Health professionals in Guatemala are facing a double threat: a potentially lethal virus, and a government that is turning their backs against them. Severe delays in salary payments, bin bags to replace disposable gowns and inadequate facilities are some of the exhausted doctors and nurses’ main complaints. The government says it has agreed a way forward with the doctors, who say help cannot come soon enough. This is what it is like to fight a pandemic against all odds.
When he came across a call, on social media, for doctors to work in a new temporary hospital in the outskirts of Guatemala City, just as the COVID-19 pandemic was starting to spread in the Central American country, Diego, a young doctor, thought signing up would be a good way to help others, to do his bit for the community.
The temporary hospital, with an initial capacity for 319 beds, was set up in an old convention centre in a record 10 days, thanks to a number of large private donations. It was meant to be one of five new establishments that President Alejandro Giammattei’s government committed to build in response to the pandemic.
When it opened on 23 March, Guatemala, a nation of nearly 15 million people, had confirmed just 19 cases of the newly discovered coronavirus. “At first everything was fine but as time went by, we started to see many problems,” Diego, who still works in the hospital and asked to use a pseudonym for fear of reprisals, told Amnesty International.
What happened next left even the least hopeful of people baffled. Fast forward more than three months and by 2 July, with more than 19,000 recorded cases and 817 deaths, doctors, nurses and cleaners are struggling not only to halt a deadly virus but also to pay their rent.
The lonely frontline
The video of a group of exhausted and frustrated health professionals, wearing blue and green scrubs and facemasks during an improvised press conference on 12 May, was telling of a story that was taking place on the forgotten frontlines, far from the desks of government officials.
“We are not here to fight with the authorities,” the voice of a young doctor in green scrubs is heard saying behind a N95 face mask. “We are just asking for our basic rights and work dignity to be respected.” The doctor, who said he had to buy the mask he was wearing himself, described the daily hardships of working through a pandemic without effective support.
He and others around him spoke of the lack of sufficient personal protective equipment (PPE) including masks and disposable gowns and gloves for them and others working at the hospital, the extremely limited space available to rest during long and stressful shifts, and the severe delays in their salaries being paid. Many had not been paid at all.
“The protective gear we are given is often of low quality. I know of some doctors who had to use bin bags as gowns,” Diego said.
The initial silence by government officials and hospital authorities in the face of the complaints triggered a string of actions, videos and letters to the hospital’s director, health minister and even the president.
Eventually, authorities increased the availability of PPE, but the delays in the payment of wages and the signing of contracts remain not fully resolved – with only a few having received a salary equivalent to the first two months of service. Doctors such as Angela, who also asked for her name to be changed as she feared for her job, said working without pay is becoming unsustainable for many of her colleagues.
The protective gear we are given is often of low quality. I know of some doctors who had to use bin bags as gownsDiego, a Guatemalan doctor
Doctors typically work a 24-hour shift every four days in one of the three areas in the facility, holding patients with mild, moderate or severe COVID-19 symptoms. They take turns and say they have around three breaks per shift. Nurses have fewer breaks between shifts.
“Most of my colleagues have not been paid yet,” said Angela, one of the lucky few to have been paid for the first two months after working at the hospital for nearly three months.
The vast majority of Guatemala’s frontline responders to the pandemic have been hired on three-month-long contracts. In the hospital where Angela and Diego work, many people laboured for several weeks without even receiving a contract, let alone getting paid.
Amnesty International was able to see one of the contracts which did not include any mention of COVID-19, information about how long their shifts would be, how many hours they would be expected to work per week, or what benefits they would be entitled to. Doctors, who said the contract was common, said they were informed of this as “days went by”.
Diego and Angela say these contracts put them in an extremely vulnerable position. They say they have been told they will be extended, but there’s no guarantee of this, or that staff will get paid for the vital work they have done and continue to do.
“The contract doesn’t mention the fact that we treat patients with coronavirus nor provide for any type of insurance or hazard pay. It’s unfair. There’s no mention of an insurance or help if we get the virus here,” Diego said, his exhaustion and frustration showing in his voice.
The delays in payments, or the total absence of them altogether, add insult to injury.
“It’s hard to understand how [the government] expects people to survive, to pay the rent, the bills, without a salary. Some of my colleagues haven’t been able to pay their rents since they started working in the temporary hospital, others have had their phones cut off for lack of payment. Debts are piling up. No one in the private sector wants to hire us because we have been working here, around people with coronavirus. The situation is truly desperate,” Diego added.
