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Fluid illness: Dialysis, undercare, and the social life of kidney disease in rural Guatemala



In response to the rising rate of end-stage renal disease (ESRD) in Guatemala, the public health system established a national community-based dialysis program to enable people living in rural areas to complete treatment in their homes. Here we explore how this newly available, life-prolonging technology has altered local worlds by transforming ESRD from an acute, life-ending illness into a managed chronic condition with an uncertain trajectory. Through case studies, we describe how living with dialysis influences family relations and caregiving in rural Guatemala. We find that dialysis interacts with an insufficient health care system, one that avoids life-ending complications but does not sufficiently manage life-altering symptoms. In addition, the need to care for people with ESRD for an uncertain amount of time may disrupt and strain family-based caregiving networks. Amid this meager health and social welfare infrastructure, life on dialysis exacerbates the chronic insecurity and structural inequality of life in postwar Guatemala. As both life and illness are prolonged through dialysis, the unceasing demands of the treatment and illness strain the webs of obligation and care that Guatemalan families and communities have developed to adapt to their decentralized and fragmented public health care system.
Medicine Anthropology Theory 6 (1): 7494;
© Jillian Moore, Caitlin Baird, and Peter Rohloff, 2019.
Published under a Creative Commons Attribution 4.0 International license.
Fluid illness
Dialysis, undercare, and the social life
of kidney disease in rural Guatemala
Jillian Moore, Caitlin Baird, Peter Rohloff
In response to the rising rate of end-stage renal disease (ESRD) in Guatemala, the public
health system established a national community-based dialysis program to enable people
living in rural areas to complete treatment in their homes. Here we explore how this newly
available, life-prolonging technology has altered local worlds by transforming ESRD from an
acute, life-ending illness into a managed chronic condition with an uncertain trajectory.
Through case studies, we describe how living with dialysis influences family relations and
caregiving in rural Guatemala. We find that dialysis interacts with an insufficient health care
system, one that avoids life-ending complications but does not sufficiently manage life-
altering symptoms. In addition, the need to care for people with ESRD for an uncertain
amount of time may disrupt and strain family-based caregiving networks. Amid this meager
health and social welfare infrastructure, life on dialysis exacerbates the chronic insecurity and
structural inequality of life in postwar Guatemala. As both life and illness are prolonged
through dialysis, the unceasing demands of the treatment and illness strain the webs of
obligation and care that Guatemalan families and communities have developed to adapt to
their decentralized and fragmented public health care system.
rural, dialysis, indigenous, caregiving, Guatemala
Medicine Anthropology Theory
‘I feel I have an artificial life’, Alma remarked one afternoon, sitting at her kitchen table in a
dim, cinderblock-walled room in a forested town in the Guatemalan highlands. We had been
discussing peritoneal dialysis, a life-prolonging treatment for end-stage renal disease (ESRD).
For the last two years, Alma had performed dialysis on herself four times a day, every day.
Looming over us were towers of cardboard boxes filled with dialysis solution that, together
with a few wooden planks, formed shelves on which Alma stored mugs and plates. She did
dialysis every four hours: warming a bag of dialysate, scrubbing her hands twenty times in
every direction, connecting the bag to her abdominal catheter, then sitting for thirty minutes
while she exchanged the dialysate for the fluid in her abdomen, which would then sit and
collect uremic toxins and water until her next exchange. The whole process left her feeling
nauseous, cold, and tired. ‘I live by the clock’, she exclaimed, ‘I drop everything to do
dialysis. . . . You have to leave your life to do it, and this time can never be recovered’.
Alma developed ESRD in her late thirties as a complication of longstanding, undertreated
diabetes. As a single mother, given her strict and time-consuming dialysis regimen, she
struggled to care for her daughter on her own. She could no longer earn her own income.
Her younger sister often helped with cooking, cleaning, and childcare; and her brother living
in the United States sent remittances to support her financially. Her father helped care for
his granddaughter but rarely helped Alma care for herself, reasoning that getting out of bed
to do dialysis would strengthen her. Alma wished she could once more jog through the
cornfields surrounding her town, walk to the vegetable market, or simply eat without the
dietary restrictions of her disease. She took solace in the presence of her daughter, although
Alma no longer had the energy to play with her.
A year after this interview, Alma died. At age forty-one, she succumbed to complications of
ESRD. Yet long before her death, life as she knew it had been transformed until it became
nearly unrecognizable. As the incidence of kidney disease and dialysis use continues to rise
around the world (Jagger and Fraser 2017), stories like this are becoming more common.
Alma was but one of a growing number of people with ESRD living in lower-resource areas
like rural Guatemala with limited access to dialysis. In ESRD, kidneys no longer adequately
filter the blood, and eventually people require replacement therapy in the form of
hemodialysis, peritoneal dialysis, or kidney transplantation. While transplantation is
considered the first-line intervention, it is expensive and depends on organ availability, and is
thus not an option for many people, including those living in Guatemala where the national
transplantation rate is less than six percent (Cusumano, Rosa-Diez, and Gonzalez-Bedat
2016). Instead, many people with ESRD depend on lifelong dialysis to survive.
Dialysis and undercare in rural Guatemala
There are two kinds of dialysis. Hemodialysis is a mechanical filtering of the blood by
pumping it through a dialyzer, then back into the body, typically in four-hour sessions, three
times per week. These sessions occur in centralized dialysis facilities often located in urban
centers. Globally, hemodialysis is more commonly used, especially in high-income areas
where it is a profitable venture. Peritoneal dialysis, on the other hand, removes uremic toxins
and water by exchanging abdominal fluid through a permanent catheter multiple times each
day; these exchanges may be gravity driven, allowing people to undergo dialysis in their
homes without machinery. Peritoneal dialysis offers similar survival rates and quality of life
at lower cost, and is more common in low-resource areas. Still, particularly in low- and
middle-income countries, each year millions of patients with ESRD do not receive renal
replacement therapy and die prematurely (Liyanage et al. 2015; Anand, Bitton, and Gaziano
2013). To expand access to dialysis in low-resource settings, some have established
community-based peritoneal dialysis programs, for instance in China (Jiang and Yu 2011),
Colombia (Sanabria et al. 2015), Sri Lanka (Nanayakkara et al. 2017), and Guatemala (Flood
et al. 2017). These programs enable people who are marginalized from health care systems to
both initiate and continue dialysis.
