approach.

we’re not going to be of any use to anyone unless we remain humble about all the things we still don’t know

- medical director of Kixok

slow death occupies the temporalities of the endemic

-Lauren Berlant

INTRODUCTION

Small glass beads, brilliantly colored, litter the table by the unfinished window. Doña

Julia uses them to “muestra sillas”; stringing tiny bead after tiny bead onto clear plastic thread, gathering up the slippery poppyseed-sized bits of black and green and blue and yellow and tur- quoise and indigo glass until they form a rabbit, a snake, a cluster of grapes. A penguin. It is her only reliable form of income, but it brings in only a few dollars a week. Julia holds up her latest creation, lifting it to catch the light. A small green bird spins in a slow circle beneath her fingers, the ruby beads at its throat flashing as it turns.

“Un quezalito,” she tells me.

Julia’s latest arrival is sleeping in my lap. She is three months old, plump and happy and swaddled in layers of pink and white. She whistles a bit through her nose when she exhales, and she’s new enough that she still feels birdlike and fragile when I hold her in my arms.

“¿Tapada?” I ask.

Julia smiles down at her daughter. “Un poquito,” she answers, shrugging. “No mucho.”

The child doesn’t wake when I lift her off my lap and place her on the bed beside me. She whistles softly through her nose, her breaths small and measured and barely audible. As I’m set- tling her on the fleece blanket, tucking the ends of her multiple swaddling cloths beneath her small body, her brother, Victor, peeks his head around the wooden doorframe.

“Are you ready?” I ask him in Spanish. Victor doesn’t reply, but his eyes dart between me and the plastic stadiometer I’ve erected in the corner of the room, painstakingly leveled on the hardpacked earth floor. Fully assembled, the stadiometer (talimetro, in Spanish) stands almost six feet tall, a tall, thin, white monster of a thing, and even though I covered it in stickers in an effort to make it look less imposing, most children approach it with some measure of trepida- tion.

“It’s ok if you’re not ready,” I tell him in Spanish. “I can wait.”

Victor’s eyes go back to the talimetro, and he appears to steel himself, drawing himself up to his full height (a little over three feet, as I would find out in a moment’s time.) He walks directly toward the wall against which I had set up the talimetro, arms swinging, head held high in a show of proto-masculine bravery. His mother meets my eyes, and I can see that she’s trying not to smile.

I helped Victor shrug out of his puffy blue jacket, dotted with puffs of white cotton in places where it has been torn and haphazardly patched. Small squares of duct tape cover the worst of the tears, clean silver against the navy blue. “Stand here,” I tell him in Kaqchikel, rearranging his bare feet on the white plastic base. His feet are calloused and dirty, with dark cres- cent moons of black dirt under his toenails, and also, apparently, ticklish. Victor giggles as I adjust his posture, making small adjustments to his shoulders and pelvis, tapping the middle of his back so he stands tall, tilting his chin up to simultaneously situate the base of his skull above his spine and bring his eyes to mine. Eye contact often helps, I’ve found, even with the smallest children. I cross my eyes and make a face and Victor laughs. I’ve measured enough children that this routine has almost become muscle memory; “ta’ba’na utzil, ta’welesaj ach’ap” (“do me a favor and take off your shoes”), I tell them; “kab’a’e wawe” (“stand here”); squat, rearrange their feet, a small touch here, another small adjustment there; “taq’a üxla” (“take a deep breath”), I say, a few fingers of my left hand resting just under their sternum, a reminder to stand tall and stay tall; a quick shift of my left hand to gently tap the underside of their chin, eye contact, make a funny face.

I slide the plastic measuring tab down the spine of the stadiometer until it touched Vic- tor’s scalp. 96 centimeters. Greater than 2 standard deviations below expected height-for-age, according to the charts taped to the back of my clipboard. Stunted, but not too badly.

Victor’s sister, the pink and white wheezy-bird on the bed, is not stunted. At three months, she was still breastfeeding exclusively and had not yet started complementary feeding.

Growth curves in rural Guatemala often start to level off, veering away from expected after six months of age; often irrevocably. In villages like this one, an aldea of one of the small towns that dotted Lago Atitlán’s tule-and-pumice dotted shores, up to 85% of the children under the age of five are likely to be stunted; a figure that has yet to get better despite a plethora of local NGOs, many of whom run nutrition programs, extensive governmental programming— or at least the promise of such— and the end of a 36-year-long civil conflict. (UNICEF 2011) The major question underlying my research has been: why? Why haven’t rates of malnutrition dropped, as programming and awareness has increased? Why have things, according to some measures (Chase-

Dunn 2000; Jonas 2000; Robinson 2000), actually gotten worse?

What to Expect

This dissertation tackles stunting synergistically; approaching the issue as it exists and is seen on-the-ground by the multiple actors involved in its perpetuation, treatment, and diagnosis.

By situating the problem of stunting in rural Guatemala within its own unique historical and so- ciopolitical contexts, I have taken seriously Goodman and Leatherman’s (1998) insistence that critical biocultural medical anthropology should combine “rich history, political economy, and assessments of health while also putting peoples’ experiences, stories, and words in the foreground.” Above all, my dissertation research is rooted in a school of thought within applied anthropology that considers the highest calling of our subfield to be “develop[ing] and sustain[ing] an approach to global health in which priority is given to a reduction in poverty and inequities”

(Lock and Nyugen 2010.) In the case of rural Guatemala, I argue throughout this text that the first pragmatic step in giving priority to these inequities is through addressing chronic undernutrition in early childhood. Stunting results in a theft of biological capital and individual potential

that is cemented in the first years of life and plays an immense role in the intergenerational transmission of poverty. In order to address the condition, bridges must be drawn and made effective between the multiple actors and modes of thought that play a role in its failed amelioration. This dissertation is a first attempt at sketching out a cartography of thought: to start filling in the roads and rivers, mountains and valleys of a continent which every actor (young mothers, local doctors, parachuting U.S. physicians, NGO management and staff, government health workers, philanthrocapitalists and community members) involved in the perpetuation and amelioration of stunting sees differently. It is an attempt to draw together the threads of the disparate and competing ideas on the origins of chronic disease that have a direct impact on stunting’s prevention, diagnosis, and treatment. I now see the “problem of stunting” as being, first and foremost, one of epistemology.

Fieldwork

This work is the compilation of over three years spent living and working in Guatemala between 2010 and 2016. The bulk of the work took place during my 2014-2015 dissertation field season, but I also pull from a multi-sited ethnographic study that I took part in in 2013, as well as from my time spent volunteering in-country as a medical translator and anthropometrist, obser- vations from my time spent simply living in Guatemala during write-up, and two summers spent living with local families studying Kaqchikel. My dissertation research took place in the department of Sololá, Guatemala, where I observed, accompanied, participant-observed, and spoke with healthcare providers, NGO workers, visiting donors, volunteers, mothers, fathers, children, community members, and grandparents. I visited NGO nutritional programming centers, rode along on visiting donor tours, sat in on charlas and lectures, accompanied NGO workers on home visits, helped train others in anthropometry, and volunteered my services as a translator. Alto- gether, I spoke with representatives of fourteen different NGOs in the area or with connections to

the area, two organizations in the process of becoming NGOs, and three unaffiliated short-term medical missions. I went to the Ministry of Health, local government-run and corporate-sponsored clinics and nutritional centers and to national hospitals and spoke with nurses and physicians about desnutrición, I met with mothers of small children, chatted over coffee, accompanied them on family visits and various errands, and spent time in their homes. In addition to field notes and memories based on thousands of hours of participant observation and the more quiet epiphanies of the day-to-day, this dissertation is informed by 44 semi-structured interviews on infant feeding practices and caretaker autonomy (2 each with 22 women), and unstructured but recorded key-informant interviews with affect workers. I also revisited the transcripts from an earlier ethnographic study I took part in focused on infant feeding in 2013; including re-examining and re-coding sections of the transcripts of ten focus groups (5 each in two areas; in each area, two for women, one for men, and one for pregnant women), and my notes from a market study I participated in during the same year. I conducted all interviews in Spanish, except for a few of the interviews with affect workers, which were conducted in English (their language of preference.) Using Livescribe technology and the qualitative data analysis software, MAXQDA, recorded interviews were transcribed and coded inductively in either Spanish or English (depending) under the broad themes of invisibility, serendipity, and indivisibility. Most of the mothers I interviewed were either bilingual (Spanish/Kaqchikel or Spanish/Tz’utujil) and expressed a preference for speaking in Spanish, but some were either monolingual in Kaqchikel or Tz’utujil, or bilingual (Spanish/Kaqchikel or Spanish/Tz’utujil) and expressed a preference for speaking their first language. In the latter cases, I conducted the interviews in Spanish, but enlisted the aid of a bilingual interpreter. (In the vast majority of cases, monolingual Kaqchikel or Tz’utujil speakers would bring along a family member who spoke Spanish; if this was not the case, I

called on the aid of friends of mine who were bi- or tri-lingual and willing to serve as interpret- ers.) Most of the names and proper nouns in this text—towns, individuals, and organizations— are pseudonyms. In some cases, there were things that needed to be said, but couldn’t be, for reasons of ethics, age, or anonymity. In that case, I’ve injected brief pieces of ethnographic fiction, which I italicized. Above all things, I have tried to prioritize the story of stunting, in order to give all of us a better understanding of what the different situated knowledges of the condition mean, and to whom, and why the conflict between them is so very important. After all, “storytelling re- veals meaning without committing the error of defining it” (Arendt 1957.) Some of this text is fiction (which is not to say that it is either untrue or unreal); the vast majority is not. All of it is as close as I could come to the truth.

This study is limited, and is not meant to be a comprehensive study of all the differing etiologies of the discourses surrounding stunting, as much as it is meant to be a study that points out that these differences exist, and that they have a very real effect on the identification and successful treatment of the condition, in addition to playing a role in influencing its continuing proliferation. In the future, I would like to conduct more formal, structured interviews with primary healthcare providers, especially nurse-programmers, on their views on what is driving malnutrition in their country, and expand upon my work thus far with primary caretakers.

Guideposts

This dissertation has two broad aims. One, to “solve” the “problem of stunting”, as it has been outlined above. How is it—why is it—that a condition that can prove so devastating over the lifecourse, one for whom effective treatment is already known, is still so prevalent? If “the key to stopping the cycle of poverty in rural Guatemala is to feed children— feed them early and feed them well.” (Rohloff, personal communication), then the successful identification, diagnosis and treatment of stunted children is of paramount importance, on both individual, generational, and

community-wide levels. The Guatemalan nutritional context is paradoxical, on two major fronts.

For one, Guatemala has a year-round growing season and rich volcanic soil. It is responsible for producing much of the produce that is imported the US. And yet at Guatemala has, by far, the most chronically malnourished population in the Western hemisphere (Chary et al. 2013.) Sec- ondly, much attention has been paid to the issue of desnutrición, but there has been little overall improvement in the nutritional status of rural children or the amelioration of chronic disease. It is impossible, no matter where you go in Guatemala, to turn on a radio or walk down the street without running into evidence of nutritional programming or advertisements for nutritional supplementation. In an environment inundated with nutritional programming and rhetoric, how is it possible that this is still the case? Solving the “problem of stunting” within the context of a single dissertation—or perhaps even a single lifetime— is not an achievable aim. However, framing the content and analysis of this dissertation around this goal allows me to streamline the text, pri- oritizing the one result I hope for most out of this work: applicability.

And two, to use stunting in rural Guatemala as a case study to illustrate the dangers of unchecked global capitalism and the high price of neoliberalism for the world’s poor. Following in the footsteps of ethnographies that have traced the history and political ecology of a single commodity (Sidney Mintz’ Sweetness and Power, Brenda Chalfin’s Shea Butter Republic, Ted

Fischer and Peter Benson’s Broccoli and Desire, Anna Tsing’s matsutakes in The Mushroom at the End of the World), this text has done the same with a single (though highly prevalent) health condition, tracing the roots of stunting’s endemicity through a history of structural violence manifested through colonialism, postcolonialism, corporate and state interventions and the resulting neoliberal subjectivities that are currently the “hegemonic mode of discourse…[which] has become incorporated into the common-sense way many of us interpret, live in, and understand the world” (Harvey 2005) and the role these subjectivities and situated histories play in stunting’s

continuing prevalence. In doing so, this text is following the examples set by Farmer’s 2005 collection of case studies in Pathologies of Power and the collection of essays in Postcolonial Dis- orders edited by Mary Delveccio-Good and collaborators.

The rest of this first Chapter aims to set the tone as to the realities of life, health and healthcare in “postwar” Guatemala by providing an introduction to the setting in which stunting became an endemic condition. It also provides background on the currently known and immensely broad-reaching later-life pathophysiology of chronic malnutrition in early childhood, broken down by what we now know of its effects on the cardiovascular, vascular and metabolic systems, on cognitive development and on maternal morbidity and mortality. This review provides the evidence for the underlying premise of this text that stunting’s well-established links to chronic disease in later adulthood play an overwhelming role in the intergenerational transmission of poverty— especially in the context of a broken and overtaxed healthcare system and the relative absence of primary care.

The second Chapter, “Invisibility” lays out how the multiple dimensions of the invisibility of stunting affect its successful identification and treatment: in its pathology and hidden pathophysiological progression through the lifecourse; in the context of appealing to an affect economy in a country who healthcare systems are more and more reliant on external aid; and within the context of a nation divided by the violence of the neoliberal order into those who exist, truly, as individuals in the eyes of the governmental polity, and those who exist only as a theoretical— useful, essential, but non-voting— labor collective on the margins of the government’s concern.

Next, “Serendipity” addresses the luck involved in accessing aid; and the on-the-ground perceptions of who is, and who is not, a likely recipient. It addresses the problem of “not being attended” as well as the necessity of raced- and gendered- performances of poverty within the strictures of the affect economy, and contains an argument regarding the means by which how

donor-driven chaos within NGOs not only has an effect on programming, but can functionally realign expectations of, and ascriptions to, certain identity groups. It talks about the concept of

“crisis” in affect-generated care, and gives a broad overview of the “jagged landscape” of nutritional aid.

The fourth Chapter, “Indivisibility” addresses the the indivisibility of primary caretakers from their immediate family and circumstances; the constraints put on choice and agency not just by interpersonal violence and the structural violences of poverty and intersectional racism, but by the learned body praxes of what it means “to mother” and the day-to-day lived practices of what it means, in context, “to daughter” and “to wife.”

The last Chapter is a conclusion, which brings full-circle the argument that the diagnosis and treatment of stunting cannot start and stop at the individual if it hopes to be effective, and pushes for nutritional interventions that have their roots in a community-based, intergenerational approach.

Part I: Stunting

The mechanics of childhood stunting in Guatemala are intimidatingly complex. On the one hand, the root cause of stunting is clear—chronic undernutrition in early childhood. (Primar- ily energy-based undernutrition, as we know from the longitudinal INCAP studies that micronu- trient deficiencies do not play nearly as determinative a role as energy constraints in faltering linear growth (Ramirez-Zea et al. 2010.)) On the other hand, rates of stunting are delineated along lines of race, ethnicity and class so predictably that it would make even the most lax epidemiolo- gist uncomfortable. Poverty accounts for much of the variability in rates of stunting, but not nearly enough; even after accounting for socioeconomic status, children from indigenous families are almost twice as likely to be stunted as children from non-indigenous families (Gragnolati

and Marini 2003.) Some argue that this disparity is couched in improper infant feeding tech- niques. However, nutritional intervention campaigns that have focused solely on education have met with demonstrably lower success rates than food-distribution programs (Chary et al. 2013.)

Through a complex and intertwined collection of socio-physiological mechanisms, stunting can also become intergenerational. Chronic undernutrition in early childhood and subsequent faltering growth and development cause a host of later-life problems (metabolic, cardiovascular and endocrine disorders; chronic anemia and higher rates of maternal morality; permanent delays in cognitive development) that have marked effects on an individual’s productivity. Researchers have found significant decreases in level of education (Alderman 2006; Walker 2000; Grantham-

McGregor 1997) and lifetime earnings (Hoddinott et al. 2008) among stunted individuals across three continents. The combined effects of the greater disease burden and decreased productivity of stunted individuals helps to perpetuate the cycle of poverty, which in turn contributes to higher rates of stunting in and of itself. The increased likelihood of stunted mothers giving birth to children that go on to be stunted may also involve adaptive physiological mechanisms, some of which take place even before birth (Gluckman and Hanson 2009.)

Additionally, poverty alone does not account for the disparity in the rates of stunting between indigenous and non-indigenous children (Gragnolati and Marini 2003); nor does rurality, as even in urban areas, indigenous children are more likely to be stunted than their non-indigenous peers (SIVIM 2012.) A comprehensive, synthetic understanding of the driving forces behind this disparity in health (the kind of understanding that would prove useful in future nutritional interventions) calls for a more complex analysis of the structural factors at play. Prelimi- nary data (Chary, et al. 2013) suggests that gender, race and class combine to form intersecting inequities that are enacted and reinforced on both structural and interpersonal levels and play a role in the household ecology that influences early childhood nutrition.

Pathophysiology

The nutrition a child receives from conception to around the age of two is of critical importance for the health and well-being of that child for the rest of their life. This so-called “first thousand days” serves as a litmus test for future health and human capital, creating permanent changes in the structure and function of the body and brain that cannot be ameliorated through nutritional intervention after the passing of this critical period. Stunting, or faltered linear growth, commonly defined as height-for-age below the fifth percentile, is an adaptive response of the body in the context of undernutrition, when limited resources are shunted toward the basic metabolic needs of sustaining life, rather than invested in growth and development. A recent estimate places the global incidence of stunting at ~170 million (UNICEF 2011) or one in four children under the age of five. Undernutrition is one of the largest contributors to child mortality, playing a role in over one-third of all child deaths worldwide (WHO 2013.) While children suffering from severe (acute) undernutrition (manifested as extremely low weight-for-height (below

-3 z-scores of the median standards as defined by the World Health Organization), visible wasting, or by the presence of nutritional edema) are nine times more likely to die than their well- nourished peers, even mild undernutrition can contribute to child mortality (Black et al. 2008).

Undernourished children are more susceptible to infectious disease, which can lead to recurring patterns of illness and faltering growth, leading to permanent delays in development and cognition. Moreover, stunting during intrauterine development and infancy can “program” the body, resulting in dramatically increased rates of chronic disease among adults who were stunted as children. Additionally, girls who are born to stunted mothers and grow up to be stunted themselves tend to have smaller uteri which itself is predictive of lower birthweight (Ibanez et al.

2000.) Metabolic and vascular disorders such as diabetes and heart disease are very strongly associated with childhood stunting (Victora et al. 2008; Barker 2005), as are delays in cognitive

development (Walker 2000) and underperformance in schools, as compared to non-stunted peers

(Victora et al. 2008). This disease burden, cemented before the age of two, has a tremendous impact on health and human capital (Victora et al. 2008), with height at two years of age very clearly associated with increased productivity in adulthood. A longitudinal study in Guatemala that followed the lives of infant boys who had been provided with high-quality nutrition during this critical period found their earnings as adults were 46% higher than those of their peers in the same community who had not participated in the nutritional intervention (Hoddinott et al. 2008).

All in all, the cumulative effects of childhood stunting are perhaps one of the biggest contributors to the “cycle of poverty” that affects much of the developing world.

Setting

Guatemala has the highest rate of childhood malnutrition in Latin America, and the highest rate of stunting in the world (Grantham-McGregor 1997). It is also home to an indigenous majority that have undergone a decades-long genocide and are still subject to endemic intersectional racism (Hale 2002.) Although poverty plays a determinative role in promoting chronic undernutrition in early childhood, even after accounting for socioeconomic status Mayan children are almost twice as likely to be stunted, at 58%, than their non-Mayan counterparts (at 32%)

(Gragnolati and Marini 2003.) Rates of stunting are also very strongly delineated by levels of rurality, which can be masked by national surveys. For example, a recent national survey put the overall rate of stunting in children under five in Guatemala at 43% (MSPAS 2009.) However, a regional survey of the mostly rural, indigenous departments of Western Guatemala (San Marcos,

Queztaltenango, Totonicapán, Huehuetenango and El Quiché) found much higher rates of stunting than the national average (SIVIM, 2012; Chary et al. 2013.) Of those surveyed, 60% of all children between the ages of 3 and 59 months were stunted. Of those stunted individuals, 86%

were from rural communities and 77.5% identified as indigenous (SIVIM 2012.) In some indigenous communities, the rate of stunting can be as high as 80%, making it a truly endemic public health issue. The extremely high prevalence of stunting in rural areas of Guatemala, and the chronic, “quiet” nature of the condition and its accompanying co-morbidities, can give rise to issues of normalization (Chary et al. 2013), especially in areas and households where resources are strained. Until fairly recently, stunting also went more or less ignored by the scientific and public health communities, causing some organizations to refer to stunting as the “silent epidemic”

(UNICEF 2011.)

The Myth of “Zero Cost” Adaptation

Despite its worldwide prevalence and the tremendous impact it has on health and human capital, stunting has only recently been recognized as a global health crisis (UNICEF 2012).

Much of this might have to do with the populations who are typically affected by chronic undernutrition—stunting is predictably delineated along lines of race, class and ethnicity (Gragnolati and Marini 2003, UNICEF 2008)—but part of the reason for stunting’s relatively late rise to preeminence in global health research may be traced back to misinterpretations of public health data by the scientific community. In 1980, David Seckler, an economist from the University of

Colorado, published a treatise on what he referred to as the “small but healthy hypothesis” (Seck- ler 1980). According to Seckler, the shortened stature associated with poverty in many of the world’s developing countries was in no way detrimental, but rather a positive, no-cost adaptation of the body to the strictures of its environment. Since fewer calories were available, the body adapted, limiting its growth so that less energy would be needed to sustain it over a lifetime. The basic principle of his theory holds true—that of adaptation—but the “small but healthy” hypothesis is flawed on two main counts. One, in the assumption that there is such a thing as a “zero-

cost” adaptation (and that stunting is such an adaptation), and two, in his definition and understanding of associated health and well-being. For example:

Concepts like ‘health‘ (or ‘welfare‘ or ‘happiness’) are better defined in terms of what they are not, rather than what they are. I contend that people who are not demonstrably ‘functionally impaired‘ in any of the physical, mental, or emotional dimensions of life are ‘healthy‘ people. In other words, people should be considered to be ‘healthy’ unless they show clear signs or symptoms of being ‘unhealthy’—in the case of EPM, of functional impairments caused by energy-protein deficiency. Thus, the SBH hypothesis is that small people in the mild to moderate degree of pure chronic EPM are healthy because they do not demonstrably have signs or symptoms of functional impairments caused by energy-protein deficiencies. These small people are normal, healthy people in every functional respect. (Seckler 1984)

Other empirical works of the time supported this theory, suggesting that there is no

“functional cost” to individuals whose growth has adjusted to levels of caloric intake far below the minimum as recommended by the World Health Organization (Sukhatme and Margen 1978,

1982). Still others argued that applying Western standards of growth and development to populations who have adapted to different physical and socioeconomic environments over the course of their history is not only technically incorrect, but vaguely imperialist (Seckler 1984; Srinivasan

1981a; Srinivasan 1981b; Sukhatme 1962, 1978). This was in keeping with a broader pattern within anthropology: “among the ecologists, including the cultural materialists”, writes Scheper-

Hughes (1992, p. 131) “malnutrition and chronic hunger tend to be viewed within a broader framework of biosocial adaptiveness.” (She cites Harris 1985, Cassidy 1980, 1982, 1987, and

Lepowsky 1985 as examples.)

Contemporary critics of the “small but healthy” hypothesis countered the idea of sufficient growth in context, suggesting that stunted individuals (1) had no margin of safety for physiological and environmental demands on the body like pregnancy and infectious disease (Rand et al. 1984a); (2) that a reduction in productivity in response to low energy intake and reserves is both socially and economically expensive and thus not a “zero-cost” adaptation (Gopalan 1983;

Rand et al 1984); and (3) that there was no current evidence to support the idea of a ‘metabolic adaptation’ in the first place (Torun, Young and Rand 1981; Rand 1984). Raynaldo Martorell, arguing from his own experience in Guatemala argued that while, yes, smaller bodies may require fewer calories, their very “smallness” entailed significant “social, behavioral, and biological costs” (Singer and Erickson 2011; Martorell 1989.) Pelto and Pelto (1989) asserted that given this evidence, “the concept of a ‘no-cost’ adaptation makes virtually no sense.” Others argued that economists, remotely arguing cost of grain prices vs. rough population estimates of household “survival” expenditures to form a definition of health through “lack of functional impairment” (Seckler 1982) had no place in a debate that was fundamentally sociocultural and biological in nature. Ellen Messer, in 1986, summed up the small but healthy debate, as it stood, as follows:

The current ‘small but healthy’ analysis, or better, ‘opinion’ differs from earlier efforts to forge a distinctive set of nutritional analyses and standards with food policy implications for India, in that it ignores the evidence for, and implications of, mild to moderate malnutrition. Furthermore it is based on no (Seckler, 1982) or scientifically refuted (Sukhatme and Margen 1978, 1982; Rand and Scrimshaw 1984b; Rand, Scrimshaw and Young 1989) evidence. Whereas earlier nutritionists and social scientists had tried to understand how Indian physiological reactions to the climate, work, and diet might have produced a different nutrition picture for Indians, they nevertheless sought to learn the true extent of the food problems. They also sought food policies which may alleviate the amount of current and future malnutrition, and limit the interference with work capacity. By contrast, Su- khatme and Srinivasan, with their colleagues, attempt to define away the problem, for a combination of political, professional, and psychological reasons. (Messer 1986)

Although it had its fair share of critics, the “small but healthy” hypothesis remained a prevalent theme in the literature for much of the next two decades and brings into the forefront the importance of “the theoretical and applied significance of how bodies were ‘read’” (Good- man and Leatherman 1998.) The debate itself is reflective of another aspect of stunting that may have slowed its trajectory as a category of public interest and concern; for all that it is easy to

recognize and diagnose, stunting is a slow and stealthy killer, lacking the dramatics of acute malnutrition. Stunted children do not always look unhealthy; often they just look small. It would be easy, therefore, for a nutritional survey or rapid ethnography to miss the very real long-term costs of early childhood undernutrition.

Long Term Costs

In direct contrast to the “small but healthy” hypothesis, we now know that chronic undernutrition results in system-wide stunting, affecting much more than linear growth. In an effort to sustain life the body makes sacrifices, redistributing energy that would have been directed toward growth and development toward the maintenance of vital systems. When this redistribution happens during a key point in growth and development—such as, for our purpose, the first three years of life—this sacrifice results in the creation of a life-long deficit that cannot be fully re- couped during periods of later “catch up” growth. In fact, according to tenets of fetal programming, and from what we know of stunting in contexts undergoing the nutritional transition (Pop- kin et al. 1996), like Guatemala, early-childhood undernutrition followed by periods of adequate nutrition is one of the main risk factors for a host of metabolic disorders (Martins et al. 2004;

Sawaya et al. 2005). This may help explain the co-occurrence of maternal obesity and child stunting (the so-called “SCOM paradox”) common to areas like Guatemala and Northern Mexico and the high incidence of metabolic disorders among stunted adults (Ferreira et al. 2009).

Cognitive

Longitudinal studies of stunted individuals have found strong correlations between stunting and underperformance in school, when compared to non-stunted peer groups. Work in rural

Zimbabwe (Alderman 2006) found that stunted individuals completed, on average, 0.85 fewer grades of schooling and started school six months later than their non-stunted counterparts. They theorized that this presented a lifetime loss of earnings of around 14% (Ibid.).

Work in Guatemala has been even more conclusive. A follow-up of ~1500 individuals involved in the 1969-1977 INCAP longitudinal study found that male children who had been randomly assigned to receive atoles (Incaparina; 6.4g protein and 91kcal/100 ml) fared better economically as adults than those who had been assigned to receive refrescos (0g protein and

33kcal/100 ml). Both supplements were fortified with micronutrients in equal measure. Those who had received the atoles before age three showed statistically significant increases in their earnings as adults—a mean increase of US$0.67 per hour (95% CI), which equated a 46% increase in average wages over their lifetimes (Hoddinott et al. 2008.) This increase only held true for men; there was no statistically significant difference in earnings among the females who had received atoles before age three.

In another cohort study, Victora et al. (2008) also linked stunting to a reduction in lean body mass, intellectual capacity and decreased earnings over the lifetime. “...Height-for-age at 2 years [is] the best predictor of human capital and undernutrition is associated with lower human capital. We conclude that damage suffered in early life leads to permanent impairment, and might also affect future generations. Its prevention will probably bring about important health, educational, and economic benefits.” (Ibid.)

This “productivity” hypothesis is gaining more and more support as the scientific community gains a better understanding of precisely how chronic undernutrition in early childhood acts on the body. A longitudinal study of stunted children in Indonesia found that at age ten, stunted children performed worse than their non-stunted counterparts on IQ tests (the Weschler

Intelligence Scale for Children, Revised), vocabulary tests, and tests of logic and reasoning (all P

< 0.5, sample size of 127) (Walker 2000.) There is also evidence to suggest that these changes in cognitive functioning are scaled, with results worsening with every standard deviation below the internationally-accepted mean (Ibid.) Grantham-McGregor, et al. (1997) found the same inverse

correlations between stunting and IQ, as well as stunting and school achievement, memory, and fine motor skills, after controlling for the verbal intelligent quotients of the participants’ mothers.

Metabolic

In addition to causing permanent structural damages to the brain, chronic undernutrition in early childhood is very strongly correlated with the development of metabolic disorders in later life. Moreover, there is reason to believe maternal undernutrition “resets” the fetus’ expectations of the extrauterine environment, often leading to an environmental “mismatch” (Gluck- man and Hanson 2009) in the presence of adequate nutrition later in life, which in turn can lead to obesity, diabetes, and the development of the more comprehensive but less well understood metabolic syndrome. The once-mystifying co-occurrence of maternal obesity with early childhood undernutrition has been well-documented (Garrett 2005; Barquera et al., 2007.) There is ample evidence suggesting that these two diverse outcomes are not, as it would seem at first glance, in opposition, but rather expected, and related, consequences of the particular environmental demands of the nutritional transition in developing nations.

Every field that concerns itself with the growth and development of complex organisms has concluded that a single genotype can give rise to multiple phenotypes, depending on environmental context. There is increasing evidence to suggest that this plasticity in development is most affected during particularly sensitive periods in the life course; moreover, there is evidence to suggest that these uncoded adaptive changes may occur not only in the organism in question, but in its offspring (Gluckman and Hanson 2004.) Empirical research on childhood nutrition has established the programming effects that undernutrition during certain critical periods in growth and development can have on metabolism in later life (McCance 1962; Lucas 1998) and monozygotic twin studies have demonstrated that genetics alone cannot be the sole driving factor

behind the scope and range of these periods of adaptive development plasticity (Ozanne and

Hales 2002.)

The first three years of human life, from conception to the age of two, are one of these

“sensitive periods.” Stunting has been positively, and significantly, associated with adult fatness

(measured as waist-to-hip ratio (WHR) and/or kg/m2 (BMI)) in three different continents

(Sawaya et al. 1995; Sawaya et al. 1997; Doak, Monterio and Popkin 1999; Popkin et al. 1996.)

In São Paulo, Sawaya et al. (1997) found a positive correlation between high dietary fat intake and excess weight in stunted individuals, but not in their non-stunted counterparts, suggestive of a decreased ability in stunted individuals to efficiently metabolize fat. A follow-up study (Hoff- man, et al. 2000) found that stunted individuals have a decreased ability to oxidize fat ( measured

via VO2 to VCO2 conversion during fasting and postprandial periods, after controlling for energy expenditure, basal metabolic rate and BMI); a trait that has been linked to an increased risk of obesity in other at-risk populations (Zurlo et al. 1990). Animal models back up these studies; early diet restriction has been shown to cause permanent detrimental effects to long-term energy regulation in mice and rats (Widdowson and McCance 1963; Aubert 1980; Duff and Snell 1982;

Faust, Johnson and Hirscht 1980) and non-human primates (Cryer and Jones 1980; Lewis, et al.

1986.)

Moreover, stunting has been shown to have a strong positive correlation with Type 2 diabetes (Ferreira et al. 2009.) While this in and of itself may not be surprising, given the increased likelihood of stunted individuals becoming obese adults, what is interesting is the cyclical socio- physiological effect that stunting has on the intrauterine environment and how this is related to an increased likelihood of developing diabetes. We know that stunted women are more likely to give birth to low birth weight babies (Victora et al. 2008.) We also know that having a stunted mother and small size at birth are both very strongly correlated with the Pro12Ala polymorphism

of the peroxisome proliferator-activated receptor-γ2 gene (PPAR-γ2) (Eriksson et al. 2002) and that this particular polymorphism (and consequent change in gene expression) is strongly associated with altered insulin sensitivity and the development of diabetes later in life (Deeb, et al.

1998; Valve, et al. 1999; Meirhaege, et al. 2000.) Low birth weight also increases the likelihood of developing hypertension and high cholesterol in later life (Kuzawa 2005a), although the mechanisms are not as well understood.

Stunted individuals are therefore at triple peril (or more) of developing metabolic disorders later in life. Part of the “pathology” of the stunting adaptation (Bogin et al. 2007) is manifested through fetal programming and environmental “mismatch” through gene-environment interaction, which in turn results in increased insulin sensitivity (Eriksson et al. 2002.) Chronic undernutrition in early childhood also results in a decreased ability to effectively metabolize fat, which in turn increases the likelihood of obesity in later life and the development of metabolic disorders. Moreover, to complete the cycle, both stunted women and obese women are more likely to have low birth-weight babies, which in turn increases the likelihood of stunting and metabolic disorders.

Cardiovascular/vascular

Chronic undernutrition in early childhood is also associated with cardiovascular disease, and is yet another example of the adaptive mechanics of “evo-devo” (evolutionary-developmental) modeling of critical periods in child growth and development (Hochberg 2009) and the trade- offs involved in preserving life instead of investing in development during periods of research scarcity. Children who “fail to thrive” during infancy are much more likely to die of heart disease, stroke, and to develop hypertension and hypercholesterolemia later in life (Ferreira, et al.

2009; Sawaya et al. 2005; Martins, et al. 2004). Chronic undernutrition in early childhood is also linked to early-onset dementia and changes in adult cognition (Griffiths and Kikafunda 2015.)

These conditions, if treatable, are expensive to treat and in contexts like rural Guatemala, where many households survive on less than US$2 a day, they often go undiagnosed and untreated or undertreated, and the subsequent reductions in productivity and the early deaths of primary earn- ers and caretakers become a permanent drain on household resources and reserves.

Maternal Mortality

Stunting during infancy is also associated with chronic anemia, which is one of the highest risk factors for maternal mortality (Subramanian et al. 2009.) In and of itself, this helps contribute to the cycle of poverty and stunting, as the loss of the primary caretaker in the household creates an enormous psychosocial and economic deficit. Additionally, since stunted individuals carry a comparatively high disease burden, pregnant women who were themselves undernourished during infancy are at an elevated risk for a host of complications during pregnancy, including preeclampsia and gestational diabetes (Victora et al 2008.)

Catch-Up Growth?

While much emphasis has been put on the first “thousand days” of life (which is problematic in and of itself, as discussed later in this text) there is some evidence that catch-up growth (defined as “ the phase of rapid linear growth that allow[s] the child to accelerate toward and, in favorable circumstances, resume his/her pre-illness growth curve” (Boersma and Maarten

Wit 1997) is possible (Martorell, Khan and Schroeder 1994; Adair 1999.) If this is indeed the case, it would have immense implications for programming and the fact that so few people are talking about it or researching it is a complete mystery.

The Cycle of Poverty

Although the word “stunting” was originally coined to describe faltering linear growth, the term itself provides a surprisingly succinct and accurate portrayal of the reality of the condition’s system-wide effects. Chronic undernutrition during gestation and in infancy stunts not

only the height of a child, but their potential. Before the age of three, structural changes to the brain cause permanent delays in cognitive development that will influence levels of education and literacy, as well as wages earned over a lifetime (Alderman 2006; Hoddinott 2008; Victora, et al. 2008; Walker 2000; Grantham-McGregor, et al, 1997.) Developmental delays and environmental mismatches will cause irreversible changes to the endocrine and cardiovascular systems, ladling already at-risk individuals with an incredibly high disease burden (Hochberg 2009; Ku- zawa 2005a; Victora et al. 2008.) Chronic diseases in such a context will often go untreated or under-treated due to the structural constraints and intersecting inequalities that led to stunting in the first place, further affecting the productivity of stunted individuals and the health of their households. The combination of the decrease in productivity, the tax on human capital, and the multiple burdens placed on health by chronic undernutrition in early childhood has, functionally, made a non-heritable, non-infectious disease both hereditary and transmissible.

Part II: Violence

Neoliberal maneuverings: As much as the term “neoliberalism” has become frustrating to some scholars, perhaps because the word itself is ‘“a bit of a dopey term, that really just means

‘small government-pro-market’ policies” (Jericho 2017) and also because it has been employed widely and imprecisely as a catch-all term for most every critique of the state or of shifting international priorities, I like the concept, I find it useful, and you will see it sprinkled throughout this text. It provides an excellent shorthand for the mechanisms by which structural violences are enacted and replicated. I also like the construct in part because it strikes me as an antithesis of the way the term globalization has been employed; globalization being a discourse that Nicole Berry

(2010) argued “smacks of becoming a ‘stor[y] we tell ourselves about ourselves’” (from Geertz

1973.) Arjun Appadurai called globalization itself and the discourses surrounding the theory a

“double apartheid” that separates the poor both from localized “vernacular discourses about the

global” that attempt to retain economic autonomy even as the sand shifts beneath them, and from

“nationalist discourses about globalization…surrounding trade, environment, disease, and war- fare” (Appadurai 2000.) If globalization theory is a new chapter in what Obeyeskere (1992) would call “European myth-making”, then neoliberalism, employed as a critique, is the antidote to a subtle and bitter poison.

For the purposes of this text, and in general, I understand neoliberalism as the continua- tion of “a class war, typically one-sided” (Chomsky 2016.) Adam Smith’s “merchants and manu- facturers”, his “masters of mankind” may have changed tactics and increased the scale of their operations since he published The Wealth of Nations in 1776, but they are no less present. Now state and global policies are shifted by an incestuous network of “masters drawn from the top ranks of increasingly monopolized economies, the gargantuan and often predatory financial institutions, the multinationals protected by state power, and the political figures who largely represent their interests” (Chomsky 2016.) I should also mention that, in this text, I prioritize Lauren

Berlant’s definition of capitalism; “the relations between capitalists and workers and capitalists and consumers amid the shifting character of capitalist strategies and the net effect of the interaction of those strategies on the relevantly vulnerable populations, which include people of color and the aged, but more broadly, too, the economically crunched” (Berlant 2008.)

