AN ANALYSIS or THE NATURE AND EXTENT OF REHAETLTTATTON IN GUATEMALA Thesis for H1: Degree 0‘ pk. D. MICHIGAN STATE UNWERSET John Charles Toth 1963 This is to certify that the thesis entitled tn.Analysis of the Nature and Extent of Rehabilitation in Guatemala presented by John Charles Toth has been accepted towards fulfillment of the requirements for _Ph_']_)_°_ degree in Guidance and Personnel Services Date August 2, 1963 0-169 LIBRARY Michigan State University ABSTRACT AN ANALYSIS OF THE NATURE AND EXTENT OF REHABILITATION IN GUATEMALA by John Charles Toth In many underdeveloped countries of the world today, the prevalence of disabilities resulting from diseases and accidents has created a major health problem. This is espe- cially true when disabilities result in lifelong handicaps and forced dependencies. In an effort to understand the problems faced by underdeveloped countries, the present study was designed to investigate the nature and extent of rehabilitation practices in the Central American Republic of Guatemala. The study began with a preliminary investigation to obtain some rudimentary knowledge regarding current rehabil- itation facilities and practices. The resultant information helped in planning the methodology and selection of the pop— ulation to be studied. The data in the present study were obtained through structured interviews, observations, examination of records and a Personal Information Inventory. Eight institutions in Guatemala were found to have rehabilitation programs; all were included in the survey. The information obtained from each institution was organized under the following headings: John Charles Toth 1. History and Development Administration and Organization Finance 2. 3. 4. Facilities 5. Personnel 6. Programs and Services 7. Clientele. The data were analyzed for each institution after which a general overview of rehabilitation in Guatemala was prepared. The results of the survey indicate that organized rehabilitation in Guatemala began about fifteen years ago and is still in the developmental stage. It began through the efforts of a few local physicians who received post- doctoral training in foreign countries. This gave early rehabilitation programs a medical orientation which still exists today. The training of the rehabilitation personnel determines the quantity and quality of the services. The training and competence level of the professional rehabil- itation personnel may be listed in the following order of decreasing competence: physiatrists and other medical Spe- cialists, prosthetists, physical therapists, social workers, occupational therapists, vocational instructors, psycholo- gists, and vocational rehabilitation counselors. Rehabilitation institutions have three major sources of income: the Social Security Administration, government John Charles Toth allocations, and public lotteries. The Social Security Re- habilitation HOSpital is the most complete rehabilitation institution in Guatemala and has the best financial support, although realistically it is inadequate for the services rendered. It provides excellent medical, physical therapy, prosthetic, occupational therapy, and vocational training programs. Most of the physical facilities of the institutions in Guatemala are old and inadequate, and all of the institu- tions, except one, are located in buildings that were built for other purposes. Many of the handicapped presently receiving rehabil- itation services are farm laborers who are unable to pay for protracted treatment. The nature of the medical profession, clientele, and the socio-economic structure of Guatemala influences the develOpment of rehabilitation programs. Generally Speaking, all of the rehabilitation pro- grams and services are inadequate and only a fraction of the handicapped individuals in Guatemala receive services. How— ever, rehabilitation is rapidly developing and considerable improvements in the quantity and quality of the services may be expected within the next few years. AN ANALYSIS OF THE NATURE AND EXTENT OF REHABILITATION IN GUATEMALA By John Charles Toth A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Guidance and Personnel Services College of Education 1963 To: To: To: To: To: To: ACKNOWLEDGEMENTS Dr. John ‘13. Jordan, my committee chairman,.for his interest, encouragement and guidance throughout the study. His foresight and personal sacrifices made this study of Guatemala possible. The other members of my dissertation committee: Drs. Gregory A. Miller, Donald E. Hamachek, and Edgar Schuler for their valuable time, assistance, and suggestions in the preparation of this dissertation. Dr. and Mrs. Guido Barrientos for their guidance, patience, and understanding extended to the writer and his family during their residence in Guatemala. The appropriate officials of Michigan State University and the University of San Carlos in Guatemala, who made available the complete resources of the-Institute for Educational Research and Improvement (IIME) at the University of San Carlos in Guatemala for the purpose of this investigation. The data within the study were obtained during the author's affiliation with IIME. The Cultural Affairs Bureau of the Department of State of the United States who provided the initial overseas study grant which culminated in the present investiga- tion. However, all opinions expressed within the study are those of the author. The International Society for Rehabilitation of the Disabled whose early interest in the study has been of great value. ii To my wife, Gladys, and sons, Norman and Nolan. TABLE OF CONTENTS LIST OF TABLES LIST OF FIGURES Chapter I. INTRODUCTION An Overview of Guatemala Geography Population Civil Heritage Political History Economic Development Occupational Structure Health Conditions Statement of the Problem . Justification of the Study Limitations . . . . . The Thesis in Perspective II. REVIEW OF LITERATURE . III. METHODOLOGY Preliminary Investigation Population Instrumentation Procedure . . . Data Validation Data Analysis IV. ANALYSIS OF THE DATA . Recuperation Center No. 1 iv Page viii xi 37 37 39 41 42 43 45 46 47 Chapter IV. (Continued) History and Development Administration and Organization Finance Facilities Personnel , Programs and Services Clientele Recuperation Center No. 2 History and Development Administration and Organization Finance Facilities Personnel . Programs and Services Clientele Children's Polio Hospital History and Development Administration and Organization Finance Facilities Personnel . Programs and Services Clientele Alcoholic Sanatorium History and Development Administration and Organization Finance Facilities Personnel Programs and Services Clientele Mental Health Clinic History and Development Administration Finance Facilities Personnel Programs and Services Clientele 99 99 100 100 101 102 103 Chapter Page IV. (Continued) Robles Institute . . . . . . . . . . . . . 106 History and Development . . . . . . . 107 Administration and Organization . . . . 108 Finance . . . . . . . . . . . . . . . . 109 Facilities . . . . . . . . . . . . . . . 109 Personnel . . . . . . . . . . . lll Programs and Services . . . . . . . . . 112 Clientele . . . . . . . . . . . . . . . 114 The Neuropsychiatric Hospital . . . . . . 117 History and Development . . . . . 117 Administration and Organization . . . . 119 Finance . . . . . . . . . . . . . . . . 122 Facilities . . . . . . . . . . . . . . . 126 Personnel . . . . . . . . . . . 128 Programs and Services . . . . . . . . . 129 Clientele . . . . . . . . . . . . . . . 132 Social Security Rehabilitation Hospital . 135 History and Development . . . . . . 136 Administration and Organization . . . . 138 Finance . . . . . . . . . . . . . . . . 140 Facilities . . . . . . . . . . . . . . . 145 Personnel . . . . . . . . . . . 155 Programs and Services . . . . . . . . . 160 Clientele . . . . . . . . . . . . . . . 167 An Overview of Rehabilitation in Guatemala 169 History and Development . . . . . . . . 169 Administration and Organization . . . . 170 Finance . . . . . . . . . . . . . . . . 170 Facilities . . . . . . . . . . . . . . . 173 Personnel . . . . . . . . . . . 174 Programs and Services . . . . . . . . . 176 Clientele . . . . . . . . . . . . . . . 178 V. SUMMARY, CONCLUSIONS, RECOMMENDATIONS FOR FURTHER RESEARCH, AND IMPLICATIONS ... . . 180 Summary . . . . . . . . . . . . . . . . 180 Conclusions . . . . . . . 183 Recommendations .for Research . . . . . . 185 Implications . . . . . . . . . . . . . . 186 vi BIBLIOGRAPHY . . . . . . . .,. . . . . . . . . . . . APPENDICES A. List of Agencies and Institutions Obtained for the Preliminary Investigation B. Structured Interview Data Sheets (English Translation) . . . . . . C. 'Personal Information Inventory (English Translation) . . . . . . . . . . . . . . vii Page 191 196 201 231 Table 10. 11. 12. 13. 14. LIST OF TABLES Occupational Classification of Workers Seven Years of Age and Over, 1950 Budget for Recuperation Center No. l and the School of Physical Therapy in 1961-62 Expenditures for Recuperation Center No. l in 1961-62 . . . . . Patient Movement at Recuperation Center No. 1 in 1962 . . . . . . . . . . . . . . . Discharges from Recuperation Center No. 1 in 1960-62 Common Disabilities Treated at Recuperation Center No. l in 1962 ‘Expenditures for Recuperation Center No. 2 in 1962 Professional Personnel of Recuperation Center No. 2 Clientele Movement at Recuperation Center No. 2 in 1962 Monthly Budget for the Children's Polio Hospital in 1957-63 . . . . . . . . . Estimated Monthly Operating Expenses of the Children's Polio Hospital in 1963 Personnel and Salary Schedule of the Children's Polio Hospital in 1962 Services Offered at the Children's Polio Hospital in 1962 . . . . . . . . Services Offered Inpatients at the Children's Polio Hospital in November, 1962 viii Page 14 52 52 58 59 60 65 68 -74 78 78 82 84 85 Table 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. Services Offered Outpatients at the Children's Polio Hospital in November, 1962 . Geographical Origin of Patients at the Children' s Polio Hospital on August 7, 1961 . . . . . . . . . . . Age Range and Number of Inpatients Treated at the Children' s Polio Hospital from 1952- 62 . . . . . . . . . . . Sources of Income for the Alcoholics Sanatorium from July 1, 1959 to June 30, 1962 . . . . Alcoholics Sanatorium Expenditures from July 1, 1959 to June 30, 1962 Personnel and Work Schedule at the Alcoholics Sanatorium in 1962 . . . . . . Services Rendered at the Alcoholics Sanatorium in 1962 . . . . . . . . . . . . . . . . . . Ages and Number of Patients Treated at the Alcoholics Sanatorium in 1960 and 1961 Sex and Number of Patients Treated at the Alcoholics Sanatorium in 1960-62 Adult Patients Treated at the Mental Health .Clinic in 1960-62 Personnel Schedule of the Robles Institute in 1962 . . . . . . . . . . . . . . . . Clientele Served by the Robles Institute in 1960-62 . . . . . . . . . . . . . Children and Adult Clientele Served by the Robles Institute in 1962 . . . . ‘Expenditures of the Neuropsychiatric Hospital for July, 1962 Personnel and Salary Schedule of the Neuropsychiatric Hospital in 1962-63 ix Page 86 87 88 92 92 94 96 97 98 104 112 114 115 123 124 Table Page 30. Services Provided at the Neuropsychiatric ‘ HOSpital in 1962 . . . . . . . . . . . . . . 132 31. Classification of Inpatients at the Neuropsychiatric Hospital in 1961 . . . . . . 134 32. Expenditures of the Social Security Rehabilitation HOSpital in 1960- 61 and 1961- 62 . . . . . . . . . . . . . . . . . . 144 33. Costs per Inpatient-Day at the Social Security Rehabilitation Hospital from 1958-62 . . . . 144 34. Personnel and Salary Schedule for the Social Security Rehabilitation Hospital in 1961-62 . 158 35. Schedule of Benefits Paid Disabled Workers by the Instituto Guatemalteco de Seguridad Social in 1961-62 . . . . . . . . . . . . . . 163 36. Prosthetic and Orthopedic Devices Fitted at the Social Security Rehabilitation Hospital in 1961- 62 . . . . . . . . . . . . . . . . 164 37. Type and Extent of Services Offered at the Social Security Rehabilitation Hospital in 1961—62 . . . . . . . . . . . . . . . . . 166 38. Average Number of Inpatients at the Social Security Rehabilitation Hospital from 1958-62 . . . . . . . . . . . . . . . . . . . 168 39. Inpatient and Outpatient Movement at the Social Security Rehabilitation Hospital in 1960- 61 and 1961- 62 . . . . . . . . . . 168 LIST OF FIGURES Figure 1. Organization Chart of Recuperation Center No. 1 . . . . . . . 2. Organization Chart of Recuperation Center No. 2 . . . . . . 3. Organization Chart of the NeurOpsychiatric Hospital . . . . . . . . . 4. Service Organization Chart of the Neuropsychiatric Hospital . 5. Financial Administration Chart of the Social Security Rehabilitation HOSpital . xi Page 51 64 121 131 142 CHAPTER I INTRODUCTION There are millions of men, women, and children throughout the world today who are facing life with some serious mental or physical disability. Many of them have been disabled since birth while others are victims of diseases or accidents. The nature of their disabilities and handicaps are described by various medical and paramedical terms such as blind, deaf, paraplegic, retarded, and psychologically maladjusted. Their handicaps began with a disability and then became greater as the individual realized that he could not obtain gainful employment, assume customary reSponsibilities or otherwise function as a normal member of society. In many countries the prevalence of diseases and accidents of man and nature have become a matter of national concern and a major health problem. This is especially true when disabilities result in lifelong handicaps and forced dependencies. The burden of dependency in a relatively large segment of society may significantly contribute to a country's poverty and relative backwardness. From the social and eco- nomic point of view, a waste of manpower is a matter of grave concern, not only because of the loss of productive capacity, but arse because of the added burden imposed upon the rest 1 of the population. These facts are now being recognized by a number of underdeveloped countries which are presently attempting to lift themselves and bring about an industrial revolution (55). Since physical disabilities know no geographical, racial, linguistical or political boundaries, the field of health and rehabilitation may be a uniquely effective area of service in improving international understanding. Health and the rehabilitation of the chronically handicapped are fundamental to the prime democratic concept of equal opportu- nity and social justice for all. A country in which good health is enjoyed only by a minority cannot be politically or economically stable. Good health is a prerequisite for economic self-sufficiency and good government. PeOple who are sick, crippled, or otherwise disabled have difficulty in seeking human rights and the principles of democracy and freedom. Citizens can enjoy the fruits of their labor only if they work and become customers for the goods they, and the rest of the world, produce. Ill health, poverty and bad government are circular; they generally foster the existence of each other. Assisting these countries to develOp effective re- habilitation programs may be one way of helping to break this circle of unfortunate events. This is true eSpecially since rehabilitation involves much more than medical treatment. It may include a variety of necessary services to integrate each handicapped person into society. Services in addition to medical restoration may include vocational training and educa- tion--factors which are also essential to good government. The disability areas that need the most attention differ from one country to another. It depends largely upon national occurrences such as wars, occupational hazards, and various disease incidences and epidemics. Rehabilitation programs and services are generally planned to meet the im- mediate pressing needs of the particular country. Until comparatively recent times, efforts in the development of rehabilitation programs in most underdeveloped countries have been of a circumscribed nature. It is important to remember that the very nature and conditions of underdeveloped countries indicate that they are lacking in rehabilitation resources. They lack wealth to invest in medicine, education, technology, and community services. They concentrate their efforts and limited finan- cial resources on economic development such as manufacturing, industrial processing, tranSportation, and other wealth— generating activities. As a result, health and rehabilita- tion programs receive relatively small amounts in the national budgets. Privately operated institutions are also unable to adequately finance themselves because of the generally de- pressed economy. However, the fact that the need for reha- bilitation exists cannot be obscured. Today, the picture is changing as many of these underdeveloped countries are struggling to develop complete and adequate rehabilitation programs for their handicapped. This need is pressing for expression and the time is right in many of these countries to develop their rehabilitation programs. An Overview of Guatemala The present study was directed toward obtaining in- formation regarding current rehabilitation