In high-income countries, multiple studies have explored how dialysis affects the lives and
identities of patients, families, and caregivers (Tijerina 2009; Lindsay, Macgregor, and Fry
2014; McQuoid 2017; Kierans and Maynooth 2001; Constantinou 2012), and the ethical
implications of using dialysis to prolong the lives of people who are not candidates for
kidney transplantation (Russ, Shim, and Kaufman 2005). In lower-income countries, dialysis
research tends to focus on strategies to disseminate services to more patients, reduce rates of
infection, and improve patient adherence. However, several ethnographers have written
important accounts of ESRD and dialysis in lower-income countries that demonstrate how
social inequality, state neglect, and health care disparities shape experiences of ESRD and
dialysis (Moran-Thomas 2012; Burnette and Kickett 2009; Crowley-Matoka 2005; Hamdy
Here, we contribute to this literature by exploring how, given limited access to health care,
the burden of caring for people with ESRD falls to kin and community. In particular, we
draw on the notion of ‘undercare’ defined by Feldman (2017, 53) as partial care provided
within ‘system[s] of concern’ that are fragmented, unreliable, and inadequate. The expansion
of dialysis into rural Guatemala transforms a once-fatal condition into a chronic managed
state, one that is dependent on undercare – minimal and precarious biomedical health care –
around which entire households and caregiving webs reconfigure. In this article, we use case
studies to explore the use of dialysis in rural Guatemala, interrogating how the lives of those
on dialysis are nurtured and prolonged, and how dialysis and undercare interact with local
caregiving networks.
Medicine Anthropology Theory
The research presented here is part of a larger study of how people live with terminal illness
in rural indigenous communities in the highlands of Western Guatemala. In particular, we
draw on twenty-three home visits and interviews conducted by Jillian Moore with two men
and two women with ESRD and their families, in June and July 2014, and again between
September 2016 and May 2017. At the time of these visits, the participants were between
thirty-seven and forty-seven years old. Jorge, Pedro, and Elena identify as indigenous Maya,
and Alma as mixed ethnicity. Pedro, Elena, and Alma developed ESRD due to
complications from undertreated diabetes, and Jorge developed ESRD of uncertain etiology.
All four received medical consultation at the Unidad Nacional de Atención al Enfermo
Renal Crónico (National Unit for Chronic Kidney Disease Care, or UNAERC), the public
nephrology clinic in Guatemala City. Jorge received hemodialysis at the UNAERC unit, and
the other three performed peritoneal dialysis in their homes.
All four were also patients of Wuqu’ Kawoq Maya Health Alliance (hereafter Wuqu’
Kawoq), a nongovernmental organization providing health care to people living with chronic
illnesses in rural communities. All authors of this paper are clinicians or researchers affiliated
with Wuqu’ Kawoq, and our affiliation with this civil society organization has afforded us
opportunities to interact with patients and families in their homes. We also have professional
relationships with UNAERC and the other public health care entities mentioned in this
study. Our intention is not to provide a unilateral critique of the care provided by these
institutions; instead, we offer this perspective of chronic illness in rural Guatemala as a
supplement to public health narratives about life-prolonging technologies like dialysis, in the
hope of raising questions about the collateral and often unrecognized consequences of
dialysis for local caregiving networks.
End-stage renal disease in rural Guatemala
Guatemala has one of the highest levels of poverty and income inequality in Latin America,
which especially impacts rural and indigenous Maya communities (Cabrera, Lustig, and
Morán 2015; Ministerio de Salud Pública y Asistencia Social (MSPAS), Instituto Nacional de
Estadística (INE), and ICF International 2017). This inequality has complex political and
economic roots in the concentration of agricultural land holdings, a weak tax code, free-trade
agreements that have transformed rural economies and consumption patterns, and public-
sector corruption and fraud. Importantly, rural Maya communities have also been subjected
to organized violence and discrimination, most notably during the thirty-six-year civil war.
However, since the end of the war in 1996, peace agreement provisions to alleviate inequality
have been poorly implemented (Oglesby and Nelson 2016), and efforts to restructure
primary health care have been largely ineffective, with continued over-investment in specialty
and hospital-based health care. As a result, in Guatemala, hospital-level resources exist to
Dialysis and undercare in rural Guatemala
treat end-stage complications of chronic diseases, but for most communities, preventive and
early treatments are largely unavailable (Chary and Rohloff 2015).
One chronic disease rapidly becoming more common in rural Guatemala is chronic kidney
disease (CKD), most of which is attributable to a rising prevalence of undertreated diabetes
(Rosa-Diez et al. 2014). While the epidemiologic shifts leading to higher rates of diabetes are
often accounted for with theories of transitions towards sedentary lifestyles, these transitions
themselves are in part driven by socioeconomic and political inequity (Nulu 2017), including
the ways free-trade agreements and international food policies have influenced rural-to-
urban migration patterns and the turn from traditional staple crops to nontraditional export
crops (Gálvez 2018; Flood and Rohloff 2015; Chary et al. 2012).
Together with these epidemiologic transitions, poor access to primary and preventative
health care hastens the progression of diseases like CKD (Garcia-Garcia et al. 2015).
Although some public primary health care does exist in Guatemala and is free to all citizens,
it is designed to address acute and episodic conditions, and is not resourced to care for
people with chronic illnesses like diabetes or CKD (Maupin 2009). Public health posts are
understaffed and lack basic equipment and medications for managing chronic diseases. For
example, most facilities do not stock insulin, a medication commonly required to halt the
progression of diabetes and prevent kidney failure. Given these deficiencies in public
primary health care, most people seek biomedical care for their chronic illnesses in the
private sector, funded out-of-pocket as their finances allow, and turn to kin and community
for additional support (Chary et al. 2012). At Wuqu’ Kawoq, most people we care for with
diabetes or CKD seek our care after years without regular or reliable biomedical care. For
some, the transition to ESRD and entry into a peritoneal dialysis program may be their first
stable relationship with biomedicine.
Another factor contributing to rising rates of ESRD in Guatemala is a recently recognized
epidemic of ‘chronic kidney disease of nontraditional causes’ (CKDnT) primarily in young
agricultural laborers without common risk factors for CKD like hypertension or diabetes.
Although the causes of CKDnT continue to be debated, the leading theory is that CKDnT
results from kidney injury caused by recurrent dehydration and heat stress (Silva, Albert, and
Jayasekara 2017; Laux et al. 2015; Correa-Rotter, Wesseling, and Johnson 2014). Similar
epidemics exist in India, Egypt, and Sri Lanka where people also withstand strenuous
agricultural labor in heat and high humidity. However, because strenuous agricultural labor is
by no means a new phenomenon in Guatemala or elsewhere, the confluence of factors and
vulnerabilities underlying the epidemic remains a topic of ongoing research.