Even in so-called democratic countries, the U.S., for example, we know that campaign funding, to give one example, is a “remarkably good predictor of policy choices. (Chomsky

2016.)” A recent study by Princeton economists Martin Gillens and Benjamin Page (2014) used twenty years of survey data on opinions regarding proposed policy changes, coupled with re- spondents’ self-reported socio-economic statuses, and measured these against whether or not those policy changes did go into effect to ask the questions of whether, and to what extent, individual wealth and collective corporate interests influenced policy changes over the interests and

desires of “average citizens and mass-based interest groups.” What they found was, in their own words, “troubling.” The U.S. is no longer (if indeed it ever was) what it believes itself to be— a populist or majoritarian electoral democracy.

The democratic deficit in nominally ‘democratic’ countries such as the US is now enormous. Political representation is there compromised and corrupted by money power, to say nothing of an all too easily manipulated and corrupted electoral system. Basic institutional arrangements are seriously biased. Senators from twenty- six states with less than 20 percent of the population have more than half the votes to determine the Congressional legislative agenda. The blatant gerrymandering of congressional districts to advantage whoever is in power is, futhermore, deemed constitutional by a judicial system increasingly packed with political appointees of a neoconservative persuasion. Institutions with enormous power, like Federal Reserve, are outside any democratic control whatsoever. Internationally the situation is even worse since there is no accountability, let alone democratic influence, over institutions such as the IMF, the WTO, and the World Bank, while NGOs can also operate without democratic input or oversight no matter how well-intentioned their efforts. (Harvey 2005.)

“When the preferences of economic elites and the standards of organized interest groups are controlled for,” writes Gillens and Page (2004), “the preferences of the average American appear to have only a minuscule, non-zero, statistically non-significant impact upon public policy….in the United States, our findings indicate, the majority does not rule— at least not in the causal sense of actually determining policy outcomes. When a majority of citizens disagrees with economic elites or organized interests, they generally lose. Moreover, because of the strong status quo bias built into the U.S. political system, even when fairly large majorities of Americans favor policy change, they generally do not get it.” This would, of course, in even the most classic of definitions, render the U.S. not a democracy, but an oligarchy.

Much the same pattern can be seen in Europe. Take, for example, “the contempt for democracy…revealed in the savage reaction in July 2015 to the very idea that the people of Greece might have a voice in determining the fate of their society, shattered by the brutal austerity policies of the troika—the European Commission, the European Central Bank, and the International

Monetary Fund” (Chomsky 2016), or the more recent and violent police response to the Catalan 41

vote for independence. Following patterns in recent history, I would expect that in the coming years, the localized austerity measures once championed but eventually abandoned by the conservative Catalan political party (Convergence) will come to pass, whether or not the vote for

Catalan independence is deemed legal and secession takes place. These austerity measures, while ostensibly championed as a means to reduce debt, will actually result in increasing localized debt relative to GDP, effectively cutting the socialist movement of Spain’s left and center-left off at the knees and rendering the precariat all the more precarious, much as it did in Greece. Even more recently, the U.S. tacitly approved of a right-wing dictatorship in Honduras, after the sitting president, Juan Orlando Hernández decided not to leave office after he lost the latest election to a left-leaning incumbent, Salvador Nasralla, of La Alianza de Oposición contra la Dictadura (you know things are bad when you have an major political party named “Operation Alliance Against

Dictatorship”.) This decision was made possible in part because Hernández sacked four out of the five Supreme Court justices back in 2012, replacing them with people he felt loyal to himself as an individual. The new Court, unsurprisingly, ruled that the legal term limits did not apply to

Hernández, making him eligible to run again in 2017. When it became obvious that he was losing the popular vote to Nasralla, the Supreme Electoral Tribunal, or TSE, shut down. When it re- opened three days later, Hernández had been declared the winner.

The stealing of the 2017 Honduran election was also made possible—and this should be noted because it is a very familiar tactic to anyone who has ever read about the rise of fascism or has been introduced to Hannah Arendt’s “Origins of Totalitarianism”— by Hernández’s use of military and police forces in suppressing the protests following the election, an action that resulted in hundreds of deaths. In something else that will ring very familiar to anyone familiar with the history of US intervention in Central America, Hernandez’s top security advisor comes

from the CIA-created death squad, Battalion 316. “Sections of the security forces loyal to Her- nández have been entering people’s homes at night, arresting them, disappearing them…We have a large group of missing comrades,’ reported Dr. Luther Castillo Harry, former National

Commissioner of the Ministry of Health in Honduras. They “have been captured and disappeared and are not yet reported missing.” (Prashad 2017.)

I am familiar with this last story because I have Honduran friends who called me, elated, when it became obvious that Nasralla had won, and called me again, infuriated, when the election results were announced. As obsessed as I have become with keeping up with the news in

2016 and 2017, I did not read about the Honduran election in U.S. newspapers as it was happening; it didn’t make any of the front-page feeds I had grown used to refreshing every few hours.

Given the understandable panic about the rise of totalitarianism in the US and Europe, I was cu- rious as to why a blatant power grab by a right-wing militaristic dictator on our doorstep didn’t merit more media coverage, and I was not alone in this confusion. “The US,” wrote Vijay

Prashad about the “stolen” Honduran election, “is keen to keep the oligarchy in power” (2017.)

The United States has fully backed Hernández in his campaign for re-election. Professor

Dana Frank of the University of California Santa Cruz and a close observer of Honduras told me that "President" Trump’s Chief of Staff John Kelley was close to Hernández when he was the head of Homeland Security. He called Hernández a "good guy," a "great friend" and said that

Hernández was doing a "magnificent job." Stolen election or not, Frank says, "Everyone knows that the US wants Hernández in power no matter what.”

Palmerola (Soto Cano) Air Base, in Comayagua, 50 miles northwest of the capital Tegucigalpa, is one of the few major US military bases in Latin America. It was set up in 1983 for the US to support its contra allies in Nicaragua and its allies in the Honduran military. It is said in Honduras that the US actively participated in the coup against President Zelaya in 2009 because his agenda included the closure of this base. It should be pointed out that the US has directly intervened in the Honduras several times to protect its interests: in 1903, 1907, 1911, 1912, 1919, 1920, 1924 and 1925. Since the 1980s, however, it has relied on friendly people in 43

the Honduran military and in the Honduran oligarchy to do its bidding. No wonder then that the US is keen to keep the oligarchy in power rather than allow left- leaning Nasralla and his popular alliance to take office. (Prashad 2017.)

In each of the above examples, in supposedly “democratic” countries, the will of the majority was ignored or oppressed, often violently. The analogs, of course, do not end there.

Nowhere, I would argue, is the disdain for democracy by the powers-that-be more obvious than it has been, and continues to be, in U.S. state interventions in Central and South Amer- ica. In case any of us are still laboring under the impression that the US engaged in these tactics in the “name of democracy”, it is important to remember that many of the coups in which we took part were designed to overthrow democratically-elected officials and replace them with dictators who were more amenable to US interests, the vast majority of which had their roots more in corporations than in politics (making the argument that the two are indivisible.) Take just a few actions of a single organization—The United Fruit Company—as an example:

…it changed governments whenever it didn’t like them, like the one in Guatemala in 1954 that had wanted to donate some of United Fruit’s unused land to landless peasants. In 1961 United Fruit ships sailed into the Bay of Pigs in Cuba in an effort to overthrow Fidel Castro. As far back as 1928 the company was implicated in the massacre of hundreds of striking workers in Colombia….As for repressive regimes, they were United Fruit’s best friends, with coups d’état among its spe- cialties….it counted on the help of the US and the CIA. (Chapman 2007)

This disdain for democracy in our actions, both internally and in foreign relations, even as we continue to cloak ourselves in the term and the glowing post-WWII nostalgia of the “good fight” it entails is of direct import to the current state of health and healthcare in Guatemala, as the US has played a major role in both the history of violence within the country and in its continuing poverty and insecurity. Even after the official end to the war in the signing of the Peace

Accords on December 29, 1996, corporatocratic violence took other forms:

…neoconservative technocrats and international financial institutions were also actively involved in shaping the peace process, and their interests generally won out over demands for truly substantial democratic and social justice reforms. As social scientists have repeatedly pointed out, the decade since the signing of the

accords has seen increasing disparities—in education, health, housing, socioeconomic status, and access to capital—that actually diminish possibilities for the full democratic participation of all citizens. (O’Neill, Thomas and Offit 2011)

Although the years following the signing of the accords have resulted in a vibrant and surging indigenous rights movement, the on-the-ground successes of pan-Mayan activism have come head-to-head with a sort of “racial ambivalence” Charles Hale has termed “neoliberal multiculturalism” (Hale 2002, 2005), in which neoliberal policies are happy to recognize and cele- brate advances and claims to rights made by disenfranchised and marginalized groups…so long as these claims do not “demand control over [the] resources necessary for those rights to be realized” (Hale 2005.) Diane Nelson described neoliberal multiculturalism as being a useful construct to the corporatocratic state in that it allows them to simultaneously acknowledge and cele- brate the cultural heritage of the indigenous majority while continuing to uphold centuries of ladino superiority by failing to address any of the structural disparities that continue to suppress the rights of Mayan peoples (Nelson 1999.) Despite the successes of the pan-Mayan movement in legitimizing their place at the table, and despite the Peace Accord’s written guarantees of structural change, more than 80% of rural Mayans still live in extreme poverty (O’Neill, Thomas and Offit 2011.)

It is especially important in this current moment in history that we recognize our own culpability, as a nation, in the poverty and suffering found outside our borders, and to remember that “it is the profoundly anti-democratic nature of neoliberalism backed by the authoritarianism of the neoconservatives that should surely be the focus of political struggle” (Harvey 2005.) In the words of one leading political philosopher; “there is not much time” (Chomsky 2016.)

In 1999, at a Roundtable Discussion on Peace Efforts in the National Palace of Culture in

Guatemala City, President Bill Clinton offered an apology to the Guatemalan people for the role the United States played in supporting the 1954 CIA-backed coup that prematurely ended the

term of left-leaning president Jacobo Árbenz, re-establishing rule under a string of conservative military dictators and resulting in a protracted, and bloody, civil war (Schliezinger and Kinzer

1999.) Clinton’s hand had been forced, in part, by the findings of an independent truth commission (Navarro 1999, Hayner 2002), but he was “unequivocal in his condemnation” (Gibney and

Warner 1999) of the role U.S. foreign policy had played in a conflict that, based on statistical projections by the United Nations Commission for Historical Clarification (UN CEH 1999), cost

200,000 lives.

Of course, it is hard to count the dead when so many have been, in quite literal terms,

“disappeared.” In the years before the UN calculated the incalculable and made the death toll of

200,000 an oft-repeated “fact”, “Guatemalans used to estimate the toll of thirty-six years of military state counterinsurgency and revolutionary mobilization by saying every extended family had lost at least one person— so everyone is minus one” (Nelson 2015.)

For the United States, it is important that I state clearly that support for military forces and intelligence units which engaged in violence and widespread repres- sion was wrong, and the United States must not repeat that mistake. We must, and we will, instead, continue to support the peace and reconciliation process in Gua- temala. -U.S. President Bill Clinton, March 10, 1999, Guatemala City

In this dissertation I do not attempt an accounting of the decades-long genocide helped along by the U.S. and perpetrated against the indigenous majority; though, like most anthropologists who choose to focus on Guatemala, I’ve heard many stories about “la violencia.” Nor do I attempt to assess whether or not the promise, made by Clinton on behalf of the United States of

America, has been kept. I mention that meeting in March and the U.S. admission of past culpability because it is useful to unpack not only the meaning of “violence” in the context of postwar life in rural Guatemala, but also the meaning of “peace.” The 1996 signing of the Peace Accords under the administration of PAN President Álvaro Árzu led to an official laying down of arms between the Guatemalan counterinsurgency and guerrilla forces, and an official end to the war. 46

An end to the war. Not an end to conflict, nor an end to violence. A Guatemala at “peace” is still a Guatemala besieged. Structural and interpersonal violences have increased since the

1996 Peace Accords, in part due to the adoption of neoliberal doctrines by the Guatemalan state resulting the increased privatization of social services (Maupin 2009) and security forces

(O’Neill and Thomas 2011.)

More than ten years after the Peace Accords of 1996, postwar peace seems little more than a bloodied banner. Postwar violence has coincided with a formal reconciliation process, an uneven transition from authoritarian regimes to democratic institutions, a shift from state-centered to free market economic policies, and a booming drug trade. About 90 percent of the cocaine shipped from the Andes to the United States flows through Central America, with 200 tons of the drug moving from Colombia through Guatemala into Mexico and finally to the United States each year. Guatemala City is now one of the most dangerous cities on the planet. Interestingly, the spike in violence during the postwar period has prompted not public debates about the structural conditions that permit violence to thrive in the first place, but rather a new set of practices and strategies that privatize what would otherwise be the state’s responsibility to secure the city. (O’Neill, Thomas and Offit 2011.)

Violence: To begin unpacking violence in the context of postwar Guatemala, it is important to remember that annual homicide rates continue to outnumber the violent death rate during the civil war (O’Neill 2011.) The already weak, co-opted and underfunded governmental ap- paratuses responsible for maintaining the peace have been stretched thin by the post-war uptick in narcotics trafficking and urban violence (Chary and Rohloff 2014; O’Neill and Thomas 2011), leaving the majority of the country functionally outside the governmental polity, living under “no rule of law” (Sanford 2003.) Moreover, police forces have been increasingly privatized, replaced or re-invented as private security and paramilitary groups (Argueta 2010.) Guatemala continues to have one of the highest rates of homicide and violent death in Central America (Godoy and

Ceron 2006; Handy 2004; Sanford 2008.) “The good thing about Guatemala,” said a friend of mine, a musician who grew up in Guatemala City and now splits her time between Antigua and

New York, “is that you can get away with murder. The bad thing about Guatemala is also that

you can get away with murder.” In 2007, the homicide rate was 41.8 per 10,000 individuals (Ib- arra 2008) (compare this to the U.S. rate for the same year of 5.6/1000 (U.S. Department of Jus- tice 2007)), making Guatemala one of the world’s least peaceful nations, as ranked by the Insti- tute for Economics and Peace (IEP 2011.) On average, seventeen people are murdered every day

(O’Neill 2013.) It is likely, however, that this number is underestimated (Bellino 2010), especially in the case of femicide, as many deaths and disappearances go unreported in a country where only 10% of femicide cases are ever investigated (Cházaro and Casey 2006) and only 2% of all reported homicides result in a conviction (O’Neill 2013.) In the decade between 2000 and

2010, the bodies of 5,000 women and girls were found murdered in Guatemala (Prensa Libre

June 4, 2010), and the number grew year by year. In 2000, there were 213 bodies; in 2003, 383.

In 2005, 655. In 2008, the bodies of 722 women and young girls were found “in city streets and urban ravines” (Carey and Torres 2010), wrapped in plastic or not at all, in parts and pieces or left whole. These murders are widely covered in Guatemalan mass media, and have led to “the sense that life is much more dangerous in the postwar context than it has been in the past”

(O’Neill, Thomas and Offit 2011.) To a large extent, postwar violence, especially violence against women, has become “normalized” (Carey and Torres 2010) but in the urban areas in and around Guatemala City, where homicides are not as likely to go unreported, crime and urban violence is still a “pressing and politically urgent” issue, making it “difficult to sustain public interest in advancing the causes of indigenous people who, for the most part, reside in rural parts of the country, with which the bulk of Guatemala’s urban polity has little contact” (Chary and

Rohloff 2014.) This intentional oversight is in keeping with a pattern of sustained conflict, abuse and neglect between the Guatemalan state and the indigenous majority (Smith 1990.)

Peace: In unpacking peace in postwar Guatemala, it is important to note that the provisions for indigenous rights, including those governing rights to health and healthcare, as outlined

by the Agreement on Identity and Rights of Indigenous Peoples in the 1996 Peace Accords

(which was heavily influenced by the United Nations International Labour Organization (UN

ILO) Convention 169 on the Rights of Indigenous and Tribal Peoples ratified by the Guatemalan

Congress in 1995) were very heavily influenced by neoliberal rhetoric and policy reform (Chary and Rohloff 2015.) Neoliberalism is “a theory of political economic practices that proposes that human well-being can best be advanced by liberating entrepreneurial freedoms and skills within an institutional framework characterized by strong private property rights, free markets, and free trade” (Harvey 2005.) It’s also a theory that even the International Monetary Fund (IMF) has admitted was “oversold,” as “neoliberal policies have increased inequality and jeopardized durable expansion… instead of delivering growth” (Ostry, Loungani and Furceri 2016.) In the case of health in Guatemala, neoliberal reforms have resulted in a fractured, pluralistic and heavily privatized healthcare system that has become over-reliant on foreign aid (Chary and Rohloff 2015.)

Moreover, neoliberal trade reforms like CAFTA (the Central American Free Trade Agreement) have had an overwhelmingly negative effect on the most vulnerable portions of the population and have exacerbated the already stunning social disparities between the “haves” and the “have- nots” in a country with an already markedly unequal distribution of wealth (Fischer and Benson

2006; Jansen, Morley and Tererro 2007.) Of particular import to the underlying theme of this dissertation, neoliberal reforms impacting agriculture have exacerbated food insecurity (Isakson

2014.) Many scholars have, therefore, argued that disparities in health and well-being between indigenous and non-indigenous Guatemalans have increased, rather than decreased, since the signing of the Peace Accords (Little and Smith 2009). Though ostensibly in an era of post-war,

“life in Guatemala is still life during wartime” (Peter Benson, from Chary and Rohloff 2015.)

Part III: Theoretical and Practical Framework

“You can’t be too angry in academia, because then you’re an activist.” —Lisa Munro, PhD, Guatemalan historian 49

personal communication

Before I started graduate school, I was working as a technician in a cellular biology lab, studying the signaling patterns of a kind of neoplasia known as Barrett’s esophagus. After about a year, my P.I., a surgeon who ran the lab in his off-hours, asked me to stay in the lab and pursue a PhD in biochemistry under his tutelage. When I told him I was leaving in the next year to pursue a PhD in medical anthropology, he was not enthused.

“You shouldn’t go,” he told me. “You’d be wasting your talent.”

This was my first introduction to the fact that “biosocial approaches to disease and health that could help to specify dynamic causal connection and local politics are relegated to the low- authority category of ‘soft science’” (Biehl and Petryna 2013; see also Adams 2013 and Krieger

2011.)

My first year of graduate school, I came face to face with another hard reality about my perceived future utility as a scholar; “the sense, within anthropology, that its medical subfield is somehow pedestrian” (Farmer 2013.) Among other clues as to the embedded prejudice against the subfield, when I expressed interested in going to the SFAAs my first year, a senior scholar expressed her surprise.

“Why would you want to go to the SFAAs?” she asked me. “They’re so…applied.”

She said the word “applied” as if it were something dirty and quite possibly contagious.

In the interest of reflexivity, any and all readers of this dissertation should go into it with the understanding that its author is, and has always been, primarily interested in applied anthropology; in fact, I’ll take it one step further and attest to the fact that I am interested in the appli- cations of anthropology, which could be argued to be something else entirely. Despite years, at this point, of discussions about the topic, I don’t draw a hard line between critical medical anthropology and applied medical anthropology, and I’m uncomfortable picking a side, even when 50

asked. And although I understand some of the history behind the rise of the divide between the two sub-sub-fields (Singer 1992), I don’t understand the continued tension between them. I can’t think of a single “applied” medical anthropologist who finds theory to be “abstract, obstructive,

[or] even irrelevant” (Singer and Erickson 2011); nor can I think of a single critical medical anthropologist who “cling[s] to the old-fashioned belief that applied work is infra dig” (Ibid.), though I have met (and frankly am on the side of) more than a few who are “concerned with ad- vanc[ing] the larger discipline” (Ibid.), in guarding George Stocking’s (1988) “sacred bundle.”

I personally see the subfield of medical anthropology as one that sits quite comfortably between both biological and cultural anthropology, a subfield that demands in its thought and ex- ecution what Goodman and Leatherman (1998) called “a new biocultural synthesis.” The subjects of interest to medical anthropology provide excellent foils for understanding and interrogat- ing Gidden’s structuration, Foucault’s knowledge and power, Bourdieu’s “structuring structures”, or any of the other ways in which we’ve come, as a field, to think about and write about the means by which power in all its forms is attained and distributed. “I am convinced that a ro- bust medical anthropology could be critical to our understanding of how structural violence comes to harvest its victims…what is fragile is rather our enterprise of creating a more truthful accounting and fighting amnesia” (Farmer 2004.) Medical anthropology shouldn’t be seen, as I think it often is, as a bastardization of some “purer” incarnation of the discipline, but rather a subfield of anthropology that holds within it the promise of fulfilling Alfred Kroeber’s wish that anthropological understanding should take into account both the biological and the social.

Rudolf Virchow had this synthetic approach in mind when he called physicians “the natural attorneys of the poor” (Saussy 2010) and just as I have failed to understand and continue to lament what I see as unnecessary divisiveness between medical anthropology and cultural anthropology and, to open up the matryoshka that are our insistence on the creation of further

niches within the field, between “applied” medical anthropology and “critical” medical anthropology, I am also confused and disappointed at the overall lack of communication between physicians and anthropologists, even when it comes to the idea of culture within medical pedagogy.

This is of immediate import to the main subject of this dissertation—stunting—as the “racing” of human growth and development and the overall lack of cultural humility in US clinicians visiting

Guatemala play important roles in the condition’s failed amelioration, as we will discuss in the next few Chapters.

But even here, in the above mini-critique of the praxes and practices of medicine, we have to remind ourselves of Farmer’s “immodest claims of causality” (1992.) Stunting is not just the result of a biased understanding of its own etiology and consequences among clinicians. Nor is it simply an artifact of some quirk of intra-household ecology particular to rural Guatemalans, or the consequences of some nationwide hankering for sugar or tortillas. (Despite the prevailing rhetoric of in-country education-only nutritional programming.) It cannot be blamed in its entirety on the various miscommunications between providers and patients or nutritional programmers and parents, nor can it be laid fully in the lap of faulty pedagogy or incomplete constructions of what it means to be ill. Although all of the above factors play some part in its continued prevalence, Guatemala’s disproportionately high rate of stunting is much more an issue of infrastructure than it is one of intransigence. It is the result of a complex entanglement of variables; the combined trickle-down effect of the country’s unique history, political economy and demog- raphy that, folded together and given a few decades, has proven lethal. Understanding stunting means embracing this complexity.

Stunting in Guatemala is, for lack of a better word, deeply, powerfully frustrating. It is a condition for which we know both the cause and the cure, but it strikes with such rapidity and in such isolation that it is difficult to draw comfort from either of these knowledges. What use is

there in knowing how to treat a disease if it so often goes undiagnosed? What use is there in di- agnosing a condition if it most often goes untreated? How do we go about studying something that has its roots in so many places? How do we begin to address a condition that is both endemic and invisible?

Critiquing our historic tendency to focus on singular, discrete “cultures” as if they continue to exist in isolation from the rest of the world, George Marcus (1998) argued that ethnog- raphers should embrace the idea of multi-sited ethnography in order to remain relevant in an increasingly globalized world. Marcus’ conception of “multi-sited” didn’t necessarily connote spending time at multiple field sites, so much as it meant thinking seriously about the ways in which larger structural forces and particular regional and global histories shape the localities in which we find ourselves and influence our topics of interest. Almost twenty years later, reflect- ing on Marilyn Strathern’s and Annelise Riles’ anxieties that their work on the “already known”

(Riles 2002) (Strathern’s work on audit culture and and Riles’ work on bureaucracy in academia) push the borders on what is accepted as ethnography, he doubles down on the importance of a broader, systemic construction of what ethnography is and should be, asking for “a radical rethinking of Malinowskian premises” (Marcus 2016), which he defines as a dependence on tropes of “otherness”, or its “expected idioms” of the “frankly exoticized” or of the “ordinary life”

(Ibid., Ibid., Ibid.)—especially in dissertations and dissertation fieldwork.

Dissertation fieldwork and ethnography are where the shape of anthropological research gets collectively and normatively defined in the shadow of its tradition. How this is so is not a straightforward story of indoctrination, but rather a more complex one of the ways in which anthropology has accepted and negotiated influential interdisciplinary models over the past two decades. If basic change is to come it will be in this context. (Marcus 2016)

Paul Rabinow (2008) echoed the same sentiments, this time rooting the importance of multi-sited ethnographies less in space and more in time, asserting that ethnography’s importance lies in its understanding of “the contemporary”, acting as a filter through which change 53

and the exchange of ideas can be understood and given relevance. Margaret Lock and Vin-Kim

Nyugen’s “Anthropology of Biomedicine” (2010) argued that the multiple actors, the divisions between these actors, and the role power plays in healthcare delivery and research necessitate multi-sited ethnographies that address the interactions of all of the above.

For example, ethnographic research on HIV should engage experts and policy- makers who seek to change sexual behavior through HIV prevention programs, and not only the individuals who are targeted by those programs. Current debates about the role of male circumcision, abstinence, or condom use in HIV prevention require that the cultural beliefs and practices of NGOs, development agencies, and international organizations be examined in the light of the expertise and critical perspectives (rather than the “culture”) of their intended “beneficiaries.”

I have tried to take their advice. I did not go to Guatemala at the beginning of my dissertation research knowing that working on “the problem of stunting” would necessitate gaining a deeper understanding of the intricacies of aid culture or the attitudes of affect workers, but it quickly became clear that that was the case. And so, in this text, in the hope of relevance, I have situated this ethnography among multiple sites and multiple actors: “expert helpers” and affect workers, parents and grandparents, NGOs and clinics, ministries of health and philanthrocapitalist nutritional centers, homes and markets in rural Guatemala and meeting halls in Geneva, grassroots development workers and international banks. While emphasizing the kind of anthropology that “focuses close up on ‘the poor’”, I have tried to also include an examination of the ways in which the “larger machinery of oppression” and the “brutality [of] taken-for-granted arrangements” (Kirmayer 2004) serve to replicate structural violences and increase inequity. Nyugen and Peschard (2003), in writing about the uses of anthropology in an era of unchecked global capitalism remind us that “in modern society, inequality becomes embodied biologically, as those lower on the ladder suffer higher morbidity and mortality rates.” They go on to write something incredibly encouraging (p. 270); “ethnography has emerged as a key research strategy not for reciting a pious liturgy on the horrors of the forms human misery takes but for demonstrating

the links between policy and everyday life and for carefully scrutinizing the legacy of those who rightfully seek to correct conditions that are all too often beyond their control.”

Speaking of the recitation “of pious liturgies”, Leslie Butt’s “suffering stranger” (2002) is a critique of the use of “truncated first-hand accounts” of pain and suffering in medical anthropology that she argues don’t “listen to the voices of the poor” so much as they serve to impose a broader set of global moralities (which she deems an “illusion” and a relic of “tainted claims to universality” which she in turn brands “human rights culture.”) She dismisses the recent use of

“gut-wrenching, emotionally charged” stories in the work of anthropologists interested in social justice as “rhetorical devices [used] to strengthen claims of collaboration and consultation” and argues that the impetus behind such work is not in understanding or addressing the needs of the poor, but in speaking for them to a larger international audience.

Peter Redfield’s examination of the work of Médecins Sans Frontières and his resulting argument “for a less modest witness” (2006) is an effective practical rebuttal to Butt’s above critique on the framing and uses of narratives of suffering:

A clear line of tension runs through MSF’s advocacy work between individual narrative testimony and evidence presented in the form of more-objective “data.” Both certainly derive from different traditions and address different audience sensibilities. But one would be mistaken, I believe, to focus solely on the contrast between them and not to consider the extent to which one affects the formation of the other when brought into continuing association. My argument here is that when taken together as examples of related practice by a collective subject, rather than seen as separate epistemological traditions, they suggest a more intimate relationship between morality and science than is usually assumed in discussions of the topic. Following the lead of work in the social sciences that considers truth to have a distinctive social history, I focus on the manner in which the objectivity presented in this case is hardly “value free” but, rather, clearly in the services of humanitarian imperatives. Technical capacity and ethics are not simply opposed; rather they are tensely, but absolutely conjoined.

“Writing culture” (Clifford et al. 2010) “no longer [means speaking] with automatic authority for others defined as unable to speak for themselves.” In engaging seriously with the

voices of others—some of which are certainly emotionally charged—I by no means wish to reduce the lived experiences of those who were kind enough to speak to me over the past few years to “rhetorical devices” (Butt 2010.) I don’t know how else to go about addressing the critique of the “suffering stranger” except by being careful in both my representation of the individuals with whom I worked and in the conclusions I draw from that work. I don’t know how to put “peoples’ experiences, stories, and words in the foreground” (Goodman and Leatherman 1998) without including the stories they told me; I don’t know how to privilege “the voices of the poor” without including their words. And it’s impossible to speak to any of the truth to power to be found in the lived realities of stunting without addressing the suffering entailed therein.

We are bound by the tenets of decolonizing theory to “move toward an anthropology of liberation” (Harrison 1992.) To this end, I believe there comes a point when critical medical anthropologists have to get out of our own way, to document inequities as best we can, to try to the best of our ability to privilege the voices of those we with work with above our own, and to situate all of our work as well as we’re able within the broader, operative structures of power that take from the poor and give to the rich. For as much as we might be divided over the hows of ethnography (beyond Dr. Butt’s work, see Ong and Collier 2005 and Rabinow 2008 for their takes on the ethics of representation in ethnography), we seem to all be in agreement that neoliberalism and unchecked global capitalism have led to the unrelenting, and arguably unnecessary, suffering of the majority of the planet’s population. In our time of rampant capitalism and unequal resource distribution, we that have have in large part because others do without, and Chom- sky’s 1967 essay on “The Responsibilities of Intellectuals” holds just as true now as it did on the eve of the Vietnam war. That particular piece of work is so relevant, and so timely, in fact, that the essay has been re-issued as a slim blue hardcover and is now a bestseller. Noam’s contempo-

rary introduction to the work reads as follows: “responsibility I believe accrues through privilege. People like you and me have an unbelievable amount of privilege and therefore we have a huge amount of responsibility….beyond that, it is a question of whether you believe in moral certainties or not” (Chomsky 2016.)

Anthropologists and scholars like Didier Fassin, Paul Farmer, Vinh-Kim Nyugen, Arthur

Kleinman, Nancy Scheper-Hughes, Jim Yong Kim, Merrill Singer, João Biehl, Margaret Lock,

Adia Benton, Noelle Sullivan, Adriana Petryna, Vincanne Adams, Bill Dressler, Lance Gravlee,

Mark Nichter, Claire Wendland, Betsy Brada, Peter Rohloff, Anita Chary, Kelly Knight and

Chris Kuzawa (I could go on, this is more or less a “greatest hits” mixtape of the synthetic bi- oculturalists and critical medical anthropologists who came to mind as I was writing this sentence) have all produced/are all producing work that is immediately and powerfully relevant to the pursuit of global health equity. I doubt that any of them chose this work simply because they found questions of human health and well-being interesting, in the way Dr. Egon Spengler found spores, molds, and fungus enthralling. There is a calling to the work of critical medical anthropology, a moral impetus behind the study of human suffering that exists whether or not we choose to ignore it because we find it discomforting or vaguely unprofessional. Pretensions of objectivity aside, we can’t effectively study humanity by removing our own.

INVISIBILITY

She walks the street, ataxic, legs rubbery beneath the heavy swath of her corte. The same street, always, every day, back and forth, up and down, as she has for a decade now. She is

“cute”; she knows this, tan chula, viejita, and she capitalizes on this with her toothless smiles, the way she pats your hand with her own, cool and dry and brown and wrinkled as a walnut hull.

Pat smile pat pat, reassuring, slightly obsessive, soothing in its repetitiveness, echolalia of the forelimb. A backpack, new running shoes, white skin; she follows these, popping up beneath their chins, her own leveled at some point in their ribcage, sometimes even their navels, if they’re Dutch. She lifts the small plastic basket up, showing them the contents. She babbles at them, even though she can speak (but why bother when they do not listen?) and smiles. If they buy something, she takes a small woven bracelet (ten to twenty for un quetzal) and ties it around their wrists with shaking fingers as they smile down at her. Oh look, they think, they’ve made a connection. This is an experience. Look how cute she is. Can I take a picture? Wait until I tell the folks back home.

It isn’t usually until early evening when the veneer begins to slip, her shoulders cave in- ward, and her smile begins to fade around the edges, bits and pieces of her true feelings escaping from her face and form like the powdery wisps of white hair unwinding from her toycoyal, blue velvet to save her scalp from the sun.

Nothing today.

We walk the street alone, in pairs, rarely in groups larger than three. We know the rules, unwritten, uncodified, unstated, but not unenforced; no large groups- large groups are intimidating. No buying food in front of the gringos. No eating in front of the gringos. Be clean, but not too clean. Be polite, but not too polite.

Busking. It’s an art form.

Box, brush, tin, polish in two shades. “Shoe shine?” we chorus, so many baby grackles on the pavement.

If we make 50Q, each, we can return to the big house tonight, sleep in a bed, have beans, tortillas, salt. Dinner. Maybe some cheese. Soda. Kaxlan ya’.

Pan francés.

“Shoe shine?”

“¡Hola amiga!”, she calls. The baby is hot and sweaty under her perraje, his hair damp against the curve of her breast. He is not feeding right now, just asleep, her nipple cracked and engorged between his slack lips. She watches as the girl crosses the street, water bottle and notebook in hand. These malditas gringas, useless, all of them. All broad smiles and bad Spanish.

Still. Maybe one of them has connections, can get her in an aid program. If she had a stove, she could eat something warm, boil water. Hierbas, cafe, frijolitos that aren’t served cold out of a can. The girl passes, and she waves, a smile blooming unrestrained across her unlined cheeks.

“¡Hola amiga!”, she calls.

His grandmother appears to shrink a little more every time he puts her in the wheelchair, covering her with a blanket, tucking the plasticky lavender yarn under her slack, stick-thin legs.

She doesn’t really speak anymore, but her eyes, though clouded, are sharp enough and follow him around the room, around the street. She communicates in hisses and cackles and the occasional word that sounds either half-swallowed or croaking and laden with effort. He parks her on the corner, in front of a café with a hand-painted sign and as the white people pass, she shoots out a still-elegant hand and croaks “¡un quetzal!” aggressively, accusingly, at the passersby.

Every day they do this. There is one gringa, tall, middlingly-pretty, who his grandmother waits for, on her good days, when she remembers. She gives sometimes, not always, not much, a coin or two or three, but she always responds politely in qa’chab’al. And whether she gives or not, his grandmother always barks in surprised laughter. Kaqchikel. From a gringa. Ja. Mira pues, Doña

Qanchita.

Every day, she watches the street for the pure-white dog. She thought she saw him, last week, but then he turned and she saw he had a brown spot on his left side. Different browns, grouped together like a clump of leaves. Just another street dog, one of dozens. Her father tells her often about the cadejo, the pure-white dog who comes to help those that deserve it. She doesn’t fear the black cadejo, like some do, but she waits for the white one. She waits for the white dog as she straightens her father’s sign “AYUDAME POR FAVOR/ SOY CIEGO/ NO

PUEDO TRABAJAR/ DIOS LE BENDIGA”, hanging from a retired scrap of clothesline around his neck, hands him his cane, adjusts his hat and takes his arm for the day’s work. She waits for the white dog at night, while he sleeps. She waits for the white dog in the morning, when she goes to grind the corn and while she makes the tortillas. She waits for him as she rummages through the day’s coins in the guacal, swishing them against the hard plastic, stacking them up, counting. She waits for the white dog, and she waits to stop waiting.

Opening Remarks

This Chapter gives an accounting of stunting’s multiple invisibilities, and how the different ways in which the condition goes unseen play a role in its continued prevalence. First of all, chronic malnutrition in Guatemala is overwhelmingly a disease of the rural indigenous majority,

80% of whom live in conditions of extreme poverty (O’Neill, Thomas and Offit 2011.) Due in

large part to structural adjustment policies prohibiting public health spending following the height of the civil war, much of the collective health of Guatemala’s rural indigenous majority exists outside the care of the state, in “zones of social abandonment” (Biehl 2005) and neglect.

Because of the increased privatization and outsourcing of social services to non-profits (Chary and Rohloff 2015), much of the healthcare that is available in rural Guatemala is managed by nongovernmental organizations (NGOs.) Not to mention the fact that the vast majority of NGOs are clustered around Xela, Antigua, and the lake (the three most “touristy” areas of Guatemala), leaving large swaths of the country without any access to care (See Owen, Obregón and Jacobsen

2010 for a geographic analysis of health services in rural Guatemala), NGOs are poorly equipped to manage endemic chronic malnutrition even within their communities of interest for multiple reasons. One, many NGOs rely on short-term medical missions (STMMs) for their healthcare delivery services, and the foreign clinicians who take part in these programs are often not trained to recognize chronic malnutrition, so it goes unseen in clinical encounters; two, NGOs operating

“pop-up” clinics often lack the follow-up and/or referential services necessary for the successful treatment of the disease, which requires long-term care; and three, NGOs rely on foreign donations for much of their revenue, and the “hidden” nature of the disorder means that chronic malnutrition is most often unsuccessful in generating the senses of crisis, urgency, and empathy necessary to generate an affective response, and thus donations. When donations dictate revenue streams, and thus NGO organization and programming, this can lead to stunting being pushed to the back burner when it comes to spending and infrastructure within the organization. Addition- ally, since the more deadly co-morbidities of the condition often take decades to develop, even if a child’s nutritional status is known, the very endemicity of the condition (“if everyone is ill then no one is”) and the day-to-day immediacies of extreme poverty can take priority over treatment of the condition, which takes resources in the form of time and money that many rural families

simply do not have. These multiple invisibilities—those of poverty, infrastructure, and of the body—combine in ways that create challenges for the prevention, diagnosis, and treatment of the disease.

Sight Unseen

Stunting, for the most part, is invisible. The vast majority of stunted children do not look ill. They play, they laugh, they giggle; they pull at necklines and tails and hair. They look like children, like normal children. Fleshy, soft, rosy cheeked and smiling, squishy as newly risen dough. Active, playful. Obviously, once you get to the tail end of the bell curve, to those who are six or seven standard deviations below what would normally be expected in height-for-age, some of whom are also flirting with cases of acute malnutrition, you see some obvious listlessness, a lack of engagement, or affected speech. During my time in Guatemala, I met five-year-olds who barely came past my knee and were still not speaking. But most children— children whose z- scores are three or four standard deviations below what would be expected— look healthy. Your eyes would pass right over them without once labeling them as “sick.” Certainly they fail to come close to generating the immediate and gut-wrenching sense of urgency and pathos that the sunken eyes and skeletal limbs of acutely malnourished children do; there are no flies, no waiting vultures, no readily apparent metaphors of death and injustice. There are no knobby knees, sharp elbows, or bellies swollen from kwashiorkor. Sally Struthers never campaigned on their behalf.