provisions in Guatemala. However, to more fully understand the conditions and problems in Guatemala, it is first necessary to become familiar with the country in general. Geography Guatemala is bounded by Mexico to the north; British Honduras, Honduras, and the Caribbean Sea on the east; and El Salvador and the Pacific Ocean on the south and west. Guatemala has an area of 108,889 square kilometers and is approximately the size of the State of Ohio. This area does not include Belice (British Honduras) which is claimed by the Guatemalans. It is the third largest Central American Republic and has the largest pepulation. Geographically it may be divided into three regions: (1) the Pacific Coast flat lands; (2) Central highlands; and (3) the Jungles of Peten. The Pacific Coast area is mostly farmland and is generally owned by large ”finca" operators. It has roads and a railroad for the tranSportation of produce to the port of San Jose and to Guatemala City which is located in the highlands 4,850 feet above sea level. The Jungles of Peten are virtually uninhabited and undeveloped (19:657, 30:213). Population The estimated population of Guatemala in December, 1960 was 3,822,233. This figure is a projection from the last national census which was taken in 1950. If the pop- ulation were evenly distributed over all of the land, there would be thirty-five persons for each square kilometer. How— ever, this is not the case since the entire country is very unevenly populated. The country is divided into twenty-two Departments: the three most heavily populated are Guatemala, with 283 persons per square kilometer, Sacatepequez with 167, and Quezaltenango with 126. The three least populated Depart- ments are Peten with one person per square kilometer, Izabal with nine and Quiche with twenty-nine (10:31). The city of Guatemala is the capital of the Depart- ment of Guatemala and is the seat of the national government. It has a population of about 400,000 (6:3). The people of Guatemala live in a highly stratified society with a relatively large lower class and small middle and upper classes. People may be clearly contrasted in many ways--for example, by the type or absence of shoes, clothing, language, color of skin, education, employment, mode of tranSportation, diet, house and property, ancestry, et cetera. It is estimated that 71.9 per cent of the population is illiterate and 73 per cent live in rural areas (10:35, 17:121). Sixty per cent of the pOpulation are pure Indian; 35 per cent are ladinos, i.e., a mixture of races and cul- tures; and 5 per cent are of pure Spanish ancestry (19:658). The only Negroes in Guatemala are those who have migrated in from Belice in order to find employment; however, they consti- tute an insignificant percentage of the total population. British Honduras is claimed to belong to Guatemala by the Guatemalans; therefore, Negroes are considered citizens of Guatemala. The religion of most Guatemalans is Roman Catholic, but all creeds are granted freedom of worship. Many Indians supplement their Christian faith with pagan rites and beliefs. The official language is Spanish; however, thousands of Indi- ans Speak only their native dialects. Civil Heritage The history of Guatemala is rooted primarily in the Mayan civilization which had its beginning over 1,000 years before the discovery of America. The Mayan civilization occupied an area comprised of Chiapas, Tabasco, Campech, Yucatan, and Quintana Roo in today‘s Mexico and almost all of the territory of Guatemala including Belice and the extreme western part of Honduras. Some archaeologists estimate that the Mayan civilization existed from about 400 B.C. to 1500 A.D. These dates span a period of years during which time the Mayans developed their highest level of civilization. How- ever, it is questionable if such an advanced culture could have developed entirely in such a short period. The actual beginning date of the Mayan civilization is not known at the present. The Mayans could record time and they knew the length of a single lunation (29.52 days) and the tropical year (365.24 days). These facts and their demonstrated abil- ity to build huge temples, palaces, and use the concept of zero, indicate that the Mayan civilization had a relatively long deve10pmental period. The Gregorian equivalent of the beginning of their calendar is October 14, 3373 B.C.; how- ever, on the basis of other evidence, most archaeologists do not accept such an early date (33:17-48). The apogee of the Mayan civilization was between 700 and 1000 A.D. (after which time the civilization began to decline). Reasons for its decline and ultimate collapse are not known with certainty; however, civil wars, social decadence, food shortage or epidemics may have been etiolog- ical factors. Gradually the Mayan civilization was infil- trated by the Mexicans who brought new leaders, causing a dilution of both cultures. The Mexican-Mayan mixture led to a compromise and the formation of the League of Mayapan. The new Mexican-Mayan dynasty flourished until a great civil war broke out between the two cities of Chichen-Itza and Mayapan in the year of 1194 A.D., marking the end of the "golden age" of the remarkable Mayan civilization. Incessant warfare against each other and continued disorganization caused them to be easy prey for the Spanish conquistadores of 1524-1546. The conquest, under the leader- ship of Don Pedro de Alvarado, swept through Guatemala and moved down Central America to Panama. The Spanish consol- idated and set up the kingdom of Guatemala which covered all of present-day Central America and the southeastern parts of Mexico. On September 15, 1821, Guatemala declared its in- dependence from Spain and annexed to the newly formed Mexican Empire under the rule of Agustin de Iturbide. This lasted only until 1823 at which time Guatemala became a part of the United Provinces of Central America. The Federation col- lapsed in 1839 after which Guatemala formed its own inde- pendent government (33:49-83). Political History Since the Guatemalan declaration of independence, its history has been one of gradual and intermittent progress-- politically, socially, and economically. There has been a long series of dictatorships interSpersed with bitter fac- tional turmoil and resistances. In 1944, a p0pular revolu- tion suddenly broke down the political, economic, and social structures of the regime of General Ubico. A subsequent regime headed by an exiled school teacher, Juan Jose Arevalo, opened the door to communism and the communists gained con- trol of the most important governmental positions. The com- munists lost control June 18, 1954 to the exiled anti-com- munist leader, Castillo Armas. On July 3rd of the same year Castillo Armas became president of the governing Junta. During the following period the United States furnished substantial economic aid to Guatemala in order to help establish a democratic form of government. Castillo Armas was assassinated on July 26, 1957, and a period of political uncertainty and instability followed, during which time two interim presidents ruled (19:667, 7:231, 55). General Ydigoras was elected president and took office on March 2, 1958. He renewed relations with the United States and upheld the constitution of 1956 which states the separate powers of the executive, legislative, and judicial branches of the government. As this constitu- tion was written, but not necessarily practiced, it out- lined a representative form of government. This may be seen from the translations from Title 1 quoted below (36:1). Title 1, Article 1. Guatemala is a sovereign, free and independent nation, established for the purpose of guaranteeing to its inhabitants reSpect for human dignity, enjoy- ment of the fundamental rights and liberties of man, security and justice, to promote the complete devel- Opment of culture, and to create economic conditions which are conducive to social well-being. Title 1, Article 2. The system of government is republican, demo- cratic, and representative. Sovereignty rests with the people, and power is exercised by legislative, executive, and judiciary bodies, which are not subordinate one to the other. The functions and powers of state bodies are governed by this Constitution, and officials are 10 not owners, but mere depositories of authority, responsible for their official conduct, subject to and never above the law. Numerous unsuccessful attempts were made to remove Miguel Ydigoras Fuentes from the presidency. Early in 1963, a few months before the end of his term of office, the Gua- temalan Army defected and the office of the presidency was replaced by an Army Coup. The motivating force behind the removal of Ydigoras as president was the threatened rightist factions who thought former president Arevalo would be per- mitted to return to Guatemala. Juan Jose Arevalo had an- nounced earlier that he would be a candidate for the pres- idency in the forthcoming elections. Economic Development Economic activity in Guatemala is currently level- ing off or declining to some extent. For three years after the fall of the communist Arbenz regime, high coffee prices, strong United States economic aid, and considerable new business investment created active rising economic conditions. Subsequent price reductions in the world coffee market (Gua- temala's chief export), less United States economic aid, the completion of road building and other projects which put many workers into the labor market, and graft may have caused a general economic slowdown. The government was slow to re- adjust to the new economic conditions and an acute cash shortage develOped that caused delays in the meeting of pay- rolls and other obligations by the government. This cash ll shortage caused internal stress, discontent, and political unrest which resulted in periodic demonstrations, strikes, and revolutions. These uprisings were believed to have been incited by leftist groups who knew how to capitalize upon prevailing conditions. ,However, none of these uprisings were successful to the point of bringing about any major govern- mental reforms (55, 19:667, 7:231). The overall long term economic trend in Guatemala is upward and is relatively strong. Guatemalan money has been on a par with that of the United States for over thirty years except for recent 2 to 4 per cent discounts caused by legislation restricting the outflow of money (53:246). The Guatemalan government is currently seeking ways and means to stimulate the economy. Various public works projects, such as building roads to open up new areas to commerce and agriculture, fostering economic interaction with neighboring -republics, increasing revenues by broadening and enforcing income tax, and high import taxes, are some of the current measures being taken to improve economic conditions. The Guatemalan national economy is largely based upon agriculture. Industry is limited chiefly to the proc- essing of agricultural products, principally textiles and leather. Industrial processing is also provided for the production of cigarettes, cement, beverages, furniture, soap, plastic products, tires, soluble coffee, plywood, and recent- ly added petroleum products (55, 17:121, 19:656). 12 Principal exports include coffee, bananas, chicle, abaca, sugar, cotton, and timber. The three exports of coffee bananas, and cotton comprise 90 per cent of the country's total value of exports (17:121, 19:667). Leading imports in Guatemala are petroleum products, clothing, processed foods, and steel manufactures such as cars, trucks, and various types of machinery (8:45-332). Occupational Structure Guatemala is one of the many countries of the World that may be classified as economically underdeveloped. The average worker has a very low income derived principally from agriculture. Their agricultural techniques are relatively old and not based upon modern scientific technology. This does not imply that all Guatemalans are poor; it only in- dicates that the majority of the peOple live under substand- ard conditions. Like many other Latin American countries, Guatemala has striking social and economic contrasts between a few rich and middle class and the many poor. Industrial revolutions in the other parts of the world have had little effect in Guatemala, eSpecially outside of the capital city. Production for domestic consumption as well as for export has predominantly been of an agricultural nature. Corn is the principal crOp grown throughout the country, although it is not exported. Coffee is the chief commercial crop and it accounts for about three-fourths of the total value of ex- ports (56:85). 13 a The wealthy people are mostly large land (finca) owners and may also have business enterprises in Guatemala City or hold high positions in government or industry. These "finca" operators provide employment for the majority of the working population. The small middle class in Guatemala is composed of such occupational groups as white collar workers, highly skilled industrial workers, shOp keepers, large farm (finca) managers, average sized "finca" operators, school teachers and other professional groups. Members of the middle class are too few to have much influence on economic or government policies although they do provide an element of threat to some of the upper class, eSpecially since their number is steadily increasing. Approximately 70 to 80 per cent of the population belong to the lower class. Most of them are illiterate farm laborers who have very low incomes or they are subsistence farmers who supplement their income with household handi- crafts. The proportion of these people is so large that it holds down the average per capita income of the nation. Guatemala ranked fifth from the bottom among sixteen Latin American countries in 1957, with an annual per capita income of only sixteen dollars (56:87, 43:22). Farm and road con- struction laborers receive from forty to sixty cents a day. According to the last census (1950), 68 per cent of all economically active persons over the age of seven were 14 engaged in agriculture (Table 1). Table 1. Occupational Classification of Workers Seven Years of Age and Over, 1950 r 03:52.30}. mii§e2§ Per Cent Agriculture 659,550 68.2 Manufacturing 111,538 11.5 Domestic services 43,755 4.5 Non-domestic services 51,950 5.4 Commerce 52,561 5.4 Construction 26,427 2.7 TranSportation and communication 15,352 1.6 All others 6,681 .7 Totals 967,814 100.0 Health Conditions The level of living conditions in a country may be quite accurately estimated from the health standards and mortality rates. The Guatemalan infant mortality rate in 1955 was 101.4 per 1,000 live births. The seriousness of this figure can be vividly appreciated when it is realized that between one-fourth to one-fifth of all Guatemalans who die are infants under one year of age. Children under five 15 constitute 51.2 per cent of all deaths (56:215). Even these figures may be too low since many births and deaths are not registered or reported. Only about 5 per cent of all births in the country occur in hOSpitals and only 13 per cent of all deaths are certified by physicians (32:112). The limited statistics available indicate that the principal causes of infant mortality in Guatemala are diar- rhea, enteritis, intestinal parasites, malaria, bronchitis, and pneumonia. Inadequate sanitation, lack of medical facil- ities, malnutrition, and poor housing are all contributing factors to the prevalence of these diseases. Perhaps the best illustration of the nature of Gua- temala's health problems may be found in the percentage of deaths due to infectious and parasitic diseases. Most of these diseases could be eliminated with proper sanitation and medical care. Infectious and parasitic diseases are reSpon- sible for about one-third of all deaths in Guatemala. In the United States, only about 2 per cent of the total deaths are due to these diseases (56:218). Many of the health and disease problems in Guatemala probably result indirectly from malnutrition due to deficien. cies in animal protein, vitamin A, riboflavin, and iodine (32:110). Malnutrition lowers the individual's resistance to diseases which might not otherwise prove serious or fatal. The incidence of malnutrition is greatest among children from one to five years of age and is related to feeding practices 16 that are poorly adapted to the children‘s needs after wean- ing (56:208, 14:157). An inadequate supply of physicians and medical facil- ities also contributes directly to the problem of raising health standards in Guatemala. In 1950, there were 420 phy- sicians in the entire Republic, or an average of one physi- cian for every 6,600 inhabitants. In 1955, the number of physicians had increased to 469, but the total population had also increased so the new ratio became one physician to 6,800 persons (56:229). If one takes into consideration the distribution of the physicians, the shortage is even greater than indicated above. In 1950, nearly three-fourths (310) of the physicians were practicing in Guatemala City where only about 10 per cent of the population lived. There were 917 persons for each practicing physician. The ratio for the rest of the country was 22,787 persons for each physician (56:229). Most of the hOSpitals in Guatemala are operated by the