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Interventions were minimized during the study, to the extent compatible with ethical principles. Medical services in the clinic conformed with government policies but were better than in most Guatemalan villages. Three programs were implemented in the village: a) improvement of medical care and hygiene during the three-village study (1959-1963) and the Cauqué, study described in this chapter (1964-1972); b) and subsequently improvement of the diet through maize fortification (19721976); and c) improvement of housing and income after the 1976 earthquake (1976-1980).
Improvement of Medical Care and Hygiene (1959-1972)2
Prior to the study described in this chapter, Santa María Canqué was the village that received enhanced medical care and some hygiene measures as part of the "three-village study" described in Chapter 1. During the present study, treatment in the clinic was continued and extended to the homes. The quality of the central water supply was improved but not its distribution.
Traditional village infusions and intravenous fluid therapy were used for dehydration from diarrhea, although many mothers refused the latter. Breast-feeding was encouraged for all infants and children still at the breast, even when they were suffering from infectious diseases, especially with dehydration. Invasive diarrhea was treated with broad-spectrum antibiotics. Penicillin was used for complicated bronchitis, pneumonia, and other bacterial infections. Personal hygiene improved somewhat, although it continued to be deficient. The latrine program was stagnant during the study, but usage improved considerably to reach 54% of the families at the end of the study period. In summary, slow progress was evident at the end in personal hygiene, water supply, sanitation, education, and literacy (Mate, 1978a), along with some reduction in mortality.
Improvement of the Diet (1972-1976)
The Cauqué, study officially ended on May 29,1972, in its eighth year. At that time there was still controversy with respect to the relative value of food supplementation versus infection control, despite the fact that the Canqué study had demonstrated a strong deleterious effect of infection on host nutrition and growth. There was considerable international interest in the implementation of nutrition programs in developing countries, even though they had shown only limited or negligible impact. The experience gained in field work during the Canqué study justified an intervention consisting of adding a supplement to maize, the staple food, to correct most of its nutrient deficiencies, and "make it like beef" The improved maize supposedly should significantly improve the nutrition of pregnant women, infants, and preschool children, enhance resistance and response to infection, and raise the overall level of health.
The maize fortification study began in June of 1972 and continued for almost four years (Mate, 1971). The fortifying mixture, developed in INCAP by Ricardo Bressani, contained 97.5% soybean flour, 1.5% Llysine, thiamine, riboflavin, niacinamide, vitamin A, and ferric orthophosphate. When nixtamal (maize kernels cooked with lime) was fortified with 8% of this mixture by weight and fed to healthy rats and to children who had recovered from malnutrition, normal nitrogen balances and adequate growth were achieved (Bressani et al., 1976).
Meetings with leaders and villagers were held to discuss the convenience and scope of the intervention. A scale and a set of tin cups were installed in each of the two mills to measure the nixtamal and the supplement. The supplement was added at the time of milling to produce the fortified dough for tortillas. Grinding was done almost exclusively at the mills. A literate youngster from the village, posted at each mill, added the supplement in proportion to the amount taken by the women. The operation began as soon as the mills opened early in the morning, to closing time at dawn, every day the mills operated during the study period. The amounts of nixtamal and of the fortifying mixture were recorded for each family each time maize was milled.
For the first two days, 95% of the people accepted the supplement. Shortly thereafter, the taste and odor of soy flour led to self-distribution of the families into three groups: a) 40% accepted supplementation at the higher fortification index (FI)3 of 40-100 (this group contributed 504 newborns to the study); b) 10% accepted a lower FI of 20-39 (43 newborns); c) 50% refused the mixture entirely or allowed an FI no greater than 19 (255 newborns) (Mate et al., 1973; Urrutia et al., 1976).
Fortification was monitored in random samples of tortillas for dietary and chemical analysis, and in random samples of women's urine for riboflavin. Intake was monitored by individual dietary studies. The variables measured and the methods and personnel were those of the Canqué study (Mate, 1978a). The study of infection and colonization of the intestine could not be repeated. The intervention lasted 45 months, during which there were intermittent problems of acceptance of fortified tortillas, related to odor and taste of soy, previously unknown to the villagers. The perishability of fortified tortillas also was a problem.
At the end of the intervention, no significant changes were noted in mean birth weight and gestational age from previous values of the Cauqué, study (Urrutia et al., 1976; Mata 1978a). The supplement which did not affect calorie consumption had no apparent effect on mean weight at six months of age. At 18 months supplemented children actually weighed less. No differences were noted in the mean weight of children when siblings were paired for comparison, in which one sibling was offered the supplement and the other was not (Urrutia et al., 1976; Mata 1978a). The supplement did not influence growth velocity or the development of ossification centers of the hand (Urrutia et al., 1976).