There is no bearded, white, grandfatherly man reminding you during breaks in your regularly scheduled programming that you can help them “for just the price of a cup of coffee a day.”

A full third of the world’s children under the age of five are chronically malnourished

(Chary et al. 2013), but until recently, chronic undernutrition was both understudied and under- reported, prompting UNICEF to label it a “silent epidemic” (UNICEF 2011.) Stunting joins the ranks of other diseases (AIDS in the 1980s (Nyugen 2010); HIV and tuberculosis today (Farmer

1999); malaria (Farmer 2005) and cholera (Briggs 2003) more or less consistently) that hit poor and marginalized populations with a one-two punch; not only are the poor more susceptible to contracting these conditions— they are also less likely to be able to find, navigate and access the care necessary for treatment. This pattern holds true for stunting as well, even though it is not an infectious disease. In fact, I will argue throughout this text that although the condition of being chronically malnourished is neither contagious nor hereditary, the mechanics of stunting as it exists on the ground in rural Guatemala render the disorder both inheritable and transmissible.

Stunting is a problem that has its roots in a multiplicity of causes and contributing factors.

It is a structural issue; it is also interpersonal one. The history of violence and intersectional racism endemic to the country plays a role, as does the fact that most of the people that suffer from the condition live in rural areas outside what is readily visible and of apparent interest to the governmental polity, judging by the allocation of state resources. (O’Neill, Thomas and Offit 2011.)

Normalization of the disease due to its very prevalence plays a factor (Chary et al. 2013), as does

Guatemala’s pluralistic and patchy healthcare system (Chary and Rohloff 2014.) Even the ways in which stunting is seen, or not seen—visible or invisible (and by whom)— are complicated, multi-sited and multifaceted. At the most basic, stunting leaves no visible marks on the body— sometimes even to a practiced eye, unless you happen to know the age of the child and routinely walk around town with a collapsible stadiometer. Additionally, the ways in which stunting is understood; the ways it is seen (or unseen), noticed (or unnoticed), treated (or left untreated), are shaped by both the groups who are most at risk for the disorder and those who are the most well- positioned to identify and treat the condition. These competing etiologies play a major role in the perpetuation of an already endemic disorder. An invisible disease, stunting does not mark the body in a way that is either expected or likely to generate a sense of urgency.

Additionally, there are temporal components to stunting’s invisibility. With the exception of the fact that chronically malnourished children are much more likely both to contract and to die from infectious diseases during childhood (see Caulfield et al. 2004; Black, et al. 2008;

Nandy, et al. 2005; Victora, et al. 2008), stunting’s hardest-hitting effects—resulting in symptoms that are both seen and seeable—occur decades after the window for its possible amelioration has closed. The central adiposity and swollen ankles of metabolic disorders; the chronic fa- tigue of unshakeable anemia; the breathlessness and loss of function of congestive heart failure; the tip-of-your-tongue cognitive loosening of vascular dementia …all of these somaticized long- term side effects of chronic undernutrition during early childhood took a leap of logic and decades of research to connect back to their shared and underlying correlate. For many of these conditions, the pathophysiological progression from stunting to later-life disease is still under debate; the biomechanics that tie stunting to later-life chronic disease are, to a very large extent, still unknown. It is no wonder if there isn’t a connection between later-life chronic disease and early-life undernutrition in the public consciousness when the connections themselves are new enough in the literature to remain tenuous and undefined in medical practice and unlikely to play a major role in guiding patient-physician interactions (see later Chapters in this volume for a discussion of physician pedagogy, short-term medical missions, and the role of the NGO in primary care in this context.)

There are multiple cognitive discrepancies underlying the discourses surrounding stunting in rural Guatemala. Of course, it is important that children are well-nourished, mothers would tell me. Of course, it is. ¡Tiene que alimentarselos! But when I pressed further, and asked that perennial favorite question of every ethnographer (and small child); “why?,” I was always, almost without exception, answered by a thoughtful pause that proceeded any concrete explana- tion. “Because vitamins?” one woman told me. “Because it is important,” scolded one nutritional

programmer authoritatively, as if his tone itself put an end to the inquiry. Others followed suit, most often saying after some hesitation that children needed to be well-fed either because it would keep them from becoming ill or because it would help them to grow up strong (fortalec- erse.) Both of these points, obviously, are true, however hesitantly they were offered. However, I would argue that there is power, here especially, in the lack of specificity; something useful and telling in the knowing-but-not-knowing. No one ever told me that it was important that their children be well fed so that they would not, as adults, become chronically ill. “Healthy,” and

“strong”, remained, for the most part, overwhelmingly undefined and/or under-defined by key informants and study participants—abstract constructs of wishful well-being. Would parents be, if possible, more invested in seeking out nutritional programming if they knew that there was a predictable line of development starting with stunting in childhood and ending with diabetes?

With heart disease? Early-onset dementia?

Possibly.

Then again, possibly not.

When speaking of stunting, and the setting in which stunting occurs, education and the erasure of the condition’s often devastating effects over the lifecourse are just two of many challenges to the condition’s amelioration. The largest and perhaps the most daunting challenge is the setting itself. Stunting is also invisible in no small part because it is a disease of the poor. It is insidious not only because it is the ghost of future to come, one of many thieves that prowl unseen and silent alongside every rural toddler in the Guatemalan highlands, leaching potential and might-have-beens with every passing day as development is slowed, but because it is a disease of the voiceless, of those who live their lives outside the gaze of the state.

The violent reorganization of the country’s infrastructure in an effort to align with neoliberal interests has resulted in a marked division in the kinds of care available to urban, non-indigenous Guatemalans and rural indigenous peoples, even while the expansion of MOH PEC programming (government subcontracting of healthcare services to NGOs) has, by some measures

(UNDP 2010, from Chary and Rohloff 2015), decreased the percentage of Guatemalans living without any access to coverage at all. Given that the situation in Guatemala prior to neoliberal reform was one of “no care” (Chary and Rohloff 2015) a discussion of the effects of the expansion of care through increasing privatization isn’t one about access so much as it is a question of the means by which social inequities are “refracted” (Chary and Rohloff 2015) and reproduced in the ways in which care is delivered. Contracting out the care of the country’s most vulnerable to outside agents means, in some cases, that conditions that are endemic to rural indigenous Guate- malans but uncommon elsewhere, like stunting, may go unnoticed and, therefore, untreated. It also means that that the contractors of care (NGOs) become increasingly accountable to the state, and less and less accountable to the beneficiaries of their services (Chary and Rohloff 2015.)

Moreover, poverty itself plays a role in health that can be self-replicating. Being poor may mean lacking access to family planning and/or an increase in food insecurity (for studies of this in Guatemala, see Gragnolati and Marini 2003b; Metz 2001 and Immink and Alarcón 1990, respectively); that much should be obvious. But the day-to-day lived realities of gnawing hunger, insecurity, and parenthood in the face of both means that a life lived in poverty walks hand-in- hand with immediacy in ways that are difficult to quantify but measurably different from a life lived above the poverty line. A knowledgeable physician, nutritional programmer or community health worker may look at a stunted child and project twenty, thirty, forty years into the future.

They can see the potential of stunting’s associated co-morbidities: the rounded abdomen of metabolic disorder, the pale gums of chronic anemia, the red sheets of a childbed death. A mother,

once informed that her child is falling below the curve of expected growth may see the same when she looks at her infant—but if she is very poor that knowledge, that foresight, is very quickly—and of necessity—replaced by a much shorter-term projection of want and need, what

Chary, et al. (2013) called the “deprioritization of child health.” Poverty is always immediate, and immediacy shapes and constrains choice.

Much of this text is about how stunting is contextualized differently within certain groups of people; how these “common sense” definitions of an endemic disease so often run parallel to each other within different groups; parallel lines, of course, being those that never intersect. Why is it that certain groups conceive of stunting in certain ways, and what is it that shapes and helps maintain these perceptions? How do these differing constructs of malnutrition and the origins of chronic disease affect the identification, treatment, and prognosis of stunted children?

The rest of this dissertation is about how stunting is seen; how it is identified, treated, marketed. This Chapter, however, addresses another commonality and the opposite side of the coin; the politics and complications of treating a chronic condition endemic to a marginalized group. This Chapter addresses not the seen, but the unseen: the mechanics of managing a hidden disorder in a population that, on global, local, and state levels, has, in many ways, been rendered invisible.

If Everyone Is Ill, Then No One Is

There are a number of reasons why treating common sense as a relatively organized body of considered thought, rather than just what anyone clothed and in his right mind knows, should lead to some useful conclusions; but perhaps the most important is that it is an inherent characteristic of common-sense thought precisely to deny this and to affirm that its tenets are immediate deliverers of experience, not deliberated reflections upon it. Knowing that rain wets and that one ought to come in out of it, or that fire burns and one ought to not play with it (to stick with our own culture for the moment) are conflated into comprising one large realm of the given and undeniable, a catalog of the grain-of-nature realities so peremptory as to force themselves upon any mind sufficiently unclouded to receive them. Yet this is clearly not so. No one, or no one functioning very well, doubts that rain wets; but there may be some people around who question the 67

proposition that one ought to come out of it, holding that it is good for one’s character to brave the elements—hatlessness is next to godliness. And the attractions with playing with fire often, with some people usually, override the full recognition of the pain that will result. Religion rests its case on revelation, science on method, ideology on moral passion; but common sense rests on the assertion that it is not a case at all, just life in nutshell. The world is its authority. -Clifford Geertz Local Knowledge

Earlier ethnographic studies of chronic malnutrition in early infancy in Guatemala have established that in communities where stunting is endemic, it often becomes normalized. A study in 2012 by Chary, et al. captured the following quote after a community-centered informational session in the village of Chi Poqol (psuedonym): “we didn’t know we were malnourished,” said one woman. “We thought it was normal to have short children, and no one told us differently.”

(Chary et al. 2013) I’ve been told the same—that Guatemalans are short by virtue of their heritage and nothing else—by visiting physicians from the States. One first-year resident scolded me over a beer after I told him about my research, blithely mansplaining my research back to me and telling me that he was disappointed that my research was “ethnocentric” in assuming that Guate- malans should “grow to a European standard.” “Anthropologists,” he told me, “should know better.”

We know, of course, that this is not the case; Guatemalans who are adequately nourished during their first three years of life usually meet or exceed international means of growth at age seven, and the difference one can observe in heights between urban and rural Guatemalans has everything to do with nutrition during early infancy and very little to do with heredity. (See Bo- gin (1997, 2012); Dewey 2011; Chary et al, 2013; the longitudinal INCAP study (Martorell, Ha- bicht, and Rivera 1994) and the WHO cohort growth study (see de Onis et al. (2004) for methods, Acta Paediatr Suppl 2006 for reporting, and Wright, et al. 2007 for programming implications.)

The understanding of endemic early-childhood malnutrition in Guatemala as “normal” instead of pathological mirrors other studies of endemic disease where endemic conditions have become normalized; see Thompson, et al. (2014) on childhood obesity in the US, Scheper-

Hughes’ work on infant mortality, HIV/AIDs in pockets of the Côte d’Ivoire (Nyugen 2010) and

MDRTB in the Russian prison system (Farmer 2005.) It is also emblematic of what Scheper-

Hughes has called “the violence of everyday life” (1992) and Amartya Sen's (1994a) discussion of the “explanatory and predictive relevance” of gender inequality. Poor, rural women, writes

Sen, possess an “acceptance of greater discomfort and illness as part of the prevailing mode of living.”

In the Guatemalan setting, this dynamic becomes apparent as childhood disease is normalized as part and parcel of the everyday landscape of poverty and struggle. Women…come to accept their children’s poor health as baseline, and because their children have never been any healthier, they do not aspire for a model of child health beyond the limits of their daily experience. (Chary et al. 2013)

In the case of stunting, this acceptance of ill-health in the face of poverty- Chary’s “deprioritization of child health”- is further complicated by the very prevalence of the disease and its overall lack of clinical markers: Guatemalan children are still very much believed to be short simply because they’re Guatemalan.

Stunting, in this context, has become raced, shortness linked with “Guatemalaness” and indigeneity, which is in keeping with a history in medicine and public health of assuming that disparities in health statuses that exist between populations have their origins more in intrinsic biological or genetic differences between racially distinct groups of people than in structural factors like poverty or violence. For other contemporary analogs, see Michael Montoya’s (2011) work on the racialized politics of genomic research on Type 2 diabetes, in “Making the Mexican

Diabetic”, or Jonathan Kahn’s (2013) treatise on BiDil, a vasodilator used to treat heart failure and approved by the FDA to be marketed specifically to African-American populations. In both

cases, researchers and research-based infrastructures (both in government and in the private sector) privilege genetic differences between populations as the major causative factors for disease, even though the best information we have available from multiple fields, including genomics, suggests that the causative roles played by these underlying, intrinsic differences are negligible, at best, when compared to environmental factors. This is of course in keeping with the dominant rhetoric within capitalism of individual culpability in health outcomes: “biopower operates when a hegemonic bloc organizes the reproduction of life in ways that allow political crises to be cast as conditions of specific bodies and their competence at maintaining health or other conditions of social belonging; thus this bloc gets to judge the problematic body’s subjects, whose agency is deemed to be fundamentally destructive” (Berlant 2008.) We can see much the same in ethnographies of addiction (Kelly Ray Knight’s “Addicted, Pregnant, Poor”), HIV (João Biehl’s “Will to

Live”), and obstetrics (literally anything by Claire Wendland.)

This approach, which locates illness and disease within imagined population’s inate characteristics, which remains a major driver in science and industry, is both ironic (at least in theory, environmental factors are more easily manipulated than inborn intrinsic bodily differences between groups) and quixotic (if structural factors are the main drivers of health disparities, why aren’t we devoting manpower and resources (genetic research on diabetes alone is a multi-million dollar industry) to the areas where it could potentially do the most good?)…but it is also politically convenient. In focusing on tracking and tracing genetic differences between races— even when those socially-defined categories (see “Mexican”) don’t even exist, in any real terms, as genetically meaningful population groups— we are both remaking “race” by giving precon- ceived notions of difference unmerited scientific validity and effectively depoliticizing what is essentially a deeply political topic. A focus on racial differences when it comes to disparities in health says to the public and to the (structuring) structures that 1) race is real and operative, 2)

that differences in health are intrinsic to certain populations and to be expected, and 3) that any other causative factors are either negligible and thus not worth investigating; too complex or var- ied to be studiable; or intractable, and cannot be helped, changed, or ameliorated. This mode of thought, while containing relics of science's arguable even more racist past, remains highly prevalent. “The vast majority of healthcare spending, as much as 95 percent by some estimates, is directed toward medical care and biomedical research. However, there is strong evidence that behavior and environment are responsible for over 70 percent of avoidable mortality, and health care is just one of several determinants of health” (Institute of Medicine 2002.) The importance biomedical research places on innate diferences between populations is the biomedical complex’s analog to James Ferguson’s (1990) critique of development in The Antipolitics Ma- chine— a set of “unintended yet instrumental elements in a resultant constellation that has the effect of expanding the exercise of a particular sort of state power while simultaneously exerting a powerful depoliticizing effect.” Essentially, the a priori ascription of disease to heritage above all else is a complex piece of victim-blaming, intentional or not; the structure, which has made people sick, has in turn invented other structures whose sole purpose is now rooted in the effort to both invent systems for defining who the populations are that become ill, and rooting the source of illness within that identity, effectively diverting attention away from any role the structure itself plays in creating and maintaining disparities in health. It is, after all, much easier to continue to believe that some people are simply more prone to illness, infirmity and early death than it is to acknowledge our own complicity in maintaining the power differentials that actually serve to make them ill—and either of the two above options are much easier than actually insti- gating the systemic change that would be required to end such disparities.

Geertz wrote that “common sense consists in an account of things which claim to strike at their heart” (Geertz 1973.) Kant (1914) and Arendt (1992) called this the sensus communis; a

“perpetual event that bypasses cognition and hits the subject the way a song does” (Berlant

2016.) Raymond Williams (1977) called it “a structure of feeling”; Roland Barthes (1972) saw it as a classed Truth, Ann Laura Stoler (2008) as a “folk epistemology.” Multiple scholars and thinkers have tackled the seemingly universal riddle of “common sense”; this visceral surety of the rightness of some things and the wrongness of others, so entangled with our respective times and cultures that ethnographies themselves could be considered simply a recording of the communal “sense” of any one time, people, and place. If experience—the world itself, according to

Geertz—is the ultimate authority on common sense-based knowledge, and “illness” is defined as a departure from the norm, then a world is which everyone is ill is a world in which no one is.

Aquí, Pero No Aquí Mismo

Katherine and her mother, Marta, look very much alike. They move the same way; narrow shoulders held up by the same quiet pride, arms gesturing with the same breed of graceful economy. They share the same high cheekbones and solemn eyes, the same delicate lines to their jaw. Their hands are the same size, fine-boned and slim, though Marta’s are curled, her knuckles swollen by the beginnings of arthritis. Both of them were dressed in the traje típico of their town, in brilliant blues and greens, metallic thread twisted through the weave of their cortes; seaweed and sunshine turned silver on the waves. They even wear their hair the same way, in thick plaits that they wear swung over their left shoulders and secured with blue ribbons, the glossy black strands interwoven with blue and silver metallic thread that catches the light as they move.

Marta’s hair has gone grey at the temples, her features softened by age at her jaw and around her eyes. I found myself wondering if there were more generations of Pocón women at home; other women with the same face, their hair streaked with more and more silver and the details of their features increasingly obscured by time, like copies spit out by a printer slowly running out of toner.

We had decided to meet at a café on the main street in town. It had an open porch that overlooked the busy street and served excellent hot chocolate. It had been a rainy morning, and I ordered each of us a cocoa to ward off the chill, knowing the Katherine and Marta had crossed the lake to the dock in Nik’aj only a few minutes prior to their arrival. The lanchas are cheap, reliable transportation to the different villages that dot the lakeshore, but they are often over- crowded, leaving some people to sit in the bow or the stern with no shelter from the wind or the rain. In the morning before the arrival of the xocomil, the lanchas are fast, and relatively hassle- free. But the directionless waves of the xocomil, which arrive predictably every afternoon some- time between 1 and 4pm, have to be navigated carefully lest they flood the boats, which often ride low in the water, heavy with passengers and cargo. Many women wear shawls and cardigans on the trip across the lake, and an ayudante will often make an effort to secure a tarp over the passengers in the front of the boat on rainier days, but it wasn’t always enough to ward off the chill or the damp.

Both Katherine and her mother were flushed from the cold when they arrived, damp curls sticking to their necks. I knew Katherine socially—we met at the market where she worked in

Nik’aj—and I had felt guilty asking her to take the lancha over on her day off for an interview.

However, she had insisted on joining me when she found out that I was studying malnutrition, and volunteered to bring her mother, who was also mother to a toddler. Malnutrition—desnu- trición—had become a buzzword in the past few years since the initiation of Hambre Cero and the omnipresent advertising campaigns of fortified atoles like Incaparina or Corazón de Trigo.

Katherine had given birth to her first child, Ívan, two years ago, and we had struck up our first conversation over the different kinds of fortified atoles available in her store. I had been taking notes on the different kinds of fortified atoles and baby formulas available in town, and a gringa standing in the cereal aisle of the grocery store with a clipboard taking notes on the shelves

peeked her curiosity. “Which is better, do you think,” she had asked me casually, glancing up at the dusty rows of Nestlé NIDO and Cerelac on the top shelf, “breast milk or formula?”

Katherine’s mother, Marta, had given birth around the same time as Katherine, also to a boy. Marta had had Katherine, who was her eldest, when she was only fourteen, impregnated by her husband at thirteen, who was in his mid-twenties at the time. When Katherine and Marta arrived at the café both of their boys were active, squirming in their respective mothers’ arms, eager to explore. Marta and Katherine settled against the cushions tied to the painted iron chairs and fed their sons, simultaneously balancing each boy on their respective right thighs and unlac- ing the front of their huipiles with one hand. Each boy glommed on to his mother’s left breast at the same time, latching onto the nipples in perfect unison, as if the act had been choreographed.

As they settled themselves, I watched the two women, floored by their similarities—they really could have been twins—and noticed that Marta and Katherine also had similar mannerisms; they both wrinkled their noses, pulling them to the right when asked a tough question. They both covered their teeth with their hands when they laughed.

Shortly after she had relaxed into the chair, Katherine hissed, pulling her nipple from

Ívan’s mouth. “He’s started biting lately,” she said, repositioning him on her lap and refastening her huipil.

Ívan began to cry, so I fished in the back of my field notebook for the sheet of stickers I kept for this very occasion. I peeled off a sticker—this one was a shiny pink octopus, complete with silver glitter and a wide smile—and placed it on the center of his forehead. He stopped cry- ing, and reached toward the sheet of stickers. I handed it to him, and he settled back into his mother’s lap, curling one hand around the slit in her huipil and clutching the shiny pictures of un- derwater creatures with the other.

Katherine had agreed to translate for her mother, who only spoke Kaqchikel, and we proceeded with the interview in Spanish as we sipped at our hot chocolate. Marta’s boy had fallen asleep mid-feeding, his limbs loose in his mother’s lap, eyelashes dark half-moons against pale cheeks.

“Do you believe that infant malnutrition is a very serious problem here in Guatemala?1” I asked, clipboard in hand.

Katherine translated the question for her mother in Kaqchikel before she answered me in

Spanish. “Es muy…es un gran, gran problema,” she answered. “We’ve seen malnourished children, yes. I’ve seen the news, and I heard that there was a child that died, he was so malnourished. Así, me duele, de verdad2. But the economy is really bad (baja) and there are those who find, families who find that they can’t support their children. Es un gran lástima, de esos niños.”

“And you think the reason that they’re malnourished is because the economy is so bad?”

I asked.

“Yes, I imagine that it’s because of economic reasons. You know last year the president—the president stole so much money. ¡Eso sí! I don’t know what to say to them, but there are many in need. This is the main thing; they took so much money and there are so many who are suffering, it’s true.”

“Sí,” I responded. “Almost the entire country….and do you believe that malnutrition is a big problem here, in this community?”

“No,” Katherine answered, once again posing the question to her mother, who also shook her head. “No tanto. What I’ve seen, hoy en día, I’m not seeing that here, in this town, that there are many malnourished children. No. Almost all the children are growing well. A couple of times

I’ve heard that there are children who are malnourished, but they’re rare.”

Katherine turned to her mother and translated what she had told me before asking her opinion on the matter.

“Maybe it’s a problem here,” Marta told me in halting Spanish. She turned to Katherine and asked her, in Kaqchikel, to translate for her.

“Why?” I asked.

“Because they don’t care for them well,3” Marta told me. She turned to Katherine and let out a burst of chirping Kaqchikel that was far too fast for me to follow.

“She says,” Katherine translated for me in Spanish, “she says that people don’t tell their children to wash their hands before they eat and so they get sick.”

This was a common pattern in all of my interviews. Both in my formal interviews, and any chance I happened to stumble onto, I asked mothers whether they thought that malnutrition was a problem a) in Guatemala, and b) in their own community. Although mothers contextualized the problem of malnutrition differently, and attributed it to different underlying causes (not enough fat in the diet, illness, junk food, bad husbands, no money, etc.), overwhelmingly the responses followed the same patterns of national prevalence and communal displacement. Yes, chronic malnutrition is a very serious issue in Guatemala, but no, it’s not really a problem in this community. As Kevin Lewis O’Neill pointed out in his 2011 edited volume “Securing the City”, poverty has become criminalized, part of a larger “moral vocabulary” that also includes “de- lincuencia”, “choice”, “character” and “self-discipline.” Here, hunger becomes part of a larger discourse of maternal responsibility and culpability, the lived reality of want inseparable from local understandings of the mother’s role in the social contract.

Data from my one-on-one interviews echoed that of the focus groups that were part of a larger ethnographic study focusing on malnutrition that I had taken part in in 2013. The 2013 study was multi-sited in the more traditional sense, taking place in K’exel, a larger town in the

mountains bisected by the Pan-American highway, and in Xejuyu’, a sleepy coastal town located in the densely humid and impoverished bocacosta region. I was only one of a team of researchers from multiple universities, and my experiences that summer helped form the basis of many of the questions that make up the framework of this dissertation. In both sets of interviews, there was a pervasive rhetoric of blame and personal culpability that most often rested on the heads of primary caretakers, who were overwhelmingly the children’s mothers. Many mothers also expressed guilt when discussing malnutrition, placing the blame on either themselves or on the behavior of mothers in general. When asked “who is to blame?” (regarding malnutrition) one mother expressed the following “...we are to blame because we do not care for them well; in my case I am the responsible one because I did not have milk [for] my baby, and so the baby grew sick from this...if I give him milk, then he grows, if I do not give it to him then he grows thin

(adelgaza) and does not grow...only his stomach grows and he grows thin-- this is what causes the disease, only this.”

Pero pienso que tiene que ver con la madre, el cuidado que les da, por ejemplo una madre tiene que lavar bien las manos antes de preparar sus alimentos de los niños y también tiene que lavar bien sus ropas o sea cambiarlos cada día que estén limpio los ni- ños, eso ayuda a que no se enfermen mucho, eso es mis hijos casi no se enferman porque los cuido para que no agarren sucio lo metan en la boca porque eso es lo que pasa a muchas madres que dejan a sus hijos por allí y ellos todo lo que halla en el suelo lo agarran y lo llevan a la boca por eso se enferman los niños.

But I think that you have to look at the mother, the care she gives them. For example a mother has to wash her hands well before she prepares the food for the children and also she has to wash their clothes well or change them everyday so that the children are clean, this will help make sure they don’t get sick often, this is why my children are almost never sick because I care for them so they don’t get dirty and put it in their mouths, this is what happens, many mothers just leave their children there and they [the children] grab things from the ground and put it in their mouths and this is why children get sick.

Others echoed similar sentiments, resting the blame solely on the behavior of mothers, either in their caretaking abilities: “this is always the case, if you do not care for your child or bathe them then they grow ill”; “if you do not keep them clean they become ill; if you take care

of them there is no problem”. Others blamed the mothers’ food choices or lack of education. In the words of one mother, “The one to blame is yourself, because you are the mother, because you do not care for them, like they say [now] children eat whatever, for example there are things that children did not eat before; when I was growing up I did not eat many things, we could not, what you gave a child was fruit, a banana. Now there are many things like the things in stores that come in little bags; they cause sickness, therefore they are not good. ” This focus on junk food, or “comida chatarra” as an underlying cause of malnutrition is also part of recent public health rhetoric (Rohloff 2012.) This is, in my opinion, yet another way of reframing the rhetoric of personal culpability for stunting even in the context of extreme poverty and is reflective of the individual-authoritative approach to health care programming that filters down through education- based nutritional programming efforts that owe their lineage to the colonialist schools of hygiene and tropical medicine.

Other mothers also mentioned a large number of children as a factor in malnutrition, citing both poverty and maternal depletion; “what I think is if you do not already have children...this is what I understand; do not have more children and you will not suffer with them”;

“like the others said, the more children you have, the more you suffer...one gets so tired, you don’t feel like eating...and you will suffer from malnutrition.”

I observed the same pattern in my one-on-one interviews. On the subject of culpablity, mothers blamed other mothers for not knowing enough, not doing enough, or cited large families as playing a role in childhood malnutrition:

Es por la falta de educación y información a la gente…por que muchos desconocen de las nu- trientes que tienen verduras o frutas, entonces ellos prefieren darle una Tortrix, una galleta, un bonbón, entonces para que niño se pase mas tiempo solo, ju- gando, y para no darle alimentos a sus hijos para si requiere tiempo. Yo me doy cuenta con mi nena, aparte de yo cociné mi comida, tengo que preparar la comida de ella. Tengo que se aloca tiempo tres, cuatro veces la comida de ella, requiere mucho tiempo, lo cual muchas familias no quieren o no pueden hacerlo.

It’s because of the lack of education among the people…because many of them don’t know about the nutrients that are in vegetables or fruits, so they prefer to give a Tortrix, a cookie, a bon bon, their children spend a lot of time alone, playing, and because of this they don’t give nourishment to their children because this takes time. What I realized with my little girl, aside from cooking my own food, I have to prepare hers. I have to allocate time three, four times [to prepare] her food, it takes a lot of time, which a lot of families either don’t want or can’t do.

La falta de información, y quizás a veces por pereza, por que a veces las mamas tienen suficiente tiempo, pero no quieren hacerlo.

The lack of information, and maybe sometimes it’s because of laziness, because sometimes moms have enough time, but they don’t want to do it [prepare food]

Cuando hay muchos niños en la casa, también no les da tiempo suficiente, eso es cierto, falta, si hay muchos hijos

When there are a lot of children in the house, also they can’t give them enough time, that much is certain, there’s not enough, if there are many children

Que las familias trabajan o no

Whether or not the families work

Por que las mamas no se cuidan bien

Because the moms don’t care for them well.

The similarities on the theme of culpability aside, it is interesting to note that the communal displacement of stunting—the “here-but-not-here” cognitive framing of childhood malnutrition—was much more prevalent in my one-on-one interviews than it was in the earlier focus groups. For one, almost without exception, the women in my ethnographic interviews believed, at the beginning of the interview, that their child was “growing well”, and in the cases where they believed their child wasn’t growing well, the disruption in growth was most often linked to a recent illness and subsequent weight loss. This would obviously not have been the case for the

2013 focus groups, many of which had participants whose children were already enrolled in nutritional programming. For another, when asked “is child malnutrition a problem here, is this community?” most women in my one-on-one interviews answered no, or gave a qualified yes.

This theme did not arise in the 2013 focus groups. 79

During the focus groups, we sat in a circle on folding metal chairs, squeezed into the corner of town halls or the front porch of local general store. The groups were both divided factori- ally by gender and by stage-of-life; one group each for men and women and another for women who were currently pregnant. There was a bi- or tri-lingual moderator (Span- ish/Kaqchikel//Kiche), and everyone was encouraged to speak, but as is almost always the case in focus groups, one or two or three strong personalities ended up ruling the group, with the others chiming in to occasionally offer a word of disagreement, but most often to concur. And although every individual who had participated in the 2013 study had been told during informed consent that their participation (or lack thereof) would in no way effect their relationship with, or eligibility for, any of the NGO’s programs, most participants in the focus groups were aware of both the interests and the affiliations of the researchers. This hive-mind approach to answering questions is interesting in many ways—it could even be considered a quick-and-dirty method of obtaining a rough cultural consensus, and is a useful way of eliciting cultural domains. Focus groups can also be used to efficiently frame out the theoretical underpinnings of a codebook for qualitative data analysis—but there are limitations. For one, participants may be less willing to talk about sensitive or shameful issues in front of a group of their peers, or to appear ignorant of the topic under discussion (see the “third-party effect”, Bernard, Wutich and Ryan 2017.) In the case of chronic childhood malnutrition within the household, the rhetoric of which I have already established is often dominated by the individual-authoritative narrative of personal culpability and underwritten by narratives of shame and poverty (cf. O’Neill, Thomas and Offit 2011), this is worth considering. In this case, even the use of focus groups to gather “information about content—about why people think [what they think]” (Bernard 2002) can sometimes offer only a biased view of the topic at hand, carefully edited for the consumption of both the peer group and

the researchers. It is not surprising, therefore, that the theme of “si, aquí; pero no aquí mismo” appeared in the individual interviews much more often than it did in the focus groups.

In both groups of interviews, however, poverty was a dominant theme. Fathers, especially, in both the focus groups and in my own informal and ethnographic interviews, cited poverty as a dominant factor in malnutrition. “It is very difficult, difficult that in our family there are always malnourished individuals, it’s when we have low income that we don’t give them nourishment (“no les damos alimentación”.) “It is important to give them the highest-priority things...[our resources in] the current economy are not enough for us because in this time (everything) is very expensive, we can’t...we cannot afford to maintain our children, and that is why they appear malnourished.” Other men cited their inability to give their children certain foods, most notably the atol Incaparina, which has been heavily advertised since the late 1960s as a cure for malnutrition and has been distributed door-to-door in various nutritional interventions since the longitudinal INCAP studies of the 1960s and 1970s. It is impossible to board a bus or enter a public area without hearing the Incaparina jingle (sung by children) on the radio:

Vamos a vuelta en la tienda de aquí A pedir Incaparina para ti y para mi Nos da mucha salud y no puede faltar A diario Incaparina tenemos que tomar Toma Incaparina, Todos Los Días

Let’s go back to the store to ask for Incaparina for you and for me it gives us a lot of health and it can’t fail everyday we have to drink Incaparina drink Incaparina every day

However, the omnipresence of Incaparina (and other fortified atoles like Corazón de

Trigo and Quaker Mox), while doing much to promote the importance and prevalence of chronic undernutrition in the public consciousness, also relies heavily on the ideology of choice and the rhetoric of personal responsibility. 81

Advertisements for Incaparina are painted on the sides of buildings, or slapped up in poster form on the outside and inside walls of tienditas. The red-white-and-yellow slogan of In- caparina, featuring two playing children in bright yellow t-shirts, is as prevalent in rural Guate- mala as is the bright blue of pepsi or the familiar red/white of Coca-Cola. It derives both its name and its current formulation from INCAP— the Instituto de Nutrición de Centroamérica y Pan- ama, which is, yes, the same INCAP that was responsible for the longitudinal trials (1969-1977.)

Incaparina was “always a generic concept, never a specific formula” (Scrimshaw, n.d.) intended to alleviate, but never cure, endemic stunting. From the beginning, Incaparina was never intended to “solve” or even to treat the problem of stunting in Guatemala—even at the time of its creation (1961), “there was no expectation that a commercially produced and marketed vegetable mixture could solve the problem of protein-calorie malnutrition in Guatemala or in any other country”, and that such a feat could only be accomplished “through an increase in income among the groups in need, or by effective programs of subsidized [food] distribution” (Scrimshaw, n.d.)

Incaparina was intended to be used as a weaning food and a short-term dietary supplement, not as a treatment for the chronic condition of stunting. “It is a fact,” wrote Nevin Scrimshaw, Senior

Advisor to the World Hunger Programme (n.d) “that Incaparina has been of very limited benefit to the large Maya [redacted] population largely living at a subsistence level. Without it, however, the nutritional situation in Guatemala would almost surely be perceptibly worse.” His colleague,

Robert Wise, citing the “conflict between nutritional impact and profits” added the following

(n.d); “Incaparina or any commerical product [can not] be a panacea against hunger second to poverty. There does not exist any simple solution to the web of historical, economic, and historical factors that jointly determine the povery complex, in which malnutrition is but one reflection of inadequate real income.” He went on to add, however, that “precisely because there is no

cure-all, it is essential to derive the maximum possible contribution from those partial solutions that do exist, such as Incaparina.”

Although Incaparina was never intended to cure or even to effectively treat the condition of stunting, and is perhaps incapable of doing so in its current easily-diluted and often over-sug- ared formulations, the pervasive advertising campaigns and dominant rhetoric on the ground in rural Guatemala suggest otherwise, and help feed into the rhetoric of personal culpability. Many mothers expressed guilt over not buying their children Incaparina. One of the mothers in the focus groups stated “if I buy a bag of Incaparina for my children, I am unable to buy corn to feed the rest of my family.” A concurrent market analysis that I helped conduct in 2013 revealed that

Incaparina (which is among the cheapest of the atoles) is still very expensive; 450 grams of In- caparina (enough to make 24 1-cup servings) averages 10Q (US$1.2); for many households living on less than US$2 a day, this is far out of their price range. Most of the shops inventoried did carry Incaparina and other fortified atoles and dried milks (Corazón de Trigo, Quaker Avena

Mux, Maizena, Nestlé Nestum, Leche Anchor, etc.), but many of them had them shelved either behind the counter, where they could not be seen by the customers, or on very high, or very low shelves. On closer inspection, many of the bags were covered in thick layers of dust. When pressed, shopkeepers admitted to selling only one or two bags of fortified atol a week, and sometimes only one or two bags a month. Shopkeepers also suggested that the average amount people were willing to spend during a single trip to the store was about 4Q (US$0.50); placing Incapa- rina well out of range. When asked their opinions on fortified foods like Incaparina, shopkeepers responded with sentiments like the following (many of which mimicked the product’s packaging) “they have more nutrition because they supply vitamins, calcium and iron and they are more healthy” and “they are very good for growth.” One shopkeeper, when asked why he sold foods like Incaparina, responded as follows; “They’re good, because today’s diet is terrible.” When

asked why he sold so few every week, he replied “There is much hunger and malnutrition, but fathers cannot afford to provide anything more sufficient than tortillas and beans. There is no money.”

This rhetoric of personal responsibility—and culpability in the case of illness—is pervasive throughout health programming in Guatemala. Moore et al. (2017) argues that the dominant rhetoric in current aid circles in Guatemala places a “double burden” on the people who need it most; not only are they expected to demonstrate compliance in their affective performance of the ideal aid recipient, but they are also subject to neoliberal subjectivities in which they “are consti- tuted as subjects for whom each social interaction is understood transactionally and as an opportunity for investment” (Moore et al 2017:3; see also Foucault 2008) This process of “buying-in” for recipients of aid has become more and more formalized. In the case of conditional cash transfers, for example, funding institutions exchange cash for completed check-lists of tasks that are intended to ensure child health and well-being, like attending well-mother/well-baby visits or monitoring school attendence. These programs take full advantage of the “feminization” of aid

(Moore et al. 2017), systematically placing the burden (and thus the blame, if anything were to go wrong) of caregiving on mothers and making motherhood both a political and a transactional condition (Dasgupta-Tsinikas and Wise 2015.)

The conflict between the prevalence and multiple invisibilities of stunting and the public health rhetoric of personal responsibility and culpability, when enacted in the context of extreme poverty, forms a culture of suspended guilt surrounding the knowledge, attitudes, and practices of infant feeding. Discussions of the prevalence of malnutrition are everywhere; in health-and- nutrition programming, in the national news, in announcements of national programs like Ham- bre Cero or local philanthrocapitalist projects; in advertisements on the radio, on walls, on store shelves—you would be hard-pressed to walk through any small village and not see the results of

several decades worth of efforts at increasingly stunting’s visibility. However, the idea remains that a malnourished child is not well, is sick, and therefore should look sick. This “common sense” rhetoric of what malnutrition is—and what it is not—means that most families living in rural Guatemala still conceive of a malnourished child as one who shares the clinical markers of acute malnutrition, which is something that they see happen only in the sickest of infants, or to those born to the poorest among them. Combine this common sense definition of malnutrition with its association with poverty, and the criminalization thereof (O’Neill 2013) and you have the cognitive re-framing of malnutrition as it makes sense within the bounds of the new sensus communis: yes, said the women I interviewed, malnutrition is a problem—una problema tan grave—it’s just not really a problem here.