Regardless of how people develop kidney disease, in Guatemala many cases of CKD
progress to ESRD requiring dialysis. In fact, Guatemala has one of the highest per capita
Medicine Anthropology Theory
rates of peritoneal dialysis in the world (Jain et al. 2012). Most rural Guatemalans do not
have access to insurance-based care provided by social security and military facilities and
instead seek dialysis through UNAERC, an institution founded after the civil war and tasked
with caring for poor patients with kidney disease. The first nephrology department in
Guatemala was founded within the social security health system, the Instituto Guatemalteco
de Seguridad Social (Guatemalan Institute of Social Security, or IGSS). In 1992, IGSS
created the first peritoneal dialysis program in the country with support from Baxter, a
corporation that produces dialysis supplies. With time, IGSS nephrologists began to also
care for patients without social security insurance, through a program overseen by the Order
of Malta, a Catholic humanitarian organization that had received dialysate donations from
private companies in the United States and was searching for a way to make use of them
(Lou Meda 2011). Then in 1997, with funds from the Order of Malta, the Guatemalan
government founded UNAERC to assume care for all peritoneal dialysis patients once cared
for though the IGSS charity services.
By recent count, UNAERC now has a caseload of about 4,500 dialysis patients and each
month accepts more than one hundred new patients requiring therapy (UNAERC, n.d.).
UNAERC shoulders a daunting responsibility, as it lacks the capacity to care for its rapidly
growing and extremely underserved patient population, and it functions within a larger
primary health care system that does little to prevent or slow the progression of CKD
(Muñoz Palala 2016). For people on peritoneal dialysis, UNAERC provides the resources
necessary for dialysis itself, including dialysate, catheters, and laboratory monitoring of
dialysis function, all through government-contracted private corporations. However,
UNAERC does not have the resources to offer patients comprehensive care, including
diagnostic exams or medications for conditions commonly associated with ESRD like
anemia, mineral bone disease, diabetes, and hypertension. Therefore, while access to dialysis
technology keeps people from swiftly dying of ESRD, these individuals receive minimal care
for the symptoms and comorbidities that arise as the disease progresses. Furthermore, since
kidney transplantation is largely unavailable in Guatemala, kidney dialysis is not a temporary
bridge to curative treatment as is often the case in higher-income settings. The situation in
Guatemala is similar to that described by Moran-Thomas (2012, 202203) in Belize, where
diabetic nephropathy is also common and access to dialysis is limited; in this context, dialysis
becomes a ‘holding measure against death . . . stretching the remainders of time’.
The case studies we share demonstrate how in rural Guatemala, experiences of ESRD and
dialysis are shaped by the patchy and unreliable system of undercare through which people
gain access to a biomedical technology that prolongs their lives and illnesses. Lives
structured around dialysis provided through undercare become defined more by the
unknown than the known, more by the uncertain than the certain. Furthermore, in a place
Dialysis and undercare in rural Guatemala
where illnesses are understood and addressed communally (Chary 2015), this uncertainty
reaches beyond the individual and encompasses entire families and communities in
narratives of struggle and irresolution.
Jorge lives in a rural highland village with his wife and five sons. From childhood, he
supported his family through subsistence farming and logging trees, until his early thirties
when his kidneys failed. He had been healthy until one day he began to feel nauseous and
noticed his feet and face were swollen. These symptoms worsened over the next week until
he finally sought care at a public hospital where he was diagnosed with kidney failure and
referred to UNAERC. For the next two years, Jorge performed peritoneal dialysis in his
home. After developing multiple abdominal infections, he transitioned to hemodialysis in
Guatemala City. Now, twice a week Jorge leaves home before sunrise on a four-hour journey
by public bus to arrive at UNAERC by nine in the morning. If he is late, his appointment
and machine are given to another patient. The hemodialysis lasts four hours, during which
Jorge waits while his blood whirs through a machine. Afterwards, he makes the four-hour
trip home.
These bus trips cost US$40 per month, but for the last six years, because of his disease, Jorge
has not had the stamina to farm or log trees, and thus has earned no income. Instead, his
wife and mother earn money washing clothes or collecting firewood, in addition to tending
to their home and the five boys. Their wages are used for food, electricity, and schooling, as
well as the bus fares for Jorge. To supplement these earnings, Jorge seeks support from
charitable organizations. Wuqu’ Kawoq provides him primary care and medications for
conditions associated with his kidney disease, and when our finances allow, we fund a
portion of the bus fares. Another charitable organization donates school supplies and
clothing for his sons. Sometimes the family borrows money from neighbors, unsure of how
or when they will pay them back. When money is particularly tight, Jorge skips treatment,
which leaves him feeling even more tired and nauseous than usual. Although his life has
been extended by dialysis, for Jorge and his family, this prolonged life is a state of perpetual
Like Jorge and his family, many people in rural Guatemala live with unpredictable and
unreliable sources of income, food, and health care. In the rural areas of Guatemala, most
households are landless or land poor, with farming plots too small to maintain subsistence.
To earn incomes, families rely on short-term, physically intensive jobs without contracts or
benefits (Krznaric 2006). These labor conditions can, as they did for Jorge, provoke or
accelerate the progression of chronic illnesses like CKD. When kidneys fail, biomedicine
Medicine Anthropology Theory
offers patients dialysis, which staves off death but is not itself curative. In Guatemala, organ
transplant is exceedingly rare due to the resource and financial constraints on institutions
providing kidney care. Furthermore, medications to alleviate the symptoms caused by both
dialysis and disease progression fatigue, nausea, swelling, loss of appetite are expensive
and unsubsidized. Dialysis supports life, but only at the point of death: minimal care serving
only to prolong vital bodily functions to keep people alive amid crisis, but not to help them
thrive (Redfield 2012).
Without adequate ancillary support from the institutions providing dialysis, people ‘make do’
(de Certeau 1984) by mobilizing social networks – family, friends, churches, and increasingly,
nongovernmental organizations like Wuqu’ Kawoq to fill gaping holes in their care (Chary
and Rohloff 2015). However, just like the people they seek to help, organizations like ours
face unpredictable financial and existential futures, relying on transient funding from
disparate sources to provide patchwork care for chronic illnesses like kidney disease that do
not capture the imaginaries of global health donors and policy makers (Baird 2018). As
clinicians and companions of the patients we serve, we also find ourselves improvising and
‘making do’.
