Guatemalan coffee is revered as a most tasty brew throughout the world.  I’ve even read reports from connoisseur “cuppers,” or coffee tasters, about it being a “kaleidoscope” coffee.  Apparently that’s a good thing, and certainly something the Guatemalans are proud of. 

In June 2008, Guatemala successfully sold the world’s most expensive coffee at the auction of Cup of Excellence.  Yes, such a thing exists.  This coffee is described in the world’s most respected cupper’s list of the top 30 as ‘delicate in mouthfeel, with a continued tart, marmalade-like, orangey sweetness complicated by cocoa’.  I’m now trying very hard to pay a little more attention to the “mouthfeel” of my daily cup.  I’m no cupper, but it is worlds above the acrid but comfortably familiar flavour of NHS gravy granules.

The coffee land here is either worked by small collectives of farmers, or run as a finca.  These are often controlled from overseas by foreign owners primarily from the USA or Arabic countries.  A finca is a community which exists to harvest and process coffee, or other such crops.  Each has a school which is free for children to attend until the age of 11, after which boys generally begin to work in the plantation, and girls in the household.  History has repeated itself for many generations and I’m told there are few that manage to break the pattern. 

The coffee workers of the Atitlan area are having a tough time of it at the moment due to a combination of poor conditions and long foreseen circumstances. Lake Atitlan has a severe bloom of cyanobacteria currently.  You can read about it here in Spanish  and here in English .  For those averse to reading, there’s a good video here. As part of the action plan to save Lake Atitlan, the government has clamped down on the use of fertilisers and nitrogen based products to prevent run off into the lake, meaning that many of the usual buyers are pulling out of buying in this region.  It is currently uncertain what effect this will have on the trading of coffee, and therefore the decisions made by finca owners and the consequences for those working on the plantations.

There are owners who apparently provide some level of healthcare, and at the other end of the spectrum, there are those that have failed to build basic sanitation facilities.

We heard news of a coffee finca, or plantation of approximately 250 people, where many children were falling ill with jaundice and gastrointestinal symptoms.  In conjunction with the Guatemalan Ministry of health and Santiago Centro de Salud, we organised a “jorneada,” or visiting clinic, to assess the situation and see what we could offer. 

The finca is a 45 minute drive from Santiago Atitlan, passing a number of small farming communities and up the volcano beyond the smoking landfill.  We drove into the finca, and were each adopted by a gang of small children and shown around.  There were two toilets for the community both of which dropped directly into the river.  Clean water ran into a concrete pool for bathing in front of the toilets.  Downstream women were washing clothes in the contaminated water.

Armed with boxes of antimicrobials and vitamins, we set up shop in the school.  As the photo shows, patients queued and were given a number, each of which amounted to a mother with her children, and often a gaggle of her sibling’s children to be seen.  The main concerns were poor growth, lack of appetite, diarrhoea and skin diseases.  Only having a handful of different drugs available to us made clinical decision making a much easier task, and given the volume of patients to be seen, we simply had to sift out those that needed something more than anti-parasites, antibiotics and vitamins.  It may sound like lazy medicine, but it becomes much easier to decide how to treat an infection, when the only available treatment is amoxicillin and albendazole.

We were on the look out for any pattern of infection, such as hepatitis A, but despite what we had been hearing on the grape vine, there didn’t seem to be an identifiable outbreak of anything specific.  Each patient needed vitamins and anti-parasites and each family needed education regarding sanitation.  I found it difficult to explain the necessity for clean water, as was it difficult for the women to understand.  I hadn’t thought before about how hard it could be to comprehend becoming sick from invisible organisms in the water.  It is not a visual concept, and requires some level of education to understand that something exists, and causes damage although it can’t be seen.  Interestingly many of the mothers told me that while the water makes their children sick, the coffee doesn’t.  Being unable to conceptualise a flaw in the water, or understand the benefit of boiling, they had extrapolated from what they could see and believed that there was something about the coffee that protected the children.

Out of the 100 or so patients I saw, there were two skin afflictions which I could not identify but treated empirically and two with conditions which I knew for certain could not be treated from our supplies.

Sadly the 2 patients requiring help beyond our resources, one a elderly woman with a blood glucose of 33 mmol/L and the other a 1 month old infant with severe respiratory distress, refused to accompany us back to the hospital.  The reason for this was that although the travel to the hospital and a proportion of the treatment would be free, both families were unable to pay the travel to return to the finca, and therefore made the decision to remain in their homes.  One of our team, a paediatric nurse from the USA was particularly distressed by the infant, but despite assuring their return trip would be funded, out of her own pocket if needs be, the family declined help.

The following photos show lesions which I was unable to identify, but treated all guns blazing with anti-fungal cream, anti-parasitics and antibiotics. 

This one shows the buttock of a 9 year old, afebrile, systemically well girl with lesions which developed rapidly over 2-3 days.  These were multiple painful ulcerating lesions with no discharge and no surrounding erythema. 

The edges of these ulcers were friable, bled easily and were rolled with an appearance somewhat similar to a BCC.

The photo below shows the leg of a 6 year old boy, also systemically well and afebrile with a 2 month evolution of painless, itchy lesions on both legs.  Within some of the ring shaped lesions were pustules and other were bullous containing serous fluid.  Surrounding skin was erythematous and hot to touch.

Over the course of the day, we saw several cases of the latter infection.  Given the ring shape of the early lesions, my guess was a parasitic infection, such like ring worm, which due to excoriation and contaminated conditions had developed secondary bacterial infection.  Expert opinion, or a more educated guess would be greatly valued for when we return, in case our ‘give it a go and see’ treatment has failed.
 
I have never visited a plantation before, and although I always try to buy fair-trade coffee because I know it is better for someone, I have to admit that I hadn’t really given much thought to who or why.  Generations of finca-families have been picking coffee day-in day-out to provide my daily cup and although many finca owners have now apparently cleaned up their act, and would intervene in the event of an infective outbreak, there are some families that are simply just surviving. 

I saw a finca worker in the ER recently who had amputated the top of his finger with a machete.  He was kind enough to answer some of my questions about life on the finca.  He knew nothing of the owner, or of the intended destination of the coffee.  He was only able to answer questions about the job, schooling, housing and pay at the finca.  I was struck by the sudden realisation, that there are people all over the world working at the very bottom of the chain of industry who have no idea about how big and far above it goes.  He works to live and lives to work with no inkling of the latest mocha concoction at the trendy boutique coffee shop in London or New York, let alone that there are people actually employed to judge a competition such as the cup of excellence.  His world of coffee is about managing to pick 100lbs a day for 30 quetzales, or £2.50.  Unlike the rest of us who think we can’t live without coffee, he really can’t.  His world of coffee is about existence.  Our world is full of choices and coffee is a superfluous addition to help us function in the mornings or dip a buttery pastry in. 

Coffee is often only second in world-trading value to oil and in the UK alone we drink 31 billion cups a year.  Here workers earn £0.025 per lb, which is sold on at an average of £2.20 per lb and hits our streets at around £7.50 per lb.  It’s big business and despite many a mocho-choca-frappe-cappuccino, I had never thought about the hand that picks the bean.

Louise Kenny has completed F2 year in the Northern Deanery and is now working in Guatemala.

The patients’ consents were obtained for this blog.