Clinical Encounters of the Third Kind

“How do you say ‘next’ in Spanish?” the physician asked me. “Próximo.” “¡Próximo!” he yelled out the door. “And how do you say ‘next’ in that other language?” he asked, a moment later. “Jun chik.” “Jun chik!” he yelled into the hallway. “Hey, look, Jim,” said the physician to his colleague across the room. “I can speak Spanish and Aztec now.” — actual exchange witnessed while accompanying a STMM

When I first decided that I was going to focus my dissertation work on stunting, I did not anticipate that I would be focusing so much of my time and interest on the issues people face in accessing primary care. I should have. Stunting is an endemic issue in Guatemala; “endemic”, in this case, meaning that it is so highly prevalent among children in rural Guatemala that it has become the new normal (Chary et al. 2013.) The fact that chronic malnutrition in Guatemala is very much a structural issue, constantly reinforced by circumstances of history, poverty, and structural violence does not negate the fact that, as a disease, it still has to be diagnosed to be treated. And like all invisible diseases, knowledgeable intervention is required to first identify the condition

before it can be treated. Primary care visits—specifically well-mother/well-baby visits—is one of these opportunities for indentification and treatment. And primary care, like most healthcare in

Guatemala, is endlessly complicated. While much of the previous anthropological literature has concentrated on the interface between biomedicine and ethnomedicine (the diverse array of traditional midwives, bonesetters, and curanderos, among others), Chary and Rohloff (2015) write about the prevalence in Guatemala of what they are calling the “new medical pluralism”:

Healthcare decision-making in Guatemala does not occur only only a dichoto- mous ethnomedical-biomedical line…especially in the case of complex chronic diseases, Maya people must decide between multiple biomedical practitioners and systems, as well…Guatemala presents a striking case of the diversity of biomedical institutions, many of which may very well constitute their own medical ‘systems’. Healthcare privatization has encouraged a proliferation of community health workers, health promoters, health guardians, pharmacists, pharmaceutical representatives, nurses, and physicians, with the public, private, or NGO sectors. Healthcare privatization has also intensified the involvement of local and foreign donors and philanthropists in determining the priorities and structures of care. (Chary and Rohloff 2015.)

The period between the 1976 earthquake and the 1996 signing of the Peace Accords was characterized by “an authoritarian state that maintained strict control of relief and development processes for political purposes” (Rohloff et al. 2011.) Because of this, the critique of neoliberal healthcare reform in Guatemala is fairly unique, as “the situation in Guatemala prior to neoliberal reform and privatization was not one of affordable, publicly-financed care, with a transition to private, expensive care. Rather, it was one of no care” (Chary and Rohloff 2014) After 1996, much in the same way as Haiti, the state afforded NGOs “free reign, with no practical oversight by any entity within the state or otherwise” (Chary and Rohloff 2014.) The NGO sector grew ex- ponentially. The last published estimate, in 2011 (Beck 2011) estimated the number of individual

NGOs at 10,000—and there is no reason to believe it hasn’t grown since then. This means there is one NGO for every 5,000 individuals in a country roughly the size of the state of Tennessee.

Small grassroots NGOs, many of which exist only for a few years at a time, are very much “the

face of development” (Rohloff et al. 2011) and one of the primary means for accessing healthcare and/or aid for many rural Guatemalans. During my first few months of dissertation research, when I first began talking to young mothers about desnutrición, most of them responded by grilling me as to my affiliations and friendships with and within local NGOs. They would tick off a list of their childrens’ most recent illnesses, or press me for enrollment in school or food-based aid programs. If I met them through an NGO (say, for example, at an NGO-sponsored preschool), they would often tell me of their cousins’ or sisters’ or cuñada’s children and ask if there was anything I could do for them, or if I had any other connections, with other organizations.

Talk of NGO programming dominated many of the conversations in which I found myself in the first few months of my dissertation fieldwork. The people I spoke to often wanted an

“in” to NGO-sponsored programming, which underscores the prevalence of NGO-sponsored care. As discussed earlier, many NGOs rely on short-term medical missions (STMMS) for the healthcare delivery programs. What this means is that many of the most readily available primary care providers in rural Guatemala—the individuals who are the most well-positioned to diagnose chronic malnutrition in early infancy—are among those least well-equipped to do so.

STMMs, which are transient by nature, often have tenuous ties to the communities in which they serve (ties that are much more often situated within “sister churches” or “sponsoring NGOs” than in health care or research centers), and are left without any real capacity to make referrals or to enroll children and their families in nutritional programming. Because of this, even if they were cognizant of the rates of chronic malnutrition in the communities in which they choose to practice medicine for one week every year, or educated as to its long-term effects, they would find themselves incapable of treating the condition, even after its successful diagnosis. In the dozen or

so STMMs that I shadowed and/or translated for since 2010, I never once saw a stadiometer or heard a discussion about chronic undernutrition.

Short-term medical missions are an ineffective way of treating most chronic diseases (See

Berry 2014, Sullivan 2016; Baird 2017), in no small part because they are “short term”; their

“ephemeral nature…virtually guarantees that providers and patients will come from vastly different social locations” (Berry 2017), and they are subject to little, if any regulatory oversight. To give one common example, diabetes is endemic in Guatemala, due in large part to the high rates of stunting, but taking someone’s blood glucose level and telling them they “probably have diabetes” before sending them home with a month’s supply of metformin is not going to do much to improve their health in the long run. Without a glucometer, they have no way of measuring their blood sugar; when the metformin runs out, they may have no way of purchasing more. If they need insulin, they may not have a refrigerator at home, or the money to buy needles, or anyone to train them on giving the injections. If a hypoglycemic emergency were to occur—which can happen, especially after switching to a new medication and lacking any way of monitoring one’s blood sugar—they lack access to emergency services. Along the same vein, thirty days’ worth of

Aleve is not going to do much for the arthritis pain of a man who has been doing hard labor twelve hours a day for fifty years; and if he has chronic gastritis (which many people living in rural Guatemala do) he might end up with a gastric bleed. STMMs are well-suited to dentistry, surgical cases, or prosthetics, and would also be well-suited to treating infectious disease, if the visiting group brought any of their own diagnostic equipment and/or partnered with local labora- tories. Personally, with only one exception, I’ve never seen a group that did anything in the way of diagnostics save taking blood pressure and/or blood sugar. However, in the case of rural Gua- temala, where primary care is catch-as-catch can, and a country that, like most of the developing world, is well into its second epidemiological transition (see Omran 2005; Amuna and Zotar

2008 ), most of what the physicians in STMMs see is the provenance of the PCP; chronic disease, pregnancy, issues of diet and nutrition, heart disease, cancer. All issues that require long- term care and follow-up…which are the two things STMMs are incapable of offering.

Like much of the foreign-outsourced healthcare in rural Guatemala, STMMs operate on the principle that “something is better than nothing”, but that is not always the case. STMMs cause perhaps as much harm as they prevent. Their very existence helps to justify the patchy network of care available year-round. Physicians routinely work outside their scope of practice; field-hopping in a way that would never be permitted in their countries of origin. Diagnosis is often haphazard at best, treatment minimal. Students and aspiring future doctors often practice medicine without licenses, something which would never be allowed in their countries of origin.

Barriers of language and local knowledge result in missed opportunities for diagnosis, treatment, and prevention. Local networks and opportunities for referral are often ignored. And the biggest dangers, those conditions endemic to Guatemala that can drastically shorten the life of an individual; cancers of the cervix, metabolic disorders, heart conditions, stunting— these often go unnoticed, unmentioned, undiagnosed and untreated. In the past seven years, I have seen dozens of stunted infants proclaimed “perfectly healthy” by smiling North American doctors, and handed back to newly reassured parents.

In 2016 I was asked by a friend for a favor—would I mind translating for a group of women traveling from the States? The women were all nurses, some RNs, some LPNs, none advanced practice. They had each come to Guatemala after paying ~$4,000USD each to a new

NGO that, in addition to selling típico handbags, shawls and traje modeled on white women on their website, advertised trips that focused on “voluntourism”. The front page of their volunteer site shows smiling blonde women holding Guatemalan babies. On our second day, we were stationed at an elementary school in San Marcos La Laguna, an extremely tourist-friendly town on

the northwestern shoreline of Lake Atitlán. Dozens of patients had come in from the surrounding aldeas for the pop-up clinic, some of whom had been waiting in line since before dawn. I sat with one of the nurses, a young, pretty blonde woman in her early thirties. Her Spanish was non-exist- ent; she had greeted me by asking “Como esto! Oh, wait…it’s como est-AH, isn’t it, since you’re a girl?”

After about twenty patients, a man somewhere between his seventh and eighth decade approached us. He spoke very little Spanish, and had come to the pop-up clinic alone. We had no

Kaqchikel translator, and sent someone to run for one. After waiting about half an hour with us for the translator to return, the man began to pantomime his injury, and the nurse told me that I would just have to “try my best.” I understood enough of his toothless, mumbled Kaqchikel and careful gestures to be able to tell her that something deep inside his left shoulder hurt, that he had mobility problems, and that sometimes his arm stopped working entirely. Having had a labral re- pair myself the year before, I had a good guess as to what was wrong with him.

The LPN made a show of examining him, palpating his shoulder, making him move his arm up and down, noting the grimace of pain and small moans he made when he neared the edges of comfortable mobility. She then handed him a ziplock baggie of ibuprofen and a granola bar and asked me to thank him for her. After he left, she sat back in the plastic chair, leaning against the concrete wall.

“What can we even do for these people?” she asked me, taking the blood pressure cuff of the table and folding its rubber tubing around her hand. “Why are we even here?”

______

The walls of the schoolroom were painted a deep blue. Hand-drawn posters littered the walls; along with numbers, the alphabet, and one caterpillar the size of a small sofa, colored in with green crayon. A row of wooden cubbies was screwed into the wall behind our folding table,

each with a name, a hook, and a toothbrush propped up in a labeled jar. I was closest to the toothbrush belonging to “Josue ”. In the far corner of the room, the only one without windows, someone had pinned up a sheet, using a clothesline to provide some privacy during more intimate patient exams. Above my head a large orange “P”, for “pájaro”, judging by the carefully- crayoned robin below it, dangled from the ceiling on green yarn. Other letters dropped from the ceiling at various heights, swaying in the slight breeze and giving the room a chaotic, cluttered feeling.

There were four “stations” in this classroom, each with one physician, one translator, and three chairs. I was the translator at the one furthest from the door, and a row of patients had already filtered through, lounging and chatting on the chairs that lined the walls.

“That is…” I paused, unsure of how to phrase what I wanted to say gracefully, before deciding that the important thing was just to get the message across. “That is not a normal-looking baby.”

The child I was referring to was 18 months old, and big; even by American standards.

Sitting in the lap of his diminutive, 16-year-old mother, he dwarfed her to the point that she looked a bit like a kid at a fair, peeking over the shoulders of the giant teddy bear someone had won for her in a ring toss. Like most of the short-term medical missions (STMMs) with whom I had tagged along as a translator/fixer/shadower, we were not taking growth data, but I could tell just by looking that his height-for-age z-scores would have been off the charts, as would his weight. The little boy was tall, very tall for an 18-month old rural Guatemalan from Sololá proper, and, moreover, he was chubby. Very chubby. Disturbingly chubby. Sumo-esque. The kind of chubby that I never saw in children this age from this area; or in children at all from rural areas.

I tried not to squint as I studied the child’s face. There was something “off” about it; it seemed a tad too squishy, even for a baby’s face, the features smudged a bit, flattened, blending into each other like I was looking at them through a piece of cheesecloth. The boy’s forehead was broad and unblemished, sloping back to a patch of thin black hair. He grinned toothlessly at me as I scrutinized him.

Having always been interested in clinical medicine, I had spent part of my time in Guate- mala since 2010 shadowing a pediatrician— who also happened to be the medical director of another NGO— at clinic and home visits as often as he would let me. Something about this baby seemed familiar. Something I had learned, something I half-remembered.

“Could you tell me his date of birth again?” I asked the mother, although I was pretty sure I had written it down right the first time. She told me. It was the same. 18 months old, as of this week.

The doctor, Amy, was an emergency physician from Texas. She was here with a group of doctors, PAs, and nurses on a week-long medical mission trip sponsored by a church group in

New Mexico. I had spent the last three days with this group, rotating from physician to physician to intake to their makeshift pharmacy; rows of folding plastic picnic tables covered with OTC meds organized alphabetically. I went where I was needed, or where I was called. There were rarely enough translators, so everyone who spoke more than one language kept moving from station to station, trying to fill needs as they arose. Translators were also the general dogsbodies of the group; earlier in the morning I’d been sent to the market to buy a forty-pound basket of bananas. Amy, however, had that trait that I valued above all others among the doctors who allowed me to shadow; she taught while she worked. She often did so absentmindedly, quietly ruminating

out loud as if she were dictating notes to an invisible stenographer. Like the vast majority of parachuting docs I had worked with over the past few years, she spoke no Spanish. Her group had been coming here now once a year for five years. I drifted back to her table whenever I could.

“What are you thinking?” Amy asked me.

“He’s so….” I hesitated. “Big. Isn’t he?”

Amy chuckled. “Yeah. You see this a lot in Mexican kids, too. They eat a lot of sugar.”

I wondered if she was forgetting the two dozen or so other infants who had come in this morning, none of whom looked like this. Children in rural Guatemala did not look like this.

I said as much, though I kept my concerns about dysmorphia and what I thought might be an underlying metabolic issue to myself.

“He’s fine,” she said, reassuring me. “He’s just got a poor diet. It’s pretty normal in La- tino populations.”

Jonathan Maupin’s 2012 study of Mexican migrants in the Nashville, Tennessee healthcare system found that physicians tended to over-emphasize the “folky-ness” of their Mex- ican patient’s constructions of illness, situating their beliefs in perceived cultural differences in the understanding of disease that did not, as it turned out, exist. Maupin blames cultural competency (CC) training in medical pedagogy; something which historically has reduced “cultures”

(“hispanics”, “asians”, “blacks”, “jews”, “arabs”) and “cultural beliefs” into short “trait-lists.”

While this form of cultural competency training has been renounced roundly by physicians and anthropologists alike (Carpenter-Song, Schwallie, and Longhofer 2007; Gregg and Saha 2006;

Kaufert 1990; Kleinman and Benson 2006; Kumaş-Tan et al. 2007; Lee and Farrell 2006), it still continues to find its way into biomedical training. Just this past year, the following “XXXX’ were published in a commonly-assigned nursing textbook by Pearson Education ; regarding

“Hispanics”, they “may believe that pain is a form of punishment and that suffering must be en- dured in order to enter heaven”, and that “Catholic Hispanics may turn to religious practices to help them endure the pain.” Of “Arabs/Muslims”, the book stated that they “may not request pain medicine but instead thank Allah for pain if it is a result of a healing procedure”, they “may consider pain a test of faith”; “Asians” “value stoicism as a response to pain, a client who com- plains openly about pain is thought to have poor social skills”; “Jews” “may be vocal and de- manding of assistance” and “believe pain must be shared and validated by others”; and “Native

Americans” “may prefer to receive medications that have been blessed by a tribal shaman”

(Pearson Education 2017.) A host of poor Amazon reviews led to the section’s retraction and an official apology by the publication team, but the fact that the book made it all the way through a stringent editing and reviewal process by teams of medical experts and was subsequently published speaks volumes (pun intended) as to the persistence and popularity of CC “trait-lists” in medical pedagogy. In taking far too many shortcuts in the pursuit of cultural sensitivity, medical pedagogy has, at times, resulted in re-enforcing racism and cultural stereotypes, rather than un- dermining them. This has had immense implications for the quality of patient care, perhaps most notably (in the literature) resulting in the mismanagement of pain among African-Americans, and contributing to the insanely high disparity in maternal mortality between black and white women in the US. Hoffman et al. 2016, found that physicians across the training spectrum continue to hold anachronistic, racist, and incorrect beliefs in inherent biological differences between blacks and whites that may play a role in their practice, such as “blacks have thicker skin”

(and are thus less sensitive to pain) than whites.

In Guatemala, I have seen that the practice of diluting “culture” in medical training into the obstructions it might pose to patient compliance; of conflating culture with race, nationality, and religion; and of assuming that cultures are homogenous and static, has led some physicians,

at least in my experience, to develop a practice of treating Guatemalan patients as if they belong to some kind of easily-distilled “latino monolith.” As seen in the above vignette, rural Guatema- lans are lumped in with all other “Hispanics”, seen through a trait-list of haphazard epidemiology and cultural stereotypes that can be a direct impediment to care. “CC initiatives may in fact increase the potential for conflict in cross-cultural clinical encounters, as medical staff may construct cultural differences that do not exist, while failing to recognize measurable differences”

(Maupin 2014.) In this case, relying on her knowledge of what was “normal in Latino populations”, Amy missed the difference between the child in front of her and all the other children who had come through the clinic that morning. To her, Guatemalans were latino, and her firmly- established idea of what is “normal for [all] latinos” meant that it never occurred to her to wonder whether her patients could be undernourished…and to understand obesity in a child something to be expected, and no cause for concern, even when all the contextual cues available to her in that present moment, and the all scientific literature on the area, suggested the exact opposite.

The Pathologies of Profit

White plastic buckets of water were stationed by each toilet and wash station. Indoor plumbing was still more of a dream than a reality, but Kixok’s coastal clinic was very different from how I remembered it when I had first visited, years ago. The coastal clinic that first summer had been a dark and stuffy one-room adobe home, the walls prickly with unmixed straw, the only illumination sunlight that filtered through the open door and the small window cut into the mud bricks. When the door was pulled shut and the shutters on the window closed for privacy’s sake, the doctor made do with a headlamp and the flashlight built into his cell phone. All the medications they had available were brought with us, dragged across the uneven dirt floor in two scuffed and generic-looking black suitcases, they kind people tie colorful handkerchiefs to at the airport so someone else doesn’t walk off with it, thinking it their own. Outside the pop-up clinic

was a woven hammock, torn in spots and perpetually occupied by at least two children. The swept-dirt porch also housed as a pig, a small flock of balding chickens and a cobalt blue fiber- glass pila where the physician washed his hands between patients.

After conducting an exam either entirely in Spanish, Kaqchikel, or a mix of the two, the doctor would sometimes nod at me and then at the suitcases and I would dart over to fetch the medication I thought he needed. There was a pattern to these patient visits; many of them seemed to have the same complaints. Menstrual cramps, muscle aches, arthritis, high blood sugar, children with coughs and runny noses and itchy red patches on their skin “que pica bastante.” Pri- mary care in a place dónde no hay doctor.

Now, five years later, many of the patients were the same, but the setting had changed drastically, as had the tenor of the visits. Patients, I noticed, were calmer now than they had been years ago, less harried as they waited in the concrete-and-mortar clinic, circulating now among permanent staff with familiar faces. This was my sixth visit to the coastal clinic over the past half-decade, and I had had the chance to watch it evolve. Kixok’s coastal clinic was now a clean and well-organized multi-room bloque building, with a large communal entry space rendered full of light by multiple windows and a vaulted tin ceiling. The floor was smooth, well-poured concrete, and hand-built woodern shelves lined the walls of the clinic’s storage room, where medications and supplies were kept neatly organized by the site’s permanent community health promoters. A padded, leatherette examining table in a separate room had replaced the plywood boards propped on top of four 10-gallon buckets and covered by a children’s fleece blanket that had served as an examining table on my first visit. The chickens in the front yard had been replaced by children.

Part of Kixok’s expansion and establishment in the small coastal town had been a widespread nutritional aid program focusing on the distribution of lipid-based nutritional supplements

to children between the ages of 6-24 months. Kixok has a programmatic dedication to ethnographic research, believing it to be an important part of successful interventions. One of their earlier findings was that the most prevalent and easily attainable form of nutritional supplementation in Guatemala—and thus the one that most aid programs tend to distribute most often and rely on in their programming—were atoles, or fortified hot cereal mixes meant to be cooked with milk or water. With a little digging, Kixok’s researchers realized that household distribution of atoles like Incaparina were problematic for multiple reasons. One, Incaparina’s popularity and prevalence made it more likely that cash-strapped households might turn around and sell the product at their local market rather than using it in the home; but more importantly, Incaparina and other atoles can be diluted—in fact, are supposed to be diluted—with water. There are instructions for how to correctly dilute Incaparina on the back of the packaging that would ensure that every serving size contains the intended amount of calories, protein, and micronutrients. (It should be noted, however, that these instructions have changed over time and the current formulation is more dilute than it had been previously.) However, at 10Q a bag, Incaparina is expensive, and after the Thousand Days Initiative grew in popularity, food-based aid became increasingly more focused on children under 24 months of age. In a resource-poor setting characterized by large families, it was only natural that one serving of Incaparina or other fortified atol would be diluted to serve three or more people, to the point where it becomes little more than “a delivery vehicle for sugar” (Kixok staff, personal communication.)

Even in the U.S.-sponsored NGOs that I observed who boasted of “comprehensive nutritional programming” in their advertising (programming that was in fact limited to school-based lunch/refación2 programs), Incaparina, when it was used, was not prepared according to the company’s guidelines. I spent a few weeks visiting the preschool programs run by one lake-based

NGO, Juntos Podemos. The preschools themselves were bright little buildings, covered with colorful murals that had been painted by visiting groups of U.S. volunteers, their front yards filled with flower beds whose blooms tumbled into the brightly painted wooden playground. The rooms themselves resembled those I remembered from my own kindergarten in the U.S; tables, benches, a large chalkboard, the walls covered with colorful instructional posters. In addition, each school boasted fortified atoles as part of its nutritional programming. However, on the days when it was served, the women preparing it in the kitchen would do a quick head count before diluting whatever they had on hand accordingly, and sweeten the mixture to taste. If they began to run low at some point during lunch, they would simply add more water to the diluted mixture.

In fact, on many days the children enrolled in the school and thus involved in the programming would receive atoles that weren’t fortified at all—simply a mixture of ground corn and salt, boiled in water and sweetened with sugar. Nothing was said of this, however, and I had the impression that the children’s parents, many of whom would come every day at lunch to assist with serving and clean-up, as well as visiting donors, who often stopped by the school as part of programming development, were left with the impression that Incaparina was served daily. A typical menu for a single school week was as follows:

Monday: atol, boiled plantains

Tuesday: atol (fortified; Incaparina), one hardboiled egg

Wednesday: caldito de pollo, tortillas

Thursday: atol, boiled plantains

Friday: atol, boiled plantains, one chuchito (tamalito)

In another NGO, one worker described her disappointment with her organization’s “comprehensive” nutrition program:

Respondent: They were feeding the kids really poor nutrition, based on the diets and the menus. Just based on the diets and the menus, their nutrition was shitty. But every single 98

time we went out to see the pre-schoolers and saw what they were eating, it wasn’t the food on the menu, it was less nutritional intake, like more garbage food. Like, they were giving the kids, like, atol and stuff, and I was like ‘that’s not helping a malnourished kid.’

Me: Well, that depends on the type of atol.

Respondent: There was no nutrients. I mean, literally, like ground-up corn and sugar.

Me: Oh, so—it wasn’t Incaparina or Corazón de Trigo or…?

Respondent: No, no. It was like— they were also doing…there was no protein. Anyway, the nutritional value—we had a nutritionist look at the menu that we had and we actually calculated in, like, what was being served and like we couldn’t be—we were calling this a ’nutrition center’, but it wasn’t a nutrition center at all. Like, where’s the accountability? It’s because we have— even if we made decisions, there was this power structure, where it would get changed. And food would go missing. A lot of times, things would get switched and food would go missing.

It is easy to see how Incaparina and other fortified atoles, while an omnipresent part of food-based programming in rural Guatemala, are susceptible to manipulation in ways that defeat their primary purpose as a fortified nutritional supplement, and yet many familes rely on them, and many families in NGO-saturated areas like the aldeas surrounding lake Atitlán and Antigua rely on preschool-based nutritional programming. For those families lucky enough to be enrolled in nutritional programming, Incaparina and other fortified atoles are often the only barrier sepa- rating their family on a daily basis from nourishment (alimentación)—or at least the perception of it—and what I’ve termed “palliative feeding”. “No tenemos nada de alimento,” one grandmother told me. “Solo tortilla.” “We don’t have anything nourishing,” she had said, “just tortillas.”

(See the fourth Chapter of this volume, Indivisibility, for a more in-depth discussion of palliative feeding and intra-household perceptions of food insecurity.)

Crisis and Affect

Marisol Elena Rodriguez had enrolled her youngest child, a bright and talkative 26 month old boy named Luca in the program shortly after he turned six months old. Less than half the age

of his five-year old brother, Luca was now the taller of the two, and the stronger. I watched as

Elena told the health worker about him.

“Look at him!” Elena exclaimed, unsuccessfully trying to grab Luca as he darted past her, giggling. “He has so much energy!” Of the two boys, Luca was also much less likely to be sick, compared to his brother, Juanca, whose diarrhea seemed to be without beginning or end. (“How long has he had it?” asked the nurse, and Elena shrugged off the question with a wave of her hand. “Hace ratos,” she replied. (“A fair while.”))

Elena now wanted to give the supplements, the white packets of squeezable sweet brown goo, to her oldest boy, so he would grow as well as Luca. So he could catch up.

The look on Elena’s face as the health promoter explained that it was “too late” for Juan

Carlos (“Juanca”), that it had been “too late” for years, that he would never catch up to his younger siblings, that look of dawning realization and horror, of confusion and resignation—that look was the seed of this Chapter, my last NSF proposal (a cultural consensus model of infant development in the context of endemic stunting) and much of this dissertation.

Much of current public health programming in Guatemala, including the programming dominant in NGO rhetoric on child nutrition, relies on an “individual-authoritative” (Beattie

1991) approach to programming efforts. “Authoritative”, here, means that “experts” or “profes- sionals” are the ones responsible for both creating knowledge and disseminating it (see Fou- cault’s discussion on the evolution of the “expert” in The Birth of the Clinic (1963)), and “individuals” are responsible for both the reception and application of said knowledge, even when their assignation to a collective by the “authoritative” experts is attributed to their inability to either receive or apply such knowledge, or even posited as an explanatory model for their illness in the first place (see Didier Fassin’s discussion of “culturalism” in “Culturalism as Ideology”

(2001.)) This approach to health promotion is, of course, much easier in its implementation than

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focusing on top-down approaches that attempt to address the structural issues that both underlie and reinforce health disparities in resource-poor settings. This “individual-authoritative” approach to child health in NGO programming is doubly pathological in rural Guatemala, as ethnography that attempted to elicit household and community-level perceptions of child nutrition found that “wives are still expected to feed both their children and their husbands”, “whether or not they receive gastos” (Chary et al 2013.) Focusing on “risky” behaviors that are often immediately pinpointed on attitudes and traditions that are perceived to be prevalent among indigenous populations (Araya et al. 1981) is nothing new: this is how we got the schools of “tropical medicine and hygiene” that dominated colonial medicine and still influence medical pedagogy today.

(See Anderson 1998, 2006; Bashford 2004, 2010, for a discussion of imperialism, hygiene, and postcolonial medicine.) However, this “culturalism” (Fassin 2001)—the “incrimination of the culture of ‘target populations’ (what Jonathan Maupin would call “ad-hoc groups”) as the reason for the failure of healthcare interventions” (Pylpa 2007)—is a pervasive, dominating and highly dangerous element in a context where NGOs provide much in the way of primary care or nutritional aid, made even more dangerous by the fact that culturalism’s very ease, when it comes to programming, can be highly seductive. It is, after all, much easier to design, fund, and implement preschool “health and hygiene” workshops where children are taught to wash their hands after they go to the bathroom and to brush their teeth twice a day than it is to address issues of endemic poverty, structural violence, or to design and implement large-scale longitudinal food-and- education-based nutritional programming.

Because NGO-based nutritional programming relies on donations in order to sustain itself, the programming must be “sold” to donors. And while larger philanthropic organizations and academic granting institutions often require operational transparency and accountability in addition to assurances that ethical and legal guidelines are being met, many NGOs operating in

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rural Guatemala—even some of the larger ones—rely primarily on individual donors, or donations from small, self-governing groups. In the context of Guatemala’s overtaxed and under-regulated “republic of NGOs”, this means that many NGOs are accountable, functionally, only to themselves—and to their donors. “Affect,” wrote Vincanne Adams about the economy in New

Orleans after hurricane Katrina “calls for an emotional responsiveness and generates an inducement to action” (Adams 2013.) For individual donors, this emotive response and “call to action” relies on a pathos much more easily generated by easily-digestible constructs of ethnicity and poverty than by research, solid methodology, or last years’ financial reports. The exotic other becomes part and parcel of the package that is a donation to an NGO in rural Guatemala, and there are expectations on the donor side that often grow over time and with repeated investments.

Crowd-based fundraising allows you to literally put a child in a virtual shopping cart and purchase that child the promise of a better future. Scrolling through many organizations’ websites will reveal row after row of photos of children, identified only by their first names, or, in some cases, only by their case number. Hunger always lurks in the corners of these children’ stories; like poverty, brown faces, and traje, it has become an expected part of the aid-recipient “package,” but the real money, I was told, comes from “crisis.”

Aid workers expressed to me the idea that “crisis”, more than anything else, was an effective prod for the affect response, often hamstringing their ability to address chronic conditions in their programming efforts, as chronic disease lacks the immediacy, the sense of urgency and the feelings of heroism on the part of the donor, that acute or emergent situations can provide.

Chronic conditions aren’t as glamorous, as, per se, a road accident, domestic abuse, or rape; and organizations that rely only on affect-generated responses from donors can result in programming that is systematically neglectful of the less-glamorous, chronic conditions that account for the majority of health needs in impoverished communities without any real access to primary

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care. An advanced-practice nurse who worked with Friends reported the following regarding her work in their clinic: “there were no policies, no procedures, no protocols,” she told me. “Every- thing was done on a crisis basis.”

In addition there was no budget, there was no funding for this. So every time we needed money, we would have to write a sponsor or this group of people that we had access to by email, or these people that the founders had by telephone, like some very rich Americans, they were mostly Americans. The founder would call them up and tell them a very sad story and get money for that cause, or that problem. But none of it would be sustainable or preventable, it would all be on an emergency basis. And then with this would accompany this horrible story, often very inappropriate graphic pictures that we would send the young boys—they were boys, because they were like 15, 16, 17 years old. They called them like, ‘the IT team’, they were the tech team, they were the photographers, but their job wasn’t the tech stuff, it was to, like, carry stuff and to take pictures. Um, it’s almost like selling these pictures to people—it’s almost like commodifying poverty, like ‘here are some really horrible things, now can you pay for it?’ And there’s accounts of these donors, like, actually caring because they’re following their students and feeling so awful because they’re never told ahead of time that this is going to be part of what they’re going to be expected, or questioned about, to pay for. So people go in thinking that a sponsorship is going to be x,y,z dollars, but the reality is it’s far more if your sponsored child gets in a tuc tuc2 accident or something else happens. And they feel this grave responsibility to do something. So you end up putting these people out or causing a lot of stress on their end, but then as a result of asking them to pay for this and showing them this information, they also ended up having a lot of entitlement and ownership over what happens, and how things would be carried out.

In this case, the affect economy within the NGO itself relies on a packaged commodification of what it means to be poor and Guatemalan; and the rules of this packaging —the rules of the performance of poverty—depend more on donors’ whims and pre-conceptions of what poverty looks like in the global South than they do on any measurable assessment of real need.

Here, we see that another possible point of intervention in the alleviation of the intergenerational burden of stunting—the small grassroots NGOs that, for many Guatemalans, are very much “the face of development” (Chary and Rohloff 2015), and an important point of access for primary health care—are often poorly situated to aid in the prevention, diagnosis, or successful treatment of the condition. NGOs interested in chronic malnutrition enter the game with the deck

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stacked against them. Guatemalan NGOs depend on donations and affect-generated labor. Crisis, as we have seen, sells well within the context of the affect economy. Disaster sells. Tragedy sells. Calamity, catastrophe, emergency…sell. Stunting, a chronic condition that is invisible in the body and often takes decades to reach a point of “crisis” is not as successful in generating pathos or the sense of urgency necessary to mobilize an affect response as less endemic issues of crisis or calamity. Invisibility, in this case, reinforces itself.

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SERENDIPITY

The bloque house smells strongly of boiling chicken. It’s a warm, comforting smell, and it is a warm, comforting house, small and squat and brown and grey, almost hidden behind its aggressively green front garden. The house is spartanly furnished, block-and-lamina and hardpacked earth, clean and well swept. Sunlight filters through the floral sheets that cover the windows.

We are welcomed inside by a daughter of the house and led to the family’s bedroom. In the center of the room is the patient, lying on a plain box spring covered by a worn pink chenille bedspread whose fringe has been all but eaten away by time and moths and repeated pila wash- ings. Her mother sits at her head, stroking her hair as we come in, and she smiles at the doctor, welcoming him back. She is tiny and round like many of the rural Guatemalan women I know, and she reminds me of a finch, flitting from perch to perch on the pink chenille, her movements and her hands quick and light and never, seemingly, still. She is soft-spoken, and warm and effusive in her speech and manner. The smiles of welcome she offers us are genuine, but fleeting.

In anticipation of our arrival, three plastic stools line the concrete block and mortar wall of the bedroom. After a whispered request from his mother, a boy runs back carrying a fourth.

The physician, ever efficient, immediately takes the stool nearest the patient and pulls it forward, addressing the child directly and in Kaqchikel. The local health promoter follows his lead, and

Anna, the intern/soon-to-be-medical-student and I follow our normal protocol, sticking to the pe- riphery and trying to make ourselves as small as possible. I take the stool near the door, farthest from the bed; from my vantage point I can see the caldo de pollo simmering on the stove, and the carefully tended wood fire beneath it.

The girl is dying. I know this because the physician briefed Anna and I on the drive here.

She has Gorham-Stout’s disease; an extremely rare condition, etiology still unknown, in which

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the process of bone cell production and reabsorption—which is balanced enough in healthy bone—becomes disrupted, osteolytic, once healthy bone pitted by vascular anomalies and lym- phatic vessels whose thin walls aren’t up to the structural challenges faced by the body’s skeletal system. (Imagine, for example, replacing the studs in your walls with foam pool noodles.)

Gorham’s disease is also known as “vanishing bone disease” or “phantom bone disease”—both names are cruelly spot-on. However, it is not a death sentence, or does not need to be; not always. This girl might have lived, had the NGO now managing her care found her sooner, had her family known where to go, had the local healthcare system been more streamlined and con- nected, had the NGO, once they found her, been able to raise the money for her spinal surgery in time for it to have made a difference. If, if, if, if. None of these things happened, and now it’s too late; the disease has written checks her body is unable to cash, and it’s just a matter of time. A matter of waiting.

The window above the bed is cracked and missing one pane.

During the physical exam, the doctor switches without any apparent effort from

Kaqchikel to English to Spanish and back, informing, teaching, noting, without once interrupting the flow of the exam. The child is emaciated; the long lines of her arms are never wider than her wrist except at the elbow. Her ribcage is clearly visible against her lime-green Smurf’s t-shirt, straining against the fabric on one side, sunken in on the other, collapsed and collapsing further.

The unsunken portion of her ribcage is easily the largest part of her body; from there, her stomach slopes down dramatically to a tiny pelvis, her hip bones prominent beneath the skin. A still- new, still-clear catheter coils from beneath the adult diaper taped loosely around her hips. I watch the doctor’s hands as he conducts the exam; they are competent, composed, and gentle as he rearranges the thin sheet covering the girl to check the pressure sore in her left thigh. The sore is small; a perfectly round hole maybe three centimeters deep and another three centimeters

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wide. It is clean and well-maintained, though still leaking pus and lymph. The bandage, stained amber and red on the inside, has been recently changed, and the doctor smooths it back into place.

The physician’s Kaqchikel is quick, much quicker than mine will ever be, the edges of his words rounded, sentences flowing together in fluid tangles, and I struggle to keep up. I catch enough to hear him say, as he leans back, stethoscope in hand, that she has wet sounds in her chest; either pneumonia, or she has “vomited blood into her lungs.” I gather that there is nothing they can do for the latter, but the antibiotics she has already been prescribed will help the former.

During the exam, the patient’s three siblings circle her like house cats, pausing occasionally to crawl onto the bed and whisper something in her ear. Her mother waves away the omnipresent flies with a child health pamphlet from UNICEF. When she tucks the sheet—also pink,

Disney’s Aladdin—back under her daughter, she does so with the kind of unstudied, absent- minded competence that comes from having already done something a thousand times before.

The whole family hovers around the child, orbiting her, so many planets around a dying sun. I get the feeling that this little girl is the center of their home. She is beautiful, stunningly so. Sym- metrical features, a wide, clear brow; dark brown eyes edged with soft lashes and a generous mouth that turns up at the corners and smiles easily, even when in pain, even during the physical exam.

She would have become a lovely woman, had she been given the chance to grow up. I can see her adult features inscribed over the hollows of her face, shown and hidden in turns and shadow, like the layers in a palimpsest. The eyes that would remain open and kind, the cheekbones that would broaden and sharpen, the planes of her skull revealed not by illness but by time.

Even ill, her skin is glowing, pearlescent and smooth like the flesh inside of a walnut. I wonder if she would still have had those soft, dark lashes at thirty, at fifty, and I have to look away.

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I spent the rest of the visit listening intently to the Kaqchikel consult and studying the makeshift altar in the corner. A folding card table has been propped against the wall and covered with a blue plastic tarp. Two waterlogged Bibles are centered on the table, their gilded pages wavy and stuck together, yellow-green mold dusting the plastic covers. A framed print of the

Virgin is propped behind against a dingy wine glass covered with oily fingerprints and half-filled with water. Above the table, a tangled collection of wooden and plastic rosaries hang from a rusty nail driven into the soft mortar between the concrete blocks, a silk flower woven carefully among the beads. A prayer card, which looks new, leans against one of the bibles. Thick blue ita- lic script reads Santa María, ruega por nosotros pecadores, ahora y en la hora de nuestra muerte.

After the home visit we all pile back in the van, and there is a pause in the team’s usual rhythm of unhurried but unceasing efficiency and quiet cordiality. No one speaks. I watch the physician shake off the encounter—physically shake it off, much like a dog does after a bath. I’m not sure he realizes he’s done so. He says nothing. We say nothing. The driver starts the car, and we head toward the next appointment.

Part I: Serendipitous Care

Non-Governmental (dis)Organizations

“Do no harm” is supposed to be the mantra in medicine. But there are development projects that do harm, as well—and they’re well-intentioned efforts to promote development, to promote access to healthcare. And being honest about that and thinking about that is one of the most difficult parts of global health equity. —Paul Farmer

Let us temper our criticism with kindness. None of us come fully equipped. —Carl Sagan The Demon-Haunted World: Science as a Candle in the Dark

“You know,” Lydia told me during what must have been our sixth cup of coffee that day,

“I hate to say this—but it’s just so fucking neocolonial.”

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She laughed, running a hand through her recently cropped black curls. “If I ever had to write a book about this,” she said, staring pointedly at me and stamping out her cigarette on the table between us, “I’d call it ‘Dónde No Hay Pacientes.’”