Peter Rohloff, a physician who has cared for Jorge for several years, regularly confronts the
reality that Jorge’s persistent weakness and fatigue are due to insufficient dialysis. Jorge
receives dialysis twice weekly based on the availability of machines at the UNAERC facility,
but ideally he would receive three or more sessions per week. After one clinic visit with
Jorge, out of frustration Peter exclaimed to Jillian, ‘His neck veins are up to his ears, and he
has high blood pressure. The only way to fix this is more dialysis. Everything else is like
moving chairs on the Titanic’. Despite these constraints, we continue to do what we can to
offset inadequacies in UNAERC care and manage his dialysis-related symptoms. For
example, to treat his anemia Peter continues to prescribe erythropoietin, a very costly
medication that Wuqu’ Kawoq can only afford to subsidize at half the optimal dose. Thus
we watch his illness unfold, uncertain of how long our organization, Jorge and his family can
each bear the tensions produced at the intersection of the necessities of disease and the
inaccessibility of treatment.
In this way, life-prolonging technologies like dialysis push those in civil society to their
caregiving limits. Approaching these limits is especially unsettling for us as physicians and
reluctant humanitarians educated in an individualistic society infused with discourses of
human rights and autonomy, from which we have absorbed the notion that everyone has a
right to access the medical care required to keep them alive. In alignment with this idea,
patients who would have otherwise had a swift and perhaps painless death now depend on a
minimal technology within a substandard health care system. Caring for these individuals, it
Dialysis and undercare in rural Guatemala
is unsettling to ask ourselves whether it is possible that these technologies have in the end
caused more harm than good, as we watch families struggle and strive to get by each day,
and as we ourselves feel the palpable and disquieting uncertainty that infuses their lives and
defines their futures.
Pedro, who lives with peritoneal dialysis and who we discuss below, describes the anxiety
engendered by this existential uncertainty: ‘the hope is that through this medicine [dialysis]
one can live, but for how long? . . . [The doctors] do not know what will happen, and neither
do we: what will happen in the course of time while on dialysis’. For dialysis patients,
caregivers, and family members, this uncertainty is emblematic of undercare (Feldman 2017).
In Guatemala, undercare keeps individuals with severe chronic illness alive, but not in ways
that foster dignified and whole lives. Rather, they work constantly to compensate for the
scarcity and fragility that surrounds them, using ground-level ‘tactics’ (de Certeau 1984) to
resist precarity: taking advantage of opportunities as they come and to mobilizing existing
social networks and their resources. In this way, an advanced biomedical technology like
dialysis may preserve life while simultaneously reinforcing the violent and unequal social and
political structures that create the conditions for disease in the first place (Kalofonos 2010;
Feldman 2017; Stevenson 2012). Through dialysis, Jorge has lived years beyond his
diagnosis, yet he has spent those years feeling exhausted and weak, and unable to live as he
wishes. Furthermore, his wife and mother labor each day to earn bus fares, replace his lost
income, and procure basic necessities for their family. Keeping up with the incessant
demands of dialysis can push people to their limits, perhaps threatening to exceed their
capacity to ‘make do’.
Life-limiting technologies
Jorge’s hemodialysis trips are only possible due to the exceptional efforts of his family and
financial support from community-based organizations. Many other people cannot access
these serendipitous resources (Baird 2018), and as a result may discontinue or never initiate
treatment. In recent years, community-based peritoneal dialysis programs have emerged as
an important public health response to this need (Nanayakkara et al. 2017; Liyanage et al.
2015). Advocates of these programs, like the UNAERC peritoneal dialysis program in
Guatemala, insist that all people deserve life-prolonging treatment, no matter their
circumstances. The UNAERC website promotes its peritoneal dialysis program in terms of
autonomy and enablement:
Medicine Anthropology Theory
Most people enjoy the independence and flexibility they get with peritoneal dialysis. . .
. It provides the freedom to dialyze and manage the disease mainly from your home. .
. . The material you need to do it arrives at the door of your house, and you only have
to go to the clinic every six weeks. . . . People on peritoneal dialysis treatment can lead
normal lives. . . . You can maintain the balance of your normal work with minimal
interruption by therapy.
In the remainder of this article, we explore these assertions by examining the experiences of
three people who use peritoneal dialysis. We show that although peritoneal dialysis does
alleviate some of the financial and logistical stressors that people like Jorge experience while
on hemodialysis, with peritoneal dialysis undercare continues to affect families and
communities through the symptoms caused by dialysis and disease, both of which create
needs for intensive caregiving.
‘I am like a little baby’, Pedro observed, as his wife Luz transferred him from their bed onto
his wheelchair and tucked his atrophied legs under a wool blanket. Pedro once supported his
family as a carpenter, until eight years ago when he was diagnosed with diabetes. Because the
local public health clinics were inaccessible and unreliable, and he could not afford private
health care, Pedro lived for years without treatment. He gradually became emaciated, blind,
and unable to walk. One day a local midwife introduced Pedro to Wuqu’ Kawoq, and he
began treatment with us. However, irreversible damage had already been done, and several
months later he developed ESRD. Our organization referred him to UNAERC, and he
began peritoneal dialysis in his home. Pedro has performed peritoneal dialysis four times
daily for nearly three years. Due to nerve damage from diabetes, he cannot live
independently, and Luz and their four children must help him walk, bathe, toilet, and do the
dialysis treatments.
Through peritoneal dialysis, Pedro has continued to live when he would otherwise have died.
The treatments relieve distressing symptoms like nausea and swelling, allowing him to
engage in some activities that bring him joy: being with his children, singing, praying with
friends from his church. However, while peritoneal dialysis enables Pedro to live at home
surrounded by his community, the treatment has significant effects on his wife and children,
who work to adapt and keep up with the demands of dialysis and ESRD. As Jain (1999, 40)
writes, prosthetic technologies have effects ‘that are enabling in certain capacities for certain
people and disabling for overlapping sets of bodies and interests’. In this case, Pedro relies
entirely on his wife Luz for care and dialysis. She earns their household income weaving
traditional Maya belts between dialysis sessions and her other chores and errands. She
finishes two belts each month, for which she earns the US$30 they use for food,
transportation, and education expenses. Luz once earned more as a housekeeper, but she
Dialysis and undercare in rural Guatemala
had to abandon this job because she would have to interrupt her workday to return home to
help Pedro with dialysis. She explained, ‘If you go to work, they want you to be there
working. You cannot show up, and then go home in one or two hours. . . . But I have to
give him my time. Any free time, I give to him for his medication [dialysis]. This must be
done because this treatment is his life . . . only through dialysis does he have life’. Luz
structures her life knowing her husband will depend upon her continued presence and effort
for the foreseeable and uncertain future.