Angela is also angry, although she considers herself lucky that her family has been able to help her.
“We complained about the contracts. We had to sign them because if we didn’t there was a risk we were never going to get paid. We’re now asking for changes to any future contracts we sign, for those to include guarantees, life insurance, health insurance, some form of protection,” she said.
Erika Guevara-Rosas, Americas director at Amnesty International, said authorities have the obligation to protect workers, even in these exceptional circumstances.
“Such short-term contracts leave some health workers with lower protections than their colleagues, and increase the insecurity they face in their jobs, which are already very difficult given the scale of the pandemic. The government should ensure that all health workers involved in the COVID-19 response have equal access to benefits and protections, irrespective of the nature of their contract.”
The situation is even more precarious for cleaning and other maintenance staff. Doctors told Amnesty International they see them working more frequent shifts and they have less access to proper rest areas and protective equipment.
The speed with which COVID-19 has spread across the world, including in Guatemala, has pushed an already weak national health system to the brink. The system is so frail that the country was already receiving training and funds from the Pan American Health Organization (PAHO) before the pandemic.
In Guatemala, there are 3.5 doctors and 0.7 nurses per 10,000 people, according to 2018 data from the World Health Organization. This is a significant reduction from 2009, when there were nine doctors and almost nine nurses per 10,000 people. In comparison, in Argentina there are more than 27 doctors and 25 nurses per 10,000 inhabitants, in India there are eight and 17, and in France there are more than 32 and 114, respectively.
The pandemic is exposing this weakness, turning problems into disasters. Zulma Calderón, health inspector at Guatemala’s Human Rights Ombudsman’s office, has described the response to the pandemic in the various hospitals across the country as “chaotic”. The independent body, which conducts regular visits to all facilities treating COVID-19 patients across Guatemala, reported a series of issues with the temporary hospital – including regarding the treatment of staff and availability of supplies – shortly after it was opened.
Authorities’ reactions to the complaints have also evolved over time.
The government should ensure that all health workers involved in the COVID-19 response have equal access to benefits and protections, irrespective of the nature of their contractErika Guevara-Rosas, Americas director at Amnesty International
First, there was denial. After the first letter, where doctors demanded access to effective PPE, the director of the temporary hospital, Dania Hernández, said this was not an issue. She told El Periodico there were enough KN95 face masks, disposable gowns and gloves, shoes, and protective glasses for all staff.
Then authorities went on the offensive. When doctors and other staff issued a public letter to President Giammattei and his Health Minister, Hugo Roberto Monroy Castillo, demanding to be paid for their work and threatening a strike, the state response escalated.
On 5 June, the Ministry of Health fired 46 facilities and cleaning staff, most of whom had been working from day one. Authorities claimed they hadn’t filled in the required paperwork, which included presenting high school or university diplomas – requirements impossible to meet for many of the workers who only have a primary-school education.
More recently, the Ministry of Health, and even the President, appears to have adopted a more conciliatory approach. On 10 June, Ministry staff meet with the 46 workers who had been fired and reported a provisional agreement which may involve paying or re-hiring them.
The Ministry also recently paid the first two months’ worth of salaries to a small number of health workers, in what some described as a strategy of appeasement in response to complaints.
President Giammattei even visited the hospital and promised to resolve the “administrative issues” that prevented doctors from being paid.
Although she was one of the people paid, Angela does not think this is enough.
“Sometimes I just want to quit,” she says, her voice turning teary. “We will not abandon our patients but we need authorities to know we need things to change. We need better supplies, more specialists, we need everybody to be paid, on time. Some things have improved but there’s always something missing. We are facing an extraordinary situation, but authorities have the means of doing extraordinary things if they wish to.”Doctors say the current situation should serve as proof of the wider problems facing Guatemala’s public healthcare system and the need for reform, including in hiring policies and practices.
“Building a temporary hospital with a bunch of beds is not a sufficient response to a pandemic. Without fully supporting doctors and other health professionals to do their jobs, a hospital is nothing but a building,” Erika Guevara-Rosas said. “Failing to adequately protect health workers not only undermines their human rights and puts them at risk, but also enhances the danger facing everyone in Guatemala.”