Minister of Public Health or the Social Security Insti- tute. There are a few private hOSpitals, most of which are located in the capital city. The total number of beds in all of these hOSpitals is very low. According to statistics obtained by the United Nations, there were only 8,738 hos- pital beds in Guatemala in 1956. Just as the capital has a diSproportionate number of physicians, it also has most of the medical facilities. In 1956, over 52 per cent of all 17 hospital beds in the Republic were located in the Department of Guatemala (56:232). The matter of health and mortality should not be viewed apart from Guatemala's other problems. Inadequate communication and a pattern of isolated settlements pose serious obstacles to any effort to raise the standards of health. If more Guatemalans could read, Speak SpaniSh and afford radios, knowledge of the fundamental rules of modern medicine and sanitation could be more widely disseminated. A final and critically important consideration is the low overall economic condition of the country. Because of the high cost of living and the low wages received by the aver- age worker, even the simplest medicines are often prohibi- tive in cost to many rural Guatemalans. Statement of the Problem This study was designed to investigate the nature and scope of rehabilitation practices in the Central Amer- ican Republic of Guatemala. The investigation included all agencies and institutions in Guatemala, both public and private, which actually provided or professed to provide rehabilitation type services for the chronically handicapped. All relevant data was obtained, in as complete and concise a form as practicable, pertaining to the following aspects of rehabilitation in Guatemala: 1. History and development 18 2. Administration and organization 3. Finance 4 Facilities 5. Professional personnel 6 Programs and services 7. Clientele 8. Research endeavors. One of the primary difficulties of beginning research in an undeveloped country such as Guatemala is to obtain com- plete and valid data. Therefore, a preliminary investigation was made of a few agencies and institutions in order to ob- tain a rudimentary knowledge of the existence or status of rehabilitation in Guatemala. This information made it pos- sible to ascertain if there was a problem, and to provide the basis upon which to formulate the present study. Justification of the Study The results of the preliminary investigations indi- cated that the concept and need for rehabilitation services have been recognized in Guatemala. This statement is doc- umented by two facts: 1. There are some forms of rehabilitation services presently being offered in Guatemala. 2. Legal provisions have been made for the support of rehabilitation as part of government social services and for the "condoning" of privately 19 Operated rehabilitation oriented agencies and institutions. However, due to the nature of the Guatemalan economy, government and social systems, cultural traditions, educational systems, material resources, and the large number of other pressing needs, they have been unable to functionally implement adequate rehabilitation services. Preliminary investigations also indicated that there was no adequate, systematic, or reliable information avail- able regarding the nature or scope of rehabilitation in Guatemala. However, it was found that there were both public and private rehabilitation type activities being conducted by various agencies and institutions. These rehabilitation services in Guatemala, as in most countries which are in the early stages of program development in this area, have emerged independently in an unplanned and unorganized fashion. No information was available regarding the number or location of the various organizations providing rehabilitation serv- ices nor the type, quantity, or quality of their services. The justification for this study is then twofold: 1. Guatemala, as a nation, has developed to the point where rehabilitation services are recog- nized, desirable, and feasible. The need is pressing for satisfaction and the time is right for providing this nation with technical and material aid in formulating and deve10ping their 20 rehabilitation programs and services. 2. There is virtually no information regarding the nature and sc0pe of the existent programs. Con- sequently, there is a need at this time for basic demographic information in order that a better understanding of the problems involved in adapt- ing and implementing rehabilitation type services may be obtained. Therefore, in light of the above facts, this research was directed toward examining, describing, and analyzing the nature and structure of rehabilitation programs and services currently being offered in Guatemala. This survey shall complete the first essential and necessary step for the future research and develOpment of rehabilitation phi1050phies, theories, and practices in Guatemala and other Central Amer- ican countries. _To this date there have been no systema- tized studies of rehabilitation made in any of the Central American countries. The purpose of this survey shall be as follows: 1. To provide a basis for further research and develOpment in both theory and practice. 2. To obtain as complete data as practicable re- garding rehabilitation programs in Guatemala. It is anticipated that this research and the resultant conclusions shall be of valuable assistance to any individ- ual, agency, or organization, national or international, 21 that may be interested in the future development of rehabil- itation programs and services in Guatemala. Limitations 1. This study is limited, to the extent that there has not been to this date any previous research, statistics, or other literature published regarding rehabilitation in Guatemala. The absence of background literature.changed-the nature of this research and created the prime necessity of providing this lack of information.‘ 2. The population was found to be very heterogeneous and each institution is unique in character, which imposes certain limitations in analyzing the data and in making generalizations. 3. Because of the underdeveIOped nature of this country, especially in the area of rehabilitation, it was found that many institutions had relatively poor internal organization and/or were otherwise indiSposed to provide or have available certain information. Some institutions kept poor records, while others hesitated to reveal certain types of information for fear they might lose their competitive advantage or because they did not care to be ”investigated." 4. The data obtained through this research are culture bound. ,Extreme caution should be exercised when comparing these data with those of other countries. There is wide variation in the usage of terminology and statistics, 22 and rehabilitation programs must be considered within the context of the particular nation's social, cultural, and economic deve10pment. 5. Because of the difficulty of personally contact- ing each professional rehabilitation employee in the country of Guatemala, it became necessary to use a personal informa- tion questionnaire to collect these data. Certain limitations inherent in the use of this type of instrument may be found in this study, especially with regard to validity and obtain- ing complete information and questionnaire returns. The Thesis in Perspective This dissertation is divided into five chapters as follows: Chapter I presents an introductory section briefly describing the country of Guatemala. It also has sections on: the statement of the problem; the justification of the study, which explains the importance of the study; and a section that outlines the most important limitations of the study. Chapter II is devoted to a review of relevant lit- erature. Chapter III explains the methodology used in the present study. It discusses the preliminary investigation, population studied, deve10pment of the survey instruments, procedures used for data collection, validation, and analysis. 23 Chapter IV contains the analysis of the data. All pertinent data regarding each agency or institution are first organized in separate sections, after which rehabil- itation is discussed on a national basis. Chapter V presents a summary on the entire study, conclusions, recommendations for further research, and implications. CHAPTER II REVIEW OF LITERATURE It has been recognized that it is important to have international c00peration in planning rehabilitation programs and services for the physically and mentally disabled and handicapped. This is evident from the fact that national governments, universities, and various public and private agencies and institutions frequently organize international seminars and arrange for the provision or exchange of tech- nical assistance and consultation services with other nations of the world where rehabilitation programs are in operation or are currently being planned. However, to this date there remains much to be desired with regard to international re- search and exchange. Many countries understand and desire to develop rehabilitation programs but are unable to gain the full benefit from international cooperative endeavors because they lack a fundamental appraisal of their existent services, conditions, and problems. In many countries there is a complete lack of rudimentary statistics primarily be- cause there is also a lack of human and material resources for obtaining this needed information. Rehabilitation sta- tistics, if available at all, for many countries fail to meet the most elementary requirements of completeness, 24 25 accuracy, recency, and comparability. Guatemala, the object of this study, is a classical example of such a country. The following is a discussion of the results of an intensive search for literature pertinent to the present study of Gua- temala. According to its charter, the United Nations (U.N.) has been commissioned to help achieve international coopera- tion in solving problems of an economic, social, cultural, or humanitarian nature. It was also designated to act as a center for coordinating the actions of the various nations in the attainment of these ends. As a result, a number of Special organizations such as the United Nations Educational,_ Scientific and Cultural Organization (UNESCO), World Health Organization (WHO), and the International Labour Organiza- tion (ILO) were created to effect international assistance and cooperation. The U.N. and its Special organizations have published a wealth of articles, pamphlets, and books which necessitated systematizing them in a logical fashion to increase their usefulness. Consequently, the U.N. Doc- ument Index was prepared which has listed and indexed reports and papers from all of the U.N. and its Special organizations. In addition many articles and papers prepared by various pub- lic and private agencies and institutions from all over the world are also listed in the U.N. Document Index. As a result, this Index is the most complete source of information available regarding international rehabilitation and many 26 other publications (48:1948-62). A review of the past fourteen years of the U.N. Document Index revealed that there was a resolution passed by the General Assembly in 1949 to draft a general report on the world social and cultural situation. This resolution initiated the preparation of a 180 page manual bringing to- gether all available information regarding food, health, housing, education, social conditions, et cetera in many of the countries of the world. Examination of this publication showed no mention of rehabilitation in Central America (50). Another resolution was passed to prepare a survey of national and international measures taken to improve social conditions throughout the world. It was understood that this survey would be concerned primarily with measures carried out since 1945 and would be a supplement to the preliminary re- port mentioned above. A 219 page report was published in 1955 which brought the previous report up to date. Rehabil- itation was discussed in broad terms and may be summarized as "the promotion of in-hOSpital rehabilitation services and Specialized rehabilitation centres has been slow, even in well-developed countries, primarily because of lack of personnel" (47:142). The United Nations‘ organizations in cooperation with the government of Denmark, World Veterans Federation, and the International Society for the Rehabilitation of the Disabled (formerly the International Society for the Welfare 27 of Cripples) organized a seminar on rehabilitation of the physically handicapped for participants from Latin American countries. The seminar was held from June 21 to July 24, 1959 for the purpose of demonstrating modern methods and techniques for the rehabilitation of the physically handi- capped which are applicable to conditions in Central and South America. A total of twenty-seven countries including Guatemala and fifteen other Latin American countries par- ticipated in this seminar. This was primarily a training program; however, Opportunities were provided for an ex; change of information regarding existing conditions in the various Latin American countries. The exchange was minimal and general in nature primarily because adequate information was not available. References to Guatemala were made in regard to a lack of trained personnel and the existence of professional training facilities for physical therapy (51: 108, 49:Vol. 6, No. 3). A seminar on the organization and administration of social services in Central America was held from February 15 to 26, 1960, in San Jose, Costa Rica. The Bureau of Social Affiars and the Division for Public Administration of the United Nations Secretariat provided the technical and financial support. Six countries, including Guatemala, were represented while social services, organization, and prac- tices were discussed. Conclusions drawn from the discussions indicated there was a need for coordination between the 28 various agencies and institutions, and that no clear dif- ferentiation existed between public and private service organizations. Social services were discussed in general and it was evident that accurate data regarding the nature and structure of social services in Central America were lacking (52). The United Nations also publishes a Yearbook as an authoritative record of all phases of its work. These books were examined for possible information pertinent to this study. Rehabilitation was included under social services; however, mention of Guatemala was limited to a brief sen- »tence or two, stating that some rehabilitation services do exist but no information is available (54:1950-62). The Vocational Rehabilitation Administration (VRA) under the United States Department of Health, Education, and Welfare has been in existence for over forty years. Six years ago the VRA (formerly the Office of Vocational Reha- bilitation) started a research program aimed at discovering better ways to rehabilitate handicapped individuals. The program was so successful in helping to meet the demands for research in this area that two years ago (1960) it was ex- tended to foreign countries. During the last two years twenty-five foreign research projects were supported by the VRA. The number of overseas research projects is expected to be doubled within the next year. A review of these proj- ects disclosed that none were conducted in Guatemala or any 29 of the other Central American countries (35:Vol. 3, No. 3). The National Society for Crippled Children and Adults publishes a monthly review called Rehabilitation Literature (34:Vol. 13-23). Rehabilitation Literature serves to promote communication between all professional personnel and students in rehabilitation and also related areas of Specialization. It is a reviewing and abstracting journal that identifies and describes current books, pamphlets, and periodicals per- taining to the care, welfare, education, and employment of handicapped children and adults. This journal lists many of the domestic and foreign books and articles that are published or privately circulated. A search of this review did not reveal any materials regarding rehabilitation in Guatemala. Another excellent source of information for rehabil- itation publications around the world is the Psychological Abstracts which is a bi-monthly publication of the American Psychological Association.' It classifies and lists non- critical abstracts of the world’s literature in psychology and related subjects. The listings are obtained through a regular search of 545 journals and various other books, monographs, and pamphlets. .A search of these abstracts did not reveal any articles or books regarding the nature and extent of rehabilitation practices in Guatemala (3:1950- 62). 