People with chronic illnesses often depend on affective labor: the labor of caregiving and
social reproduction most commonly performed by women like Luz. The efficacy of home
peritoneal dialysis often depends on the affective labor of kin and community, gendered
labor which remains implied and unspoken. So too in biomedicine, a medical system in
which practitioners often focus on how interventions affect individual bodies imagined as
bounded and autonomous rather than within the webs of care and obligation, on which they
and the efficacy of many biomedical treatments depend. As physicians it is easy to narrow
our vision to a single circumscribed body in an attempt to simplify illnesses that are socially
complex, diffusing across bodily borders. But biomedical care that neglects the social context
of disease and that ‘conceives of life as artificially severed from community’ may fail to
address how care offered without understanding this context may in fact be harmful
(Stevenson 2012, 605).
Indeed, in many settings individual bodies and lives cannot be so easily cleaved from the
bodies and lives of their kin and community. Especially amid material scarcity and with
indeterminate disease trajectories, caregiving may significantly constrain the agency and life
chances of these primary caregivers (Bergstrom and Heymann 2005). As Luz describes:
I have to take him to [UNAERC], and that requires money, as do the medications. . .
. And [Pedro] requires care: moving him into the sun, taking him out for a walk, and
other things. I have to take him to check-ups with [the nurse]. My time is a factor for
me: money makes this so . . . for while someone is supported economically, she can
achieve things. But if someone does not have [economic support], it is as if she were
tied down. She cannot move forwards or backwards along the four cardinal points.
As a caregiver for someone with debilitating illness, Luz must adhere to demanding
treatment regimens, but she is also a mother and the primary provider for her household.
She simultaneously feels pulled in multiple directions and paralyzed, unable to fulfill any of
the obligations she confronts on a daily basis.
Home dialysis even imposes significant limits on people less debilitated and still able to care
for themselves. For example, Alma was a young woman living with ESRD who performed
Medicine Anthropology Theory
her own home dialysis treatments. Until the day she died, Alma was the primary caregiver for
her young daughter, though her ability to care for her was limited by weakness, fatigue, and
the demands of dialysis treatments, rendering it difficult to leave the home. She had to quit
work because she could not find an employer who would allow her a private space for
dialysis, or the time to return home for treatment. Instead, she lived on money from her
father and remittances from her brother. Elena, another single mother performing home
dialysis on her own, described how dialysis was the defining feature of her life: ‘I basically
live to do my treatment’. Throughout their illnesses, Alma and Elena continued to support
themselves and their dependents. In Guatemala, women living with chronic illness are often
not exempt from their caregiving obligations as men are, given gendered norms devaluing
the labor and lives of women, and gendered expectations of care that have been well
established and documented elsewhere (Chary 2015; Moore et al. 2017; Webb 2015; Ehlers
In these ways, home dialysis defines, governs, and limits the very lives it prolongs. Compared
with hemodialysis, peritoneal dialysis allows people to access treatment in their homes,
making treatment more feasible and accessible. But this does not mean that people who use
peritoneal dialysis have no need for institutional support, support currently provided by kin
and community who themselves struggle with competing priorities. Furthermore, home
dialysis regimens are time-consuming and restrict physical mobility. Each of these limitations
are directly at odds with the tactics commonly employed by individuals in rural Guatemala in
response to financial or acute medical emergencies, like seeking jobs in the informal labor
market, exchanging favors in social networks, or offering short-term, intensive care (Chary
and Rohloff 2015). Affective and productive labor are not commonly considered
fundamental to the efficacy of peritoneal dialysis programs, even though many patients
require sustained intensive care from others to use the technology and engage in activities of
daily living. These caregiving demands affect the abilities of those involved most often
women – to tend to other obligations and earn their livelihoods. While home peritoneal
dialysis may enable one individual to live, someone must nurture this prolonged life, whether
that is the patient or her kin and community. When dialysis is reimagined to be both life
enabling and life limiting, these essential labors begin to materialize.
Chronicity and care
Elena lives in the same highland town where Alma once lived. She also uses home peritoneal
dialysis. When Alma was alive they often traveled together to UNAERC appointments and
became close friends. Elena once remarked that ESRD was more difficult for Alma than for
herself. She explained, ‘[Alma] has a daughter, so she has to fight. But my work is done’,
referring to her three adult children. Indeed, Alma cared for her daughter Nina despite her
Dialysis and undercare in rural Guatemala
symptoms and the demands of dialysis. But sometimes Alma would feel too tired to rise
from bed to do her treatment, let alone walk Nina to school. With so many absences, Nina
had to repeat the third grade. Alma’s sister Lupe recalled: ‘near the end of her life it was not
[Alma] who cared for [Nina], but [Nina] who cared for [Alma]. She would find her lying on
the ground with low [blood] sugar, and even though [Alma] weighed more than her, [Nina]
would have to take care of her mother’.
On the day Alma died, it was Nina who found her mother collapsed on the bathroom floor.
Now Lupe who also has diabetes and CKD cares for Nina in addition to her own two
children, just as she promised Alma she would. Livingston (2010, 6; emphasis in the original)
describes illness as ‘something that happens between people’, an idea we have encountered
repeatedly while caring for people living with dialysis in Guatemala. Families adapt to the
caregiving needs of illness and the rigorous demands imposed on them by dialysis. Yet these
gendered webs of obligation and care can fray when illness is protracted over many years and
as new responsibilities evolve.
Having escaped an abusive marriage, Elena raised three children on her own with wages
from her small eatery. She worked hard to provide for her children. ‘In my imagination,
when my children grew up, they would support me’. This has not been the case. Elena
observed how her care for others has gone unreciprocated: ‘when my mother was dying [of
diabetes], I was with her every day, by her side. If she wanted porridge, I made her porridge.
I made anything she wanted . . . but nobody does these things for me. I have no one but
God’. Indeed, Elena largely cares for herself. She lives off her own savings from the sale of a
parcel of land. She prepares her own food, administers her insulin injections, and does
dialysis on her own, despite poor eyesight and fingers numbed by peripheral neuropathy.
When Elena has low blood sugar, she often lies in her bed and waits, because there is no one
to bring her a glass of juice.