Where there are no patients.

Lydia was at the end of her first year as the medical director of an NGO in the rural Gua- temalan highlands, Friends Helping Friends, hereafter known as “Friends” or “FHF”. Lydia came to the NGO in the conventional way: through an advertisement she saw on idealist.org.

Friends mostly hires, for their “foreign” (read: non-Guatemalan) staff young men and women fresh out of college for whom FHF is their first job, because, as Lydia phrases in a typically blunt fashion, “they’re privileged enough to work for nothing.” “Nothing” in this case is about

$450USD a month. Friends was one of the NGOs that I had spent the last few years accompanying, and one of the largest in the area. As of 2007, there were 10,000 - 15,000 NGOs in Guate- mala (Sridher 2007), a number that has only grown since (Rohloff, Diaz and Dasgupta 2011).

With an estimated population of 15 million, Guatemala has one of the highest ratios of NGOs per capita in the world; roughly 1 NGO for every 1,000-1500 people in a country roughly the size of the state of Tennessee. 45-60% of these NGOs operate health programs (Carrera Guerra 2002;

Foro de Coordinaciones de ONG de Guatemala 2002.) NGOs are thick on the ground, though clustered in groups around Antigua, Flores and Lake Átitlan, which, not at all uncoincidentally, are some of the nicest areas in Guatemala and those most likely to draw tourists.

The “Business of Social Suffering”

Guatemala’s “republic of NGOs” (Kristof and Panarelli 2010) has created a fraying patchwork of nutritional aid and healthcare. While they are, for many, the “face of development”

(Chary and Rohloff 2015) there is also a pervasive sense, on the ground, of the kinds of people who are, and are not, acceptable to, and likely to be accepted by, NGO programming. Given that

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NGOs are often the source of primary care for many rural Guatemalans, and primary care and well mother/well baby visits are one of the best ways for identifying and treating stunting—this has immense implications for the condition’s continued prevalence, even outside of the possibil- ity of enrollment in nutritional programming. If only certain kinds of Mayans are acceptable as the beneficiaries of aid, it stands to reason that others will be left out. The things I was told by rural indigenous Guatemalans—complaints they voiced about who NGOs do and do not help— were borne out by my experiences shadowing NGOs in Sololá.

In the case of Friends, for example, once you are “in”—usually through a child sponsorship that funds that child’s schooling—you stay in. Families who have a sponsored child are eligible for food aid; what they call “emergency aid”, although the assistance often extends for months at a time. You also get the thrice-yearly “holiday” baskets, healthcare assistance or building assistance if the need arises and the donor is willing; and with the number of a sponsored child in your pocket, it is often easier to get onto the list for the visiting medical jornadas. “If you get a kid into a school at Friends, there is absolutely no limit to what they can get,” one employee told me. “They can get just a sponsorship—so, just school supplies, one or two pairs of shoes, the uniforms, the parades, the equipment paid for—or their sponsor can build them a house. There is absolutely no limit…it all depends on the whim of the sponsors, literally. A sponsor can build a house, a sponsor can buy presents for all the kids in one family that has seven siblings, or just for the kid…there is absolutely no cap, no limit, no nothing.”

Friends is not unique in the fact that so much of what goes on is dependent on the whims of the donors, many of whom feel a degree of “ownership” over their sponsored Guatemalan children. “It’s super creepy,” one of Friends’ volunteers told me. “a lot of people say they adopted somebody. They think that they were adopted.” The dependence of many families on aid combined with the proprietary feelings of some donors can lead to a loss of agency on behalf of

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many sponsored families. Home visits are common—not only by NGO volunteers, but by the donors, when they visit. “We go to their houses”, one volunteer told me, “and how can they consent to that? I mean—we ask them, ‘Hey, can we come?’ but it’s not really ‘hey can we come?’ it’s

‘hey, we’re coming’. You know? It’s in the form of a question because that’s how everybody talks in Guatemala. It’s not really a question.”

Poverty tourism is a common part of the NGO “package” offered to visiting donors and groups of medical voluntourists (although of course it isn’t framed or marketed as such.) Shortly after finishing my long-term fieldwork, I received an email from the CEO of a new NGO that I had translated for when they were first starting out asking if I knew any families who could use

Ecofiltros—water filtration devices that, if properly maintained, can provide a family with clean water for years.

“Sure,” I wrote back. “If you only have fifteen, I’d start with the families who have already lost at least one child to a diarrheal disorder.” She asked me for a list of names and I sent her back a volley of questions. They’d be bringing a group to the family’s houses, she said, to teach them how to clean and use the filters. Great, I replied. Who? After a few emails, the story was this: she wanted to bring 15-20 people from the United States, each of whom had paid about

$5,000USD (not including airfare) to spend a week “helping” in Guatemala, to each house, all for the entry fee of one Q575 (~ $77USD) filter. 15-20 tourists, essentially—strangers—secure in their entitlement to crowd into the house of another, gawking and awed by their “different way of life”; their tickets secured by poverty and the inability of their host to say “no.” The icing on the proverbial cake was that these individuals, none of whom spoke Spanish or had ever used an

Ecofiltro, would be “teaching” these families how to clean and maintain their new filters. It was billed as an activity in the week’s programming.

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Conflicted, I met with an old friend of mine, a long-time executive of an NGO whose ethics and methodologies I respected.

“It’s ok to say no,” she told me over coffee in a small café in Antigua. “If you don’t feel right about it, if you feel like they’re being abusive, it’s ok to say no. We say no all the time.” In the end, the decision was made by virtue of inaction. I stalled on sending back the names and contact information, and in the end, the filters were given out at random. This is one of many things about which I still feel conflicted. I know families, more than a few families, who could have benefited from an Ecofiltro; and I could have asked them how they felt about it. I should have. But the families who needed them the most; the women whom I knew lived in the kind of poverty that kept their children on breast milk and tortillas alone until far after toddlerhood; they would never had said no. They didn’t have the luxury of saying “no”. And, knowing their lack of agency, I could not bring myself to immediately offer them the non-choice. I hesitated, and to this day I am not sure if my decision was borne out of contemplation, or selfishness, or both. I do know, after having translated for this NGO before, that I hated the idea of people whom I had grown to respect being subjected to this particular brand of salesmanship. Sofia, who was so clean and house proud, would have been ashamed of their packed-dirt floor and haphazardly patched lamina. Aracely would have felt compelled to offer food to everyone, even if it bank- rupted her for more than a week. It was an intrusion, an invasion. “So fucking neocolonial”, as

Lydia would say.

The ladies in line in the Friends compound that day in December would return just before Easter Sunday and once again, on Mother’s Day. These were “basket days”—a big hit with the donors, in which the families of sponsored children received a basket filled with food; usually one pineapple, a bunch of bananas, some dried beans, a bag of refined sugar fortified with vitamin A and iron, and a single, recently cleaned and plucked, raw chicken. Friends’ staff and I

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were puzzled by the crowning addition of the chicken, which could sit in its basket in the sun for a full half day before being sent home to people who often lived hours away and had no refriger- ators. “Here,” joked one community health worker, elbowing me in the side as she and I watched the line of women filter through. “That woman has gastritis. Let’s give her an entire uncooked chicken.”

Basket day was just one of FHF’s many programs. They claimed to offer, and did, at times, and to varying extents, almost anything you could think of. Education they covered in their preschools and child sponsorship programs. Healthcare, they offered, when it was available, through rotating teams of visiting medical jornadas from the United States and Canada, who I learned to refer to as “parachuting doctors”; the same with optometry and dentistry. There was a carpentry program and a technical program to teach adolescents and adults how to use comput- ers. There was a program for live poultry (which was a running joke, as all the birds kept dying); a program for shoes, a program for stoves, and a program for beds. There was an emergency food aid program, a preschool lunch program, a program to take care of “ancianos”, or the elderly. The children enrolled in the preschools were routinely measured for linear growth, even if the measurements didn’t often make sense (kids do not grow shorter over time; measurements that say as much are usually a sign that different individuals are doing the measurements, that the people taking the measurements are untrained in anthropometry, or that the group is using more than one handmade talimetro), even if the preschools sometimes closed without warning, and even though the measurements never seemed to influence programming efforts. There was a children’s vitamin program and a nascent well-mother-well-baby program. There was even an animal program, aimed at helping the local stray dogs and cats. There was nothing Friends did not do, but as I spent more and more time with the organization, I learned that many of their pro-

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grams were patchy, poorly organized, underfunded (or overfunded with odd caveats), and over- extended. It was a classic jack-of-all-trades-master-of-none situation, born from the all-too-common “good enough/something is better than nothing” standard of care particular to endemically poor areas (Farmer 1999) and I wondered how such a large and regionally influential organization had become so unfocused.

I asked Lydia this question one day over Skype, soon after she had returned to her hometown in Ecuador. “Yeah,” she said. “The sponsors definitely have a proprietary feeling regarding their students and that kind of extends to the rest of the organization…a sponsor might say something like ‘Oh, you know, I have a great idea. Why doesn’t she start a business doing…’” She paused. “You know, they decide what business they want her to start and they’re like ‘we’re going to pay for it’—and who gives a shit what the business is, who gives a shit if she wants to do it, who gives a shit? And then it happens. And then that kind of translates, over time, to ‘I have a great idea. Why don’t you start a dental program? We will donate all the equipment—and you know, you guys do everything else.’”

Lydia shrugs. “At first, it was small and had a small impact, and it was like—not negligible, but not noticeable? You know? And now it’s just ballooned up to the point where donors have this almost absolute power…where pleasing them is the most important thing because they’re the ones who will keep giving money to FHF.”

“They’re…” she pauses, sipping at the water glass on the desk in front of her. “I think there’s no sense, within the organization, there’s no sense of budgeting, there’s no sense of planning, there’s no sense of ‘ok, when is this project going to end?’…this is the logic model of

Friends: people are going to keep asking for help and they’re going to come to us and then we’re going to ask for money and then when we run out of money we’re just going to keep asking.

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That is the extent of the planning that goes into the way most things are run. And it’s been working! People have been giving money because they’re allowed to do whatever the fuck they want.”

This donor-driven chaos in NGO programming is not uncommon. Mark Schuller in his

2012 book, Killing with Kindness, a treatise on the failures of development in Haiti, describes how almost $2 billion in private aid donated to Haiti after the 2009 earthquake seemed to disappear into a system that “was clearly not working” (2012:14.) In some ways, Haiti’s aid-is- healthcare system is much like that in Guatemala; in both cases, governmental oversight has been weakened by a pluralistic system dependent on external aid governed to a large part by unregulated NGOs; and, in both cases, donors are encouraged to give directly to these NGOs, which of course has a direct impact on programming.

And some donors, in the words of Debbie Callahan, an Australian nurse who spent eight months with Friends as their medical team director and “donor-relations coordinator” are, in her words, “crazy.” “One group wanted to tattoo babies after they had successfully completed the well-mother, well-baby program and somehow tag them, with the [redacted: symbol of their organization]. They had money for this. Somehow they wanted the babies to be tagged, perma- nently, and all I could think of was the Holocaust. Like, are you fucking kidding me?” Those donors, however, still had to be appeased. “Sometimes things like this would start to happen,” Deb- bie told me, “and it was shocking, because these are the people who are starting to direct values schools and send money and they’re the people who steer programs. And Liz would never say no to them, she would never say no. So as the coordinator and manager of the program, you would have to, like, hide that. Say ‘I’ll take care of that for you’ and then just make sure it disappears.”

Schuller’s earlier construct of “civic infrastructure” (Schuller 2006), what Julie Hemmet

(2007) called “NGO-graphy”, can be useful for revealing the underlying tensions between the

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groups involved in stunting’s diagnosis and treatment, as it is grounded in understanding the intersecting relationships between the internal governing bodies of NGOs, the people they set out to serve, the donors who take an interest, and the Guatemalan state. These relationships are constantly shifting, making the already-hard-to-navigate pluralistic healthcare system an even greater challenge for those who are seeking food-based aid or primary care.

No Se Atiende

It’s late December, and the line of women, almost all of them in traje, packs the Friends compound, spilling out of the swinging blue metal gates onto the street outside. The drunks who usually occupy that street, lolling on the elevated sidewalk with their loose limbs and lips and perpetually empty bottles of Quetzalteca were not in force this morning, pushed into retreat by dozens upon dozens of women of all ages, who either chatted animatedly with their neighbors or stood with their arms crossed across their chests, looking bored and slightly irritated. In the other towns in which I worked and volunteered, most locals who knew me called me “Cati.” But here, near the Friends compound, I enjoyed a measure of anonymity. To the brothers of perpetual ine- briation that haunted the street near the compound, I was “muñeca”, or “hey, lady”, or to one fellow, to my undying amusement, “reina de mi corazón”. To everyone else, I was “seño” (“miss”); just one more young white female volunteer, assumed to have poor Spanish and no Mayan, transient, replaceable, bound to be gone in a few months. When someone needed something I was addressed with polite distance; if not, I was treated more or less like a part of the landscape.

Most of the time. In other cases, the assumption that I was a volunteer or somehow otherwise affiliated with Friends became a sort of capital; to my discomfort, my acquaintance would be actively sought out by individuals who hoped to capitalize on that association, to get themselves or their children into the Friends system. Onto a list. One morning I passed by the compound’s gates, only to find them locked; Friends had closed down for the day. Outside the gates

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was a family from San Andres—I could tell they were from San Andres by the traje worn by the women and girls of the family; bright greens and blues like the bottom of a tropical aquarium. As

I passed by the gates, I was approached by the only adult male in the group; a wiry man who appeared to be in his late thirties. He had kind eyes, but moved with a kind of quick desperation as he stepped in front of me, and I was, for the briefest of moments, frightened.

“I don’t believe they’re going to open today,” I told him in Spanish.

“Can you help us?” he asked.

“I’m not sure.” I replied. “What do you need?” I felt bad. Obviously, this family had crossed the lake en masse this morning in order to speak to someone from the NGO—which was no small feat, considering the price of the fares for eight people—only to find the gates barred from the inside, the compound empty. Maybe I could carry a message. The man, who introduced himself as José, told me about his mother, who was dying. “She’s so sick,” he said. “And there’s no roof, no firewood. I thought…” he trailed off, gesturing vaguely at the compound’s gates.

“Can you help?” he repeated. I took down his name and he rattled off a phone number from memory; his brother-in-law’s, he told me. I passed on the name and number to a higher-up inside the NGO.

One day, a young woman (who looked to be about fifteen, so she may have been anywhere from seventeen to twenty, given the rates of stunting in the area) pulled me off the main street in town by waving her arm and shouting “Hey, lady!” in English until I stopped and turned. She motioned me to sit beside her. “I’ve seen you around,” she said. “Do you work for

Friends?”

I shook my head. She narrowed her eyes and sighed, giving me the distinct impression that she believed I was lying.

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“I have a child,” she told me; a statement which I found oddly self-explanatory and unnecessary, given that she was holding a baby. It felt like a prompt, like I was somehow missing a cue to go onstage. Unsure of how to respond but knowing something was expected of me, I leaned in and pulled back the blanket covering the child’s face. S/he was fast asleep, one fist curled by his/her cheek, dark curls damp against a sweaty forehead.

“She’s beautiful,” I said, taking a blind stab at the gender. The mother did not correct me.

“Do you go to Friends?”

“No,” she said. “There’s no point. They won’t even see you (“no se atiende”) unless you know a gringo on the inside.”

“I’m not on the inside,” I said. She did not reply.

“I could really use a stove,” she told me. “They gave one of my neighbors a stove. I think my baby is sick. She sleeps too much. The father isn’t around.” She gave me facts in a strange, truncated fashion; one after the other, pointed and staccato as gunshots. I had the feeling she had had this conversation before and was half-heartedly rattling off the highlights.

“How is your milk?” I asked as I put the back of one hand against the baby’s forehead.

She was hot; but Guatemalan babies are always hot, cradled as they tend to be in layers and layers of cloth diapers and clothing and thick blankets, wrapped in a densely-woven perraje tied against a woman’s body. The baby didn’t look sick—not that I would know.

She shrugged. “I could really use a stove,” she told me again.

My first summer in Guatemala, I was living in a tiny blue-grey town tucked into the hills above Antigua. I spent that summer, and two of the three summers that followed, living with the

Chavez family; a warm, effusive group that taught me nouns in Kaqchikel with the same combination of steady patience and consistently surprised pride usually reserved for teaching a puppy new tricks, though they rarely spoke the language amongst themselves. Over time, as the bonds

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between us grew more relaxed, expectations changed. I was no longer given my own room, emp- tied of all signs that anyone else had ever lived there, plenty of time and space to myself, and a pile of fresh towels, as I had been upon my first arrival. By the time I returned the second year, I was handed a baby and a plastic colander of chipillin to strip and clean the moment I walked in the door. This made me happier than any freshly laundered towel ever could have (though perhaps not as happy as the prospect of a hot shower.)

There were three adult sisters living there; Flora, the eldest, who worked at the Museo de

Chocolate in Antigua, was stern and strong and laughed often and easily; Marina, who was soft- spoken and prone to blushing, who kept the house while looking after her younger sister Gloria’s two children; and Gloria herself, who sold fruits and vegetables daily by the side of the road.

Gloria’s voice was so naturally loud and strident that it had become the family parrot’s favorite voice to imitate; to the point where you could often hear her talking from two sides of the family compound and would have to guess as to which one was the real Gloria, calling for her children and which one was the bird that had once tried to take a chunk out of my left earlobe as I passed him on his perch in the hallway.

The second summer I stayed with the Chavez family I contracted a nasty upper respiratory infection. I spent days in bed, dealing with intermittent but scarily high fevers, shortness of breath, and the kind of coughing fits that leave you teary-eyed and weak and unable to lay on your back. Flora cared for me as if I were family, bringing me blankets and pillows and home- made jarabes of white honey, garlic, and fig leaves, or Coca-Cola that had been laced with bou- gainvillea petals and boiled down to a syrup. One of those nights I spent, propped up and panting against the cinderblock wall (later that week, I would be diagnosed with pneumonia by a local doctor), Flora came in carrying a small blue plastic pot of Vick’s Vapor Rub, motioning impa- tiently for me to take off my shirt. I pulled off my sweater and covered my breasts with a pillow,

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prompting Flora to roll her eyes and cluck her tongue at my apparently unnecessary show of modesty. She sat down beside me, no-nonsense as always, and began rubbing the ointment into my back.

I coughed.

“You’ve got a lot of back fat,” Flora told me in Spanish. I’d grown accustomed to the nonchalant way in which rural Mayans commented on one another’s bodies in ways that would be seen as rude or disrespectful by norteamericanos. Just that morning my host brother had pointed out a pimple on my chin and I had complimented him on his lovehandles. He just nodded in acknowledgement, smiled, and passed me the pitcher of Nescafé.

“Thanks?” I replied.

She dug a knuckle into my ribs. I coughed again.

“Anita gets coughs like this,” she told me, referring to Gloria’s oldest child. “I worry about her. I don’t think she’s growing well.”

“Have you tried enrolling her in one of those nutritional programs?” I asked. I had seen them in town; trucks off-loading bags of fortified flour (not that I knew of anyone in town who cooked with wheat flour.)

Flora snorted. “Those programs aren’t for people like us,” she told me, “they’re for los que ya tienen.”

I didn’t understand what Flora meant at the time, but I began to over the years as I talked to more and more women and spent more time shadowing physicians and tagging along with

NGOs. There was a pervasive understanding that nutritional programs were accessible only to a certain type of individual, and to a certain type of family. The idea that you had to know “a gringo on the inside” came up over and over in discussions of perceptions of program accessibil- ity—and not just for nutritional programs. Preschool programs, work programs, school lunch

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programs, even free clinics were all mentioned as services that were inaccessible to most unless you met a set of seemingly arbitrary criteria. Vinh-Kim Nyugen (2010) in his book on antiretro- viral therapy in 1980s West Africa quotes the German philosopher Carl Schmidtt in his discussion on who did, and who did not, receive treatment. “Sovereign is he who decides the exception” (2005.) Schmitt’s works are clear, if mocking, considering the man’s politics, examples of the dangers and predictability of authoritarianism. Extending this argument to NGO-sponsored nutritional programming in rural Guatemala, it is clear that the form of political power Nyugen refers to as therapeutic sovereignty is embedded in a process of selection that is designed and driven in most cases not by the people who are seeking aid, but by the “gringos on the inside”; the extended network of donors, volunteers, and affect workers. “Beneath the veneer of ‘criteria’,

‘procedures’, and a glossy rhetoric about ‘saving lives’”, Nyugen writes (2010), “in the end, it is finally about who lives and who dies and how these decisions are made: triage is not just political, it is politics.”

An excerpt from an interview (translated from Spanish) with one of my key informants in

Nik’aj went as follows:

Me: and…if, unfortunately— if you were in a situation where there wasn’t much food or money in the house and your children were hungry, what would you do?

Respondent: I would look for help.

Me: Where?

Respondent: I would go to one of those organizations—but sometimes, those organizations won’t accept you, they don’t include you, because of the machismo that happens here. There are people who need help, and they don’t want to help them. Some- times.

Me: Why?

Respondent: Because….I don’t know. Because there are already so many that want food. There is a family that lives here, I feel so bad about them, they have two children and sometimes they don’t have food. This hurts me, this hurts me a lot. And I see these children—two children—sometimes their father doesn’t have work and they

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ask me if I can lend them money—this, yes. It hurts. Like this, yes, there are many. Many, many.

Me: and why did you tell me that these organizations son machistos?

Respondent: They don’t want to include, they don’t want to accept this family, they don’t want to help them. And sometimes I say to my mother about this family—why? Why don’t they want to accept them? Because I have already seen that no one is helping this family. She [the mother] is worried about the life of her children, she’s scared.

Me: And which organizations are these?

Respondent: There’s one—I don’t know what it’s called—that helps families que no tienen—that don’t have food, that have many children, I don’t know what it’s called. It’s here, on this block. They help families. BUT— they don’t help this family. This is what I want, that they help these families who have nothing.

Me: and why do they not help—

Respondent: those people who have very little money? They help people who have a house, que ya tienen todo—this is who they help. The worst, for me, that I am seeing…

Me: yes?

Respondent: that I am seeing, they don’t choose them [the poor families.]

Me: yes, that doesn’t make sense

Respondent: Yes. We should go visit them. It hurts me, these families. There are many who are poor.

The on-the-ground politics of who is, and who is not, able to enroll their children in nutritional programming is almost a mirror image of earlier colonial rule: instead, now, of deciding who dies, foreign, occupying (though officially unaffiliated) powers decide who lives, and who thrives—and not all lives, not all parents and not all children, are counted equally. Some families are deemed worthier than others and more deserving of aid; and in local perceptions and my own experience, this idea of “worth” often has more to do with who you know and how you present yourself than it does with more quantifiable measures like z-scores, family size, or rapid poverty

(QPS) assessments. Nyugen (2010), writing about his time as a physician in the Cote d’Ivoire during the beginning of the AIDs epidemic said that the way individuals were “triaged” by the

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gatekeepers to aid mirrored earlier colonial practices “that sliced and diced the colonial population according to an imposed logic that valued some over others” (Nyugen 2010: 7), a form of triage structured not by need but by a hierarchal ranking of the “ethical dilemmas of colonial subjects” (Nyugen 2010: 11.) In Nyugen’s case, as in the case of on-the-ground aid in Guate- mala, the performance of the “ideal subject” (O’Neill 2013) is confessional; a practice which is both shaped by and shapes the “social field” (Bourdieu 1993.) This constant shifting of institutional priorities and the demand for performance it places upon those who seek out care in the context of endemic disease can further obscure both the political stakes of the organizations involved and the underlying inequalities that necessitate aid in the first place (Schuller 2012); a discourse whose “technical failures” (Ferguson 1990) tend to isolate the “underdeveloped”, reifying them as such, neatly constrained within their own “savage slot” (Troulliot 2003.)

The Right Kind of Mayan

I arrived at the FHF compound one day to find the place strangely quiet. Normally, even on a slow day, the compound was buzzing with activity: newly arrived groups of visiting donors being shown on tours (“and on your left,” joked one long-term employee, as she gave me a mocking tour of the facilities, “you will see some poor people. If you turn to your right,” she said, sweeping her hand in a Vanna-White-welcome-to-the-showcase gesture, “you will see some more poor people.”); trucks pulling in or backing out filled with people or things to bring to the surrounding aldeas; children laughing in the play area of the attached preschool; people waiting in lines or plastic chairs for a program or jornada; staff chatting at any number of figura- tive or literal water coolers; bakery carts being wheeled in and out in an attempt to tempt the em- ployees into spending Q6 on a cinnamon bun. Today, however, all the office doors were closed, even though the compound was open. When I reached the offices on the second floor, Sarah, a

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staff member originally from Vermont, rushed out to greet me. Sarah is an odd mix of effortless beauty and hard angles, like a version of Grace Kelly that had decided to take up boxing.

“Liz is on the warpath,” she told me in a whisper, referring to the white norteamericana who ran the NGO. “You should probably go.”

I found out later that Liz, the chief executive officer and founder of FHF had been

“pissed” because, although a large number of people had showed up for the advertised jornada

(primary care; sponsored by a visiting group of physicians from a church group in Wisconsin), they hadn’t looked “poor enough.”

“What does that mean, ‘not poor enough?’” I asked Claire, another long-term staff member, when we met for drinks later that week.

“Well,” she said, “first of all, they weren’t indigenous.”

“Ah.”

“And, they were— you know, they were dressed like…some of the women were wearing make-up and the men were— you could tell that they were wearing nice clothes.” She seemed uncomfortable, playing with her glass. “But, I don’t know— who knows what peoples’ struggles are? There are some people who always wear nice clothes and they don’t have money to pay rent.”

Until close to the end of my year of long-term fieldwork, Friends didn’t have anything resembling formal inclusion or exclusion criteria for the individuals involved in their programs.

(Even now, as of this writing, only certain programs have any kind of inclusion/exclusion criteria, and only some of the time.) Instead, people were chosen—or left out—of programming based on the decisions of only a few individuals. More than one staff member told me that most decisions were made based on whether or not the leader of the junta felt that the person in question had “un buen corazón”. “Having a ‘good heart’,” I was told, “justifies anything.”

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“The person in charge decides.”, I was told by a frustrated health programmer after a woman she had advocated for hadn’t been accepted into the emergency food aid program. “They know who the person is, they know if the person ‘has a good heart’. It doesn’t matter what their z-scores are, or what living conditions they’re in or how many times children under five have had respiratory infections— they didn’t have a ‘good heart’, so they weren’t going to get in the program.”

“So who decides whether someone has a good heart and what does that even mean?” I asked.

She rolled her eyes. “God knows,” she told me. “God is in charge of FHF and that is what the hierarchy maintains.”

There was a pervasive sense that in addition to knowing the right people (“a gringo on the inside”), you had to be the right kind of poor—the right kind of Mayan, because poverty was very much conflated with indigeneity—to receive aid or to be enrolled in programming. There was a performance aspect to all of it; I’d witnessed women take off their shoes and throw them in a bag before entering the compound, take a tuc tuc not to the front gates, but to a church nearby, turn the corner and walk the last dozen yards or so to the front of the Friends compound. Kevin

Lewis O’Neill wrote about the politics of performance in child sponsorship in Guatemala City in

2013. “A properly assembled subject,” he wrote, “behaves well. The sponsored child asks the right questions. He writes the perfect letter. She recites a beautiful prayer.” This is akin to Su- sann Huscke’s construct of “performing deservingness” in humanitarian medical aid, or of Tick- tin (2011)’s constructs of “morally legitimate” suffering “worthy of compassion”:

When patients express choices, voice concerns, or refuse to perform their social role as a patient-solicitant according to the expectations of the physician or hospital staff, they may face rejection or exclusion from services. As a consequence, despite the efforts of some volunteer-activists, humanitarianism tends to produce docile patients who learn to adhere to the stereotype of being a destitute, helpless, and thus deserving

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migrant, and much less often empowered subjects with a sense of entitlement. (Huschke 2014)

The recipients of the baskets, for example, after receiving their bundle of raw chicken topped by a beribboned pineapple, continue in line to have their picture taken under a banner that says, in turn, “Merry Christmas” in English and Spanish, or “Happy Easter”, or “Happy Mother’s

Day.” They stand under the bilingual banner and hold up a small whiteboard upon which a volunteer has scrawled their number—not their name, only a number—and smile into the camera, their basket on the table in front of them. I spent much of one afternoon watching this; a line of women who grew increasingly tired and grumpy as the hours passed, having spent most of the day standing in line. Their expressions would change in an instant—grouchy and understandably irritated as they received the basket and went back to stand in yet another line to cheerful and beaming the moment they were in front of the camera and the cameraman called out the Guate- malan version of “cheese”, which, for reasons I have never understood, is “whiskey.” Afterward, they get back in line yet again to write or sign a thank-you note to their sponsor—and everyone, no matter their age, has to draw a picture.

“There’s this idea,” Lydia told me once, “there’s this idea that poverty has a face. And it is an indigenous person wearing traje, and, you know, looking sullen, looking hungry, and then— first, and after looking grateful. And a little bit less sullen and a little bit less hungry, but forever grateful. Always grateful.”

Gratitude, even when it is genuine, is still very much a performance and an expected— and oftentimes ritualized—part of aid reception. Tomohisa Hattori’s (2001) article “Reconceptu- alizing Foreign Aid” reframes aid itself as an act of giving, pulling both from Marcel Mauss’

1967 classic The Gift, which frames the act of gifting as a reciprocal act that occurs within two groups that are fairly symmetrical in terms of power and wealth, and, in turn helps to maintain the constantly-shifting balance of that power, and thus the peace; and Marshall Sahlins (1972), 126

who expanded upon Mauss’ theory by accounting for power differentials between groups. (I’d also like to note here that Mauss was an early critic of neoliberalism, or what would eventually become known as neoliberalism but what was popularly called “business pacifism” at the time.)

Sahlins distinguished between “balanced reciprocity”; which stipulates an eventual return of a gift “of commensurate worth or utility within a finite and narrow period” (Sahlins 1972); “gener- alized reciprocity”, which allows for diffusion of wealth through a fairly cohesive social group; and “negative reciprocity”, which occurs between two socio-politically disparate groups or individuals and negates the otherwise universal obligation to reciprocate. Hattori argues that gifts that occur between countries (here in the form of international aid) are, by and large, unrecipro- cated—at the group level. However, as other scholars have noted (Moore et. al 2017; Bourdieu

1990; Isik 2014) reciprocity, within the confines of asymmetric giving, often takes place in the performance of gratitude. This is in direct contrast to Derrida’s ideal of the unrequited gift

(1992), as the expected performance, itself commodified, both entails and partially fulfills an obligation. Aid’s “ideal subject” (O’Neill 2013) is compliant; acquiescent both in their affective performance of gratitude and “a good heart” and in the more material performances of poverty and ethnicity. The “deserving poor” (Isik 2014) become a marketable commodity.

Gratitude is an expected part of all gift exchange, but in this particular case of unilateral giving, it often took the shape of a performance. Here gratitude was expressed in part, by adapt- ing to the role of aid’s “ideal subject.” Recipients of aid, in addition to carefully navigating the paths in their social networks that could lead to enrollment in NGO programming, also took care to make sure that they were the kind of Mayan NGOs knew donors expected; namely, indigenous, poor, and humble. Uncomplaining. Women and children, mostly. Having a good story helped, especially one that read as tragic but undeserved. Maintaining the relationships that were kept intact in large part because of these performances was of utmost importance. “The influence

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of luck and civil sector patron-client relationships on healthcare access and health outcomes also cannot be overstated; indeed, these findings have been reported in other “aid-saturated” contexts such as Uganda (Scherz 2014; Whyte 2014) and Haiti (James 2012, Schuller 2012)” (Chary and

Rohloff 2015.)

This performance of poverty— stage make-up put on in an effort to play up and emphasize very real problems in ways that are palatable to the eyes of comparatively rich Western donors— was everywhere. These were Halloween masks slipped over the faces of actual monsters to render them visible and easily digestible, poverty itself becoming something consumable, the acts of witnessing and “helping” turned into commodities. The activities of aid became something that could be sold, not just to the recipients of care and child sponsorships, but to donors; as part of the “Guatemalan experience.” Ethnicity, here, was something that could be packaged and marketed. Poverty could be sold. Not only were patients responsible for taking part in this performance of identity, but so were the local staff and community health workers. All Guatemalan women who work for Friends who appeared like they could be indigenous (read: they have brown skin) were required to wear traje to work, even if they never wore it at home. The mandatory wearing of traje is an undue burden on the women for many reasons; not the least of which is that traje is expensive. Traditionally, women make their huipiles themselves for their own use and that of their family, but if you have to buy one even a cheaper huipil can cost around Q350, and can easily run Q500 or higher. In addition to the huipil, the women would also have to obtain a corte and a faja, the long tube-like skirt and the even longer, often handwoven, belt needed to hold it up. This meant that most of the local women who worked for Friends who did not wear traje at home could only afford one suit, and it was not at all uncommon to see women coming in to work early in the morning in clothing still wet from having been washed the night before, standing in front of fans in the chilly office in an attempt to dry the thick layers of fabric.

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Photography (which would then be posted on the organization’s website or on social media) was also strictly monitored and overt efforts were taken to limit and explicitly stage the number of non-indigenous people in any one shot. Aid, here, was quite literally packaged and sold, together with poverty and ethnicity—not to those seeking care, but to those looking to provide it. As such, one “Mayan women”/“person in traje” was just as easily exchanged for another, the markers of poverty, gender and ethnicity valued far over those of personhood, individuals shuffled and easily replaced.

“The Guatemalan females were mandated to wear traje,” Debbie told me, shortly after she had left FHF. “And when someone would send us something, and we’d need a photo of it, that we had received it, she would grab random people to go sit at the sewing machine or sit at the whatever, because they were all wearing traje. And I would hear Liz say shit like, ‘I need somebody in traje!’ and just some random person who worked there would go and take a picture pretending they were like…a lot of times they sponsored students, but I was just like…are you kidding? At first you don’t, quite, believe what you’re seeing, and you think it’s a joke, and then you’re like, ‘no, this is actually legitimately what is happening.’”

At Friends, groups of physicians would often come from the United States or Canada for days at a time to run “jornadas”, or free clinics where people could come (if you could get on the list) to seek primary care. Even physicians who did not practice family medicine or act as PCPs in their home country would practice as primary care physicians for the few days they were in

Guatemala. More than once I heard a foreign doctor (NGO shorthand often refers to them as

“parachuting physicians”) say something along the lines of “I’m an ER doc/ENT/ortho etc.; I never see this kind of thing” before waving over another parachuter for a consult. At Friends, the way that patients arrived at these jornadas was designed not only for flow, but to intentionally

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pack the compound with as many people as possible. Prospective patients weren’t given an appointment time to show up; only a number, and this often meant that many of them spent much of the day waiting to be seen by the visiting physicians. Their medical director had the following to say regarding the practice:

“They make them wait in line for like…they love, they just love, hordes of poor people so that the volunteers feel like they’re making a difference. Like, that— that’s what it’s all about, right? And the jornadas, if there— if there isn’t like, a bunch— basically, what the doctors are saying when they say ‘there isn’t enough patients’ is like ‘there isn’t enough people here that are going to be sitting in a hard plastic chair for the rest of the day without food, like, half of them sitting in the sun, half of them sitting in the rain…like there aren’t enough of them.’ That’s what that means. We need to have enough poor people there so that the volunteers can see, and have the whole ‘Guatemalan experience.’”

Part II: Lost in “the Jagged Landscapes of Aid”

The child she folded into her arms was nothing like the child she had spent the last six months nursing and swaddling and bathing. It was a wide-eyed alien thing; the thinness of its legs and arms made it seem taller than it was, the skin tight and stretched across its ribs and skull, lending it a sense of hideous alertness, even though the small movements of its eyes and chest were sluggish. Stilted. When she picked her up, there was no resistance, no fight left in the small form, and as she tucked her daughter’s head under her own chin and rocked them both, she did so with the knowledge that she was as scared of her child, now, as she was for her. This thing, that had been her daughter, only a few days ago. This thing, she told herself, that was still her daughter, still alive, still breathing, still warm against her throat and chest.

She lowered the child and reached into the slit she had cut in the front of her huipil, cut and hemmed, preparing to be a mother, and freed a breast that was aching and heavy with milk.

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She placed the nipple in her daughter’s mouth, and watched the milk pool, pearl drops tracing the outlines of her daughter’s slack lips before sliding down the side of her cheek, unswallowed and unnoticed. They sat like this for hours, leaning against the mud-brick wall, well into the night, long after they had both grown cold.

“How many pregnancies have you had?” asked the woman in q’ach’abal. The woman looked so neat and professional, Rosa thought, her hair twisted back into a smooth braid, the exact same shade of pink running through the details in her huipil, faja, and corte. Rosa smoothed her own hair, tucking escaped strands behind her ears, and folded her hands in her lap.

She paused, counting. “Eleven.”

“And how many living children?” asked the woman. Rosa stared past the woman’s shoulder at the bloque wall, painted a cheerful yellow.

“Eight,” she answered.

“How many miscarriages?”

“Two.”

“And the last child, what was the cause of death?”

Rosa stared down at her hands as she tried to explain what had happened during those terrifying days, so many years ago. The nights spent trying to get her daughter, once so fat and active and happy, to nurse, the day spent at the Centro de Salud where the doctor gave her pow- dered formula. She had screamed, then, and fought, yelling at the doctor, at Tomás, at anyone who came near. The formula didn’t work, she explained. Her daughter wouldn’t drink. And she filled her diaper constantly; at first a noxious yellow liquid that filled the cloth and dripped past it, running down her thighs, then, nothing but clear liquid, clear liquid with almost no smell. She

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dripped water into the girl’s mouth, bitter teas, hierbas, held her at her breast for hours until her back was aching and her breasts were so swollen they felt like a thing apart.

I did everything they told me to, she tried to explain, and still, she died.

The woman in pink nodded, sympathetic, and apologized for Rosa’s loss. On the form in front of her, as she had hundreds of times before, she wrote “DESC.” in the space provided.

Desconocido. Cause of death: unknown.

Between the Cracks

It’s just past dawn, and I am surrounded by jet-lagged North Americans. We are huddled in groups against the damp, the hoods of our raincoats pulled low to guard against the omnipresent drizzle. These groups of voluntourists seem to have unwritten uniform regulations beyond even their matching t-shirts. They pile into town, always traveling in groups, fresh-faced sons of

Adam and daughters of Eve eager to do some good in their Patagonia and North Face fleeces and rip-stop nylon cargo pants that can be converted into shorts with the draw of a zipper. Tennis shoes. Hiking backpacks, Nalgene bottles, the occasional LifeStraw. Zip-lock baggies of trail mix. Cliff bars. The contents of this van alone could have outfitted a group of Appalachian Trail thru-hikers for a good three months. We all shuffle together in our brightly colored rain jackets, warming our hands on small white styrofoam cups filled with sweetened Nescafé.