30 The Economic and Social Council of the United Nations passed a resolution in 1950 for the organization of The United Nations Coordinated International Programme for the Rehabil- itation of the Physically Handicapped. Its objectives were to ensure the closest possible co-ordination between the United Nations and rehabilitation organizations all over the world, provide direct assistance in the organization and staffing of rehabilitation programs, and to conduct research activities and provide technical advice (46:1). One type of assistance provided by the Programme is to make surveys of the existent rehabilitation services and conditions in the various countries. At the request of governments, fact-finding missions can be sent out by the United Nations and its Special- ized agencies to make a survey of local conditions and resources . . . . If the assistance provided under the Programme is to be fully effective, it must be based on adequate information about the particular problem it is designed to meet. Much information has been gathered by the co-ordinated Inter- national Programme but no studies have been made in Guate- mala (46:3-4). The oldest international organization in the world today is the Organization of American States (OAS). It unites the twenty-one republics of the Western HemiSphere into a "community of nations" dedicated to peace, security, and prOSperity (39:4). The objectives of the Organization of American States are accomplished through various means in- cluding research and publications. The Pan American Union 31 is the central organ and General Secretariat of the Organ- ization of American States and one of its functions is to publish information and research articles, pamphlets, and books of national and international interest. The Pan American Union periodically publishes catalogs of their own and various other Latin American publications (44, 37, 45, 38). A review of these catalogs did not reveal any mate- rials pertinent to the present study. Suslow, a graduate student at the University of Connecticut, made a study of the social security system in Guatemala during the summer of 1950 (43). He traced the development of the program and included some information about two rehabilitation centers that were organized as part of the Social security system. Rehabilitation was defined within the social security program as "the re-educa- tion of the injured organs as one stage of medical treatment, the replacement or improvement of the damaged organs by prosthetic or orthopedic appliances wherever possible and necessary, and vocational readaptation" (43:201). The first government rehabilitation center in Gua- temala was located in a large two-story house called "Simeon Canas," and it contained eighty-two beds at the time it was founded in 1948. In addition to ninety-two inpatients, twenty-eight outpatients were also receiving daily rehabil- itation services at the center. Rehabilitation programs at this center included medical treatment, the fitting of 32 prostheses, limited physical therapy, social services, training in carpentry, mechanics, sewing, radio repairing, adult education, and weaving. The only personnel working at the center who had formal training were the physicians and one occupational therapist who had studied occupational therapy for six months. The second center was located in a two-story cement building in the suburbs. The building was a former hotel called "Casa Linda" which had forty-two beds. This smaller center worked in conjunction with the larger one by trans- porting the patients back and forth by bus. Casa Linda was also an agricultural experiment station and rehabilitation services were limited to medical treatment, bookbinding, and agricultural training. The Guatemala social security administration spent $217,164.00 on rehabilitation up to the end of February, 1951, and had "rehabilitated” a total of 479 patients during the years of 1948-50 (43:206). In 1952, the two rehabilitation centers were merged into one large center located in a former private home in a residential district of Guatemala City. Government rehabil- itation in Guatemala in 1952 was limited to the above center operated by the social security program. The need and value of rehabilitation services was recognized and plans were made for the building of a $1,000,000.00 rehabilitation hospital which has not materialized to this date, although some 33 progress has been made in this direction. The United States Senate, 85th Congress, 1957-58, recognized and stressed the importance Of rehabilitation and directed the subcommittee on Reorganization and Inter- national Organizations to prepare a report on the status Of rehabilitation services in certain countries. The pur- pose Of the publication was "to provide background infor- mation on the status of medical and related services for the disabled in certain countries on which such information is relatively available" (41:III). Thirty-seven countries were reviewed in the report, including Guatemala. The report on Guatemala is one page in length and simply states that Gua- temala has a polio center for children, a modern school for blind and deaf, a workshop for blind adults, a school of physical therapy, and a rehabilitation center for disabled workers. The latter is Operated by the Guatemalan Institute of Social Security (IGSS) and provide services to disabled workers covered by the social security system. The report stated that services provided workers at the IGSS Center "include medical and rehabilitation care and also vocational training in tailoring, radio repair, handicraft, shoe repair, clerical work, and other trades" (41:43). The only other institution about which comments were made was the polio center. It mentioned that the polio center served an average of 100 inpatients and 100 outpatients daily and that they used a modern team approach. The team consisted Of 34 Specialists in pediatrics, orthopedic surgery, rehabilitation, social services, physical therapy, bracemaking, and nursing. The above report prepared by the Senate subcommittee was the most detailed information found regarding the nature and extent of rehabilitation in Guatemala. A number of articles in professional journals deal- ing with Special education and rehabilitation in Guatemala and Latin America are currently in process; however, none Of these articles were available at the time of the present investigation. It is likely that a number of publications on Special education and rehabilitation in Guatemala and other underdeveloped countries shall result from the re- search program currently being conducted in these areas at Michigan State University (20, 21, 22, 23, 24, 25, 26, 27, 28, 29). In addition to the above references a search was made for materials that may be available only within the country of Guatemala. The office of the Minister of Public Health was visited but no information regarding rehabilita- tion in Guatemala was found. The officer in charge stated that they lacked such information and that they would ap- preciate very much to have a c0py of any data we may obtain in regards to the nature and scope of rehabilitation in Guatemala. Visits were also made to the National Statis- tics Office, the University of San Carlos, National Library, United States Embassy, Pan American Union, United Nations 35 Educational, Scientific and Cultural Organization, and the Minister of Public Education. No information pertinent to rehabilitation was found through any of the inquiries made in Guatemala. Summary The literature cited above represents the extent to which research and information are currently available regarding rehabilitation programs and facilities in the Republic of Guatemala. The studies reviewed were found to be general in nature and incomplete in coverage and detail. None of the studies were planned research projects directed toward ascertaining the status Of rehabilitation in Guate- mala. The various Offices and agencies in Guatemala are not informed about local rehabilitation programs. Agencies and institutions in Guatemala appear to put little emphasis upon the desirability of keeping accurate records and civil reg- ulations do not require the submission Of such accounts. The results of the research of literature may be summarized in two sentences: (1) There are rehabilitation type services currently being Offered in Guatemala. (2) The nature and extent Of these services are unknown. There are no national statistics available and there have been no studies conducted Of the institutions Offering rehabilitation type services. There is not even fundamental information such as the number and types of 36 institutions in Guatemala that have rehabilitation programs. This complete lack of information clearly demonstrates the need at this time for a comprehensive study of the nature and scope Of rehabilitation in Guatemala. This information is necessary in order that Guatemala, as a participating nation, may benefit more from international seminars and conferences, and enable the representatives to act on behalf of rehabilitation in general and not limit their considera- tions to their own particular affiliations. This information is essential to all individuals who are interested in under- standing, evaluating, planning, Or improving rehabilitation programs in theory or in practice. The objective of the present study shall be to provide this essential fundamental information regarding existent rehabilitation programs and conditions in the Central American Republic of Guatemala. CHAPTER III METHODOLOGY The review of literature indicated a lack of infor- mation regarding the nature and extent of rehabilitation services in Guatemala. The present study was designed and directed toward obtaining this basic information. However, before beginning such a study, it was necessary to have at least a rudimentary knowledge of the nature and size of the population to be studied. Such information about the pop- ulation was necessary in order to determine the type of instrumentation, the particular methodology and procedures that should be used, and for the selection of the population sample. To obtain this necessary information, a preliminary investigation was made of the rehabilitation programs and services in Guatemala. Preliminary_lnvestigation The preliminary investigation was conducted in two stages. The first stage consisted of procuring the names and locations of the agencies and institutions in Guatemala which had rehabilitation type programs. Efforts were also made to Obtain a general description of the types of serv- ices provided by each agency or institution. This infor- mation was not available from any single source and it was 37 38 necessary to make inquiries at various offices and organiza- tions such as the Ministry of Public Health, the University of San Carlos, Social Security offices, UNESCO of Guatemala, National Statistics offices, Social Services Office (Consejo de Bienestra Social), Committee for the Blind and Deaf, Social Security Rehabilitation Hospital, U.N. Social Service Agent, and other informed individuals in Guatemala. As a result of these inquiries, a tentative list was made of all agencies and institutions in the Republic of Guatemala which might be providing rehabilitation services (Appendix A). The second stage of the preliminary investigation consisted Of making personal visits to six institutions for the purpose of interviewing key personnel and observing institutional conditions and operations. Efforts were made to select thOse institutions which would provide information regarding the range or limits of size, services, facilities, personnel, et cetera, which might be encountered during the survey. Visits were made to the Social Security Rehabil- itation HOSpital,.Rodolfo Robles Institute, Neurological Institute, Roosevelt HOSpital, Vocational Rehabilitation Center for the Blind (no longer in Operation), and the Alcoholics Sanitorium. The purpose of the preliminary field investigation was to acquaint the researcher with the general nature of rehabilitation services in Guatemala. In addition to the obvious advantages of actually observing the facilities 39 and practices and conversing with the rehabilitation per- sonnel in the field, the information and experiences gained from the preliminary field visits materially helped in the selection of the best methods and procedures for collecting the final data. Population All agencies and institutions found through the preliminary investigation were considered for inclusion in this survey. The concept of rehabilitation varied greatly from one institution to another and it was necessary to use a tentative criteria for the final selection of institutions. After discussing the problem with key professional rehabil- itation workers in Guatemala, it was decided that any organ- ized institution which provided services for chronically handicapped individuals, whether physical or mental, should be investigated. The services provided should be oriented toward adapting the clients to their handicaps, and assist- ing them to become self-Sufficient members of society. Institutions which provided only medical treatment, welfare Services, employment, or subsistence were not to be consid— ered as rehabilitation. Agencies and institutions which could not be obviously excluded from the study were visited and then evaluated in terms of the above tentative criteria. As a result, eight institutions were selected for inclusion in the present study. These were: 40 1. Centro de Recuperacion No. l (Recuperation Center NO. 1) 2. Centro de Recuperacion No. 2 (Recuperation Center No. 2) 3. Instituto de Rehabilitacion Infantil (Children's Polio Hospital) . Sanatorio Antialcoholico (Alcoholics Sanatorium) Centro de Salud Mental (Mental Health Center) Instituto Rodolfo Robles (Robles Institute) \IO‘UI-b Hospital Neuropsiquiatrico (Neuropsychiatric HOSpital) 8. Centro de Rehabilitacion del IGSS (Social Security Rehabilitation Hospital). Due to the limited number of rehabilitation institu- tions in Guatemala, it was possible to include the total population in the study and thereby eliminate sampling errors. This was of particular importance since the population was found to be extremely heterogeneous and diverse in all re- Spects. The individual institutions varied in size from two room Service units to the complex sixty room rehabilita- tion hOSpital of the government social security system. Large variations were also found in regard to their services,, facilities, clientele served, and professional personnel. 41 Instrumentation The results of the preliminary investigation indi- cated that structured interviews, observations, and the examination of institutional records and papers were the best methods for data collection. Therefore, a set of data sheets was devised for use by the researcher. They were used to provide structure during the interviews and as a tool for systematizing all of the information Obtained from each institution. They categorized all aSpects of institu- tional conditions and Operations under the following general headings: 1. History and Development Administration and Organization Finance Facilities Personnel Programs and Services Clientele mNO‘Ul-bww . Research Endeavors. These data sheets consisted of a number of questions under each category to guide the researcher and Spaces in which to record responses (Appendix B). All information was obtained in the above manner except the personal data from professional personnel. Since it was impractical to interview each staff member, a Personal Information Inventory was devised which they could personally 42 complete at their convenience (Appendix C). This question- naire was divided into the following sections: 1. Personal data 2. Professional training and experience 3. Professional activities 4. Professional Opinions. McAleeS conducted a study of Special education in Guatemala simultaneously with the present investigation (28). Therefore, the above instruments were constructed to permit their use in either the special education or rehabilitation study. Procedure The procedures used for collecting data from the various rehabilitation agencies and institutions were simple and direct. To initiate the study, an appointment was made for an interview with the director Of each institution for the purpose of introducing the nature of the study, and to Obtain his cooperation. This initial interview was not directed at obtaining data but rather to make definite arrangements for future data collection from the various institutional personnel. Numerous subsequent visits were made to each insti- tution and it was necessary to work with all of the institu- tions simultaneously rather than to survey them one at a time. Appointments were made with the various service and administrative personnel for the purpose of Obtaining 43 Specific types of information. Institutional data were obtained through structured interviews, observing the in- stitutional facilities and Operations, and by examining records, reports, and papers provided by the institution or other organizations in Guatemala, such as their "Patronato," central offices, or the Department of National Statistics. The interviews were conducted in Spanish by the researcher and a "National" who was intimately familiar with colloquial Guatemalan Spanish and the nature and purpose of the study. The presence of a "National" was of particular importance at some interviews because the institutional personnel were either ambivalent or had negative feelings toward cooperating with United States researchers. The Personal Information Inventories were distrib- uted and collected by the director and administrator of each institution. It was not possible for the researcher to supervise the completion of the questionnaires because of the disrupting effect such a meeting would have had upon institutional Operations and because of the irregular hours worked by most of the professional service staff. Data Validation A major difficulty in conducting survey type research in the United States is that of obtaining reliable and valid data. This problem is of particular importance when conduct- ing surveys in Latin America because of the social and cul- tural customs and values found in these countries. This 44 difficulty became vividly apparent to the researcher during the preliminary investigation and efforts were made to structure the present research design to preclude as many errors as possible. The following measures were taken to increase the reliability and validity of the data gathered: 1. Because of the limited number of rehabilitation institutions, the entire population was surveyed to eliminate errors due to sampling statistics. Most Of the data were obtained through personal interviews, Observations, and the examination of various reports and papers. Researchers obtained the endorsement of key community and institutional personnel in reha- bilitation and certain other influential commua nity members such as the University of San Carlos Rector and the Dean of Humanities, Minister Of Public Health, et cetera. Provisions were made for the active participa- tion of Guatemalan Nationals in the study. Efforts were made to preclude data biasing due to various factors such as leading questions, halo effects, and divulging the nature and pur- pose Of the study when such information may have had a biasing effect for the informers. The overall data was scrutinized for internal consistency and any irregularities were explored. 