Yet Elena does not live alone. For years, she has lived with her daughter Lucy and her son-
in-law. When she first became ill, Elena invited them to live on her land, hoping they would
care for her in return. When Elena began dialysis, Lucy would help, but after a year Lucy had
a baby. Lucy now spends her time caring for her children or selling at market. She does not
help Elena with chores or cooking, even though Elena often watches the grandchildren.
‘Now they are bored with me, because I have been sick for so many years. Or maybe now
they have more commitments’. As for her other family members, Elena offers that the
demands of their jobs could keep them from helping her, though in another instance she
declared ‘it is because they have no love in their hearts: their hearts have hardened’.
For Elena, family support gradually waned in the context of an unresolving chronic illness.
As the prevalence of chronic illnesses like CKD rises in Guatemala (IHME 2016), alongside
Medicine Anthropology Theory
access to life-prolonging technologies like dialysis, we observe that family caregiving systems
face, often for the first time, the need to sustain caregiving strategies for longer than they are
able. Chronic illnesses strain relationships already encumbered by material scarcity,
landlessness, unemployment (Manderson and Smith-Morris 2010). As we have described
elsewhere (Chary and Rohloff 2015), families in rural Guatemala typically respond to
undercare through the use of makeshift ‘tactics’, seizing opportunities as they arise and
exploiting their social networks (de Certeau 1984). Dialysis poses a significant challenge to
this improvisational approach by transforming ESRD from an acute catastrophic illness,
during which family resources can be mobilized to provide temporary end-of-life care, into a
depleting and extended effort of unpredictable duration.
In this setting, tactics may be exhausted, or competing obligations may arise that demand ‘a
certain “selfishness” that pits individuals against one another’, as when Elena’s daughter
turned her attention towards her new family and abandoned her mother (Scheper-Hughes
1992, 473; see also Biehl 2005). As illness drags on with dialysis ‘stretching the remainders of
time’ (Moran-Smith 2012, 202), people may reach limits beyond which they are unable or
unwilling to care for others. In these contexts, the use life-prolonging technology is an
experiment testing the adaptive and responsive abilities of political systems and civil society.
When bodily integrity so concretely depends on a deficient public health care and welfare
system, the fragility of caregiving networks already stretched to their limits becomes
apparent, exposing vulnerabilities just beneath the surface that families otherwise work so
diligently to float above.
While on dialysis, Elena has watched her family members become ‘bored’ with her. She gets
by on support from her church, neighbors, and charity organizations like ours, but she feels
this is no replacement for care from her family. Likewise, Jorge was recently told by his wife
and mother that they are exhausted with earning his bus fares. They tell him to either earn
the fares himself or to move permanently to Guatemala City to live near the hemodialysis
facility. Such a move would be unbearable for Jorge, as his primary joy in life is to be near
his wife and sons; but the configuration of care that sustains his life has become unbearable
to them. This is the essential existential uncertainly that characterizes living with dialysis
within the system of undercare in rural, postwar Guatemala: How long will I live with
dialysis, and under what conditions? Will our money last? Will my family continue to support
me, and for how long?
These cases of families living with dialysis in rural Guatemala show that ESRD demands a
unique sort of caregiving due to its debilitating symptoms, lack of access to comprehensive
Dialysis and undercare in rural Guatemala
care, uncertain chronic illness trajectory, and time- and energy-intensive treatment. Dialysis
requires people to regularly ‘leave their lives’ as Alma put it: thirty minutes multiple times per
day for peritoneal dialysis, and perhaps an entire day of travel and treatment multiple times
per week for hemodialysis, in addition to the labor required to fund these journeys. Dialysis
structures the lives of users, their dependents, and their caregivers. As Russ, Shim, and
Kaufman (2005, 299) write, ‘dialysis threatens to overcome and, for some patients, to
become the life that it extends’ (emphasis in the original).
In Guatemala, the experience of ESRD and dialysis is shaped by a chronically under-
resourced public health care system. Individuals whose lives are prolonged by dialysis still
suffer debilitating symptoms like fatigue and weakness because they lack access to the
resources, medications, and diagnostics necessary to alleviate those symptoms. During acute
episodic illnesses, Guatemalan households often and effectively use short-term
improvisational tactics to make do. However, in an uncertain chronic illness trajectory, these
tactics must be sustained indefinitely, which may overwhelm caregiving resources and
resolve. In these ways, dialysis care in rural Guatemala is bracketed by undercare that
prolongs life while leaving unaddressed the capabilities of caregivers, overwhelmingly
women, whose labors are rendered invisible and anonymous. Because dialysis care for the
rural poor in Guatemala does not attend to caregiving networks – nor does it have the
resources to support them access to the technology can strain these social relations.
Indeed, other authors have described how amid chronic scarcity, biomedical care may have
unintended consequences, exacerbating conditions of poverty, straining social solidarity
(Kalofonos 2010), and opening possibilities for abandonment by kin (Biehl 2012).
What we have shared about dialysis in rural Guatemala adds to a growing anthropological
literature on ESRD and dialysis, and helps to illuminate how the experience of a technology
may hinge on socioeconomic, cultural, and political context. For instance, exploring the lives
of elderly patients on hemodialysis in California who, like patients in rural Guatemala, are
not candidates for kidney transplantation, though for very different reasons Russ, Shim,
and Kaufman (2005) describe how clinically sustained existence can reconfigure intimate
relations and destabilize ideas of living and life. We build on these ideas by exploring the
effects of medically delayed death in a younger population who are yet within the years of
life in which they would otherwise be expected, and may still be expected, to care for others
and earn wages. Living on dialysis, these individuals experience overwhelming relationship
reconfigurations and identity crises that must be considered when offering these populations
life-sustaining therapy in the absence of a curative endpoint like kidney transplantation.
Especially unsettling is that the dialysis treatment offered to these populations is inadequate,
a partial treatment sufficient to stretch the remainder of life, but not sufficient to relieve
fatigue, swelling, or nausea. As Moran-Thomas (2012) describes in Belize, the experience of
Medicine Anthropology Theory
ESRD defined by these debilitating lingering symptoms is socially constructed by a state
apparatus that rations essential therapies, the same apparatus whose disregard created the
conditions for ESRD in the first place. Indeed, as Hamdy (2008) describes in Egypt, no
dialysis patient is apart from regimes of medical treatment or state infrastructure, but rather
is made physiologically dependent on the very systems implicated in ESRD etiologies.