The Friends drivers are loading plastic tubs and generic black suitcases filled with medicine and supplies into the back of the FHF vans and trucks. I pat my pocket to check for my meds list; if this trip is anything like the others I’ve been on this year, they’ll run short on ibuprofen, cough syrup and children’s and prenatal vitamins before noon and will be woefully un- derprepared for the plethora of dermatological complaints they are bound to run into. Ivermectin is not something U.S. docs think to pack; they never bring enough bottles of permethrin, and they are usually out of topical antihistamine and steroid creams by the end of the first day. After

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my first jornada I made a list of medications that tend to be needed, as well as their prices, and have added to it since, anticipating that I’ll be sent to fetch meds from a local pharmacy at some point during the day. I wait with the visiting docs, nursing my coffee and chatting. I’d offer to help load the vans, but the drivers have this down to a science and I knew from experience that I would just be in the way.

After about a half hour the trucks have been loaded and the last of the group, yawning and digging into zip-lock baggies filled with trail mix, have arrived and we all pile into the vans.

This particular morning a good friend of mine has volunteered to come along with the translators— he’s volunteered with this group before and is a favorite among the Missouri docs. Luis is tall for a Guatemalan and the kind of thin where clothes wear through at the elbows before they begin to thin out anywhere else. At twenty, he’s still beardless, bright-eyed and baby-faced. He’s also brilliant and insightful, obsessed with U.S. politics and a big fan of Bernie Sanders. He speaks English with a smooth and unobtrusive midwestern accent; if it were not for his clipped and rapid-fire Guatemala City Spanish, you would think he was from Ohio. Luis is also polite, well-mannered and self-assured in a quiet, unassuming way. He inspires trust and confidence, even among strangers, and the Missouri docs who had worked with him before were playing rock-paper-scissors to see who got to have him as their translator for the day. Luis ended up in the optometry station and expressed his disappointment to me as we sat in the back of the van, crammed together against the window furthest from the sliding door, as we were the two thinnest people in the van. “It’s always the same,” he whispered, “optometry. ‘Read this line. Now read this line. Is that better?”

When we got to the aldea we were supposed to be visiting for the day, the line of prospective patients had already filled the courtyard of the compound. Visiting jornadas had been here before; lines had already formed for optometry, dentistry, and primary care. We filed out

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with the others and began to set up; unfolding tables, lining up medications alphabetically and by class, running the pharmacy and intake forms to their stations. Luis and I were elbow-deep in plastic baggies, squinting at cheap plastic reading glasses, unscrewing the lenses with tiny screw- drivers and piling the plastic discs in the center of a rickety card table when we were told to pack everything back up.

“Are we moving the station somewhere else?” I asked.

“No, we’re leaving,” the Friends programmer told us.

“We’re leaving?!” exclaimed Luis. We both glanced out the open door, where we could see dozens and dozens of people who had probably already been waiting for hours to be seen by a provider. “Why?”

Ana Luisa Cotzil is 34, and her eyes are already set with deep lines at the corners, though her hair has less grey than mine and falls in thick waves down past the middle of her back. She lives with her two sisters and their families, all of whom are known for the blue corn tortillas they sell to local restaurants. I like Ana; she can row a cayuco— the hand-hewn wooden boats used by most local fishermen— faster than most men, and she’s always been kind to me, and patient with my questions. I run into her often, and I have never once seen her without a length of embroidery draped over her lap and a needle in her hand. Today is the same; she has brought her latest huipil to work on during our interview. This one is covered with waterfowl. The design is bright and subdued at the same time, flowing across the fabric in a way that reminds me of illustrations I had seen of pre-WWII Japanese kimonos.

As we settle in, Ana smooths her hands over her needlework, which she does in the Santi- ago style, because “it always sells well.” With one finger, she traces the vines that twine through the blue and white striped fabric, heavy with leaves and flowers and berries embroidered in bright cotton threads. The birds on the huipil are shockingly realistic, and I say as much, and she

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pulls a small hardback copy of Audubon’s illustrations out of her bag, a gift from a patron. “This way,” she says, smoothing the lines of one bird’s wing—it is a heron, I think, leggy and white- blue-grey with an orange beak—“you can see where the feathers are, the shape of the body…” she trails off. “Others ask me to teach them now,” she says quietly, smiling.

When Ana was 15, she became pregnant. I don’t know who the father was or if she was married—she is not married now, and reticent to talk about the matter. I do not press. Her son is almost twenty now, and trying to save up enough money to go to college in the city. He has done well in school and she is immensely proud. Today we came to watch her son play tennis in a cracked and abandoned court. On the edge of town there is a property that had been bought by some investors from the States, as the story goes, back in the 1980s. The investors began to build up the lakeside property in the hopes of turning it into a resort. Stories differ— either the money ran dry or the investors were scared off by the violence— but the project was abandoned by the late 1980s, and the clubhouse, gas station, tennis court, and docks now lie empty and half in ruins, crumbling bricks watched over by a single guardian and his herd of beef cattle. 20Q, given to the guardian, with a smile and a polite word, will buy you an hour in the tennis court. The forest now pushes against the tall chain-link fences on three sides, and a field of milpa crowds the other, so you have to be careful where you place your shots. Virginia creeper twines through the chain link as thick and green as Ana’s embroidery and tiny epiphytes dot the half-rotted nets.

“He’s very fast,” I say, watching her son, Raúl, dart back and forth across the court. I can tell just by looking that Raúl is stunted; he is shorter than I am by at least a few inches, maybe topping out at 5’4”. But he is not badly stunted for the area, and this is something Ana, who has been following my project with interest, comments on proudly. “He’s tall,” she says, and winks.

She knows my obsession with peoples’ height, and has only recently come to understand why

I’m always talking about it. Most of the women I’ve spoken to are younger mothers, or, at the

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very least, mothers with young children. Ana has just the one child, which is uncommon enough, and he is older and getting her perspective, in hindsight, on his growth and development is interesting. Ana is happy enough to talk about other people— she’s one of the best sources for chisme in town, and that’s saying something— but she hesitates when talking about her early years with

Raúl. Still, I gather that she sought out aid, especially after her breast milk began to dry up after his second year. There was a playground in town, she said, where people could go for awhile to go see foreigners who would give out baby formula and food. “And then there wasn’t,” she said.

“Did they come back?” I asked. She shook her head.

“No,” she said. “But others did.”

Alan Feldman’ (1994) construct of “cultural anesthesia” is one in which the “generaliz- ing” of bodies as “dead, wounded, starving, diseased, and homeless”, the tagging of broad swathes of populations with specific kinds of suffering, is a form of Othering that allows the rest of us to inflict pain while simultaneously excluding these groups from public discourse. They suffer, that is their lot. They are, to us, their suffering. And when we engage with these groups directly, instead of engaging with them indirectly through our participation as complicit and engaged actors in the structural inequities that often lie at the heart of their suffering, we engage with them as sufferers, and not as individuals. “We are no more interested in the almost six million persons infected with HIV in South Africa than we are in the three million men, women, and children killed over the past decade in the African Great Lakes region. We know they exist because the press tells us so and television shows them to us, but we we feel no need to know more” (Fassin 2007.)

We use language and a truncated view of time and space to distance ourselves from those that suffer and from our own culpability. We speak of “genocide”, thereby “paradoxically dis- tancing ourselves still farther from the events because those accused of committing the atrocities

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seem to have excluded themselves from humanity and their victims, [who] by the very inhuman- ity of the acts perpetrated against them, become inaccessible to us” (Fassin 2007.) We speak of the “history of violence” in Guatemala as if the rates of violent death went down after the war

“officially” ended (they didn’t), of “la violencia” as if it is some horrible foregone era, and not just something that changed form over time but is still ongoing. The U.S. murmurs official apol- ogies for our role in the genocide as if we didn’t still have troops on the ground, training the

Guatemalan military in the art of death-dealing and terror just as we did during the official years of the conflict, and as if we weren’t still using cheap Guatemalan land and labor as a feeder state for our own corporatocracy. The line where violence ends and peace begins is one drawn in chalk, easily washed away and changed at our own convenience. And the lines we draw between ourselves and others, it could be argued, are there solely for the purpose of making ourselves more comfortable with the idea of their suffering. They suffer, that is their lot. It is unfortunate, but they are not us, their suffering is not our own.

This is the kind of logic that allows us to be comfortable with short-term interventions, with the transient nature of week-long trips spent building a school or passing out formula, and then returning home and returning to our roles in the political structures that necessitated aid in the first place. This political anesthesia is fertile ground for neoliberalism, which requires apathy towards our fellow man for its continued justification. “In a state of political anesthesia, which makes us insensitive to the fate of others foremost by making these others appear incomprehensi- ble to us, only difference counts; neither community or reciprocity is possible” (Fassin 2007.)

Anthropologists participate in this Othering when we emphasize difference over similarity and achronicity over continuity, as James Fabian established in Time and the Other (1983.) While

“anthropology emerged and established itself as an allochronic discourse: it is a science of other

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men in another time…anthropology’s Other is, ultimately, other people who are our contempo- raries.”

Paved with Good Intentions

“Left ventricular hypertrophy” I wrote in the margin of my notebook. “Thickening of the heart wall. Young male, shortness of breath, b/p normal.” A handsome but worried young man had just left the pop-up clinic (today we were in a preschool classroom) carrying the sheaf of

ECG printouts he had brought in to show the gringo doctors. He had been complaining of palpi- tations.

“Not as scary as it sounds, apparently.” I added to my notes.

“Cait?” Bonnie, the American physician, called my name.

“Yeah?” I replied, as I finished up my notes from the last consult. I was translating today, supposedly, but Bonnie, who spoke only English, had been paired with a local translator who spoke Spanish, Kaqchikel, Tz’utujil, and English, so I hadn’t really been needed. I was still de- bating pursuing an MD, so I took the opportunity to shadow, and I was only really paying attention to what I guessed would be the more interesting cases. After the young man with the heart issue came in, looking worried as hell and clutching his own ECG printouts (interesting), an older woman had settled into the chair, bent and grey and easily well into her seventh decade

(not interesting). I made the assumption, upon first glance, that she was probably here because of something boring, however necessary, something I had seen before, most likely arthritis or muscle pain or diabetes. Maybe heartburn. The wages of old age.

“Hey, Cait.” Bonnie repeated. She laughed.

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I looked up. Bonnie was neat and clean in her blue scrubs, embroidered with her name and affiliation that had—in some miracle beyond my understanding—managed to arrive in Gua- temala still carrying the press lines from the cleaners. She was good natured and crisply professional, and her shiny brown curls smelled like herbal shampoo.

“I think we might need your help with this one,” Bonnie told me.

I set down my notes.

Bonnie was laughing and smiling, but I could tell in an instant that she must have misread the situation, whatever was going on. Her translator, Aracely, a local woman who had studied

English and tourism at the Universidad San Carlos in Guatemala City, looked upset and harried, her kind, plump face twisted into a worried frown.

I looked over at the patient. She was looking down, staring at her hands.

“What’s going on?” I asked Bonnie.

“Well,” Bonnie laughed again, loudly. “Aracely says that this woman hasn’t been feeling well since she murdered her husband. But,” she laughed again, “that can’t be right.”

I knew Aracely; she was a regular at the church I sometimes attended in town, and she liked to practice her English with me. We went to market together, where she had shown me where to buy the best fish, and had let me know that I had been overpaying for embroidery floss, shaking her finger as she scolded the woman behind the counter who had over-charged me. Ara- cely’s English was very good, but many people who learn a second or third language (and Eng- lish was Aracely’s fourth) have some ticks that they have problems ironing out; tiny little things that mark them as being non-native speakers, no matter how smooth their accent. Aracely had a problem with pronouns. He, she, it, they, them; she often mixed them up, making more mistakes whenever she was nervous or excited. As do we all.

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I could guess what had happened, and Bonnie, by laughing at what she had assumed had been an amusing translation error, could not have reacted to the situation in a more unfortunate way.

I met Aracely’s eyes across the table. She nodded. We’d worked as a team before, translating in sync whenever something particularly complex or jargon-filled called for it. Moreover, we were friends, and I could read Aracely’s face well enough to know that she was asking for emotional back-up on this one more than she needed any technical assistance. She didn’t need my language skills (which are far less impressive than hers are, anyway.) She needed my friendship. A silent agreement had passed between us in that nod, and slowly, we began to tell the woman’s story. Aracely asked the woman questions in Kaqchikel, her voice low and kind, re- peating her words back to me in Spanish, after which I would translate them into English for

Bonnie, word for word, as best I could. Slow and methodical, unhurried for once in the rushed and crowded clinic. The patient looked over at me once or twice while Aracely repeated her own words back to me, staring at me with a focus that led me to believe that she understood Spanish perfectly well, even if she chose not to speak it. I understood some of her Kaqchikel; enough to grasp the shape of her words, if not the nuance, just enough that I was struggling to keep my voice even as I relayed her words to the physician.

Her eyes were filmed over, cloudy with cataracts and sunken into the lines of her face by dehydration. Her hands shook as she told the story.

One day, she told us, a little over a year ago, her husband had been killed while walking to town. She didn’t know why they killed him, she told us. He didn’t have anything of value, but they had killed him, all the same. They had beaten him to death and left him in the tall grass by the side of the road. Since they found the body, she told us, she has not been able to sleep, and her bones hurt, all the time.

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She told us this in a flat monotone, her voice moving forward at an even clip, quiet, care- less, entirely without depth or inflection, with no more emotion than it takes to recite a grocery list. The woman stared at the wall behind the doctor as she spoke, neither her voice nor her gaze wavering, her hands woven together beneath the table.

I looked over at Aracely. Tears had pooled at the sides of her nose.

I reached beneath the table and laid my hand on top of the patient’s. Her hand was dry and cool and no longer shaking.

“I’m so sorry, nan,” I whispered. I didn’t know what else to do.

She didn’t respond.

I looked over at Bonnie.

“Is this for real?” she asked me.

“Only 10% of homicides result in an arrest here,” I told her, citing a figure I had read.

“Violent deaths have actually increased since the end of the civil war.”

“Ah.” Bonnie paused, seemingly at a loss for words. She recovered quickly, however, her professional veneer snapping back into place, the confusion in her features smoothed over by a studied neutrality.

“Does she have any stomach problems?” she asked Aracely.

Aracely asked the woman; she shook her head.

“No?” said Bonnie. “Ok, good. Tell her I can give her some ibuprofen for the pain.

Here’s the script.” She handed the “script” to Aracely, a small piece of laminated yellow paper.

They had these for the most common prescriptions, color-coded; yellow for ibuprofen, green for tylenol, purple for omeprisole. Complicated problems in a complex situation, distilled into answers that could be neatly filed and coded by color.

“Next patient,” Bonnie said to the volunteer nearest the door.

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“Privately Organized Bureaucratic Failure”

Food-based aid, linked as it often is with either local NGOs (who often go defunct or change their programming); nutritional trials or interventions (cf. Nutrinet or the longitudinal IN-

CAP trials); as an addendum to primary health care programs or visiting jornadas, in which case the food often dries up soon after the groups leave; as a publicity campaign for large companies

(Gallo and Incaparina); or as a way to drum up votes for a particular administration (Hambre

Cero) is very often patchy and transient. Children who are enrolled in programming one month are often unable to continue that enrollment as time goes on. In some cases, the food-based aid is for show only, part advertising and part political campaign for the company-families of the Gua- temalan oligarchy. I ran into two young people working for Gallo’s nutritional campaign (Gallo is a Guatemalan beer company) in an aldea above Tz’anabaj. They were wandering through the town, tricked out in head-to-toe Gallo gear; red clipboards, jackets, polo shirts and caps all emblazoned with the Gallo logo. When they showed me the nutritional center; a one-room bloque and lamina building with one long table in the middle, it was dark and empty. The table was set with placemats and bowls; both were emblazoned with the red-and-gold-and-black Gallo label.

The back wall was stacked with what must have been several dozen cases of Chocokrispis, the

Latin American version of Cocopuffs, all still in their plastic wrapping and stacked on wooden pallets. It was obvious that in this instance, at least, Gallo was capitalizing on the perception of being involved in aid and had very little interest in efficacy.

Information about the nutritional crisis in Guatemala is hard to avoid. Colorful adverts for

Incaparina, Corazon de Trigo, Quaker Mush and other fortified atoles are plastered to the walls of every tiendita, and it’s impossible to turn on the radio without hearing the jingle for Incapa- rina. “Toma Incaparina…todo los días”. Hambre Cero has dominated the news the past few years. Millions of dollars have been thrown at the issue since the Millennium Development

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Goals but rates of stunting have remained more or less steady. And the very existence of the problem and the commodification of aid allows for groups and individuals with agendas beyond simply ameliorating chronic malnutrition to capitalize on the popularity of the issue in the public consciousness to their own ends; what Vincanne Adams refers to as “the inefficiencies of profit.”

“When government funds allocated for relief are funneled through private for-profit companies on their way to being distributed to victims of disaster,” Adams writes, “something happens to the money. The interference of competing demands of the market can impede operations, pulling resources in other directions than downward to the recipients who are in need. What we see herein is an example of a privately organized, publicly funded bureaucratic failure.” (Adams

2013.) The same can be said for non-profits; especially ones, like those in Guatemala, that go largely—if not entirely—unregulated. NGOs in Guatemala, overwhelmingly, rely on donations from foreign donors for much of their revenue, and operate almost exclusively within the affect economy, which Vincanne Adams defines as an “economy based on the circulation of an affective surplus—the emotional responsiveness and ethical inducement to action generated by a recognition of an ongoing need” (Adams 2013.) As such, Friends’s jornadas were, in Lydia’s words, “as much about cultivating donors as they were [about] providing healthcare…more so the former than the latter.

When healthcare becomes more about providing a service to healthcare providers than it is about providing care to patients, there are obvious implications for the quality of patient care.

When this phenomenon is combined with foreign donors’ expectations of what poverty looks like on the ground in rural Guatemala—including the construction of an exoticed “other”—issues of presentation, gate-keeping, and performance come to the forefront.

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I asked Luis, later, to tell me the story of that morning in San Jorge, in his own words.

“Cuéntame,” I asked him. “Tell me what happened.” What follows is a partial transcript of that conversation.

Luis: We got to San Jorge at about 8:30, in the morning. We think that there were people waiting there at least— maybe around two hours, some of them. There was a line when we got there of maybe fifty patients, so we unequipped all the equipment, like literally, we moved everything inside, there were just some suitcases that we needed to put inside and there was already a line of patients waiting outside the door, basically like if the clinic was running but nobody was inside the building yet, in terms of patients. And by the time that the organizers of Friends suggested that we should move the clinic there were at least a hundred people, maybe more. And we’re talking about mothers, children, elderly people— were just waiting there. After maybe 9:30 they had a group meeting with all of the translators and all the doctors and they said “pack up, we’re going to Nahualá, so pack up the whole clinic” and so some of the translators were just like “oh, sorry, we’re leaving, we can’t do this, lah di dah”— it wasn’t well taken care of, at all.

Me: How did the patients respond? How did the patients respond when the translator told them they couldn’t be seen?

Luis: The patients seemed surprised, like they couldn’t believe that we were just going to leave. They had expected treatment and all of a sudden we decide to leave with no ex- planation. They didn’t do anything in return. We didn’t come back that week. We were supposed to go back to treat them, uh, a couple days from then, and we never went back. We did a clinic somewhere else as well.

Me: Were they informed that you were going to come back? Did they come back later that week and were lining up a six o’clock in the morning to be seen?

Luis: No, uh, we didn’t come back, at all.

Me: I know, but did they know that? The patients? Did anyone tell them?

Luis: Um, I don’t know if the patients…I don’t know if they had informed them, again, that we were going to come back, but I wouldn’t be surprised if they had told them “yeah, we’ll come back on Thursday”, because at least all the translators— we all thought that we were coming back on Thursday and then we went to the office on Thursday and they were like, “no, we’re going to San Tomás, we’re not going to go there anymore.”

At this point Luis, who is normally so even-keeled as to border on diplomatic, became frustrated. He told me that this kind of behavior hadn’t been an uncommon occurrence during his time volunteering as a translator.

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Luis: there’s been some instances where the doctors might not act properly with the patients, and, uh, it just seems like they’re here more on a tourist trip, which I hate, I don’t know, I just feel like there was this one instance, for example, where we went to one of the towns in Sololá, it was Santa Maria, Santa Maria la Laguna, and uh, we had arrived, we started unpacking for a group of maybe 100, 150 patients, indigenous patients that we were there to see, and it was a really tight place, the school we were in, we were setting up the clinic there, and the doctors weren’t too comfortable with it, there were, I think, just a couple bathrooms, they were uncomfortable with the building, so when another group had contacted them that same morning and said, suggested that they could do it in their town, since it was a little bit bigger of a facility, they decided to pack up all of their equipment, after getting all of the patients there thinking that they were going to get their treatment, they decided to go to a different town, probably because of, uh, political reasons within the organization and with the groups that they go visit.

Me: And the patients had already been waiting there?

Luis: The patients had been waiting there, probably since the morning and they skipped on; most of them had skipped on the work they had to do that day…it’s not like they take breaks, overall they’re all working people

Me: So they’d already bought in?

Luis: Yeah, they’d already bought in. They’d been waiting for hours, we’re talking about low- income patients that, in which that medical help would have benefited them greatly and that’s like maybe the only medical help that they can get

Me: And none of the patients were seen or treated?

Luis: No.

Me: And how did the doctors respond to this? Was this the doctors’ choice to move, or was it the organization’s?

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Luis: Uh, the main organizers [redacted], they went to the group leader, this doctor from— yeah, they went to the group leader, basically, and had suggested that the people in To- dos Santos, the patients that they actually gave the treatment to, uh, were ready to see them and that they should come up and see them that same day, so then, like, the medical group didn’t even hesitate, of course, but it was suggested by the organizers.

Me: And did the doctors, did anyone speak as to how this could possibly be unfair to the patients? Did the doctors say anything? Did the group say anything?

Luis: No, the group or the doctors didn’t mention anything, they didn’t think anything wrong had happened, they didn’t even notice, they didn’t seem to care.

This is only one example—and not an uncommon one—of how people seeking access to care can become lost in the cracks in a pluralistic and overtaxed system.

Where There Are No Patients

It was exhausting. Nothing ever got done, because I was always strategizing. I was like, oh. Well, shit. I just want to take care of people; I just want to set things up, do whatever I need to do to set things up, and, like, have it all well-oiled and ready to go, and have Guatemalans running this clinic and taking care of what they need to take care of. They do it best. But there was this like, ‘oh we should have this, we should have that’— like, why don’t you ask people what they want? Like, nobody asked people what they needed. We did a needs assessment— I was the first person to orches- trate a needs assessment. Nobody had ever looked at what the population needed. So my very first couple of months there, I was like ‘we need to find out what we need. We’ve got to start from scratch.’ Because people were just— that’s why the big problem of ‘there are no patients here’, because it wasn’t needed then. Right? There are no patients in this line-up because it’s not needed. So I was like, let’s create a needs assessment and see, like, from multiple sources, right? And then let’s test this? Let’s small-scale test this and see if this—if this is what our students and our families would want, but it was like fighting tooth and nail, because they wanted to have things tangi- ble and right now. —RN, Friends Helping Friends

James Ferguson’s (1990) critique of development in Lesotho outlined “technical failures” in aid that served to obscure the political stakes of the actors involved in developmental organizations and of the organizations themselves. When NGOs are encouraged, by necessity, to design

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their programming around serving donors, rather than the beneficiaries of aid, we’re left wondering who, exactly, the NGO is for. In the above case of “Friends”, we see that the beneficiaries of

Friends’ programming—while they are still very much competing for and receiving essential services—have themselves become the commodity that is being sold by the NGO to prospective donors. The political stakes of the organization become hidden behind the moral imaginaries of what aid means in the eyes of donors and affect workers and the rhetoric of “doing good”; obscured and unassailable behind a wall of well-meaning individuals.

The constant shifting of institutional priorities and the demand for performance it places upon those who seek out care in the context of endemic chronic disease can further obscure both the political stakes of the organizations involved and the underlying inequalities that necessitated aid in the first place; a discourse whose “technical failures” (Ferguson 1990) tend to isolate the

“underdeveloped”, reifying them as such, neatly constrained within what Troulliot would call the

“savage slot” (2003.) The donor-driven chaos guiding NGO programming makes it easier to fall through the cracks in an already haphazard and unpredictable healthcare system, sometimes leaving the most vulnerable behind simply because they fail to fit an expected pattern.

For many, NGOs are the gateway to primary care; a gate that they perceive to be closed to everyone but a select few. Navigating aid becomes an exercise in renegotiation; an attempt to realign your own multiple identities in order to fit the profile of what short-term medical missions and foreign donors conceive of as the “right kind of poor”, or the “right kind of Guatema- lan.” Being perceived as “too poor” or “not poor enough”; not being indigenous or performing your indigeneity in an unexpected way; not wearing the right clothes, wearing make-up, shoes, having the wrong hair-cut; not having the right connections, or putting on an inadequate performance of humility, chastity, or above all, gratitude, is enough to deny one access to potentially life-saving care. In the case of healthcare in rural Guatemala, what it means to be “deserving” of

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care—and even what it means to be “Guatemalan” or “Mayan”—is often defined, not by rural

Guatemalans themselves, but by foreign donors and visiting U.S. physicians and nurses whose tenure in the country is often only a few weeks long.

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INDIVISIBILITY

She knew them by the rhythm of their speech, brought to her in brief snatches by the wind long before they ever approached her stall. Words that fell to the ground and then bounced back up, like the sound of rain on lamina, were Kaqchikeles, from across the lake. Her own voice, that of the Tz’utujiles, of her people, of her mother and father and sisters, sounded like splashing; playful splashing, most of the time, like children playing in the shallows; at other times frantic and fierce and determined- fish fighting at the end of a line. From a distance Spanish hissed and rasped, the susurrus of an animal moving through tall grass. English drummed, loud and in- sistent; fruit falling into the bottom of a basket. As they came, she bounced and splashed and hissed in turn, and even tried wrapping her mouth around the truncated gulping grunts of Q’an- chi’, though it made the edges of her lips feel stretched and thin and left a hollow space under her tongue that hadn’t been there before.

The feria brought color, light and noise to the normally grey and somber church square.

The streets surrounding the cathedral were so tightly packed with people that Marisela imagined that she could cross all the way from her booth to the church steps, if she wanted to, without ever once touching the ground, jumping lightly from shoulder to shoulder, swinging herself from glossy black braids like a monkey. The church herself stood sentinel, ever reproachful in its dominating whitewashed facade, looming over everyone in the square like an emperor penguin over his egg. Red banners hung from the cathedral’s vaulted ceiling, spilling onto the front steps, pinned to the concrete steps by cairns of small rocks piled just outside the church’s massive wooden doors. Pigeons perched on the heads of the saints that guarded the walls, dusting their plaster sandals with grey and white.

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The walls and galleys and walkways of the church were filled with light, the doors thrown open to the people and the day. Today the church was dwarfed by the rueda de Chicago erected at her feet. Screams of fear and joy and some mix of the two echoed far above the bell tower.

Dozens of crude wooden structures had sprung up overnight, hung with lights and streamers. Children’s toys, ladies’ sandals dotted with plastic jewels and fake flowers, t-shirts, huipiles, fajas, pizza cut into thin rectangles, growing stale and hardened under hot lights. There were enough fried-chicken-and-french-fries carts, wheeled in along with their flaking blue and silver tanks of propane, that the air felt heavy with grease. The stand across from her own was selling refrescos, ladled into plastic bags from large clear containers, spun and tied shut around purple straws with small, deft fingers. The container holding tepache was filled with dead bees, she saw, their small brown bodies floating among the chunks of fermented pineapple.

Marisela sold golosinas, foil-wrapped chocolates, bars of coconut and sugar dusted with yet more coconut and sugar, dried fruit dipped in chocolate, balls of popcorn died bright pink and glued together with syrup. She wanted to try the marzipan fruits, which looked so delicate and sweet in their stiff plastic wrapping, like kinder, less complicated versions of life made small.

Her hands stroked the stiff plastic wrapping as she passed, but she couldn’t afford her own wares, those of her father. Whatever didn’t sell today would be packed carefully away, sold to other vendors, or kept guarded against insects and dust for the year to come.

By mid-afternoon the sun had broken free of the clouds and the crowds thinned a little, retreating to the shade to return in the evening. Selma came, late as always, smiling at her little sister as she tied her lantal around her waist. “Vete,” she said, shooing Marisela out from behind the booth. “Have some fun.”

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Marisela hadn’t made it halfway to the church before he found her. He always found her, sooner or later, but never when she expected it, startling her like a light thrown on in the middle of the night.

“Good afternoon, Santiago”, Marisela said, keeping her eyes fixed on the church steps.

“How are you?”

“Puro ütz,” he said, and laughed, quoting the line used by some of the gringos who lived here, who called themselves, Marisela knew, “locals”, though they weren’t and would never be.

When Marisela didn’t laugh, he continued in Tz’utujil. “Walk with me,” he said, wrapping his fingers around her forearm.

“I was going to church,” she protested, and he pulled on her arm, his fingers pressing into her skin.

“You’re always going to church,” he said. “Walk with me. Let me buy you a fortune.”

The pajaro de suerte was already outside of its cage when they arrived at the fortune- teller, perched just outside the drawbridge outside of its tiny palace, head tilted, dark eyes bright against soft yellow and white feathers. Santiago gave the pajarito’s keeper diez centavos, the coin a sliver of bright silver in his cracked brown palm, and the luck-bird chose Marisela’s fortune, hopping forward to pull a small roll of white paper from the neatly arranged assortment in front of him.

The keeper handed the paper to Marisela, and she unrolled it, squinting against the sunlight at the minuscule red lettering.

“What does it say?” asked Santiago.

Marisela squinted at the fortune, stumbling over some of the words in her mind. She had left school two years ago, only a few weeks after she had bled for the first time, red tracks wind- ing down the inside of her thighs and staining the back of her corte. She had thought she was

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pregnant when it happened that first time, remembering that her mother had bled from the same place when her brother was born, her thighs slick and sticky and red, her body hot to the touch and smelling of sweat and blood, hot wet metal, like when the neighbors had butchered their pig.

Her brother had come into the world warm and purple and silent, and they had buried them together.

“What does it say?” Santiago asked again.

Marisela thought of Selma, her sister, married only a year after mother had died, another year when the rains hadn’t come in time and they hadn’t been able to afford to buy firewood, father leaving the house early in the morning to cut wood in the mountains, sometimes not coming back for days. She thought of the marks she had seen on Selma’s neck and shoulders, blue and black and yellow and brown, visible only when her shawl slipped while she was working. She thought of Selma’s belly, swollen and ripe beneath the layers of lace and embroidery on her lantal. She thought of the smile Selma always wore now for her little sister, the smile that was always there, the one that lifted her lips but not her eyes.

“What does it say?” Santiago asked again, his fingers digging into her arm. The pajarito’s keeper turned away, seeing nothing. In a small town, everyone sees everything and nothing; says everything and nothing at all.

Marisela looked up, meeting Santiago’s eyes, and smiled. When he smiled back, she could see the gold in his front teeth. The white stubble on his jaw caught the sun.

“It’s nothing,” she said, forcing herself to laugh. “Nothing important.” The pressure on her arm eased, and Santiago turned and walked back to the booth to meet with her father, who had just arrived and was rearranging the golosinas in the front of the cart into neat pyramids.

With only two weeks until the wedding, they had a lot to talk about.

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Marisela watched Santiago speak to her father, grizzled heads bent together. Selma was talking to a customer, laughing, her hand cupping her belly. While no one was watching

Marisela let the fortune fall from her hand to the ground, the thin slip of paper quickly disinte- grating in the water and the mud, ground against the cobblestones by shoe after shoe until it was if it had never existed at all.

Young, Poor, Mother, Child

Resignation.

Aracely sits on a pink plastic banca at a table in front of the house she shared, briefly, with her husband, who is 23 years her senior. She was eleven when they married, and when she was four months pregnant her husband left, claiming the child she carried wasn’t his. Now, at 14, she is “resigned to being a single mother.” In the picture, she holds her son against her breast with one arm, her left hand picking the kernels from several ears of dried corn in a dark blue guacal on the table in front of her. She looks her age; dark hair pulled back from wide eyes and an unlined brow, her cheekbones still buried under the last vestiges of pre-pubescent fat pads, despite her thin limbs and frame. Aracely looks every bit the awkward, gangly adolescent, all elbows and sharp angles, the only soft spot on her frame her breasts, incongruously swollen and round against the dark bony shadows of her chest, pale and marbled by thin blue veins. “I thought I’d have a better life,” she told the photographer. “But in the end, it didn’t turn out that way.”

Sadness.

Carmen, 14, stands in the milpa in the early evening, watching the sun go down above the tall leaves. Three months pregnant, she crosses her thin arms over her waist, just beginning to thicken, under breasts that are newly tender. After her wedding, she left her parent’s house to

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move into the home of her in-laws, a palapa-covered one-room house nestled into a valley deep in the Petén. “I was in school until fifth grade, when I got married. I have been raising my chickens to kill them when the baby is born. I was sad because I didn’t want to be pregnant. I was just sad, I don’t know why.”

Sulmi, 14, stands half in shadow in the open doorway of her pine-board-and-bamboo- home. Her hair is pulled back from her face in a short ponytail, and she stands awkwardly, the fingers of one hand splayed in front of her face, the other arm left dangling, tucked up against the swollen mound of her nine-month pregnant belly. Her new mother-in-law’s dark frame blocks much of the light from the door, and the kitchen is poorly lit, leaving only darkness at Sulmi’s back. “My family was a little sad when I got married,” she told the team. “They said I was really little and it’s a lot of responsibility to take care of someone. I was a little sad to be married so young. I am the youngest in my family to be in a union. Getting married is a lot better and pret- tier because you get to wear a big white dress.”

Exhaustion.

The walls outside the neonatal intensive care unit are painted apple-green, a color that was probably intended to be cheerful. Two large windows, closed and partially obscured by green and yellow curtains, separate the unit from the viewing area outside. Inside, the walls are painted a soft yellow, and the room is brightly lit. Rosario, 14, stands in the dimply-lit hallway on the other side of the windows, and leans against the wall. She is staring, her left cheek resting against her forearm, looking not at her newborn, who lies swaddled in an incubator on the other side of the glass, but at the apple-green wall, only a few inches away.

Saida, 14, holds her infant son in her arms as she sits on the concrete wall of the clinic’s front porch. She sits, without moving, feet planted, her gaze soft and fixed on some point in the middle distance. There are deep circles under her eyes. “Motherhood is hard,” she said. “When

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they get sick, you don’t know why. I don’t have experience and I don’t know what to do with him, probably because of my age. I sleep very little. He doesn’t cry much, but he wants to be held all the time.”

Hope.

Manuela sits in the waiting room at the San Benito Youth clinic, balancing her one-year old daughter, Dani, on her knee. Married at 12 and now 14, she traveled two hours to the clinic from the home she shares with her husband and daughter to learn about family planning.

Daylin, 15, and Rubin, 17, huddle together as they gaze at their son through the windows of the neonatal intensive care unit. He’s being swaddled by a nurse, his hand wrapped in band- ages to hold the intravenous port in place that’s been inserted into the vein on the back of his left hand, the only one large enough to take a needle. At three pounds, he’s tiny, long and thin, and the premie diaper, the smallest the hospital has in stock, rises halfway up his back.

Soyla, 15, stands in the narrow doorway cut from the unfinished pine planks of her new home. Her daughter is in her arms, wrapped in blue, and Soyla has a burp cloth, yellow, draped across her shoulders and over the crown of her head, giving the photo a serendipitous Madonna- and-child vibe. Sunlight filters through the slots in the unfinished boards that frame out the house, giving the young mother a haphazard and unintentional halo. “I went to school until the fifth grade,” she said. “I was 14 when I was married. My husband is 21. It’s a girl. I want to give her everything. I want her to study.”

Her daughter is a newborn, only a few days old.

On February 6, 2015, Stephanie Sinclair’s photoessay on child marriage in Guatemala

(part of a series that had earlier taken her to Afghanistan, Nepal and Nigeria) was published in the Sunday edition of the New York Times. Sinclair is a Pulitzer-prize winning photojournalist,

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and her photos, which I’ve described above (the quotations are from the children she photo- graphed) are haunting and evocative snapshots of the lives of young women who married and gave birth well before their mid-teens. Guatemala has, perhaps unsurprisingly, a high rate of child marriage. This is in keeping with international trends— the Population Reference Bureau’s

2011 Policy Brief on the subject of child marriage reviewed the available data from developing countries (from available demographic health surveys and multiple indicator cluster surveys) and found that 58 million women in developing countries had been married before the age of 18, a figure that roughly equates to 1 in 3 women. 1 in 9 young adolescent girls had been married between the ages of 10 and 14. There were vast regional differences within countries in the rate of child marriage; on the whole, rates were higher in rural areas than they were in urban areas, and higher in poorer regions than in wealthier ones.

In addition to negatively impacting nearly every Millennium Development goal (of de- creasing rates of poverty, illiteracy, and discrimination against women and minorities) in addition to international agreements on the rights of women and children (as outlined in CEDAW and the UN CRC) child marriage has a very real and very lasting—even intergenerational—impact on the health of women and their families. JAMA (Hampton, 2010) reported extremely high rates of maternal mortality among child brides; Raj et al. (2009) found that child marriage is also significantly associated with multiple unwanted pregnancies, multiple births within a 24 month period, high fertility (3 or more births), and no contraceptive use before first pregnancy in India.

Another survey by the same team of the available data from 97 countries found increased preva- lences of maternal and infant morbidity and mortality across the board (Raj and Boehmer 2013.)

Childbirth in young adolescent mothers can also lead to obstetric fistulas, which in rural areas often go unrepaired, leading to incontinence and to ostracism within the community (Miller, et al. 2005.) Girls giving birth under the age of 15 are five times more likely to die during childbirth

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(UNFPA 2010) and the contextual vulnerabilities of child marriage leading to physical and mental health consequences are incredibly high (Raj 2010.)

In places where globalization has led to a shift in nutrition and healthcare, the liminal state of the “overlapping health transition” (Osmani and Sen 2003) between the high prevalence of infectious disease and the second epidemiological transition’s high prevalence of chronic disease as major players in morbidity and mortality have led to what Siddiq Osmani and Amartya

Sen (2003) have called a “double jeopardy” exacerbated in large part by gender inequality: “gender inequality exacerbates the old regime of diseases among the less affluent through the pathway of child undernutrition. At the same time, it also exacerbates the new regime of diseases among the relatively more affluent…Gender inequality thus leads to a double jeopardy: simultaneously aggravating both regimes of diseases and thus raising the economic cost of [the] overlapping health transition” (Osmani and Sen 2003.)