45 Data Analysis It Shall not be possible to present comparable types and amounts of data from all agencies and institu- tions in this study because of their limited stage of de- velopment, lack of systematized record keeping,,and great heterogeneity. Consequently, the analysis of data shall consist of descriptive statistics such as Tables, Figures, percentages, et cetera. These statistics Shall be inter- spersed throughout a systematic description of the condi- tions and Operations of each institution. After the in- stitution-by-institution analysis of the data, a national overview of rehabilitation in the Republic of Guatemala shall be presented. The analysis of the data shall lead to the genera- tion of descriptive statements, generalizations, conclusions, and recommendations for further research. Whenever possible, conclusions shall be drawn in the light of existing condi- tions and circumstances in Guatemala and not particularly by externally imposed criteria. CHAPTER IV ANALYSIS OF THE DATA This chapter presents the analysis of the data ob- tained from the eight institutions surveyed in the study. The data will be analyzed institution—by—institution in order that a complete and realistic understanding may be Obtained of the current rehabilitation practices in Guate- mala. This type of analysis is considered desirable because Of the great diversity found between the various institutions. The following is a list of the institutions studied— and the order in which they-are presented in this chapter: 1. 2. (DNO‘UIA _Recuperation Center NO. l Recuperation Center No. 2 Children‘s Polio Hospital Alcoholic Sanatorium Mental Health Clinic Robles Institute Neuropsychiatric Hospital Social Security Rehabilitation Hospital. The data from each institution were analyzed and summarized under the following headings, which are the same ones used in the data sheets: 1. History and Development 46 47 2. Administration and Organization 3. Finance 4. Facilities 5. Personnel 6. Programs and Services 7. Clientele Although an eighth category, Research Endeavors, was a part of the data Sheets, it shall not be included in the present analysis of the data because none of the institutions reported any organized studies of rehabilitation. After a detailed presentation of the data, a brief overview of rehabilitation on a national basis will be pre- sented. Efforts will be made in the overview to Show the overall nature and extent of current rehabilitation prac- tices in Guatemala. Recuperation Center No. l History and Development This center.is located in an Old residential sec- tion of Guatemala City close to the business district. It was founded about one hundred years ago as an asylum for the crippled and sick who were unable to care for themselves. Patients with all types of ailments and disabilities were accepted for treatment, and custodial care was given for various lengths of time. As time passed, the number of chronic cases given custodial care began to accumulate until 48 today most of the hospital beds are occupied by chronically disabled patients. From the time that the hOSpital was founded until about 1952, the Objectives and services were not changed except for increases in the quantity and quality of the services. Due to the large number of custodial cases, the philOSOphy of the hOSpital administrators began to change in 1952 and more emphasis was placed on the discharge of patients. It was at this time that Drs. Von Ahn and Miguel Aguilera outlined plans for developing a rehabilitation pro- gram. It was realized that the hOSpital could perform a greater community service by rehabilitating patients and integrating them into society rather than fostering increas- ing invalidism. As a result of this new philosophy, the objeCtives of the institution were changed accordingly and” efforts are currently being made to develop adequate rehabil- itation programs and services. Programs for physical reha- bilitation have already been developed and plans have been drafted for the addition of social and vocational services. Administration and Organization This hOSpital is under the jurisdiction of the Guatemalan Minister of Public Health. It is administered by a Director who is appointed by the Minister. The Direc- tor has the authority and responsibility for all institu- tional operations except for decisions involving major pol- icies which must be approved by the Ministry. Institutional 49 affairs such as administration, personnel, services, and routine matters are generally left to the discretion of the Director and his staff. The Minister is primarily interested in the budget which he must submit to the National Congress for appropriation. It has been very difficult to negotiate budget increases through Congress because of the many other pressing needs in the country and there is always the pos- sibility of receiving a budget reduction. Some progress has been made in recent years in the introduction and acceptance of rehabilitation by the Ministry of Public Health and mem- bers of Congress. As a result, it has been possible to im- plement a physical therapy section in the HOSpital under the direction of a physiatrist who received post-graduate train- ing in physical medicine and rehabilitation at New York University. He is Chief Of the Rehabilitation Department and is the Director of a small school for physical therapists which he organized at the hOSpital. The purpose of the school is to supply physical therapists for all of the hos- pitals and rehabilitation institutions in Guatemala. The school is not part of Recuperation Center No. 1 since it is supported by a separate grant from the National Congress through the Ministry of Public Health. However, it is lo- cated in and uses some of the facilities in the hospital. Part-time instructors are obtained from the University of San Carlos Medical School. The students receive practicum experience by working as physical therapy aides at various 50 hOSpitals in the community. The Director is Chief Of the Medical Staff and the reSponsibilities of directing the social services and ad- ministering the hOSpital have been delegated to the Chief Social Worker and the Head Sister Of Charity, reSpectively. The Sisters of Charity have been delegated full responsi— bility for routine hOSpital operations. They provide nurs- ing services and are in charge of the domestic employees. Figure l is an organization chart showing the lines of authority and responsibility at the hOSpital. Finance The budget is prepared by the Director and his staff and sent to the Minister of Public Health. The Min- ister approves it after making any necessary changes and submits it to the National Congress for appropriation. The members of Congress review the proposal and make any further changes they consider necessary before deciding upon a monetary assignation. Their annual appropriation has been the same for the last three years although budget increases have been considered. The hospital is, and always has been, completely supported by government funds. Table 2 shows the amount of money appropriated by Congress for the fiscal year of July 1, 1961 to June 30, 1962. 51 Minister of Public Health I Director Executive Chief of So- .Secretary cial Service Social.Worker 1 Medical Service Student Social Worker JA _ Chief of Rehab. Dept. L FT Special Servi Department Ortho. Surge Pediatrics Internal Med. C85 IV, 9 , etc. Chief Admin. Sister of Charity Sisters Of Charity Sister Nurses Aides Medical Interns Rehabilitation Programs A Domestic Staff Physical Therapy Training School Fig. l.--Organization Chart of Recuperation Center No. 1. 52 Table 2. Budget for Recuperation Center NO. l and the School Of Physical Therapy in 1961-62 . . . Operational Inst1tut1on Salaries Costs Total Recuperation Cen- ter No. 1 $72,720.00 $57,732.00 $130,452.00 School of Phys- ical Therapy 7,800.00 204.00 8,004.00 The expenditures for the 1961-62 fiscal year as they were categorized for the Bureau of Statistics are shown in Table 3. Table 3. Expenditures for Recuperation Center No. l in 1961-62 Expense Category Amount Food . . . . . . . . . . . . $ 38,539.22 Clothing . . . . . . . . . . 3,861.50 Medicines . . . . . . . . . 1,931.72 Salaries . . . . . . . . . . 71,648.54 Other Costs . . . . . . . . 16,962.51 Total $132,943.49 Records Show there were 154,088 patient-days during the 1961-62 fiscal year for an average cost per patient-day 53 of $0.86. Facilities h The hOSpital was constructed around a Catholic church which functioned as a chapel for the patients and personnel. The rooms and wards were gradually added as the number of inpatients increased. AS a result, there seemed to be no systematic or logical organization of the plant. The total facilities appeared to be generally in need of maintenance and repair. The hospital is divided into twenty-four patient wards. There are Single wards for boys, girls, Spastic children, eight wards for women” and thirteen wards for men. There are facilities for 450 inpatients and 100 out- patients. However, most Of the facilities for the inpa- tients are used for custodial care of chronic medical or congenital cases. The hospital has service rooms for per- forming Operations, laboratory analysis, x-ray, steriliza- tion, drug dispensation, isolation, physical therapy, social services, and various Special service clinics. In addition to the wards and service rooms, the hOSpital has offices for the physicians and administrative personnel, a class- room, a conference room, rooms for the School of Physical Therapy, dining rooms, various domestic Spaces, and several small recreational areas. There are two admittance clinics which are also used for outpatient treatment. One clinic is used for 54 general hOSpital diagnosis and treatment while the other is only used by the Department of Rehabilitation. The Depart- ment of Rehabilitation has sections for individual exercises, mechanical therapy, and group exercises. The section for individual exercise has provisions and equipment for four physical therapists to work simulta- neously. The room is divided into four bays with the Open side of each bay curtained Off from a central aisle. This section also has a small examination room and a general therapy room. The mechanical therapy room contains various mechan- ical exercise equipment such as pulleys, wheels, weights, et cetera. This equipment appeared to be generally inad- equate and in poor working condition. The group exercise section is simply a gymnasium which also Serves as a recreation area and a classroom. There are chairs stored in the room which can easily be placed in front of a large blackboard in order to convert the gymnasium to a classroom. The School of Physical Ther- apy uses the classroom for instruction and the hospital staff uses it occasionally for short courses. Personnel The hOSpital has a total of 130 employees to care for approximately 400 to 450 inpatients and 100 outpatients. Since most Of the inpatients are custodial cases, the major- ity of the personnel are employed for their maintenance. 55 Excluding the Rehabilitation Department, the hOSpital has the following general medical staff: a. Six orthOpedic surgeons b. Two plastic surgeons c. Two general surgeons d. Two internal medicine physicians. .The hOSpital has no graduate nurses. The Sisters of Charity, who have been trained as nurses' aides, perform all of the duties that would normally be done by graduate nurses. The Rehabilitation Department has its own profes- sional staff although it is part of the general hospital. The Chief of the Rehabilitation Department is employed on a part-time basis; he works seven hours each week at the hOSpital. There are also two volunteer physicians who work infrequent hours. In addition to the physicians there are Six physical therapy aides and one graduate physical thera- pist, all of whom work thirty hours each week. The physical therapy aides are enrolled as students in the School of Phys- ical Therapy which is located adjacent to the physical ther- apy section of the hOSpital. They are paid for their serv- ices and they obtain practicum experience. Programs and Services The hOSpital has been commissioned to accept any indigent patient who is not covered by the national social security program. It is estimated that about 70 per cent of the people in Guatemala are not covered by social security 56 and must pay for their own medical treatment or obtain free services. The hospital provides free services for some of the indigent and chronically sick or disabled; however, it is inadequate to handle all of the individuals who apply for services. Efforts are constantly being made to rehabilitate, place, or transfer as many patients as possible; however, the number of chronic custodial cases is still rising. At the present time about 78 per cent of all the inpatients are receiving only custodial care. ‘Efforts are being made to admit only those patients who may be "cured" or rehabilita- ted through the services provided in the hOSpital. In prac- tice these criteria are difficult to follow because many chronic cases do not have any other place to go for treat- ment or maintenance. Patients are first received in the admissions clinic and are given a general physical examination after which they are interviewed by a social worker who Obtains the relevant background information pertaining to each case. NO decisions are made at this time regarding the patient's admittance. These decisions are made only after the cases have been discussed at one of the weekly case conferences. The services offered at this hOSpital are predom- inantly medical. All of the patients receive medical treat- ment; 50 per cent receive some type of social Service, 20 per cent physical therapy, and 20 per cent receive limited 57 outpatient treatment. A few of the patients are given sim- ple duties such as cleaning, helping other patients, selling lottery tickets, et cetera at the hOSpital. There are some Organized leisure time activities such as sewing and ceram- ics, but none Of these are considered as part of the reha- bilitation program. The primary purpose of these types of activities is to provide Something for the patients to do in order to reduce boredom. There are no programs or serv- ices for occupational therapy, vocational training or place- ment, Specialized nursing, psychiatric or psychological services, rehabilitation counseling, or follow-up. The Rehabilitation Department (physical therapy) treats most Of the patients that are ultimately discharged and also a limited number of the chronically disabled custo- dial cases. This amounts to about 100 patients per year who are treated for periods of time ranging from three months to one year. There are not enough physical therapy personnel or facilities to provide these needed services to all Of the patients at the hOSpital. Many patients are treated on an outpatient basis but with only limited success because the patients do not return regularly for treatment. One of the reasons they do not return for treatment is the time and transportation costs involved. Many of the patients come from distant Depart- ments since patients are received from all parts of Guatemala. 