There were no differences in the rates of infectious diseases among the three groups by FI, but the total number of days ill was larger for children with the lowest FI (Urrutia et al., 1976). Also, infant mortality was lower for children in the group with the highest FI. There was no effect on infant mortality, and an actual increase in one- to four-year-old mortality for the village as a whole during the intervention (Urrutia et al., 1976; Mata 1978a). A plausible explanation for the lower morbidity rates in families with high FI is that acceptance of the supplement by families reflected cooperation with the study personnel. Families with the strongest ties with the clinic would also be likely to have better social development and a greater tendency to seek medical treatment as well as to use the food supplement. Families with a higher risk of infection and malnutrition might have had poorer relations with the staff and have been more likely to reject the supplement.
The Principal Investigator (Leonardo Mata) left Guatemala one year before termination of the maize fortification study, and the Field Director Juan Urrutia) left two years after its termination. New duties and lack of enthusiasm for publishing negative findings of this intervention delayed release of these data.
Improvement of Housing and Income
At 3:05 a.m. on February 4, 1976, an earthquake (40 seconds, 7 Richter) destroyed homes, mill houses, granaries, mud walls and other structures of the village. Only the clinic, the school, the municipal building, the slaughterhouse, and one private house were left standing, because they had been built with concrete, iron frames, and more adequate materials. The leveled houses had walls made of layers of adobe blocks without supporting frames, with roofs placed on top without enough binding. The structures collapsed while villagers were sleeping. There were 78 deaths (5% of the population), mainly of children and old people (Glass et al., 1977); this number was replaced within 18 months by the 3.6% population growth estimated for 1970-1972.
Immediately after the earthquake, the clinic staff shifted the maize fortification study to full-time relief activities. In any case, the maize fortification study could not have been continued because the houses, the mills, and the warehouse storing the fortification mixture were destroyed. The local people rapidly rebuilt the village with the aid of national and international organizations. Ulike their former houses, most of the new ones had separate sleeping quarters and improved sanitation. Water toilets became popular and latrines were used more often. A cooperative was organized, widening the opportunities for diversified agriculture, more commerce, and more income. Water quantity and quality increased notably, although the village remained deficient in basic needs. Health services suffered a prolonged attrition and were reduced to sporadic visits by a physician of the Ministry of Health and the services of one or two resident auxiliary nurses.
Infant mortality rate which had been decreasing leveled off or increased after the earthquake. Nevertheless, one-year semilongitudinal data collected 15 years after the Cauqué, study (1986-1987) showed moderate increments in maternal body size, breast milk output, and child growth (Delgado et al., 1988). Since no documentation of infectious morbidity and of microbial entities was done on that occasion, no judgment can be made of the force of infection in comparison with the period of the Cauqué, study. Nevertheless, it is fair to assume that infections had decreased in the intervening 15 years, consequent to greater availability and usage of latrines, flush toilets, and drinking water. Also, education, communication, personal hygiene, and income had increased in the intervening period.
Prior to the Cauqué, study, most knowledge of interactions between infection and malnutrition was obtained through clinical and cross-sectional field observations. The background of poverty and deprivation affecting children throughout the world had been mostly ignored or taken for granted, resulting in equivocal interpretation of the origin and nature of the infection-malnutrition complex and its biological and environmental determinants.
The Cauqué, study pioneered long-term observation of rural children in their natural ecosystem. The detailed clinical, dietary, microbiological, anthropometric, and epidemiological observations, unique at that time, are still a subject of discussion, because our studies have not been replicated. Different approaches, however, have confirmed or widened the main observations of the Canqué study. Meantime, paradigms derived from the study have probably influenced changes in policy and management regarding rural health in less developed countries.
In the last 30 years, there has been an emphasis on "primary health care" and "health for all by the year 2000," "growth, oral rehydration, breastfeeding, and immunization" (GOBI), "expanded program of immunization" (EPI), and "improved delivery of medical care." The effort has been more on control and prevention of infection than on improving the diet. Also, more emphasis has been given to holistic strategies to combat poor health than to independent food supplementation and fortification programs. The Cauqué, study taught lessons about the positive and negative determinants of health and survival of contemporary less developed populations (Mate and Behar 1975. Some of these lessons were the following.