Socioeconomic inequality between men and women has also been linked to long-term consequences for women’s health at both macro- (country) and micro- (household and individual) levels (Moss 2002.) Additionally, a review of the available data on 2.24 million children in

38 developing countries suggested that child health is very strongly associated with maternal health (Bhalotra and Rawlings 2011), indicating that there is an intergenerational component to the negative consequences for health and human capital caused by gendered inequities. Bhalotra and Rawlings called this the “hidden penalty” of gender inequality (2011.)

In the Guatemalan context, the “feminization of poverty” (Chant 2006; Durbin 1999) can be seen in the perhaps-unsurprisingly high rate of child marriage (20% of all children are born to adolescent females (INE 2014)); younger girls to older men. However, understanding gendered inequities in rural Guatemala as they exist currently demands at least a basic understanding of

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the multiple histories of violence that have served to construct the intersecting inequalities of being poor, rural, indigenous and a woman.

If you extend the discussion to monographs covering the civil war and its aftermath, then

Guatemala’s history of conquest has very much dominated the anthropological literature of the region. From Sol Tax’s depiction of “native” life as one very much defined by a “heritage of conquest” (1952); to Oliver La Farge painting a picture of “Kanjobal Indians” as “eternally chaf- ing under the yoke of conquest and never forgetting that they are a conquered people” (1947) to

Harvest of Violence’s (1988) recitation of the horrors of the civil war, the history of ethnographic discourse in Guatemala has very much looked back more than it has looked forward, and, it could be argued, of a necessity emphasized discussions of structure over those of agency.

“To identify the indigenous,” writes Metz (2006) “is often to identify generations of people who have been wronged by colonialism.”

To be fair, the history of “Guatemala” is very much one of colonialism; “Mayans com- prised many communities, identities and languages, all agreed in their wish to keep themselves to themselves. ‘Guatemala’ was a theory devised and imposed on them by others” (Chapman

2007.) And Guatemala’s health and the health of its citizens can’t be understood if taken out of its context as a postcolony of Spain and as a feeder state for the stronger imperialist nation to the north, in what Peter Benson would call “a bad conscience of justice” (Chary and Rohloff 2015.)

When speaking of culpability and “responsibility” for the state of care (and lack of it) within the state of Guatemala’s pluralized healthcare systems, he asks:

Does accountability reside within the family and the immediate community? Does responsibility belong to private organizations that…provide care? Can we talk about responsibility as something that is more thoroughly social and historical and more interestingly transverse? Can we implicate the United States, which ousted a democratically-elected Guatemalan president in 1954 because the economic interested of U.S, corporations were at stake? Should we consider the fact that this coup helped to launch the long Guatemalan civil war? Does Spain owe something in the way of

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healthcare, education, or responsibility…because of its long history of stripping Gua- temala of resources? …These are questions about responsibility that take history and geopolitics seriously and see structural violence not so much as an analytical framework but a long-lived reality. (Benson 2015, in Chary and Rohloff 2015)

Situating the knowledges of stunting among the different actors at play in its continued prevalence means having at least a basic understanding of the embedded histories in which they find themselves. Much of the nutritional programming in rural Guatemala is designed around the individual/authoritative approach to healthcare programming, in which “expert helpers” are des- ignated authorities responsible for teaching and “persuasion”, and primary caretakers are understood to be individuals capable of acting autonomously. Within the individual/authoritative approach to healthcare promotion, “the responsibility for ensuring good health rests on the individual” (Bunton, Nettleton and Burrows 1995)

While still a major component in health promotion—education-only based nutritional programming remains exceedingly popular among Guatemalan NGOs—the individual/authoritative approach to nutritional programming in the Guatemalan context is flawed not only in its failure to consider structural constraints on agency, but also in its guiding assumption of “the individual” as an autonomous unit. Understanding the indivisibility of poor, rural Guatemalan women (especially young mothers) from their own personal embedded histories, the larger structures in which they find themselves, and their families and communities requires an understanding of Guatemalan history of colonial and postcolonial violence.

Under Spain’s guidance, the Catholic Church played a major part in the Spanish colonial conquest of Latin America, using their familiar dual tactics of conversion and violence. Once converted, the gendered division of labor that existed in among the Precolumbian Maya was reinforced and amplified by the Church, which regarded “good” women primarily as wives, and good wives as humble, obedient, modest, and, above all: chaste. The colonial Catholic model of

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femininity was primarily one of passivity and unquestioning obedience to men; one’s father, husband, and, through the Church, one’s father in heaven. Earlier politheistic religions that had emphasized the interdependence of male and female roles were replaced by a single, male, god; and the new paradigm largely became one of female dependence upon, and submission to, male authority. Behaviors that threatened this paradigm of dependence and humility, including female promiscuity or “deviance” from expected norms of behavior were punished, sometimes severely

(Few 1997; Schwaller 2011.)

The gendered politics of sexuality continued through the colonial period, as property owners of European descent, espousing the eugenecist ideas common at the time, sought to “en- whiten” (blaqueamiento) the country through interbreeding with the indigenous population. Do- ing so while ensuring that hereditary access to political power and wealth remained in the hands of the Spanish elite was enacted culturally through the control of white women’s bodies and reproduction. Women of Spanish descent (criollos) and those born on the continent (peninsulares) became the “biological ‘repositories’ of descent systems” (Smith 1995) and their sexuality was closely guarded. Simultaneously, there was a systematic disinheritance of any children born of

“mixed” unions. In direct contrast to the guardedness of white women’s sexuality, indigenous women’s bodies were “hyper-sexualized” and they were often subject to rape, concubinage, or forced unions with white men, any children of which would be considered illegitimate (Smith

1995.) “Whites would allow their sons to have a sexual relationship with an Indian woman only if it were extramarital. They would never allow their daughters to have such a relationship” (Nel- son 1999.) “A fact admitted by the entire community…is the right of sexual access and the fact of rape that plantation owners exercise over the indigenous women on their fincas” (Casaus Arzú

1992.) By the 16th century, the words “mestizo” and “illegitimate” had become interchangeable

(Casasu Arzú 1992.)

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Even in cases where unions were consensual (assuming “consent” is possible in such a dynamic) the “racialized fantasy [where] indigenous women are to be impregnated by but never legally married to whiter men” (Nelson 1999) pervaded. This can be seen in the cautionary Mex- ican legend of “La Llorona”, or in the way the history of Cortés’ Nahual mistress, La Ma- linche/Doña María, widely considered the mother of the first mestizos, has become linguistic shorthand for malcontent (in either “malinchista”; a denigratory term for Mexicans who idolize all things gringo, or in “La Chingada/la chingada”—“the fucked one”, which in addition to being immortalized in Octavio Paz’ “Labyrinth of Solitude” has also become a common (and beauti- fully flexible) slang for all things awful), and in the Central American legends of La Siguanaba and El Sombrerón. (Fun fact: the legends of La Siguanaba, El Sombrerón and el cadejo remain so prevalent to this day in Guatemala that all three tales were featured on disposable Taco Bell cups in Guatemala City in October 2016.) The story of El Sombrerón is particularly apt, as the legend describes him as a charming, guitar-playing ladino man who preys on indigenous girls after dark. If you fall for his charms, you are warned, he will bring you home and feed you a plate of soil which will leave you unable to sleep or eat. In my own work, I have been told that the perceived rights of ladino men over the bodies of indigenous women (where men of European descent “are seduced as much by the absolute power of their racial and sexual advantage as by their partner’s sexual charms” (Sommer 1991) is still a common sexual fantasy. While driving through Guatemala City, a friend of mine pointed out that the brothels on the outskirts of town often exist in clusters of two, one next door to the other. One of them, he said, was for “normal” prostitutes, and the other, for women in traje. “Even though,” he added, “most of these women are not even Guatemalan, but trafficked in from further South.”

The racing- and gendering- of indigenous women’s sexuality has been covered extensively by other scholars. Since in “Guatemala’s ideal race-and-gender matrix, mestizos would

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only ever be born of indigenous women out of wedlock” (Nelson 1999), affecting both their social and legal standing, “impurity” of blood (Stolke 1993) became something inherited from indigenous mothers and was conflated with a lack of status, with poverty, and with the still-common ideology of “el indio sucio” (Hale 2006.) The colonial ideals of the superiority of European descent, the inferiority of indigenous descent, and constructions of maleness as hyper-virile, authoritative, and dominating over women are still evident in both patriarchal norms and in the still-prevalent construction of “machismo” (Gutmann 2006.) The raced/gendered sexualization of the indigenous woman’s body in contest with that of the ladino male continues today—Diane

Nelson (1999) reported multiple accounts of sexual abuse among largely indigenous domestic workers by their ladino employers, calling it “a common experience of young Mayan women working in ladino homes.” Additionally, “Catholics in modern-day Guatemala continue to receive messages during mass and other religious activities about women’s primary purpose as

‘giving children’ (dar hijos) and ‘serving their husbands and children’, as well as misinformation about diseases caused by birth control…the Church continues to promote women’s reproductive roles in society” (Chary 2015.)

The Catholic emphasis on female fecundity and self-deprivation in the service of others served plantation owners well; as Ann Stoler pointed out in her 1995 interpretation of Foucault’s biopower, the bourgeouis body is supported primarily through “certified knowledges and juris- diction” over discourses of race and gender. This much was obvious in the colonial conquest of

Latin America, where structures of power and the acquisition of wealth (the classic model here being the plantation, later finca) depended upon the subjugation of indigenous bodies. Earlier in the colonial period, this was accomplished through encomiendas, grants awarded to individuals by the Spanish crown that allowed them to lay claim to the vassalage of any indigenous peoples

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within the granted area. Later, forced resettlements of indigenous populations fueled the country’s growing agro-export economy; some of these same fincas are still run by the descendants of the original German owners and are still staffed by descendants of the people who were forced to resettle there and work under harsh conditions that could very well be considered slavery by another name. Laws prohibiting forcible labor drafts were still being overturned at the state’s convenience as late as 1904, when United Fruit came to prevalence and the current Guatemalan president, Estrada Cabrera, allowed United Fruit to forcibly recruit men from the highlands to work the banana plantations in the Guatemalan lowlands. (As an aside, so many of the men died either during the move or after resettlement that the plantations fell behind schedule, even after multiple drafts (Chapman 2007.)) This inability to keep up with demand resulted in a chain of events that, within a few years, led to United Fruit’s complete monopoly over the railroad on the

Atlantic side of the country (including “all rolling stock, stations, and telegraph lines, plus the

Atlantic port of Puerto Barrios…all [of which] had been built at national expense” (Chapman

2007), followed shortly by the complete control of the railroad on the Pacific side of the country.

Like a game of Monopoly gone very, very wrong, by gaining and maintaining complete control over both railroads (each built at national expense), United Fruit had essentially seized control of the entirety of Guatemala’s agro-export economy.

The switch from subsistence agriculture and Eric Wolf’s “closed corporate peasant communities” to an increasing reliance on men’s wage labor and debt peonage led to the increasing dependence of women on men even for basic sustenance. Women continued to be celebrated for their roles in childbearing and childrearing (read: for their contributions in increasing the labor pool), but their role as workers was increasingly devalued—both in the household and on the plantation, where women were consistently paid less than a man’s already very low salary

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(Carey 2005, Chapman 2007.) “It was not uncommon for women on the plantations to enter unions as adolescents, carry to term more than a dozen pregnancies, and raise 9 or more living offspring…in this way, women performed the reproductive labor on which the human capital of the agroexport economy was based” (Chary 2015.)

Carey and Torres (2005) trace gendered violence in Guatemala to “authorities’ failure to prevent and punish all violence against women (not just homicide) as early as the turn of the century.” They argued that the failure of authority to recognize and punish gendered violence led to an environment of “impunity” that continues today, similar to de los Ríos’ conclusions regarding femicide in Ciudad Juaréz, Mexico (2006.) In these cases, violence against women has been

“normalized” as a form of “social retaliation” and control (Carey and Torres 2005.)

Early in the twentieth century, social constructions of gender that restricted women’s roles and possibilities as well as customary and state law that asserted women’s subordination to men reinforced (and at times explicitly condoned) gender-based violence. Women who failed to live up to society’s expectations of them as diligent, docile producers and reproducers could be beaten. Although judges did not explicitly affirm these notions, by not contradicting them or not doling out stiff sentences, they contributed to the conditions whereby gender-based violence propagated. Informed and influenced by patriarchal regimes, these cultural and legal premises helped the dictatorships of Estrada Cabrera and Ubico legitimize violence over less powerful groups.

The expected subjugation of women to men was also embedded in the legal code; until reforms were made following the signing of the peace accords, men had the legal right to prevent their wives from taking on employment outside of the home (Chary 2015, Musalo et al. 2010.)

The “disciplining” of wives through beatings was summarily accepted as expected. Among the most commonly cited justifications for hitting their spouses was a failure to keep the house and

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children in order” (Carey and Torres 2005.) The process of “bride-stealing” was also officially legal until 2006, as laws were still on the books that cleared a rapist of any and all culpablity so long as he married the girl he had raped, as long as she was over the age of 12 (Carey and Torres

2005.) Alejandra Colom (2015) reports that “bride-stealing” is still understood to be a common practice. “It still happens,” she reported one of her interlocutors as saying “and some parents accept giving their daughters away.” As discussed previously, given rural Guatemala’s “no rule of law”, the illegality of an action has little effect on its prevalence, and the practice of kidnap and rape as a precursor to marriage is still a reality. There is also pattern in Guatemala of “femicide without repercussion” (Carey and Torres 2006) characterized by and large by a repetition of rape, dismemberment, and machetes. My first full year in Guatemala, I was told that a woman (a

“blonde tourist”) was raped and murdered by three men with machetes on the road between

Santa Cruz La Laguna and Jaibalito (I did not see this reported anywhere, but it dominated conversations around the lake for weeks.) The same year a six year old girl from a Kaqchikel-speaking family of my acquaintance went missing. She was found three days later, bleeding and dehy- drated. I was told by her sister’s primary school teacher that she had to undergo a hysterectomy due to severe internal trauma.

The expected deference of women to men is also evident in the high rate of child marriage; which has a “historical normalization” (Colom 2015) exacerbated in poor communities.

“A common justification [for early marriage] is that [in my husband’s house] they feed me” (Co- lom 2015.) Young women living in extreme poverty start to feel pressure from their family and the community to marry as young as 12 or 13 (Colom 2015; Population Council 2013), a pattern that was backed up in my own interviews.

The combined effects of history, patriarchy, and violence have served to define the role of the indigenous woman as one of subjugation, servitude, dependence, and the deprioritization

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of one’s own needs when measured against the needs of others. These raced- and gendered- ex- pectations are very much bound up with constructions of indigeneity, and what it means to be “a good wife”, “a good daughter”, or “a good woman.” I overheard a conversation between a mother and daughter one day as I took the bus from the lake to Antigua. I could tell from their traje that they were from a small aldea above Tz’unun’a. The daughter was complaining to her mother about her husband, who I gathered she suspected of having an affair. Her mother was encouraging her daughter not to mention anything regarding her suspicions to her husband or anyone else. At one point the mother grew frustrated and scolded her daughter loudly, gesturing to her daughter’s outfit. “Tsss,” she scolded her daughter, “are you wearing pants or are you wearing corte?” This effectively stopped the argument, and they rode in silence for much of the next hour.

Good Mothers, Bad Mothers

Sonya, her two sisters, her two cuñadas, and two neighbors were all in the large bedroom, sprawled across one of the three beds, chatting. They all looked elegant and comfortable in their brilliantly-colored Santa Clara traje. It had been Sonya’s idea to gather everyone together so we could all talk at once, and the atmosphere in the room was warm and comfortable and decidedly feminine.

I crouched on the floor, digging through the contents of my bag for an extra pen. I knew most of these women already and the ones I didn’t smiled at me encouragingly if they took the time from their various tasks and conversations to notice me at all. Sonya smoothed her daughter’s hair back from her forehead, her fingers quick and competent as she interlaced the glossy strands into twin braids. Sonya’s sister was playfully scolding her cuñada over mishandling her husband, their brother. Other women joined in, teasing, trading quips about the foolishness of men and veiled jokes about sex. When one of Sonya’s nephews darted into the room to fetch a

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toy he had left behind, one of the women sent him scurrying with a sharp tsk and a wave of her hand.

I had interviewed most of these women separately, before we had decided to all meet at once so we could chat as a group and I could measure all of their children in one sitting. To be honest, I think the women were just looking for an excuse to get together; one that they could justify to their suegras and husbands with the Q20 and bags of Incaparina (one for each child they had at home) I paid each of them for their time and bother; after drilling me extensively on my romantic life, they paid very little attention to me. Because I had interviewed many of them separately, I already knew some of the ties that bound them together; the ways that their individual stories intersected and intertwined. They were so tightly knit that when I asked questions, often they would answer the questions not only for themselves, but for the other women they knew

I knew in the community.

I met with Sonya’s sister-in-law alone one day, and interviewed her as she sat nursing her newborn daughter.

“Are there occasions in which violence against a spouse is justified?” I asked her.

“No, I don’t think so,” she told me. “I don’t have any problems with that.” She leaned in conspiratorially, and I flinched. I didn’t think I wanted to know what she was about to tell me.

“Sonya does, though,” she told me. Dolores knew Sonya and I were friends. She seemed happy to tell me this, though I couldn’t imagine why. I purposely did not ask her a follow-up question; this was for Sonya to tell me, or not, at her discretion. I had purposely worded the question rhetorically, in order to avoid exactly this kind of situation.

“Sonya’s husband hits her sometimes,” she pushed, answering the question that I hadn’t asked. After a moment, she stopped searching my face for a reaction and switched her daughter to her other breast.

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I knew Sonya’s husband; we were on friendly terms. He was a tense man, jumpy, constantly worried. Sonya was a small woman, perpetually cheerful, and much smarter than she liked to let on. She had a habit of easing tensions by making small jokes, often self-deprecating ones made at her own expense. That Antonio abused Sonya— this wasn’t something I should know. This wasn’t something, I thought, that she would want me to know.

Friends, family, and neighbors, in this case, form a nexus of control—enacted in large part through chisme and threats of violence from spouses or in-laws—through which a young mother ceases to be autonomous. Her actions are monitored and weighed against the expectated body praxes involved in being “a good woman”, “a good daughter”, a good daughter-in-law, a good wife, and/or a good mother. To be any of these things is to lose, in part, one’s autonomy, to become, increasingly, indivisible from the expectations of your own social network. Throughout all my interviews, day-to-day interactions, and even casual conversations, there existed an acute awareness of an underlying pattern of surveilance. (This observation has been extensively backed-up in the ethnographic literature; see Chary 2015; Chrix García 2008; Hendrickson 2010;

Menjívar 2011; Metz 2006; Webb 2015.) Many of the mothers in my study reported being unable to go to the market, pharmacy, or to visit friends or relatives unless they were accompanied by their children, cuñadas, or mother-in-laws. This was not the case for young fathers, and even asking if the men of the household had to “ask permission” before going to the to the pharmacy/to the market/visiting brought on fits of laughter among my female participants. For women, here, the panopticon is crafted through gendered expectations and moral imaginaries

(Livingston 2005) of what it means to be “a good woman”, and is staffed, not by a single watch- man, but by mostly well-meaning neighbors. To be a woman in this context is to exist at the center of a web of observation and expectation.

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As Nancy Scheper-Hughes (1992) pointed out, “mothering” is a set of body praxes, no more “natural” or unlearned than dancing, cooking, or sex. Women learn how to mother—how to perform the daily requirements of parenting—from others; from observation and from instruc- tion. It makes sense to wonder, therefore, if the body praxes of mothering—the learned acts of parenting—change in the context of endemic disease. How does “common sense” parenting change in the face of endemic hunger? Diarrheal disorders? Stunting? Does this change then become what Gramsci would call “good sense” (1957), as opposed to common sense, a useful and active adaptation to an untenable previous discourse rather than a passive and unexamined acceptance of unchallenged “fact”? Is an adaptation still considered “useful” if it carries with it the potential to serve as a psychological balm while simultaneously obscuring the very real consequences of endemic stunting? How long—how many generations—does it take to shift to the

“new normal” of endemic disease? And how many more would it take to shift away, if the condition stopped being endemic in the area? Sontag (1979) argued against poeticizing illness, and wrote that we should see the body as it is, a human machine, but a machine nonetheless, that breaks down and whose successful patching-up won’t be aided by metaphors, but this argument does not—can not—hold true in the identification and treatment of invisible disorders. “There is also an irony in calling on already normally reductionist physicians to return to the ‘basics’ of their practice”, wrote Scheper-Hughes in Death Without Weeping, her treatise on child health in

Brazil:

Strip away the ragged metaphor of nervos, and you will find the bare skeleton of ‘hunger’ shivering under its mantle. But my argument is not, as is Sontag’s, against the ‘poetics’ of illness, for hunger and thirst are no more ‘objects’ and ‘things’ than is any other aspect of human relations. Hunger and thirst are mindful as well as embodied states, and they come trailing their own metaphorical meanings and symbolic associations” (Scheper-Hughes 1992.)

If mothering is a set of learned body praxes, then assuredly “womaning” is the same, subject to being shaped by gendered expectations, Judith Butler’s “performativity”, many of which 169

are couched in moralized constructions of “good” womanhood. What does it mean to be a good woman? A good mother? A good husband?

Anita Chary shared data with me on what it means to be a “good husband” from her own dissertation fieldwork on cervical cancer (unpublished, and used with her permission.) Compared with data from the 2013 ethnographic study, which were re-coded inductively along the themes of “culpability” and “responsibility”, there is a marked difference between what it means to be

“good” as a husband and a father, and what it means to be “good” as a mother and a wife.

“Good husbands”, found Chary, “think about and are dedicated to their children.” They

“give gastos”, are “responsible”, and provide financially for the family. They “do not drink.”

They work, are “conscious of the responsibilities of the household”; they do not “beat” or “mis- treat” their spouses.

“Bad husbands”, she found, are nothing if not a litany of common sins and “mal ca- rácter”: they “drink”, they “lie”, and they “cheat”. They beat their wives, do not provide gastos, and abandon the family. They don’t work, and leave it to the wife to “work to feed the family.”

As for the expectations of mothers, study participants expressed the following:

Female Respondent (Mother): La responsabilidad de las madres es cuidarlo desde el naci- miento, buena atención, alimente a sus niño, dar de mamar cada rato para que crezca bien, si el niño no mama no crece, si no crece es porque le falta alimento.

The responsibility of mothers is to take care of them [the children] from birth, good attention, nourish their children, breastfeed every once in awhile so they grow well, if the child does not breast does not grow, if it does not grow is because it lacks nourishment.

Male Respondent (Father): Creo yo que una de las responsabilidades de la madre…creo que es mayor que el padre porque creo que la madre tiene, allí si ama más a sus hijos que del padre…está eso del cuidado de los niños, el higiene y se preocupa un poco sobre su educación porque ya llega a los cuatro, cinco años piensan, bueno que hacemos, mandamos al niño a la escuela o no? También creo que su responsabilidad, es la de economizar un poco las cosa y sobre todo el mantenimiento de los niños, creo yo que la madre tiene un alto nivel de responsabilidad…ahora la responsabilidad de los padres es yo quiero compartir la experiencia, de que algunas veces fallamos en algunas situaciones como la irresponsabilidad, de dejara

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abandonado a los niños en algún tiempo, salimos de viaje sin pensar que si está bien o está mal el niño, sin pensar que comió o no comió el niño, mientras que la madre que si lo hace, entonces eso es la gran diferencia que ya está en la responsabilidad de la madre y del padre.

I believe that one of the responsibilities of the mother…I think that it is greater than that of the father because the mother has, she loves her children more than the father…is that of the care of the children, the hygiene, and [she] worries a bit about their education because they reach four, five years and they think, well, what do we do? Do we send them to school or not? Also I think that her responsibility is to econo- mize, to save a little, and above all the maintenance of the children, I think that the mother has a high level of responsibility…now the responsibility of the fathers is I want to share the experience that sometimes we fail in some situations like ir- responsibility, sometimes we abandon the children, sometimes we go on a trip without thinking if it is good or bad for a child, without thinking if the child eats or doesn’t eat, while the mother does [think these things], therefore that’s the great difference that exists between the responsibilities of the mother and the father.

Men, all of them fathers, also reported that it was the responsibility of the father to “provide” “el padre de familia tiene que ver en cuanto al recurso, es suficiente o no” (the father of the father has to see as per the resource(s), is there enough or not) and to make the call as to when and whether children were ill enough to merit medical treatment, but childcare, in its immediacy, was not, overall, considered to be the responsibility of fathers. Even if a mother were sick and unable to care for her children, the father’s responsibility fell, rather, on finding someone else— someone female—who could care for the children in her absence.

Bueno tal vez pedirle favor a una hermana o a una cuñada a una sobrina para que se quede en- cargada del niño porque si no puede la mamá podría buscar a alguien y cuidarlo

Well maybe, ask a favor of a sister or a sister-in-law or a niece to see if they can care for the child, because if the mother can’t [care for him] she can look for someone and [have them] take care of him.

¿Si hay una mamá que no puede cuidar muy bien a su niño, si está enferma, si tiene que ir para trabajar, quien la sustituye?

If there is a mother who can not take good care of her child, if she is sick, if she has to go to work, who will replace her?

Las mamás son las cuidadoras principales para sus niños, o hay muchas también que comparten responsabilidades, hermanas o suegras, nueras, casi todas… 171

Moms are the main caregivers for their children, or there are many who share responsibilities, sisters or mothers-in-law, daughters-in-law, almost all [of the women in the family]…

This emphasis on the responsibility of mothers, of women, above even that of fathers, for the health or ill-health of their children is also evident in state- and aid-based nutritional programming. The mandatory privatization of what were once state services following the debt crises of the 1970s and 1980s resulted in drastically increased burdens on the most vulnerable (see

Molyneux 2007, for a discussion on how structural adjustment policies increased poverty.) The subsequent pivoting in international economic development policies which concluded that “social deficits—not just fiscal deficits—must be addressed as part of the agenda” (Dasgupta-Tsini- kas and Wise 2015) resulted in the creation of programs that were themselves reflective of the neoliberal thinking that led to the increased burden of poverty in the first place. These programs emphasize “participation” (Moore et al. 2017) and are often strongly gendered, relying on a backbone of mostly unpaid female labor (Neumann 2013) who were expected to behave as rational economic actors even within the context of gendered inequity. By shifting the burden of responsibility onto rural female actors, “such discourse may obscure the devolution of state welfare functions onto vulnerable populations, forcing citizens to to ‘take care of their own development needs’, even as states increasingly fail to do so” (Moore et al. 2017.) Additionally, through mandated privatization, much of the burden of care was shifted to NGOs and other subcontrac- tors, who work with, alongside, and are occasionally dependent in part, upon state-based anti- poverty measures. This had led to an overall shift in how aid is conceptualized and delivered in

Guatemala, what Moore, et al. (2017) calls the “projectification” of aid. These trends are evident in development projects worldwide, as noted by Farmer (2005):

As states weaken, it’s easy to discern an increasing role for nongovernmental institutions, including universities and medical centers. But it’s also easy to discern a trap: the withdrawal of states from the basic business of providing housing, education, and medical services usually means further erosion of the social and economic rights of 172

the poor. Our independent involvement must be quite different from current trends, which have non-governmental organizations relieving the state of its duty to provide basic services. We must avoid becoming witting or unwitting abettors of neoliberal policies that declare every service and every thing to be for sale.

As non-governmental programming becomes increasingly enfolded into neoliberal structures, the burden of care tends to fall more and more upon the shoulders of the already-vulnerable. (Remember here Berlant’s analysis of biopower in the face of neoliberal subjectivity: “biopower operates when a hegemonic bloc organizes the reproduction of life in ways that allow political crises to be cast as conditions of specific bodies and their competence at maintaining health or other conditions of social belonging; thus the bloc gets to judge the problematic body’s subjects, whose agency is deemed to be fundamentally destructive” (Berlant 2008.)) In the case of Guatemala, this is evident in the creation of Mi Familia Progresa (MFP), Guatemala’s response to Mexico’s largely successful conditional cash transfer (CCT) program, and in the ways in which access to Hambre Cero, MFP, and other programs influenced by the Safe Motherhood

Initiative have been structured. The CCT programs in Mexico, while largely successful in their goals of reducing rates of childhood malnutrition (this has not been the case in Guatemala, where rates of chronic malnutrition have actually gone up among CCT enrollees (Dasgupta-Tsinikas and Wise 2015) have been criticized for shifting blame onto already marginalized young mothers

(Smith-Oka 2013.) In both the Mexican and Guatemalan CCT programs, poverty and, accordingly, the access to the aforementioned programs, has been feminized; Dasgupta-Tsinikas and

Wise (2015) assert that the very structure of CCTs—periodic cash transfers to mothers for meeting ongoing pre-set criteria—mean that poverty/aid is both feminized and maternalized, resulting in the shifting of culpability/responsibility for child health onto impoverished mothers. Speaking of a poster advertising MFP throughout the country, Dasgupta-Tsinikas and Wise write of their versions of Kevin Lewis O’Neill’s “ideal recipient” of aid:

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As MFP expanded throughout rural Guatemala in early 2009, a new health education poster appeared on the walls of health post waiting rooms in rural San Lucas Tolimán. Two mother-child dyads—cut out from stock images provided by the local PEC NGO—were juxtaposed on a large piece of colored card stock: under the heading “Healthy Child” (Niño Sano) appeared a woman in form-fitting pants and blouse, ef- fortlessly balancing a smiling child on her hip; next to this image was a Maya woman—identifiable as such by her traditional blouse and woven skirt—accompanied by an unhappy child, this time under the heading, “Sick Child” (Niño Infermo). Beyond obvious racialized bias about Maya women as inadequate mothers, the poster’s incorporation of affect reflects a broader tendency within CCT programs to attribute children’s health outcomes to the individual-level characteristics of others. The Maya woman—who in almost every rendition of the poster is wearing a generic blouse, suggesting that she is too poor to acquire a more expensive, hand-woven blouse that would represent her ethnic and geographic identity—displays a flat or de- pressed affect. The poster presents a technocratic view of Maya women as passive, in- ert, and unmotivated—perhaps unable—to act on behalf of their children’s health: the ideal recipient of an aid package. (Dasgupta-Tsinikas and Wise 2015.)

The conflation of ethnicity, poverty and gender in the construction of the “ideal” aid recipient is common in Guatemala, as the distillation of feminized poverty to a base root of “motherhood.” “The restriction of poor Guatemalan women’s agency and the subordination of their needs to those of others occurs not only at the level of the household, but also through the state and developmental apparatus’ continual reduction of women to their reproductive roles” (Chary

2015.) Alejandra Colom (2015) critiqued the nutritional programming influenced by the Thou- sand Days Initiative: by narrowly focusing the attention of aid programming on the “first thousand days” of an infant’s life, “TDI programs paradoxically ensure that adolescents are only able to access reproductive health services by already being pregnant.”

For the TDI, with its emphasis on chronic infant malnutrition, adolescent females are only relevant to society when they become pregnant. After dropping out of public education in early childhood, which is almost a statistical inevitability for an indigenous girl from a rural community, this child falls out of the public eye. She does not have access to educational opportunities, enrichment activities, or social outlets. Indeed, she become visible again, and “fundable” again, only by becoming pregnant. Focus- ing all societal efforts—both public and private—on pregnancy management and child malnutrition prevention, in the absence of also developing sexual rights programs for young women, is akin to waiting expectantly for these adolescents to become pregnant. It is equivalent to planning for poverty (Colom 2014.)

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The indivisibility, then, of a poor rural Guatemalan woman extends beyond the constraints placed on personal autonomy by other members of her own household, or the social expectations of what it is to be a “good” woman or a “good” mother. It also extends to her indivisibly from her own reproductive capacity in the eyes of the state, and in the eyes of those the state has sub-contracted in to be the providers of aid and basic services. To be a woman-child, here, is to be a mother. To be a poor, rural woman is to have your ethnicity and parenting capacities conflated into a simple equation, and your eligibility and acceptableness to aid programs depend in large part on your willingness to compliantly and gracefully acquiesce to being so defined.

Adaptation

We spoke over the scarred wooden table that Claudia had received as a wedding present.

The sun had set, so the only light in the kitchen came from a single bulb over the table and from the dying red glow of the brick wood-burning stove in the corner. A dented silver pot sat off to the side of the fire, partially filled with a white, gloppy atol that had congealed on the sides of the pot and on the wooden spoon that had been used to stir. A bowl of the same sat on the table in front of Claudia, who was holding a squirming toddler on her lap. Her son, Javi, kept turning his head to the side as she tried to spoon-feed him the atol, and now both his face and Claudia’s corte were smeared with white globs of Incaparina.

“He doesn’t like it,” she sighed, setting down the spoon.

There are swiftlets in Indonesia and Malaysia and Borneo, birds whose nests are prized by traditional Chinese herbalists for their medicinal properties. The nests themselves are made of twigs and spit, and cemented into the walls of limestone cliffs by the same, shallow little half- cups filled with eggs the size of a thumbnail. So fragile, so creatively industrious, and so…high.

They’ve been reached by acrobatic harvesters for thousands of years through the use of bamboo

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scaffolding, rope ladders, and a marked lack of acrophobia. Every time I visited Claudia I thought of swiftlets.

Her home, like those of her neighbors, was built piecemeal, room-by-room, section-by- section using whatever materials happened to be on hand when the building began. The two rooms farthest from the edge; those dug into the rich earth lining the inside of the caldera are framed to about knee-height with mud-bricks and chicken wire. Above, the walls are either more mud-brick, earth, bamboo, tin, or some combination of all the above. The roof is lamina; tin and plastic, patched in places with palapa; the interwoven palm fronds that are more common on the coast than in the highlands. Both the kitchen and the one bedroom have no doors that close; curtains cover the doorways, leading out onto an area of hard-packed earth that houses a pump and a pila. Laundry hangs from lines strung across this makeshift courtyard, and a fence—bamboo and rusted wire, about knee-high—separates the yard from a a fall of at least a hundred feet into the lake below. Bits of the packed earth floor behind the pila would occasionally crumble and fall down into the water during a heavy rain, leaving behind the blackened, exposed bones of steel rebar. The bamboo fence was constantly being rebuilt.

Claudia had given up on the Incaparina and Javi was nursing contentedly at her breast, making little snuffling noises like a very tiny truffle pig. Claudia had been complaining, recently, that her son only ever wanted breastmilk or what she called “comida chatarra” (“trash food”, aka

“junk food”), but wouldn’t take anything else save sometimes a little bit of mango or banana.

However, she said that sometimes it was necessary to simply cave in, just to “terminar el día”

(“finish the day”.) She blamed her son’s yearning for sweets on her sister-in-law. “¿Hay algunas clases de comida que las mamás les dan a sus hijos para quitar el hambre cuando hay poco dinero o comida en la casa?” I asked her. (“Are there types of food that moms give to their children to kill the hunger when there isn’t much food or money in the house?”)

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Solo quitar el hambre? Un dulce.

Only to kill the hunger? A sweet (candy.)

¿Algo más?

Anything else?

Un Tortrix o algo así, nada más.

A Tortrix or something like that, nothing more.

¿Y cree Ud. que las mamás ya saben que esto no va a ayudar con el desarrollo, es sola- mente para quitar el hambre, para “terminar el día”?

And do you believe that moms already know that this won’t help with development, it’s only to kill the hunger, to “finish the day”?

Yo creo que saben, pero no lo quieren aceptar. No quieren aceptar. Simplemente es como…por que yo se de muchas madres, inclusive de mi cuñada, digo yo ‘ya no les des dulces a los niños, ‘ya no les des dulces’, ah! pero ellos quieren, entonces saben que esos hacen daño, si, pero ellos quieren, entonces, a veces por la urgencia.

I believe that they know, but they don’t want to accept it. They don’t want to accept it.

It’s simply like this…because I know of many mothers, my sister-in-law included, and I tell them, “don’t give sweets to the kids anymore”, “don’t give them sweets”, ah! but they want them, therefore they know they cause harm, but they want them, therefore, sometimes [they do it] for the urgency.

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Sí, es más fácil.

Yeah, it’s easier.

Y a veces, ellos no tienen la capacidad.

And sometimes, they lack the capacity.

¿Como?

Come again?

Me dijo que la desnutrición infantil es una problema muy grave aquí en Guatemala, no?

Eso ya lo supe. Pero…las padres no tienen la culpa de eso. Uno, si tiene poco la culpa; dos, tal vez no, por que de la necesidad economicamente no…mira. Si su esposo gane 15 quetzales al día, puedes comprar una libra de carne para toda la familia, no más, no puedes comprar una bolsa de Incaparina o algo así, vale, una nena de dos años ya sabe que no hay dinero, ella ya sabe. Eso sí por viene el problema de desnutrición.

You told me that child malnutrition is a very serious problem here in Guatemala, right?

This I already knew. But…it’s not the parents’ fault. If your husband earns 15 quetzales [~ $2

USD], you can buy one pound of meat for the entire family, nothing more, you can’t buy a bag of Incaparina or something like that, ok, a two-year-old girl already knows there isn’t any money, she already knows this. And this is why we have this problem of malnutrition.

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The never-ending problem of money, the need to “kill the hunger” (“quitar el hambre”), and the frustrations of trying to parent after relocating to the house of your in-laws (much of rural Guatemala is both patriarchal and patrilocal, and women often move in with their husbands’ parents after marriage) were common themes in the interviews on both autonomy and palliation.

While the “monitoring” of women and the threat of violence should they violate established norms of behavior has been well-documented (Metz and Webb 2013; see also Chary 2015; Carey

2005; Chirix García 2008; Hendrickson 2010; Metz 2006; Menjívar 2011), the extent to which these constraints on personal autonomy play a role in household nutrition in Guatemala has been less well explored (Wehr 2014.)