58 Clientele The hOSpital usually has from 400 to 450 inpatients at one time and about 100 outpatients registered and eligi- ble for treatment. Out of the 450 inpatients, about 350 are chronic custodial cases, some of whom have been at the hOSpital for over forty years. Since 350 inpatients are considered custodial cases, only about 100 inpatients at one time receive treatment oriented toward preparing them for discharge. Table 4 presents the movement of patients throughout the year Of 1962. Table 4. Patient Movement at Recuperation Center No. 1 in 1962 Inpatients Male Female Total T Number Of patients January 1, 1962 215 209 424 Admitted during 1962 169 158 327 Total discharged during the year 172 178 350 Voluntary discharges 163 162 325 Deaths 9 16 25 Number Of patients December 31, 1962 212 189 401 The number Of patients discharged reflects to some extent the efficiency of the rehabilitation program. Table 5 shows the number Of patients discharged during the years of 1960 and 1961 as compared to that Of 1962. In analyzing 59 these figures, it is necessary to consider the discharges in relation to the average number of inpatients. 'Table 5. Discharges from Recuperation Center NO. l in 1960-61-62 Number of Inpatients Discharged Average Number 'Year ~Male Female Total of Inpatients 1960 125 165 290 428 1961 129 161 290 416 1962 172 178 350 422 Patients come to the hospital through self-referrals, referrals from professional peOple such as lawyers and physi- cians, and as a result of letters sent to the Ministry Of Public Health by various people regarding certain individ- uals. Patients with many different types of disabilities are treated at the hospital; however, complete statistics were not available. A partial list of some of the more common disabilities is presented in Table 6. Comments This institution actually functions as a government general hOSpital for individuals who are not covered by the Guatemalan Social Security Program. It is completely gov- ernment supported without any contributions from the 60 clientele, employers, or any other organization, which makes it difficult to Obtain adequate Operating funds. The present services do not qualify this hOSpital as a rehabil- itation unit. However, a Rehabilitation Department has been organized within the hOSpital and it is headed by a very capable physician. The growth potential Of the rehabilita- tion program is good since the development of most success- ful enterprises in Guatemala can be traced to one highly motivated and capable individual. The Chief of the Rehabil- itation Department is not only the Director of the School of Physical Therapy but is also the Director of the Social Secu- rity Rehabilitation HOSpital and the Children's Polio HOSpi- tal. Table 6. Common Disabilities Treated at Recuperation Center NO. 1 in 1962 . . . Total A e Number Below Type of D1sab111ty Number Deaths Ragge 15 Years TB Of the bones and joints 8 0 1-64 6 Residual effects Of Polio 41 0 5—44 30 Brain damaged, paraplegics 10 1 1-24 6 Cerebral palsy 44 5 l-75 7 Club foot 23 0 1-64 16 ***** 61 Recuperation Center No. 2 History and Development The need for assistance and rehabilitation of the poor and socially maladjusted was recognized in Guatemala in 1947. Efforts were made at that time to form a "Patronato Contra 1a Mendicidad" (League for the Eradication of Begging) in order to launch a campaign to help the indigent. .However, due to the nature of social and economic conditions at that time, no action was taken and the need persisted. In 1952, efforts were again renewed to try to estab- lish some organized help for the beggars. Dr. Arriola was Minister of Public Health at that time and he succeeded in organizing a "Comite Contra la Mendicidad.” After its organization, the committee was converted into the privately operated "Patronato Contra la Mendicidad" which still exists today. The League (Patronato) authorized and financed a study of the causes of social maladjustment in Guatemala in order that ways and means could be found for rehabili- ting such persons. Their plans were to investigate various cases and then refer them to apprOpriate community agencies or institutions. However, it was found that the clientele could not be referred because the agencies and institutions in Guatemala were already filled to capacity. It was at this time that the need for a home for the beggars became evident. 62 A ”Home for Beggars" was organized and equipped for the rehabilitation of beggars with the help of government funds and private donations. When the home first opened, the government contributed $3,000.00 each month for its support. After a short time, the allotment was reduced to $1,000.00 per month. Most of the members of the League are professional or business people from the community. Anyone may join providing they are interested in helping the indigent; how- ever, some of the members join the League for social reasons. The League holds two general meetings each year at which time major decisions are made. The Officers of the League elected at these meetings hold office for two-year periods. The operation of the institution is under the manage-- ment of a Board of Control which is, in turn, directed by the League. The Board Of Control consists of a chairman, vice chairman, secretary, treasurer, and fifteen voting members all of whom are elected by the members of the League. ‘The board meets once every week or two for the purpose of conducting the affairs of the League and assisting in the ~management of the institution. About nine members usually attend each meeting; however, business is conducted regard- less Of the number of members present. If a quorum is not present, decisions are made conditionally, and they are voted on again at the next meeting. 63 Presently the League plans to establish a farm at Escuintla where the clientele may Obtain vocational training. The government has donated land to the League for this purpose, but no more has been done to date. The property is now used for growing sugar cane which serves as a source of income for the-League. Administration and Organization The institution is governed by a council composed Of five members, two chosen from the League's Board of Control and three from the institution's professional staff. The council meets every two weeks for the purpose of discussing institutional business and clientele. The Board of Control members are appointed for two year terms and one of the representatives acts as coordinator between the council and the League. The council members selected from the institu- tion are usually department heads. The Chief Administrator has complete responsibility for all routine institutional Operations. Technical deci- sions involving services are made by the professional staff members and decisions involving interdepartmental cooperation (other than routine matters) are decided by the council. Major policy decisions such as additional staff, program changes, and entrance criteria are approved by the League‘s Board of Control. Figure 2 shows the organization of the institution and its relation to the League. 64 | League for the Eradication of Begging Board of Control Recuperation Center Council Administrative Department Domestic Services Departments Technical Medical Department Social Department Fig. 2.--Organization Chart of Recuperation Center NO. 2. Finance a. The budget is prepared by the League for the institu- tion based upon information submitted to them by the council. The funding of the institution is handled directly by the League. The primary source Of financial support is from the 'gOVernment which has amounted to $12,000.00 each year for several years. The funds Obtained from the government are augmented by monies received from the sale of sugar cane, donations, and material gifts such as food, clothing, and medicines. The total income per year, excluding material gifts, is approximately $19,000.00. Since the income does not vary much from year to year, the expenditures are also approximately the same. . The average cost per client-day during 1962 was $0.98. The expenditures for the same year are presented in Table 7. ,EXpenses are usually categorized by the administration depart- ment as shown in Table 7, therefore, a more detailed break- down Of the costs was unavailable. Table 7. Expenditures for Recuperation Center NO. 2 in 1962 -===, is. Expense Category Amount Food . . . . . . . . . . . . . . $ 3,953.37 Clothing . . . . . . . . . . . . 540.05 Medicines . . . . . . . . . . . 670.80 Salaries . . . . . . . . . . . . 8,891.03 Other Costs . . . . . . . . . . 5,005.82 Total . . . . . . . . . . . $19,061.07 66 Facilities The institution is housed in a one story sixteen room abode building that was originally built as a large private home. The building is about fifty years Old and is in need of general renovation. The sleeping quarters, lav- atories, general utilities, Special purpose rooms, and rec- reation areas are grossly inadequate for the number of clients living in the home. There are only four toilets for the total population, and these are all located in one place so that men, women, and children must use the same facilities.. Two Special education classrooms and a fence to separate the children from the adults were under construction at the time of this survey. The dormitories are overcrowded, poorly ventilated, and dif- ficult to keep clean. There are four rooms with a total of fifty beds for men and three rooms with twenty beds for women and children. Therefore, the total capacity is seventy but there were one hundred and five persons living in the home at the time of the survey. Many of the clientele must Sleep on the floor on mattresses because of the shortage of beds. .In addition to the dormitories there is an adminis- trative Office, waiting room, reception room, social service office, medical treatment clinic, kitchen, and a storeroom for food, clothing, and other supplies. The medical treat- ment clinic is generally well equipped and has a large supply of drugs, most of which were donated to the home by various foreign pharmaceutical companies. 67 Personnel All personnel employed at the home must be approved by the League‘s Board Of Control. The selection of an employee for a vacancy is usually left to the department chiefs who submit their personal recommendations to the council. If the council approves of the candidate for a particular job, it requests the approval of the League's Board of Control. There are no written criteria for the selection of new personnel; candidates are selected on the basis of personal interviews and their ability to assume responsibility and perform the necessary work. There is no problem of Obtaining new personnel because the rate of turn- over is very low. At the time Of the survey there were six full-time and one part-time professional staff members. Table 8 shows the titles Of the variOus positions, their sex, and hours worked each week. In addition to the professional staff, there are two cooks, two laundresses, a seamstress, a janitor, and a watchman employed for domestic services. All of the institutional personnel are covered by the government social security program. There are practi- cally no opportunities for advancement principally because Of the very limited budget and the low rate of personnel turnover. Requests for an increase of personnel have been repeatedly made to the League by the council; however, new 68 positions could not be created because of budgetary limita- tions. Table 8. Professional Personnel Of Recuperation Center NO. 2 W Hours Worked Number of. . . Pos1t1on Sex Per Week Employees Administration Department 1 Chief of Administration Female 45 Medical Service Department 1 _ Gerontologist (M.D.) Male 12 3 Nurses Aides Female 45 (each) Social Service Department 1 Social worker Female 45 1 Social worker‘s aide Female 45 The Chief Administrator expressed an immediate need for a social worker, nurses‘ aide, rehabilitation counselor, and two Special education teachers. The two Special education teachers are needed because the institution was recently commissioned by the government to take into custody all delinquent, poverty stricken, orphaned, abandoned, and exploited children found in the streets. These children are held in custody for considerable lengths of time and, therefore, need education. Because of the personality, background, and educational deprivation of 69 these children, it is felt that special education teachers, who are familiar with these types of problems, should be employed to do the teaching. Programs and Services The Objectives of Recuperation Center No. 2 are to provide shelter, temporary aid, treatment, and guidance for the clientele so they may become self-sufficient members of society. Ultimate plans and Objectives of the center are to provide complete rehabilitation programs including psycholog- ical and vocational counseling, occupational therapy, and vocational training. The center worked rather informally until 1961, at which time a team approach was adopted, and a professional staff was hired to provide services. The following activities and services are available to all of the clientele upon the recommendation of the pro- fessional staff, or, in some instances, upon the request of the client: 1. General medical treatment. 2. Social services. 3. Maintenance at the center. 4. Supervised family placement, i.e., maintenance in private low income homes. Each family receives $20.00 per month per person. In effect this helps the individual placed and also the family, as it usually costs somewhat less than $20.00 per month to maintain an individual in a low income family. 70 5. Referral to various organizations and institu- tions such as: a. Committee for the Blind and Deaf b. Casa del Nino (orphanage) c. Roosevelt HOSpital d. General HOSpital e. Neuropsychiatric Hospital f. Military Hospital g. Social Security Hospitals" h. T. B. Sanatorium. 6. Limited psychiatric services by the gerontologist. 7. Limited psychological counseling by the social workers. 8. Limited occupational therapy. Some of the clien- tele make articles such as bedroom slippers, clothing, rugs, et cetera; however, they are of crude quality due primarily to the lack of equipment and adequate personnel for training. 9. Limited recreational activities. These activities are unorganized and extemporaneous. 10. Limited job placement. 'This service is also limited because of inadequate vocational counselors and vocational training programs. 11. Location of missing persons. The social workers and other personnel conduct an effective service in finding missing parents and relatives of the various clientele. Many case closures are obtained by placing the client with 71 friends or relatives. 12. Limited adoption services. A few of the orphaned or unwanted children have been adopted out. 13. Follow-up and family guidance services. The friends, relatives, or foster parents of a client may receive guidance and counseling. This service has proven effective in helping the clientele adjust to their new environment. This service is part Of the regular follow-up services pro- vided for all of the clientele. ‘Service Needs The League and the institutional staff feel that their services should be extended in the following areas: (They are presently constructing two classrooms.) 1. Special education 2. Vocational (rehabilitation) counseling 3. Occupational therapy 4. Vocational training 5. General increase in all of the services Offered at the institution. 6. More and better coordination with the community agencies and institutions 7. Better COOperation with the police department and better legislation for the control of the poor and beggars. 72 Clientele This institution has a very heterogeneous clientele. Their ages range from two months to over seventy years of age and their reasons for being in the institution are just as varied. Most of the clientele are referred by the police department, but a few are self-referrals or referrals from various other institutions or professional personnel. There are no written admissions criteria except for some informal rules that are often changed. Generally family relations and personal solvency are given considerable weight in de- ciding admittances. Individuals may be referred because of ulcers, mental disturbances, retardation, amputations, paralysis, poverty, senility, blindness, deafness, orphaned or exploited children, et cetera. The social workers are reSponsible for admitting clientele and for directing their institutional activities. The number of clientele has recently increased be- cause of a city ordinance directed to remove homeless and exploited children from the streets. All children found on the city streets after 10:00 P.M. are taken into custody by the police and brought to this institution. As a result, the number of children in the institution is increasing, especially between the ages of six and thirteen. These children generally have behavior problems which are not serious enough to warrant sending them to a detention home. It is hoped that special education and guidance will 73 rehabilitate these youngsters so that they may be returned to parents, relatives, institutions, boarding homes, or be adOpted out. This particular phase of rehabilitation has not as yet been worked out satisfactorily. The placement of clientele is difficult and Often impossible, necessitating the maintenance of clients at the institution. In January of 1963 the police brought thirty-one children into the in- stitution and thirteen were still awaiting placement the following April. At present there are eight blind clients. who can not be accepted for unknown reasons by the institu- tions for the blind. There are also some cases of "idiocy" and severe mental retardation who have been referred to the neuropsychiatric hospital, but who could not be received because the hospital was overcrowded. Other cases with chronic disorders such as ulcers, gastritis, et cetera can- not be received by other institutions for a variety of rea- sons. As a result, this center is overcrowded. Their capac- ity is seventy, but in April, 1963 there were one hundred and five clients living in the home. Table 9 shows the clientele movement at the home during the year of 1962 before children and their mothers were admitted. Comments The Recuperation Center NO. 2 of Guatemala appears to be an important and functional social service unit even though the services performed for the clientele are limited. 