Positive Determinants
a. The village population enjoyed a relatively high quality of life, despite the prevailing poverty and underdevelopment. Families were well structured, with strong bonds and low levels of domestic violence. No abandonment or abuse of wives or children was known to the clinic staff during the study.b. Women had a remarkably low incidence of birth complications. Effective mother-infant interaction contributed to successful breastfeeding and child rearing.
c. Treatment of the umbilical cord stump prevented tetanus neonatorum. There were very few cases of neonatal sepsis, diarrhea, impetigo, and other neonatal infections.
d. Small babies were kept warm at all times by mothers who slept with them from birth through lactation. In the cool climate such a practice was crucial, counteracting hypothermia in very small infants. Since children were exposed to sunlight, neonatal jaundice was corrected. Survival was absolute for infants able to suck the nipple within the first day of life.
e. Exclusive breast-feeding for five to seven months correlated with adequate nutrition, growth, and protection against infection. Prolonged breast-feeding with supplements for two to three years offered an important source of nutrition supplementation and protection against infection.
Negative Determinants
a. The high incidence of LBW infants in Cauqué, had a negative effect on village development. More than 70% of the infant deaths were of LBW babies. The priority, then, was to reduce the incidence of LBW infants instead of training more personnel to care for them.b. Protracted weaning in the village represented a constant risk of enteric infection. Weaning foods had low biological value and were a source of enteric infection.
c. Infections with pathogens of the mucosae and skin were very common during weaning.
d. Stunting was associated with low birth weight, infections, and deficient diets.
e. Deficient health services contributed to the low survival rates.
f. Lack of family planning is resulting in strong demographic pressure in the face of limited land and few opportunities for diversified work.
g. Poor socioeconomic conditions were predominant determinants of biological and environmental deficiencies of the indigenous population and its ecosystem.
h. The most pressing problem is the rapid rise in population density, resulting from greater survival mediated by better public health, and the collateral restricted land, food shortage, inflation, and political unrest. The background of intervention, amply discussed in the early 1970s (Mate, 1 978a), remains valid today.
In the years of the Cauqué, study, we discussed how rapidly improvements should be implemented, or whether it was possible to effect them peaceably. Some decided for revolt, without success. Armed violence in Central America has done great harm. My view of the current situation, resulting from sporadic visits to Santa María Canqué since I left it in 1974, is of slow progress to correct negative determinants of health, while preserving most of the positive determinants. Village life today continues relatively unaltered from that of the 1960s. Virtually all deliveries today are in the homes, assisted by two younger midwives, one of them the daughter of Doña Juana, the senior midwife of the Cauqué, study.
Strong family bonds persist, as in the 1960s, and most families are organized around the family head, usually the father or an elder. There is no evidence of emerging physical or sexual abuse of children or spouses. Vagrancy, drug abuse (including alcohol), street violence, petty theft, and other social pathologies are not evident. In fact, villagers behave now almost as they did during the Cauqué, study. Although many new houses now have locks, agricultural plots remain fenceless.
The attitude of the Mayan villagers-stoic, sturdy, hard-working, honest, and smiling-still prevails, as well as their ability to cope with adversity, to survive while enjoying the extended family, friendships, and solidarity. The Mayans are gradually participating in the global transformation that will result in better health for all. My hope is that their unique traditional and societal values will be preserved during that transition.
Special thanks are due to the Maya Cakchiqueles of Santa María Canqué, always generous and forgiving for whatever inconveniences were brought to them by the clinic's activities. We did not teach them much, but we certainly learned from them most of what has been written here. Many worked on and contributed to the study, among them Juan Urrutia and Carlos Beteta (pediatrics); Bertha García, Gustavo Linares, and Emma Blanco (dietetics, field work); Olga Roman and Palmira Dardón (nursing); Juana Cutzán and Candelaria Valle (midwifery); Raúl Fernández, Olegario Pellecer, Elba Villatoro, Roberto Rosales, Adelaida Comparini, Luis Sanchez, and Horacio Mazariegos (microbiology studies); and Eudelia Ortiz, Mélida de Tenas, Josefina Hernández, and Jose Luis Gonzalez (cleaning). The following students participated in the study: Amanda Negreros, David C. Dale, Celina Carrillo, Armando Cáceres María Laura Mejicanos, Miguel F. Torres, Robert Morhart, Richard G. Wyatt, Jose R. Cruz, David Martin, Dan Cherkin, Wendie Branwell. Most of the processing and discussion of data were cone with Richard A. Kronmal, John E. Gordon, Claire Joplin, Constantino Albertazzi, and Eduardo Arellano. Important guidance, advice, and stimulus was proffered by Nevin S. Scrimshaw, John E. Gordon, Joaquin Cravioto, and John P. Fox. Valuable secretarial assistance was given by Ada Luz Colmenares, Marion Landsberger, Patricia Sole, and Patricia Morales. The study and analyses were funded by the National Institutes of Health, the US Agency for International Development, INCAP, the Pan American Health Organization and PAHEF, the Guatemalan Ministry of Health, American Cyanamid, the School of Public Health and Community Medicine (University of Washington), and INISA (University of Costa Rica).