Especially for home-based dialysis, we extend this imaginary to include caregivers and
partners whose unrecognized and uncompensated labors are essential to the success of
decentralized dialysis programs. Indeed, as Moran-Thomas (2012) points out in her
dissertation, chronic diseases like diabetes and ESRD are para-communicable’, spreading
along the same channels by which poverty and injustice permeate families and communities.
Illnesses like ESRD are also communicable along webs of caregiving through which entire
families and communities are drawn into technologically sustained, minimal existences
dependent on partial treatments and hole-ridden state health and welfare programs.
Our intent is not to discount the importance of expanding dialysis therapies to rural areas of
the world. These technologies allow people with ESRD to live years longer than they would
have otherwise, years that may contain meaning and joy. Rather, we hope to inspire
reflection about how life-prolonging biomedical technologies are experienced by people in
places where social fabrics are already worn thin, by illuminating how life-prolonging
technologies affect users and their kin and communities in different ways that may be
harmful for caregiving networks. The notion of care tends to carry positive connotations:
care is presumed to be a gesture of kindness and rescue. However, care can be harmful
particularly when the locus of care is circumscribed to individual bodies, disregarding the
ripple effects of illness and treatment, as is often the case in biomedicine. This reductionistic
approach to health care is incongruent with lived reality in rural Guatemala: where lives are
fluid, running together, across bodily boundaries and generations.
Life-prolonging, minimal care like dialysis care in Guatemala can strain those relationships
that have been forcibly reconfigured around ‘partial treatment’ (Moran-Thomas 2012, 202).
This undercare care that attends to the end stages of disease, but fails to prevent disease
progression; care that prolongs life, but fails to address the symptoms that diminish quality
of life; care that demands a radical restructuring of the days that become weeks that become
years in the lives of patients and their families, but without attending to or addressing the
interdependencies of those lives is care that is held and enacted in suspension, weakened
and made fragile by the uncertain trajectories by which it becomes defined. Within the
privatized, pluralized, and patchwork Guatemalan health care system, this existential
uncertainty is compounded, perhaps leaving patients, families, and caregivers stressed
beyond their ability to ‘make do’.
Dialysis and undercare in rural Guatemala
We would like to thank the participants and their families, as well as the Wuqu’ Kawoq staff
and leadership, for sharing their stories and wisdom with us. Matyöx chiwe. We would like
to thank David Flood for the use of his beautiful photo. This research was funded by a
Doris Duke Charitable Foundation International Clinical Research Fellowship to Jillian
Moore through Harvard Medical School.
About the authors
Jillian Moore is a resident physician in the Department of Family & Community Medicine at
the University of New Mexico and a volunteer researcher with Wuqu’ Kawoq | Maya Health
Alliance. Her interests include gender and intergenerational trauma. Caitlin Baird holds a
PhD in Anthropology from the University of Florida. She is currently a medical
anthropologist with Wuqu’ Kawoq | Maya Health Alliance. Peter Rohloff is the Chief
Medical Officer for Wuqu’ Kawoq | Maya Health Alliance and an internist and pediatrician
at Brigham and Women’s Hospital and Boston Children’s Hospital.
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... However, our goal was to understand the challenges of providing kidney care to a large number of uninsured adults in Guatemala, and UNAERC is the dominant institution providing such care. Third, while this study did not include patient perspectives, it complements the authors' prior work studying CKD in Guatemala from the perspective of both children and adults [10,25,26,67,68]. ...
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Background: Chronic kidney disease (CKD) is increasing worldwide, and the majority of the CKD burden is in low- and middle-income countries (LMICs). However, there is wide variability in global access to kidney care therapies such as dialysis and kidney transplantation. The challenges health professionals experience while providing kidney care in LMICs have not been well described. The goal of this study is to elicit health professionals' perceptions of providing kidney care in a resource-constrained environment, strategies for dealing with resource limitations, and suggestions for improving kidney care in Guatemala. Methods: Semi-structured interviews were performed with 21 health professionals recruited through convenience sampling at the largest public nephrology center in Guatemala. Health professionals included administrators, physicians, nurses, technicians, nutritionists, psychologists, laboratory personnel, and social workers. Interviews were recorded and transcribed in Spanish. Qualitative data from interviews were analyzed in NVivo using an inductive approach, allowing dominant themes to emerge from interview transcriptions. Results: Health professionals most frequently described challenges in providing high-quality care due to resource limitations. Reducing the frequency of hemodialysis, encouraging patients to opt for peritoneal dialysis rather than hemodialysis, and allocating resources based on clinical acuity were common strategies for reconciling high demand and limited resources. Providers experienced significant emotional challenges related to high patient volume and difficult decisions on resource allocation, leading to burnout and moral distress. To improve care, respondents suggested increased budgets for equipment and personnel, investments in preventative services, and decentralization of services. Conclusions: Health professionals at the largest public nephrology center in Guatemala described multiple strategies to meet the rising demand for renal replacement therapy. Due to systems-level limitations, health professionals faced difficult choices on the stewardship of resources that are linked to sentiments of burnout and moral distress. This study offers important lessons in Guatemala and other countries seeking to build capacity to scale-up kidney care.
This qualitative study explores perceptions of chronic kidney disease (CKD) among adults with abnormal estimated glomerular filtration rate (eGFR) in Guatemala, where the burden of CKD is rising. Qualitative semi-structured interviews were conducted with 39 individuals screened for CKD and found to have abnormal eGFR (defined as <90 mL/min/1.73 m², per Kidney Disease Improving Global Outcomes [KDIGO] guidelines). Interviews occurred in participants’ homes in Spanish or Kaqchikel Mayan. Interview notes were coded for dominant themes through an inductive approach. Interviewees had limited awareness of diabetes and hypertension as CKD risk factors, but appreciated the progressive nature of the disease. While most reported willingness to pursue renal replacement therapies, if necessary, they anticipated economic and geographic barriers. Public health interventions should focus on the association between diabetes, hypertension, and CKD. Improvement of primary care and screening infrastructure is imperative in CKD prevention in low- and middle-income countries (LMICs).
Diseases of the genitourinary system are the leading cause of hospital deaths in El Salvador, and chronic kidney disease of unknown origin has been gaining attention as a public health problem among farmers in particular. Epidemiological studies point, in part, to environmental risk factors, which have shifted over time with the deployment of modern agricultural science and ongoing climate change. We examined how diseases of the genitourinary system were situated at several margins of an epidemic in one rural Salvadoran municipality where these environmental and epidemiological changes are occurring, albeit relatively slow. By using this approach to study diseases of the genitourinary system, we illustrate one way in which shifting human/environment entanglements can be experimentally “known” in the context of human diseases associated with them. Our approach offers a unique perspective in thinking with ethnographic data to compliment ongoing epidemiological investigations of kidney disease in El Salvador.