74 ”Table 9. ”Clientele MOvement at Recuperation Center NO. 2 in 1962 V7 Clientele Male Female Total Clientele January 1, 1962 34 7 . 41 Clientele admitted during the year 66 36 102 Clientele that left during the year 62 28 90 Left voluntarily 5 -- 5 Escaped 16 2 l8 Referrals due to illness 13 7 20 Died 5 __ 5 Placement and other reasons 23 19 42 Number of clientele at end of the year 38 15 53 It appears from the history of the center that its beginning was brought about by a strongly-felt social need. Originally its primary function was the placement and guidance of the clientele; however, it has become evident that it is impos- sible to find a suitable place for many Of the clients. The Patronato and administrative personnel recognize the prob- lems and they are formulating realistic plans for their solution. This may be seen from their list of needed serv- ices. - The institution appears to be relatively well admin- istered and organized and it has the potential of becoming an 75 effective social rehabilitation agency after the perceived service needs have materialized. ***‘k* Children‘s Polio Hospital History and Development The need for a children‘s polio center in Guatemala was first recognized in about 1948, at which time Dr. Monzon Malice organized Special services for polio patients at Recuperation Center No. 1. In 1955, Drs. Monzon Malice and Miguel Aguilera planned and founded the present polio hos- pital. The hospital was organized for the treatment and rehabilitation of all young polio patients in either the acute or chronic stage. The majority Of the patients ranged from six months to two years Of age, since adult cases of polio are extremely rare in Guatemala. The clientele served today have essentially the same nature and characteristics as those served when the hospital was founded. The hospital was founded in the Old laundry build- ing of the General HOSpital., It is still located in the same building, but many changes have been made, such as the building of wheel chair ramps, addition of a wing which in- cludes a special education room, and the construction of a playground for the children. A complete ShOp for the fab- rication and fitting of prosthetic or orthopedic devices has 76 also been added. The number of professional staff members has increased and new positions created. Additional per- sonnel included physical therapists, pediatricians, pros- thetic and orthopedic technicians, nurses, dietician, anesthetist, and X-ray Specialists. Administration and Organization The Children‘s Polio Hospital is owned and supported by the government under the Ministry of Public Health. It is an independent government unit and has no relation to the social security system. The hospital is administered by an executive director appointed through the Office of the Min- ister of Public Health. The Director is responsible for all institutional Operations, however, the appointment of various staff members and major policy decisions must be approved by the Minister‘s Office. The Minister is particularly interested in the hos- pital's Operating budget, since this money must be appropri- ated by the National Congress. ,Major policies such as the types of service programs that Should be Offered, eligibility requirements for service, personnel needs and standards, and hospital developments are decided by the Director, based upon his professional expe- rience, perceived hOSpital needs, and staff recommendations. The Director then submits these recommendations to the Ministry of Public Health for consideration and approval. 77 The Director hires all personnel through personal interviews and practical examinations. The practical exam- inations are competitive and the individuals who are most capable of performing the required work are selected. The individuals selected by the Director to fill vacant posi- tions are usually routinely approved by the Minister's Office. New positions cannot be readily created and filled because of budgetary limitations. Finance The budget is prepared by the Director and his administrative staff and it is then submitted to the Min- ister of Public Health for approval. The Minister of Public Health usually makes some changes and presents the budget before the National Congress for appropriation. The Congress may also make some changes before appropriating money for the next year. The budget submitted to the Minister usually con- tains a number Of increases; however, during the past few years these increases have not been granted and the budget has been approximately the same each year. Table 10 presents the monthly budget allocations of Congress for the support of this institution from July, 1957 to June, 1963. The budget is prepared according to the standard government fiscal year from July lst to June 30th. It may be noticed from Table 10- that a budget increase was granted to become effective mid- year Of 1962-63. Table’lD. 78 Polio Hospital in 1957-63 Monthly Budget for the Children's Monthly Fiscal Year Salaries giggzgigg Total 1957-58 $3,885.00 $3,000.00 $6,885.00 1958—59 4,255.00 2,375.00 6,630.00 1959-60 4,600.00 2,219.00 6,819.00 1960-61 4,150.00 2,219.00 6,369.00 1961-62 4,740.00 1,889.00 6,629.00 1962 July-Nov. 4,740.00 1,889.00 6,629.00 1963 Dec.-June 4,740.00 2,219.00 6,959.00 Efforts were made to Obtain monthly from the Administrator, but none were available. eXpense records Table 11 shows an average monthly itemization of operating expenses as estimated by the hOSpital Administrator. Table 11. Children‘s Polio Hospital in 1963 L.— _— _— f Estimated Monthly Operating Expenses of the Expense Category Amount Food 950.00 Medicines . . . 300.00 Laboratory expenses 100.00 X-ray materials 100.00 Clothing . . . . 150.00 Prosthesis shOp 400.00 General expenses 219.00 Total $2,219 .00 79 Facilities The Children‘s Polio Hospital is located in the former laundry building of the General Hospital. It is a forty room two-floor concrete structure that was built about ten years ago. The building is in fair condition and has been extensively modified to serve as a polio rehabilitation hospital. Major changes include the addition of a wing, wheelchair ramps, prosthesis shop, playground for children, various room modifications, and the installation of sanitary utilities for hospital patients and staff. The hospital has four wards with a total Of eighty- seven beds for children and youths. The wards are divided according to age groups, and differentiation is not made with regard to sex except for Older children and the few adults. There are three administrative Offices in the build- ing. The Director and the Administrator have private Offices and the third room is used for hospital office supplies, files, and records. Because of the large number of school age children admitted for treatment, a special education classroom was constructed in the new wing added to the building. Approx- imately twelve children receive special instruction in the classroom each day. Three rooms in the hospital are used exclusively for medical treatment. This is necessary because many of the patients admitted for rehabilitation are in the acute 80 stage of poliomyelitis. These patients must be kept in isolation and given intensive medical care until the acute stage has passed. One of the medical clinics is used for admittance examinations in addition to regular medical treat- ment, and another clinic also serves a dual purpose by serv- ing outpatients as well as inpatients. There are two physical therapy rooms. The main physical therapy section has eight bays that are used simul- taneously for individual treatments, including some mechan- ical therapy. The second room used for physical therapy has a large and small division, each of which contains mechanical and hydrotherapy apparatus. The large division has a sunken pool which is functional but not used because of the high cost of hot water and poor control Of the air and water tem- peratures. The prosthesis Shop occupies a large room which contains most of the necessary hand and power tools for the fabrication of prosthetic and orthopedic devices. Approx- imately twenty new prosthetic and orthopedic braces are con- structed every month, and about forty others are repaired and/or refitted. The shop needs include a drill press, a nickel plating machine, and a hand sewing machine for shoe repair. The hOSpital has one office for social services, a drug dispensary, X-ray room and film laboratory, and an Operating room. These rooms are equipped with the minimum 81 essential apparatus necessary to provide effective social and medical services for the patients. There are also two dining rooms, a kitchen with two domestic purpose rooms, and several small areas and rooms used for sterilization apparatus and storage Of materials and equipment. Personnel The Director of the hospital selects all personnel and recommends their appointment to the Ministry of Public Health. The Director's recommendations are based upon ap- plications filled out by the prospective employees, personal interviews, and practical on-the-job examinations. Empha- sis is placed upon the individual's training and ability to perform in a work setting. The employees are hired on a two month provisional basis, during which time they are subjectively evaluated by the Director and other staff mem- bers. If a particular employee does satisfactorily during this trial period, the Director recommends his permanent appointment to the Minister of Public Health‘s office. The rate of personnel turnover is very low; there is an average change of two employees per year. Although requests have been made to increase the professional staff, it has not been possible to do so in recent years because of the lim- ited budget. The personnel have no incentive plan or opportunities for advancement other then inservice training and occasional 82 professional seminars. Employees are covered by social security and they receive twenty days of vacation each year. An administrative and service personnel list is pre- sented in Table 12 which also shows the hours worked per week and salary earned per month and per hour for each employee. 'Table 12. Personnel and Salary Schedule of the Children‘s Polio Hospital in 1962 1—-_ Position Hours Per Pay Per Wages Per Week Month Week Administration department 1 Director and medical Spe- cialist in rehabilitation 15 $300.00 $5.00 1 Administrative secretary 44 150.00 .85 1 Secretary 44 50.00 .28 Service Department 1 Physician—-physical medicine 10 100.00 2.50 l Physician-—orthopedic surgeon 10 70.00 1.75 2 .Medical interns 15 60.00 1.00 1 Chief physical therapist 30 120.00 1.00 2 Graduate physical thera- pists 30 90.00 .75 10 Physical therapy aides 30 60.00 .50 l Physician--pediatrician 10 150.00 3.75 l .Physician--pediatrician 10 140.00 3.50 2 Graduate nurses 35 100.00 .71 l Physician--laboratory consultant 10 100.00 2.50 l PhySician--X-ray 10 50.00 1.25 1 X-ray technician 30 60.00 .50 l Anesthetist 5 60.00 3.00 1 Dietician 40 40.00 .25 17 Nurses aides 30 60.00 .50 4 Nurse maids 30 30.00 .25 1 Social worker 30 200.00 1.66 83 ~Programs and Services The objectives of the institution are to isolate and give intensive medical treatment to patients with acute pol- iomyelitis. After they have reached the chronic stage, the hOSpital objectives are to rehabilitate the patients and then return them to their families. When patients no longer re- quire daily treatment, they are discharged from the hospital and scheduled for Outpatient treatment. If the patients return to receive outpatient treatments regularly, they make satisfactory progress in their rehabilitation. However, many patients do not return for adequate outpatient care, hence some regress and become invalids. Patients are con- sidered rehabilitated when they have completed their out- patient treatment and are able to function satisfactorily in society. All patients with polio are accepted for treatment at this hOSpital. If there are no beds available, each patient waits his turn for admittance. Patients on the waiting list are given minimal medical treatment and guid- ance until they can be admitted for inpatient treatment. All children brought to the hOSpital must have a Sponsor to present them for admittance. The sponsor may be a parent, relative, or friend who is willing to assume responsibility for the child after discharge. It is neces- sary to do this because many parents or relatives bring children to the hospital and abandon them. In such cases 84 the hospital must take care of them indefinitely or find a foster home for them. This practice stems from the popular belief that the state is responsible for the care of all sick and disabled persons in the country. Table 13 presents the various services provided at the hospital and the approximate percentage of patients receiving each service. Table 13. Services Offered at the Children's Polio Hospital in 1962 _— Service Category Patients Receiving Service Medical treatment , , , , , , , , , , , 100% Social services , , , , . , , , , , . . 100% Physical therapy . . . . . . . . . . . 100% Prostheses . . . . . . . . . . . . . . 100% Training in ADL . . . . . . . . . . . . 100% Hospital maintenance . . . . . . . . . 100% Outpatient treatment . . . . . . . . . 100% Special education . . . . . . . . . . . 20% Follow-up . . . . . . . . . . . . . . . 50% Avocational activities . . . . . . . . 5% Table 14 shows the kinds and numbers of services administered to inpatients during the month of November, 1962. Table 15 shows the same statistics for the outpatients. 85 ‘Table 14. *Services Offered Inpatients at the Children's Polio Hospital in November, 1962 Service Category fi 0 Number of Treatments Individual muscular exercises 801 Heat treatments 295 Hydrotherapy 403 Ambulation training 633 Verticalizations 329 Mechanical exercises 70 Tractions 24 Spinal taps 28 Gymnasium classes 21 Spinal column examinations 5 Muscular examinations 15 Orthopedic consultations 26 Total 2,670 The Director feels that all of the services in the hospital should be improved and expanded, and treatment should be made available for cerebral palsy and meningitis patients. There is a need for psychological, placement, and follow-up services. A section should also be added to the hospital for preventive medicine. The latter could em- ploy mobile units for conducting virological research and 86 vaccination campaigns throughout the Republic. Table 15. ‘Services Offered Outpatients at the Children's Polio HOSpital in November, 1962 J Service Category Number of Treatments Individual muscular exercises . . . . 303 Heat treatments . . . . . . . . . . . 100 Ambulation training . . . . . . . . . 348 Verticalizations . . . . . . . . . . . 105 Mechanical exercises . . . . . . . . . 110 Tractions . . . . . . . . . . . . . . 60 Paraffin treatments . . . . . . . . . 15 Muscular examinations . . . . . . . . 10 Spinal column examinations . . . . . . 6 OrthOpedic consultations . . . . . . . 17 Total 1,074 Clientele Patients are admitted for treatment from all of the Departments Since this is the only polio hOSpital in Guate- mala. This may be seen from Table 16, which shows the number of patients from various departments at the hospital on August 7, 1961. 87 Table 16. Geographical Origin Of Patients at the Children's Polio Hospital on August 7, 1961 Department in Guatemala Number of Patients City of Guatemala , , , , , , , , , , 14 Department of Guatemala Escuintla Suchitepequez Santa Rosa Sacatepequez Jutiapa . Rehalhuleu Chimaltenango Solola . Quezaltenango Totonicapan H l-'*[\)|----‘L\)[\)-¥> NUTbNxo Peten Quiche San Marcos El Progreso Baja Verapaz Chiquimula Izabal Zacapa Unknown HF-Ul RJHLAFJNP- Total fl \] The hospital has an inpatient capacity of eighty- seven. In 1960, there was an average of sixty-seven in- patients throughout the year. This figure increased to seventy-seven in 1961, and dropped back to sixty-six in 1962. ,These figures reflect the prevailing polio incidence in Guatemala. 