Besides being situated in a history that normalizes violence against women (Carey 2005) and the subordination of their needs to the needs of others (Chary 2015), the constraints on maternal autonomy among the poor-rural-sick in Guatemala, especially considering the high rate of child marriage, are numerous. Girl-children tend to drop out of school early, often after their first period, in order to help out around the house or to find jobs in the private sector, and to save the household the money needed to purchase uniforms, books, and supplies for supposedly “free” public schools (Chary 2015.) As of 2010, only 15% of women in the country completed primary education (MSPAS 2010.) Additionally, the high rate of child marriage (often idealized, as we saw in Sinclair’s photography) means women in Guatemala have a long reproductive span

(Chary 2015), which, in the absence of family planning, generally leads to large families and higher rates of poverty. There are also well-spread misconceptions about the safety of anticon- ceptivos (contraceptives); I’ve been told by more than one (male, always male) informant that women shouldn’t take birth control because it “makes them weak” and “is bad for their bones”

(Baird 2013.) Much of the paternal responsibility for maintaining the household is centered around the distribution of gastos (Wehr et al 2014), but given that only a small percentage of

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Guatemalans take part in the formal economy (Fischer and Benson 2006); and that much of the available jobs are either migratory (Holmes 2013) or exploitative, the gastos men are able to provide are often unpredictable and vary from month to month, have a tendency to disappear entirely, and, overall, are rarely enough (Wehr et al 2014.) Moreover, the increased rate of violent deaths (O’Neill and Thomas 2011) and the well-documented tendency of men in rural Guate- mala, especially those who engage in migrant labor, to either completely or partially abandon their families after having established a second one (Chary et al. 2013; Menjívar 2011) leave many women either truly or functionally single mothers. “In this context, the burden of maintaining the family falls upon women—mostly mothers, and to a lesser extent, elder unmarried daughters—and their needs quickly become subordinate to others in the household” (Chary 2015.) The lack of education, the subordination of one’s needs to the needs of others, the relocation after marriage to the house of your in-laws, the “monitoring” of women according to moral imaginaries of what is a “good” woman and/or a “good” mother, and the normalization of gendered violence and its use in “discipline” (Carey 2005) all combine to form often severe constraints on the personal autonomy of young mothers, and it stands to reason that these constraints play a role in her ability to nourish her children as she would like.

However, measuring “autonomy” isn’t easy. Maternal autonomy, commonly and broadly defined as “a woman’s ability to have control or influence over choices that affect herself and her family within her own particular context” (Carlson et al. 2015) has been theorized to play a large role on child health and nutrition, but there are problems with measuring “autonomy”, so broadly defined. As such, researchers have historically used proxy measures (physical or fiscal autonomy, attitudes regarding domestic violence, control over decisions regarding healthcare) in order to understand the kinds of constraints on maternal autonomy and the role they play on intra- household nutritional outcomes. What we’ve found so far has been a mixed bag, perhaps due in

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part to the conflation of “autonomy” with larger structural factors. What, exactly, are researchers measuring when they equate “autonomy” with, say, opinions and attitudes regarding domestic violence? Does joint decision-making within the household mean mothers have more or less autonomy? At what point does the input received from others stop being “social support” and start being constraints placed on autonomy? (See Carlson, et al. 2015 for a more complete discussion of both the problems and the importance of using “maternal autonomy” as a variable.) In the literature to date, women’s ability to influence decisions over healthcare (either for herself and/or her children) had the strongest association with infant nutrition; in each study I could find, autonomy was significantly associated with the nutritional status of children within the home (Basu and Koolwal 2005; Dancer and Rammohan 2009; Merchant and Udipi 1997; Ross-Suits 2010;

Schroff et al. 2011.) The same pattern was found, though the associations were slightly less significant, between a woman’s access to personal finances solely under her own control and intra- household child nutritional statuses (Abbi et al. 1991; Kishor and Parasuraman 1998; Sethurman et al. 2006), and the normalization/acceptance of domestic violence, but the associations were generally weak and flipped, (positive to negative or vice versa) depending on the country (Hea- ton and Forste 2008.)

The rest of this Chapter will give a run-down on my own findings of the constraints on maternal autonomy, within the confines of this study, as well as a discussion on the adaptive strategies employed by mothers confronted by hard choices in a world in which their lives are not only their own, and their responses to the burden of care under which they find themselves.

In the words of one of my interlocutors, “it is our fault, our responsibility, because we are their mothers.”

Palliative Feeding

“No tenemos nada de alimento, solo tortilla.” — mother of three, Nik’aj 181

In medicine, palliative care is care intended to relieve pain and improve quality of life. It treats symptoms, if they are causing discomfort, but not the underlying disease. It exists in contrast to or conjunction with life-extending or curative practices, but palliative care in and of itself is not intended to heal anything, only to relieve suffering. The ideas of giving food to children simply “para quitar el hambre” or “terminar el día” was pervasive throughout the study; in many cases, mothers spoke of what they would do when there wasn’t food in the house. The “palliative foods”—foods given to children simply to keep them from being hungry—included Laky, bananas, coffee, fideos, bon bons and other golosinas/small candies, soda/refrescos; but, overwhelmingly, mothers listed “solo tortillas, solo eso” when asked what mothers, including themselves, would give to hungry children if/when there “isn’t much money or food in the house.”

Other studies of desnutrición in Guatemala have also noted this pattern; Chary et al. 2013 reported on a family who often went days ingesting nothing but café de torilla, a thin, floury gruel made from crumbling bits of stale tortilla into water and heating it. This tactic seemed to be common among the families in my acquaintance; aqua de frijol was reported as an easy way to stretch leftover Ducal, or the canned frijol en lata (canned bean paste; frijol entero, dried beans that needed to be boiled for hours before eating were understood to be too costly to make in both money (requiring too much firewood or other fuel) and time (requiring hours of cooking before they were ready.) I was told that if you ate the bean paste as is, you’d never be able to eat enough to stop being hungry, but by adding una cucharito (a little spoon) of bean paste to hot water, it would “quitar el hambre.” There was a hierarchy among foods that were considered palliative, but not nutritious; Laky, the Central American version of Cup O’ Noodle, dried ramen packaged in a styrofoam cup with a small plastic packet of flavoring, seemed to be the most popular, but mothers often lamented not being able to afford it for their children. Overwhelmingly, the most

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common food listed was simply “tortillas and salt.” “No tenemos nada de alimento,” reported one mother, “solo tortilla.” (“We don’t have anything nourishing, just tortilla.”)

Donna Harraway’s construct of situated knowledge helps put the dissonance between desarrollo (development), alimentación (nourishment) and the practice of palliative feeding into perspective, as does Reinhardt Kosselleck’s “spheres of experience” and “horizons of expectation”; given the high rates of extreme poverty, the endemicity and thus normalization of stunting

(“aquí pero no aquí mismo”), and the multiple constraints on maternal agency and autonomy, the subsequent deprioritization of child nutrition (Chary et al. 2014) makes sense, in context. What I don’t understand is the apparent lack of discussion on the experience of “hunger” within the extremely extensive and well-respected nutrition literature in Guatemala. From what I’ve been able to gather thus far, the studies of endemic chronic malnutrition in rural areas tends to treat the experience of hunger as an afterthought, if it’s addressed at all. When I first started asking questions and speaking to people, I assumed that this must be because the lived experience of chronic malnutrition differs from that of acute malnutrition, as ethnographic work on acute malnutrition in children have covered the experience of hunger extensively (Scheper-Hughes’s “Death With- out Weeping”, 1992; Howard and Millard’s “Hunger and Shame”, 1997, are two shining examples.) This does not seem to be the case; while most mothers expressed to me belief that their children were “growing well”—while the understanding of “growing well” seemed to be centered more on weight than on height and seemed to be a given in the absence of illness—many mothers expressed anxieties over their children going hungry. “Right now, I have enough,” one mother told me, “but as he grows I’ll need more money.” Others reported fortified atoles—the corn-based gruels like Incaparina that were designed to aid in chronic malnutrition—as something that was given to children only “when they get sick”, again pointing to the conflation of ill-

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ness and “growing well” (and suggesting how far out-of-budget fortified atoles are for most families.) “There are no jobs” was a common refrain when asked whether mothers felt there was usually enough food in the house; as was “there is no money”, and “la gente tiene poco de recur- sos” (“people have few resources”.) Throughout, anxieties about money ran throughout most, if not all, of my conversations, and hunger was a continuous and underlying tension. Both of these themes would benefit from further exploration.

Choosing Empathy Over Authority

“How long?” David asked. He palpated the child’s abdomen. The child’s skin was stretched so tight over the arc of his ribs that I had an irrational fear that the doctor’s hands would puncture the child’s skin as he performed his examination. I pictured a thumb going through the skin of an old drum, a rising puff of dust, mummies. Dehy- dration this severe doesn’t come from only a few days of diarrhea.

“A few weeks,” the woman answered. “Maybe longer.”

“Why didn’t you come to the clinic?” David asked, lifting a lip to peer at the child’s gums.

I knew he was focusing his attention on the child to avoid looking at the boy’s mother. I had watched him closely enough, for long enough to hear the edge of irritation in his voice.

“Mi suegra,” she said, lowering her gaze. “No me permite” I sighed. I knew the context of this story. Out of all the communities in which I’ve observed and volunteered, domestic violence seems to be endemic on the coast. Addi- tionally, it was a breed of interpersonal violence of which I’d only recently become familiar; domestic violence enacted by men, yes, but perpetuated and encouraged by women.

I was new, and the woman did not wish to speak in front of me; nor would she tell the doctor her story, not directly. But he had seen her and her children, on and on, for the past seven years, and between what others had told him, the other clinic workers and the normal gossip of a small town, his own experience, and what we had seen during clinic visits, he had been able to piece together some of the story.

Over lunch that day, the omnipresent lo mean served on the clinic’s brand-new front porch, he told me the story, speaking in English to give us both a rest and a measure of anonymity. As David spoke, I tried to foist my chicken off on the visiting medical student.

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Like many of the women who came to the clinic, his most recent patient had been beaten, well and often. But that was only when her husband was home; often he was not, off spending what little money he did make on local prostitutes, alcohol, or futbol. The clinic had treated her for STIs more than once, but asking him to wear a condom was out of the question. While her husband was away, the cycle of violence was perpetuated by her mother-in-law.

I had been privy to more than one kitchen-table conversation among older women, many of them clucking their tongues and shaking their heads at the state of many of the families in the small town. “Men,” they would say, clucking like old hens, “always the same. Always so violent and irresponsible. It can’t be helped.” I knew some of them, perhaps many of them, had been beaten by their husbands. I also knew that some of them, perhaps many of them, enabled and even encouraged their sons to beat their wives. Discipline for the new daughters that had not always been their own. The child in question had had a bad case of diarrhea for weeks now, hence the severe dehydration. His growth chart wasn’t fantastic to begin with—he had started off small at birth and began predictable losing height velocity at around eight months—but he had been receiving nutritional supplements and had been making some progress. That progress had been entirely leveled off now, and he would have a hard time recovering. His mother knew that she could have come to the clinic and received a free course of antibiotics for her son, as well as rehydration therapy, had it been needed at the time. But, as she had explained to the nurses, if she tried to leave the house for the hour or two it would take to get to the clinic to get the prescription and the meds, her suegra would tell her husband that she had left the house, had perhaps been unfaithful, and she would be beaten. Perhaps severely; it had happened before. As things were, she managed to slip out for 15 minutes on a day that the local pharmacy was open, where she was able to afford one pill. The pharmacies in rural Guatemala often cut open packages of vitamins, NSAIDs, and antibiotics and sell them by the individual pill. She had given the single pill to her child in the hope that it would stop the diarrhea, but it did nothing.

Of course it had done nothing (Baird 2013.)

The way much of nutritional programming has been designed and implemented in rural

Guatemala, it isn’t very surprising that the campaigns have met with limited success. The emphasis on the individual-authoritative approach to programming largely ignores structural constraints on agency and assumes maternal autonomy where in fact autonomy might be severely limited.

Participatory programs, grown popular after structural adjustment mandated the outsourcing of state welfare services to non-governmental and private actors, place a “double burden” (Moore et al. 2017) on primary caretakers, requiring them both to assume the posture of the aid’s ideal subject (O’Neill 2013) and demand unpaid labor from mothers “redoubling their responsibilities and 185

reinforcing devaluation of the productive and reproductive work they already perform.” The normalization of stunting in rural Guatemala, both through the condition’s endemicity and its hidden pathological progression means that many parents fail to see it as a concern, even if the “immediacy of poverty” hadn’t already led to a “deprioritization of child health” (Chary et al. 2013;

Scheper-Hughes 1992.) Faulty pedagogy and the moral imaginaries of “aid work” mean that parachuting physicians and STMMs—some of the groups best poised to identify stunted children in poor areas, though not treat them—don’t see the disease either, or even to think to measure for it.

The designing of NGO programming around the affective demands of donors that expect a return of crisis and/or drama for their investment means that stunting, being a hidden and thus fairly un- dramatic condition, gets shunted to the side. The still-fairly-tenuous-but-definitely-there understanding of stunting’s pathological progression to chronic disease in later life within the medical literature sometimes keeps it from becoming a priority in the pursuit of global health equity.

Conflicting understandings of “urgency” and “sickness” get in the way in provider-patient con- sultations. The ease and lack of investment (but high payout for donors) of education-only or school-based nutritional campaigns mean what little attention and resources are paid to the issue often get shunted in the wrong direction. The need to appear to be making a difference trumps the need to actually make a difference in corporate nutritional programming sponsored by the

Guatemalan oligarchy, and the lack of any real oversight on NGOs means, and I quote, that

“people get to do whatever the fuck they want.” And then, of course, there’s poverty, always poverty. And violence, omnipresent in its threat, poverty’s even less attractive conjoined twin.

Stunting demands an approach that is both more inclusive and more dynamic than nutritional programming has historically been within the country. In “The Body Multiple”, Anne Ma- rie Mol described the hospital-based treatment of atherosclerosis as one “of continual reform”, a continual, adaptive response to the “multiple enanctments” of the disease “marked by a flow of

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relations” (Mol 2002.) Perhaps much of the failure in stunting’s ammelioration lies in the failure to consider, and adapt for, the multiple situated knowledges at play in the condition’s prevalance and failed identification and treatment. Stunting requires a multi-pronged, adaptive, collabora- tive response involving multiple actors and multiple points in the disease’s progression. Maybe stunting’s failed ammelioration is largely a flaw in the constructions of what stunting is, in each situated knowledge at play.

Or perhaps it’s a flaw of whom is involved. Much of “the actuarial rhetoric” (Berlant

2008) of malnutrition and chronic disease in Guatemala is bound up in construction of maternal culpability and responsibility. But perhaps the limited success of most nutritional campaigns in

Guatemala have been driven in part by the emphasis they have placed on the individual agency of young mothers, as if mothers, many of whom are still children themselves, are independent actors simply by virtue of their own reproductive success. Having a child doesn’t render you less bound to your family and communities, less dependent, entangled or ensnared, but rather, arguably, more so. The indivisibly of young mothers from the structures in which they became parents complicates the feminization and maternalization of aid; leaving fathers out of the equation and treating child-mothers as autonomous units capable of acting entirely independently as rational actors misses many of the marks that often characterize what it is to be a mother in rural Guate- mala. At the same time, there is danger in engendering the idea of dependence; a balance must be struck that takes into account the on-the-ground realities of intersectional racism/sexism (and the constraints they place on agency) while situating mothers as they exist as nodes within larger networks, both social and statal. Theoretically, a practical approach in nutritional programming might revolve around changing the basic unit of concern/analysis when it comes to child nutrition from the mother/primary caretaker to that of the family, however dynamic that definition

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may prove to be in practice. Other practical approaches may include partnering with feminist social movements, often to be found in Guatemala within the Pan-Maya movement, that place an emphasis on addressing intersectional sexism. (Given the immediacies of poverty and the normalization of gendered violence, this approach is perhaps something that should not be based on a “participatory” model.)

Or, possibly it’s a flaw of when; how do we situate stunting in time? Is the current definition of stunting (stunted linear growth in children two or more standard deviations below normal) adequate, as it is thus timed, or would a more useful definition of stunting be extended to include its multiple expected co-morbidities over the lifecourse? How do we address the roles immediacy and urgency play in the understanding of illness? How do we situate our own “spheres of experience” and “horizons of expectation” (Kosselleck 2004); our own “felt times” (Wittman 2013) in our understanding of stunting as patients and providers? As researchers?

In any of these proposed case, the how of treating stunting—the solution to “the problem of stunting”—lies in abandoning our pretenses of authority and individuality, in consistently choosing empathy and humility over authority, expansion over reduction, and collaboration over contradiction. As I was told by the medical director of the NGO Kixok, “we won’t be of any use to anyone if we don’t remain humble about all the things we still don’t know.”

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CONCLUSION

There are stories that are true, in which each individual’s tale is unique and tragic, and the worst of the tragedy is that we have heard it before, and we cannot allow ourselves to feel it too deeply. We build a shell around it like an oyster dealing with a painful par- ticle of grit, coating it with smooth pearl layers in order to cope. This is how we walk and talk and function, day in, day out, immune to others’ pain and loss. If it were to touch us it would cripple us or makes saints of us; but, for the most part, it does not touch us. We cannot allow it to. Tonight, as you eat, reflect if you can: there are children starving in the world, starving in numbers larger than the mind can easily hold, up in the big numbers where an error of a million here, a million there, can be forgiven. It may be uncomfortable for you to reflect upon this or it may not, but still, you will eat. —Neil Gaiman American Gods

For all of us…who care about the rest of the world, fully embracing their humanity and letting their suffering fracture our own existence is the most difficult and most important thing we have to do. —Jim Yong Kim, 2001

Cuéntame, Nan

Doña Inés had fallen in love with a boy from the next town, she told me. She smiled when she said it. That was almost fifty years ago! Oh, she told me—he was so handsome. Kind, too. They met when they were both working at a coffee finca that was a five mile walk from her aldea. It was closer to his town, but still, in the evenings, he would walk her home, she said, and tell her stories. He was her first husband, and the father of her oldest child, a boy. They lived together for five years before the soldiers came for the first time. They left the village, that time, but they took her husband with them. He never came back.

This is how Doña Inés lost her first husband to the war.

She cried for a long time, she told me. But she had a child. She took a second husband; a man, she told me, that was not a good man. He drank, but he gave her two more children, and he brought home some money, sometimes. When the soldiers came to stay, she told me, they lived on the hill overlooking the village. You learned not to talk, she said. They looked for the talkers.

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You didn’t nod to your neighbor, she said. You didn’t meet in groups. If there was no smoke coming from your kitchen, she said, they would know you weren’t home. But, she told me, drunk men talk.

It wouldn’t have mattered, she said. They would have come for him anyway, eventually.

They came for all the men, and sometimes, she said, for the women. It is a blessing, sometimes, she told me, to not be a pretty woman.

The night the soldiers set her house on fire, she lost everything, including two of her children. Her eldest son had already run away. The soldiers raped her that night, she told me, they took turns—but not before they killed her husband. They made him dig his own grave.

This is how Doña Inés lost her second husband to the war.

She fled after that night, away from her burning house. She walked along the road for days, she told me, until she came to another town where she had family. She stayed there for years and eventually married another man, a gentle man. They were happy, but after a few more years had passed, she began to grow homesick. She wanted to come home, she told me, and they came back to the aldea where she had been born.

When the soldiers came again, they asked for help. The soldiers wanted to know who they were, she told me. They didn’t believe that she had grown up there, and that he was her husband. They said they needed help with something in the mountains, that they needed her husband’s help.

“It will be ok,” her husband had told her. “I’ll be back soon.”

The soldiers took many men from the village up the mountain. She couldn’t sleep. After a few days, the men returned, but not her husband.

“Where is he?” she asked the soldiers.

They told her he got lost.

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She waited for months before she accepted his death.

This is how Doña Inés lost her third husband to the war.

Stunting— and the hunger that accompanies it— is the visible marker of reverberating past injustices; the physical embodiment of what it means to be human and poor in a world system which values “profit over people” (Chomsky 2011.) “Doña Inés”, above, is a pseudonym, but the woman herself is very real, and her story—at least as it was told to me, is true. Doña

Inés’ story is sad, packed with more heartbreak than any one life should ever have to carry, but for anyone familiar with the history of violence in Central America following US corporatocratic intervention, it’s not unfamiliar. Her story—and the stories of hundreds of thousands of others— are clear reminders that medicine cannot stop at the borders of individual health and hope to be effective. Poverty causes more deaths than any pathogen. Violence is responsible for more suffering, more illness and infirmity, than any disease could ever be.

Farmer’s “structural violence” and Scheper-Hughes’ “violence of everyday life” are the to-be-expected consequences of a system that uses lives as currency. “Neoliberal doctrines, whatever one thinks of them, increase inequality, and reduce labor’s share in income; that much is not seriously in doubt” (Chomsky 2011.) Ted Fischer and Peter Benson, in comparing and contrasting the desires of North American suburban housewives with Guatemalan broccoli farmers (2006) wrote that “ethnographic sensibilities tend to privilege the local over the global, often assuming a broad background of globalization as either hegemonic imposition into a local world

(a globalized locality) or local resistance against distant market forces (a localized globality.)” In this context, the neoliberal “common sense” thinking that assumes that “the pursuit of one’s own self-interest works toward a greater good through the invisible hand’s transubstantiation of personal greed into public benefit” (Fischer and Benson 2006) is perhaps best viewed through

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Gramsci’s discussion of hegemony in volume one of The Prison Notebooks (1971.) Hegemony, he argued, operates and is maintained by the common sense choices of daily life, and while dam- aging and costly to the poor majority, these common sense interactions are consensual. Fou- cault’s notion of “the expert” (1979) is useful here as well; Gramsci warned that traditional experts (as opposed to “organic experts”, who are of the working class and cast their lot with the same) play pivotal roles in the construction and maintenance of both knowledge and power. Fou- cault expanded upon this in his lectures on governmentality; such a hegemony would not be possible without the “knowledges” and qualifying institutions that are used to produce “experts” and

“expert knowledge”. In Scheper-Hughes’ seminal work on child health in Brazil (1992), doctors played the role of the traditional expert, whose function, in her discussion, was to “misidentify” the true problem of hunger, situating it instead in folk ideologies of pain and suffering and mental illness. Here, in the Guatemalan context, we saw much the same; physicians and “expert helpers” whose identification and treatment of an endemic and debilitating disorder were handi- capped by their engrained participation in the neoliberal hegemony, encapsulated in their unquestioning acceptance of the “common sense” notions instilled in them through pedagogy, and experiences drawn through the filters of past pedagogical inoculations.

When speaking of “expert helpers”, we can’t help but wonder as to the extent of our own culpability, as intellectuals, as “experts”, and the culpability of those we learn, over time, to call friends. “For anthropologists to deny, because it implies a privileged position (i.e. the power of an outsider to name an ill or a wrong) and because it is not pretty, the extent to which dominated people come to play the role, finally, of their own executioners is to collaborate with the relations of power and silence that allow the destruction to continue” (Scheper-Hughes 1992.) As critical medical anthropologists concerned primarily with the ways in which inequality (read: disparities and inequities in knowledge and/or power) shape health, we are asked to privilege the voices of

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others; to put “peoples’ experiences, stories, and words in the foreground” (Goodman and Leath- erman 1998.) But in the interests of application, while breaking through the “epistemic murk”

(Taussig 1986) of stunting’s multiple and often conflated definitions, in the end we have to reify the story, not the individuals, and in this particular case that means laying claim to the very real harm done by individuals who approach the practices and praxes of global health equity with the very best of intentions. Unpacking the “problem of stunting” means including not only the common-sense, day-to-day definitions of the condition crafted by the individuals involved in its prevention, diagnosis and treatment, but also their operational definitions of stunting, which are evi- denced by the ways in which they approach the condition itself and the patients and families affected by the disorder in the daily practice of aid and healthcare on the ground in rural Guate- mala. “All variants of modern critical theory work at the essential task of stripping away the sur- face forms of reality to expose concealed and buried truths…to ‘speak truth’ to power and domi- nation” (Scheper-Hughes 2011.) Stunting is, overwhelmingly, first and foremost an epistemological challenge.

Every actor or group of actors that participates in the perpetuation or alleviation of stunting approaches the “problem of stunting” differently, carrying with them their own metaphors, mythologies, motives, and epistemological understandings of what constitutes “the shape of a child.” These dueling epistemologies, in shaping both motivation and understanding, shape behavior—and this, in turn, affects both the identification and treatment of the condition. All illness, all disease, is shaped by understanding, by the epistemological backgrounds of the actors involved—capturing the shapes of these histories of knowledge and knowing is the entirety of the content and the purpose of the field of medical anthropology. How much more so must this cognitive reframing be real, and formative, in the case of an invisible, insidious, and endemic condition like stunting? How do our own biological constraints on the understanding of time

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limit our ability to effectively study a disease whose pathological progression often remains hidden for decades? How do the pragmatics of the praxes of patient care--these conflicting ideas of

"immediacy" and the exigencies of the present--impact the treatment and identification of an invisible and endemic disease?

The ways in which stunting is seen, and goes unseen, is visible or invisible, is prioritized or deprioritized, all have immense implications for the condition’s prevention, diagnosis, and treatment. And while the means by which all of these subjective understandings are enacted and reproduced are complicated and ever-changing, my central argument is simple: stunting’s continued prevalence in rural Guatemala is due in large part to dueling epistemologies within the groups that play a role in the condition’s possible amelioration. The “moral imaginaries” of what

“aid” is supposed to be; the immediacy of poverty; the understandings of what constitutes “illness” and the “shape of a child”; all of these subjective understandings exist in conflict with each other and with the condition’s hidden pathological progression.

We need to establish, without a shadow of a doubt, the links between stunting and non- communicable chronic disease, and what this will mean for the future of global health studies.

This will force us to step back from our current ways of conceptualizing health and illness; to zoom out, to see the health of an individual not in a series of moments, in snapshots granted by interviews and primary care visits, but in decades. We need work that spurs the argument that the health of a community has to be planned for and thought of in terms of generations, and that health and well-being never begin nor end with the life of a single individual. Anthropology can aid us in making these connections, in emphasizing the indivisibility of any one life from the histories in which it is embedded or the other lives that surround it.

In this dissertation, I have provided what I hope to be useful tools for dismantling and at- tacking the problem of stunting. I have written, briefly, about time; about how stunting’s slow-to-

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manifest long-term physiological costs and, in the case of endemic stunting within a community and its subsequent normalization, the invisible short-term effects are at odds, when it comes to treatment, with the day-to-day immediacy of poverty. I have addressed the indivisibility of primary caretakers from their immediate family and circumstances; the constraints put on choice and agency not just by interpersonal violence and the structural violences of poverty and intersectional racism, but by the learned body praxes of what it means “to mother” and the day-to-day lived practices of what it means, in context, “to daughter” and “to wife.” I laid out how the multiple dimensions of the invisibility of stunting affect its successful identification and treatment: in its pathology and physiological progression; in the context of appealing to an affect economy in a country who healthcare systems are more and more reliant on external aid; and in the context of a nation divided by the violence of the neoliberal order into those who exist, truly, as individuals in the eyes of the governmental polity, and those who exist only as a theoretical—useful, essential, but non-voting and politically suppressed— labor collective on the margins of the government’s concern. I addressed the serendipity involved in accessing aid; and the on-the-ground perceptions of who is, and who is not, a likely recipient.

Some of my insights, however obvious in hindsight, are more immediately pragmatic; the construct of “palliative feeding”, for example, can be addressed fairly straightforwardly in both research and programming. The concepts of “los que ya tienen”, of crisis-based intervention, and the ideas surrounding what it means to be the “right kind of Mayan” and to have “a good heart” can help those of us interested in programming see the importance of open dialogue within the community and stringent inclusion and exclusion criteria. Changes can be made to physician pedagogy; especially for those physicians interested in practicing abroad, outside their scope of practice, or in an environment in which they are unfamiliar. These are small steps in the quest for application and applicability. However, the greatest challenges in addressing and ameliorating

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“the problem of stunting” remain ones of both epistemology and revolution; of making the invisible visible, and therefore treatable, and in addressing the daily lived challenges of mothering while poor and doctoring while blind.

Death, Fast and Slow

He was dying, yellowing, the sclera of his eyes the color of fresh piss. His lips were dry, cracked and bleeding at the corners. The bedsheet, blue calico, laid a bridge over his narrow pelvis, the fabric slung over the sharp rounds of his hipbones, exposing the dark curls below. He had gained a sort of transparency in his extremity, every line of every bone laid bare, the curves of his ribs and the lines of his still-handsome jaw opened to the light and the day, like the bones of the earth left exposed and invulnerable after a flash flood, all the green, all the life, stripped away by shit luck and worse circumstance.

He was lying in a room behind a pink curtained doorway, a volunteer paramedic adjust- ing the stiffening catheter that disappeared beneath the sheet, his hands curled into loose fists at his sides.

He was lying in a cinderblock room, propped up against pillows and surrounded by family, a grey kitten sleeping in the hollow between his legs, attracted by the heat of his deathbed fever.

He was lying on a cot in a mud-brick-and-bamboo hut halfway up a mountain, covered with a thick fleece blanket, yellow and brown striped tigers in tall grass, the small dark room dominated, incongruously, by a flatscreen TV and piles of bootleg DVDs.

She was lying on a mat on the dirt floor, stiff strands of grey hair combed carefully over her balding scalp. Clean maxi pads covered the weeping bedsores that dotted her thin hips and flat buttocks. The doctor showed me her latest head CT, holding it up against the sunlight filter- ing in from the dirty window. A massive stroke had poured black ink across both hemispheres of

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her brain six months earlier, a creeping twilight invading the white and grey of her otherwise pristine scans. She was unresponsive, short eyelashes still against thin-skinned cheeks, but when

I squeezed her hand, she squeezed back.

She wasn’t even a year old, starving, parched, the skin covering her ribs tight and dry as an old drum.

She was nineteen when she died, only a memory now, and one that rests uneasy in the bottom of every bottle her once-husband drinks after his shift wiping tables at the palapa-covered bar. Her daughter is now fourteen, and pregnant herself. Her ankles are swollen, round and ripe and tender as over-ripe melons, and her vision has changed, the edges of her world blurred and wavy. A relentless drumming starts to pound in her temples shortly after breakfast and doesn’t fade until long after dark, but she has no one to tell her this isn’t normal.

Lauren Berlant’s construct of “slow death” “refers to the physical wearing out of a population and the deterioration of people in that population that is very nearly a defining characteri- zation of their experience and historical existence” (Berlant 2007.) Berlant writes of obesity in the U.S. among the “economically crunched”; “the obesity epidemic is also a way of talking about the destruction of life, of bodies, imaginaries, and environments by and under contemporary regimes of capital”, but stunting in Guatemala is itself another perfect analog of “the destruction of bodies by capitalism in spaces of production and in the rest of life.” If Harvey’s

(2000) definition of “sickness”, under capitalism, is defined by the inability to work, then the findings of the longitudinal INCAP study are more than enough to define stunted populations as

“sick” populations. And knowing that stunted individuals are overwhelmingly poor and indigenous, we can draw the conclusion, given these definitions, that being born poor and indigenous is most often a death sentence….just a slow one. Situating stunted populations within the broader histories of violence delivered by colonialism and imperialism, we can link the “slow death” of

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the Maya, enacted in part through their loss of biological capital, as one intrinsically and predictably linked to their positionality as permanent members of the precariat. Stunting is the biopoliti- cal embodiment of discrimination, the worst of the region’s history encapsulated, embodied, and breathing. The space of “slow death”, is one in which people live, “just not very well” (Berlant

2008.) A life of slow dying is one burdened by illness, infirmity, and one determined and defined by precarity.

While a discussion of chronic disease in Guatemala is “precisely a conversation about living, and not just a conversation about not dying” (PBS 2014), it is, also, precisely a conversation about dying. In robbing the body of capital in the short-term, stunting drastically increases the number of children who die of infectious disease. By robbing the body of capital in the long term, stunting leads to the same “attrition of life” that Berlant describes in her discussion of obesity and the poor in the U.S; shorter lives robbed of joy and productivity through anxiety and infirmity.

The Chronicity of Chronic Disease

The soil was alive with ruptured stories that cascaded and rotted then found form once more and pushed up through the undergrowth and back into our lives. —Fiona Mozley Elmet

This dissertation is about connection and obligation, about perception, about love and death and fear of loss; but perhaps more than anything else, this dissertation is about time. I’m convinced that much of the collective failure to ameliorate the rates of stunting, and thus its later- life consequences of chronic illness, disability, and early death—despite the attention that is finally being paid to the issue—are bound up in the differing constructions of immediacy that exist among the major players in the condition’s prevalence, diagnosis, and treatment. In the case of stunting in rural Guatemala, we have not only warring etiologies on the origins of chronic disease, but warring ideologies on the very nature of pathology, of what does, and what does not, 198

constitute “illness” and “urgency”; and conflicts of interest and attention formed and fomented by history, economics, and the exigencies of the neoliberal state. Hunger, here, is anything but ahistorical.

Biehl’s Vita (2005) saw time as it was marked by neglect, lodged there like a splinter, or dried ink, and waiting like a text to be read. He saw Brazil’s “zones of social abandonment” as modern-day oubliettes, places where the unwanted are marked, first, as undesirable, and then for- gotten, forever fixed in time by the leavers as they were when they were left; Fabian’s “denial of coevalness” (1983) moralized and made small. If we pair this construction of abandonment with that of embodiment, of a Bergsonian body-situated present, then time becomes dynamic, versa- tile—an ongoing tug-of-war between the abandoned, and those who encounter them.

Framing this idea within the clinical encounters necessary to diagnose and successfully treat stunting is an intimidating prospect. In this case, we’re juggling a disease that has become normalized both through endemicity and because its associated comorbidities often take decades to develop—running into the multiple invisibilities of “if everyone is ill, then no one is”, and that of hidden pathological progression. All of this exists in a context where the criminalization of poverty (O’Neill 2013) and the programming-enforced constructs of maternal culpability and gendered subjectivity (Safe Motherhood Initative, Pacto Hambre Cero, CCT programming; see

Moore et al. 2017, Dasgupta-Tsinikas and Wise 2015, Colom 2015) meet a “republic of NGOs” and high rates of extreme poverty.

Health is narrative, a story written in blood and bone and biochemistry, and the story of chronic disease never begins with an individual. The underlying causes of illness never stop or start at the borders of a single life, and yet it’s the individual that has to be treated. There is a historicity to chronic disease that cannot be addressed in primary care. Two of the grandmothers of the field of medical anthropology— Nancy Scheper-Hughes and Margaret Lock—pushed for a

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medical pedagogy and practice centered around social justice; a clinical twin to the liberation theology that proved so effective (and so dangerous) in the 1980s. “Medicine, too, can serve as a point of critical reflection and practice….what might [medicine] become if, beyond the humanitarian goals that it espouses, it could see in the suffering that enters the clinic an expression of the tragic experience of the world. We might have the basis for a liberation medicine, a new medicine, like a new theology, fashioned out of hope” (Scheper-Hughes 1993.)

Nutrition, especially the diagnosis and treatment of malnutrition in developing children, is primary care at its most vital and basic. Investing in the biological capital of individuals at the time in their lives— the only time in their lives— when that investment is spent on the development of major organ systems has immense implications for the long-term health and well-being of that individual and is the most efficient way of improving the inter-generational health and well-being of entire communities. By focusing on identifying and treating stunted children, we are broadening the scope of practice; stretching the doing of medicine across generations; healing not just in the now, but decades from now.

The “cruel optimism” (Berlant 2008) of global health is this: many of the structures through which global health work is enacted are themselves part and partial to the broader systems of structural violence that are responsible for the very suffering that they hope to address.

For those of us interested in health equity and social justice in medicine, this thought can be par- alyzing. Patient advocacy and accompaniment, nutritional programming, the extension of primary health care and well mother/well baby programs; these all require resources, and, as we saw in the last Chapter, resources are rarely given freely, and so the work is not allowed to shape itself. Global health work is often forced to walk the line between constitutive work and respon- sive work, forced to please donors and funding organizations first, to put their needs above the

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beneficiaries of programming efforts. They are, like their patients and program beneficiaries, bound by place and time and care, all flies in neoliberalism’s sticky web.

In this vein, perhaps the biggest problem with the “big data” approach to global health— the idea that because resources are limited, we should spend them on programming that impacts the most lives—is that resources are not that limited, not really.

Claims that we live in an era of limited resources fail to mention that these resources happen to be less limited now than ever before in human history. Assuming that it is too expensive to treat MDRTB among prisoners in Russia, say, sounds nothing short of ludicrous when this world contains individuals worth more than $100 billion. Ar- guments against treating HIV disease in precisely those areas in which it exacts its greatest toll warn us that misguided notions of cost-effectiveness have already trumped equity…To argue that human rights abuses occurring in Haiti, Guatemala, or Rwanda are unrelated to our surfeit in the rich world requires that we erase history and turn a blind eye to the pathologies of power that transcend all borders. Perpetuat- ing such fictions requires dishonest, desocialized analyses that mask—whether through naïveté or fecklessness or complicity—the origins and consequences of structural violence. (Farmer 2005.)

In this era of unchecked global capitalism and unequal resource distribution, we that have have because others do not. Others go without. With this relative wealth comes agency, and with agency comes choice. It’s not hard to argue, knowing this, that many of us have obligations to the poor that we are currently not meeting. We can no longer allow the wheels of neoliberalism to serve as a buffer between the suffering it engenders and our own senses of action and complicity. “With agency begin responsibility and accountability” (Scheper-Hughes 1992.)

Perhaps the first step toward a world in which the human right to health is taken seriously is a rigorous public debate among those of us who live in “surfeit” as to our own culpability and continuing complicity in the suffering of others. We need to bring those from whom we continue to steal into the conversation, not isolated and Othered as sufferers, but as partners and collaborators. Critical medical anthropology can engage with social justice work and produce ethnographies centered around a duty of care. Global health work can be coupled with political action that

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demands social and economic justice for the poor. We can redefine the meaning of “humanitarianism”, and make it one of a history of collaboration and productivity, rather than one associated with violence. Many of the “humanitarian interventions” we’ve undertaken as a country in the past few decades, and are participating in now, as voting members of an imperialist body politic, have been against the wishes of those countries’ constituents, resulted in dramatically increased casualties, wave after wave of refugees, and left those countries in ruins, often in the hands of left-wing militaristic dictators. These “interventions” were taken as steps to ensure our hold on the flow of resources; to call them “humanitarian” is laughable; to speak of them as “liberations”, more so.

The cumulative effect of history on lived experience is one defined by “multiple pasts and multiple presents” that are in continuous and dynamic “conflict” with each other (Hertzfeld

1991.) Stunting isn’t seen the same way by a community health programmer, a parent, or a US- based physician, the etiology of its associated co-morbidities aren’t understood the same way by local clinicians, by NGOs, or by the donors who influence programming decisions. “It is the whole of this ‘scene’ that must be made comprehensible; it must be viewed and analyzed from the diverse local vantage points, encompassing the tensions and contradictions of local experiences, in the scientific arenas as much as in the townships, among political leaders as well as village inhabitants” (Fassin 2007.) If we are to “solve” the problem of stunting—the most prevalent pediatric health condition in the world—each of these situated knowledges must be brought into discussion with each other. Given the enormous impact stunting has on health and human capital, addressing chronic malnutrition in children is perhaps the most efficient way to address not only unnecessary illness and premature death, but the quality of life of individuals and families; the potentiality of each individual and, combined, of entire communities.

I can’t think of any health condition with higher stakes.

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BIOGRAPHICAL SKETCH

Caitlin Baird Peterson graduated from Penn State in 2006 with two bachelor's degrees; one in anthropology and another in comparative literature. She also holds a Masters of Arts in anthropology from the University of Florida. She focused on applied medical anthropology during her doctoral coursework and research, and graduated with her PhD from the University of

Florida in the spring of 2018.

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