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In 2015, 634387 million people (9% of the world's population) resided in Latin America (LA), with half of those populating Brazil and Mexico. The LA Dialysis and Transplant Registry was initiated in 1991, with the aim of collecting data on renal replacement therapy (RRT) from the 20 LA-affiliated countries. Since then, the Registry has revealed a trend of increasing prevalence and incidence of end-stage kidney disease on RRT, which is ongoing and is correlated with gross national income, life expectancy at birth, and percentage of population that is older than 65 years. In addition, the rate of kidney transplantation has increased yearly, with > 70% being performed from deceased donors. According to the numbers reported for 2013, the rates of prevalence, incidence and transplantation were (in patients per million population) 669, 149 and 19.4, respectively. Hemodialysis was the treatment of choice (90%), and 43% of the patients undergoing this treatment was located in Brazil; in contrast, peritoneal dialysis prevailed in Costa Rica, El Salvador and Guatemala. To date, the Registry remains the only source of RRT data available to healthcare authorities in many LA countries. It not only serves to promote knowledge regarding epidemiology of end-stage renal disease and the related RRT but also for training of nephrologists and renal researchers, to improve understanding and clinical application of dialysis and transplantation services. In LA, accessibility to RRT is still limited and it remains necessary to develop effective programs that will reduce risk factors, promote early diagnosis and treatment of chronic kidney disease, and strengthen transplantation programs.
Mexican cuisine has emerged as a paradox of globalization. Food enthusiasts throughout the world celebrate the humble taco at the same time that Mexicans are eating fewer tortillas and more processed food. Today Mexico is experiencing an epidemic of diet-related chronic illness. The precipitous rise of obesity and diabetes-attributed to changes in the Mexican diet-has resulted in a public health emergency. In her gripping new book, Alyshia Gálvez exposes how changes in policy following NAFTA have fundamentally altered one of the most basic elements of life in Mexico-sustenance. Mexicans are faced with a food system that favors food security over subsistence agriculture, development over sustainability, market participation over social welfare, and ideologies of self-care over public health. Trade agreements negotiated to improve lives have resulted in unintended consequences for people’s everyday lives.
Globally, increasing numbers of people face the challenge of enjoying life while living with long-term illness. Little research addresses leisure participation for people with chronic illness despite its links with mental and physical health and self-rated quality of life. I use a space-time geographical approach to explore experiences with leisure in everyday life for 26 individuals with chronic kidney disease (CKD) in Australia. I examine ways in which the spatial and temporal characteristics of illness management and symptoms shape where, when, and how participants can enjoy leisure, focusing on: 1) logistical conflicts between illness and leisure; 2) rhythmic interferences with the force of habit in skilful leisure performance; and 3) absorbing experiences of encounter with self and place through leisure. Data were collected from 2013 to 2014. Participants kept diaries over two sample days and then participated in semi-structured interviews. Findings show that the voluntary nature of leisure offered participants important benefits in coping with and managing illness over the long-term, including opportunities to experience greater sense of control, an alternative experience of one's body to the ‘sick body’, and knowledge creation that supports adaptation to the uncertainties of illness trajectories. The ability to engage in meaningful leisure was constrained by the shaping forces of illness symptoms and management on participants' leisure-scapes. Illness treatment regimens should therefore be adapted to better accommodate leisure participation for chronically ill patients, and leisure should be explicitly incorporated into illness management plans negotiated between patients and health practitioners. Finally, greater understanding of the transformative capacity of habit in activities of experimentation and play may have wider-reaching implications for leisure's potential applications in public health. Leisure should be taken seriously as a vehicle for enhancing wellbeing and adaptation to life with long-term illness.
What is it to live as a refugee over the long term? One thing that it can mean and in the Palestinian case of nearly seventy years of displacement, what it necessarily has meant for many peopleis to die as a refugee. This essay explores the consequences of the ways in which humanitarian work has been compelled to take up the end of life as a humanitarian concern. Drawing on fieldwork in the Burj al Barajneh Palestinian refugee camp in Lebanon, it explores care for the aging and dying as a setting in which key aspects of the social world produced through humanitarianism are brought into existence and view. The problems of the end of life introduce additional challenges into the conundrums of long-term humanitarianism, occurring at the intersection of humanitarian practice and Palestinian experience. With the questions of services for the aging and dying foregrounded, the possibility of the future becomes a site of confrontation among, and within, providers and recipients. Often, this future appears to be foreclosed.
General population-based studies, the chronic kidney disease (CKD) prognosis consortium and renal registries worldwide have contributed to the description of the scale of CKD as a public health problem. Since 1990, CKD has been included in the list of non-communicable diseases investigated by the Global Burden of Disease (GBD) study. The GBD represents a systematic, high-quality, scientific effort to quantify the comparative magnitude of health loss from all major diseases, injuries and risk factors. This article provides an outline of the place of CKD in the ranking of these diseases and the change over time. Whereas age-standardized death and disability-adjusted life years (DALYs) rates due to non-communicable diseases in general have been declining, such favourable trends do not exist for CKD. Altogether the GBD reports indicate increasing rates for death and DALYs due to CKD with huge variation across the globe. A substantial component of the observed increase in mortality attributable to CKD relates to that caused by diabetes mellitus and hypertension. For the increase in DALYs, CKD due to diabetes mellitus appears to be the main contributor. It is possible that these trends are in part due to new data becoming available or different coding behaviour over time, including greater specificity of coding. Although some feel there is evidence of overdiagnosis, it seems clear that in many regions CKD and its risk factors are a growing public health problem and in some of them rank very high as cause of years of life lost and DALYs. Therefore, public health policies to address this problem as well as secondary prevention in high-risk groups remain greatly needed.
Development discourse has focused on gendered dimensions of poverty, demonstrating how parastatal poverty alleviation programmes target women as aid recipients while devaluing their productive and reproductive work. However, seldom analysed is how privatisation of social services and proliferation of non-governmental organisations (NGOs) have impacted women. We explore this in a Guatemalan community where we find that although NGOs discursively commit to ‘alternative’ development approaches, on the ground they reproduce elements of a neoliberal subjectivity akin to parastatal programmes. NGOs additionally configure aid disbursement as gift giving, requiring beneficiaries to assume affective postures of gratitude, and facilitating intrusion into women’s lives.