88 The average patient spends six months in the hospital and about eighteen months as an outpatient. Outpatient con- trol is poor, and many patients do not return for treatment. The average sex ratio for inpatients for the years of 1960- 1962 was 53.9 per cent males to 46.1 per cent females. The age ranges and numbers Of inpatients treated at the Children's Polio HOSpital during the years from 1952 through 1962 are presented in Table 17. Table 17. Age Range and Number of Inpatients Treated at the Children‘s Polio Hospital from 1952-62 Age Ranges 21 or Year 0-2 3-5 6-8 9-11 12-14 15—17 18-20 M Total ore 1952 74 18 7 3 3 - 1 5 111 1953 112 22 5 2 — - - l 142 1954 113 17 3 2 - - l 3 139 1955 70 15 4 - 3 - l 3 96 1956 95 30 9 5 2 l 2 2 146 1957 78 34 19 8 2 - 2 l 144 1958 95 25 21 8 6 - - 2 157 1959 143 37 ll 7 7 4 - l 210 1960 70 18 9 3 3 l - 3 107 1961 171 25 8 8 l - l 2 216 1962 75 18 8 4 l l - - 107 Comments The services at the hospital appear to meet the min- imum needs of the inpatients; however, rehabilitation cannot be fully effective unless the outpatients receive protracted 89 treatment. This service may be improved by providing effec- tive follow-up and tranSportation for the outpatients. Out- patient clinics could be established at strategic points throughout the country and coordinated by the hospital. Also mobile outpatient clinics may be used for areas which do not warrant a permanent outpatient post. Social services need to be increased since many peo- ple do not assume responsibility for members of their family who have been stricken by some incurable or chronic disease. Also many of the children brought to the hospital are ille- gitimate and their mothers do not want or cannot assume responsibility for the children. ***-k* Alcoholics Sanatorium History and Development A group of citizens recognized that alcoholism was becoming a major problem in Guatemala and especially in Guatemala City. They observed increasing numbers of ine- briated individuals who could not control their liquor con- sumption. Consequently, this group of citizens formed an Anti-Alcoholic League (Patronato Anti-Alcoholico) in 1946 for the prevention and rehabilitation of alcoholics. They petitioned the government for an allocation of money on the 90 basis of Article 33 of the Alcoholic Law of Guatemala. The Anti-Alcoholic League received a grant in 1951 with which they founded the "Sanatorio Antialcoholico."_ The objectives of the sanatorium are the same today as they were when it was founded--to serve as a unit for the prevention and re- habilitation of alcoholics. Administration and Organization The sanatorium is a legal corporation under the laws of Guatemala and is governed by a set of by-laws written by members of the Anti-Alcoholic League. There are two classes of memberships in the association: 1. Active--Those who "should" attend all meetings and conduct the affairs of the League. Many of these members assume a rather passive role in League affairs. 2. Honorary members--These are supporting members for the League. They may donate their interest, influence, money, skill, or labor for furthering the objectives of the League. Once each year, the general assembly of the League elects officers and members to a Board of Control. The Board of Control is composed of a chairman, two vice-chairment, six voting members, and a general recording secretary. It holds meetings twice each month for the purpose of conducting the League's affairs. However, these meetings usually have low 91 attendance, and most of the League‘s business is conducted by a few members. The sanatorium operations are controlled by an executive director. The Director, a psychiatrist, has full responsibility for all activities carried out in the hOSpital, including administration, clinical examinations, and alco- therapy. ‘He is appointed by the League; however, the League is loosely organized and exercises little control over san- atorium operations. The League finds it difficult to obtain members who are interested in, and understand, the problems of alcoholism. Finance Shortly after the sanatorium opened, the government funding was reduced considerably and has never been increased again. The sanatorium became economically dependent upon the League, patient fees, and donations. The budget is prepared by the Director and is then approved by the League‘s Board of Control. Table 18 shows the amounts and sources of income for the fiscal years of 1959-61. The fiscal year is from July lst to June 30th. Table 19 shows the expenditures of the sanatorium as they are usually categorized by the administrative per- sonnel. 92 Table 18. Sources of Income for the Alcoholics Sanatorium from July 1, 1959 to June 30, 1962 Patient Dona- Truck * Year Govt. Fees tions Garden League . Total 1959-60 6,000.00 21,155.88 1,013.00 327.54 3,182.54 31,679.40 1960-61 6,000.00 23,636.38 960.00 233.35 1,269.09 32,098.82 1961-62 6,000.00 22,710.98 960.00 256.85 348.65 30,276.48 *This is an estimate of the monies received from the League (Patronato). The figures are not exact because the expenses generally do not equal income since there may be a surplus or a deficit in any one particular fiscal year. Table 19. Alcoholics Sanatorium Expenditures From July 1, 1959 to June 30, 1962 .Expense Category 1959-60 1960-61 1961-62 Salaries 16,026.80 16,830.33 16,726.57 Food 7,380.93 7,569.84 6,926.14 Overhead 1,815.38 1,379.07 1,004.19 Medicines and materials 2,999,90 2,900.97 2,412.46 Building maintenance 1,384.29 1,580.02 1,438.40 Vehicle maintenance 512.79 495.43 409.24 Office supplies 71.75 37.95 112.97 Contingencies 272.44 384.48 390.65 I.G.S.S. 1,215.12 920.73 855.86 Total 31,679.40 32,098.82 30,276.48 93 Facilities The Alcoholics Sanatorium owns two buildings located in a suburban district of Guatemala City--the sanatorium and a residence for the Director. The sanitorium is a one-floor abode building that was built eleven years ago to serve as an alcoholic sanitoe rium. It has modern utilities as well as large parking and recreational grounds. There are eighty rooms in the sanatorium of which four are service rooms. There are two medical clinics, one psychotherapy room, and a small hydrotherapy room used for immersion baths. Other rooms include two administrative offices, two dining rooms, a chapel, and a small library. The sanatorium has three wards and each ward is divided into bedrooms large enough for one bed and night stand. One ward has thirty bedrooms, while the other two have fifteen in each, which makes a total of sixty bedrooms in the sanato- rium. Personnel The Director makes all personnel appointments in accordance with his perception and judgement of institutional needs. These appointments are restricted to filling vacan- cies since all newly created or abolished positions must be authorized by the Board of Control. Table 20 is a list of personnel presently employed at the sanatorium. 94 Table 20. Personnel and Work Schedule at the Alcoholics Sanatorium in 1962 Position Hours Worked per Week Director-psychiatrist . . . . . . . . 20 Administrative secretary . . . . . . 45 Psychiatrist . . . . . . . . . . . . .28 Final year medical student . . . . . 20 5 nurses (including one female) . . . 45 Officer of the secretariat (clerk) . 45 Domestic personnel . . . . . . . . . —- The professional service staff has been reduced since the sanatorium was founded in 1951. During its first year of operation, the service staff consisted of three physicians, one psychometrist, eight nurses, and three shop teachers. Because of economic conditions, the present service staff has been reduced to two physicians, one medical student, and five nurses. The Director expressed immediate need for a psychologist, psychometrist, occupational therapist, social worker, female nurse, and two male nurses. There is practically no personnel turnover except for an occasional change in the domestic staff. ,Opportuni- ties for advancement are very limited, and there are no immediate plans for increasing the number of staff. All these conditions are attributed to a limited budget. Fringe 95 benefits for the employees include social security, free medical attention, one month's extra salary each year, and occasional tips from the clientele. Programs and Services There was no charge for services at the sanatorium during its first few years of operation. When the govern- ment allocation was reduced, it became necessary to charge patients a fee in order to obtain additional Operating funds. The Director feels that charging the patients a fee makes the rehabilitation services more effective. Each patient admitted for treatment (with some exceptions) must pay a $40.00 deposit. The patient is charged $4.00 for each day that he remains an inpatient. These charges are deducted from the patientfs initial depoSit, and any excess money is refunded or additional fees are collected when the patient is discharged. The services rendered at the sanatorium are prima- rily psychiatric and medical, with limited physical therapy and outpatient care. These services (except physical therapy) are prescribed and administered to all of the patients by the physicians. Physical therapy treatments are limited to immer- sion baths given by the nurse attendants. Table 21 presents the nature and extent of the serv- ices rendered in 1962. All discharged patients are asked to return for about thirty outpatient treatments. The average outpatient receives 96 one treatment per week at first; the number is then gradually reduced to one visit per month. The majority of the patients do not complete their treatment series, and some of the more difficult cases are readmitted for further inpatient treat- ment. Table 21. Services Rendered at the Alcoholics Sanatorium in 1962 Service Category Number of Treatments Entrance examinations . . . . . . . . . 525 General medical examinations . . . . . 1,196 Diathermy treatments . . . . . . . . . 28 Convulsive therapy . . . . . . . . . . 152 Saline and plasma transfusions . . . . 880 Injections . . . . . . . . . . . . . . 8,194 Psychotherapy sessions . . . . . . . . 798 Clientele The sanatorium treats persons with acute alcoholism, alcoholic psychosis, or other complications caused by exces- sive alcohol consumption. Because of the limited profes- sional staff, only those individuals are admitted who may still benefit from the treatment or "rehabilitation" serv- ices provided in the sanitorium. The patients admitted for treatment are not 97 classified in any manner other than simply "alcoholics" and their treatment is also rather undifferentiated. Patients that are in need of some special service such as surgery, or who have some contagious disease, are immediately refer- red to another institution. The ages of the patients range from seventeen to seventy, with the greatest number found between thirty-one and fifty years of age. Table 22 shows the ages and number of patients treated during the years of 1960 and 1961. Table 22. Ages and Number of Patients Treated at the Alcoholics Sanatorium in 1960 and 1961 ================= i:=== Number of Patients Age Range 1960 1961 17-20 5 3 21-30 107 75 31-40 178 196 41-50 167 151 51-60‘ 56 66 61 or more 29 33 Table 23 shows the number of patients by sex who received treatment during the years of 1960-62. Since the average patient remains in the sanatorium from five to eight days, the figures approximate the total number treated each year. Table 23. Sex and Number of Patients Treated at the Alcoholics Sanatorium in 1960-62 M Year _ _Males Females Totals Daily Average 1960 - 522 20 542 10 1961 512 12 524 10 1962 . 508 17 525 9 W The building and facilities of the Alcoholics Sanato- rium are spacious, relatively well equipped, and in good con- dition; however, there is a conspicuous absence of activity. At present the average number of inpatients per day is ten, whereas the capacity of the institution is sixty. The average patient remains at the sanatorium for one week. Actual rehabilitation can not take place in such a short period since alcoholics are extremely difficult to rehabilitate. It may be possible for the outpatient clinic to effect some degree of rehabilitation; however, most of the patients do not return for treatment. ***** 99 Mental Health Clinic History and Development The development of the Mental Health Clinic was primarily the work of Dr. Carlos F. Mora who was in charge of practicum training for medical psychology and psychopa- thology students of medicine at the University of San Carlos. In his efforts to find a satisfactory place to train his Students, he volunteered to direct the outpatient clinic at the Neuropsychiatric Hospital. During the time he was director, he perceived that many patients receiving treat- ment and consultation manifested considerable resistance and did not care to utilize outpatient services. On the basis of his experiences, he assumed that much of their resistance was due to the stigma of receiving treatment at the Neuropsychiatric Hospital. Therefore, he considered it wise to separate this clinic from the hospital. In 1955 he obtained funds from the Ministry of Public Health for the foundation of the present Mental Health Clinic. He organized the clinic to provide outpatient treatment for the Neuro- psychiatric HOSpital patients and to conduct Special examina- tions for other agencies and institutions in the community. .The clinic is also used as a treatment center for cases which do not require hospitalization. Administration This small clinic is administered by an executive 100 director who is in charge of clinic Operations. All admin- istrative actions and decisions concerning personnel, budget, clientele, services, and purchases are the reSponsibility of the Director. He reports directly to the Minister of Public Health. Finance The clinic is Operated from two sources of income. Patients who are able to pay are charged a service fee of twenty-five cents for each visit. In addition to the serv- ice fees an annual grant of $11,928.00 is received from the office of the Minister of Public Health. The budget is prepared annually by the Director and submitted to the Minister Of Public Health for approval. The annual alloca- tion has been the same for the last few years and efforts to secure additional operating funds from the government have not been successful. Facilities The clinic is located on the second floor of an abode building that was originally constructed as a private home. Five rooms on the second floor are used by the Men- tal Health Clinic, while the first floor is occupied by the Mental Hygiene League. The Mental Health Clinic uses one room for each of the following services: (1) adult out- patient consultations, (2) children's services, (3) psy- chological services, (4) social services, and (5) medical 101 psychiatric treatment. The clinic shares a secretarial office on the first floor with the Mental Hygiene League. The hallway in front of the adult consultation office serves as a waiting room for the patients. The facilities for the clinic are gen- erally inadequate, but they cannot be improved at this time because of budgetary limitations. Personnel All of the clinic personnel work on a part-time basis. They average from five to fifteen hours per week depending upon their case load. As a result, it is neces— sary for them to augment their salaries by accepting other part-time or full-time employment. At present there are five members on the professional staff. The staff consists of two psychiatrists, a psychol- ogy student from the University of San Carlos, a social worker, and a nurse. The Director, a psychiatrist, is in charge of all adult patients and the other psychiatrist is responsible for children's services. In addition to the regular part-time staff, medical students from the University of San Carlos periodically re- ceive some of their psychiatric practicum at the clinic. However, their work is primarily training and does not materially increase the service capacity of the clinic. 102 Programs and Services Since the clinic is small all of the programs and services are of a limited nature. However, some patients do receive long term treatment at the clinic. A consider- able amount of diagnostic work is done for various govern- ment institutions and for some private organizations. All of the patients who are admitted for treatment to the Neuro- psychiatric HOSpital must first be examined at this Mental Health Clinic. Individuals may also refer themselves for diagnosis and treatment. All patients who are referred to the clinic are given a general diagnostic examination. A team approach is used for each examination under the direc- tion of one of the psychiatrists. The psychiatrist in charge reviews each patient's record at a case conference and then prescribes treatment or referral to another in- stitution. The following services are available at the clinic for adults and children: 1. Diagnostic examinations 2. Drug therapy 3. Psychotherapy Electroshock treatment Psychological services Personal-social counseling Marriage counseling mflO‘Ul-b Vocational counseling 103 9. Social services for clientele and/or parents. The patients who are accepted for treatment at the clinic receive treatments for various lengths of time depend- ing upon the nature of their problem. Some epileptics have been treated for several years, while psychoneurotic cases average six months. The shortest term cases are patients seeking various forms of psychological and social counseling, These cases may receive no more than one interview or they may obtain weekly counseling for as long as three months. The frequency with which patients are treated varies according to their particular problems. Bpileptics may be treated each week or as seldom as once per month. Patients receiving psychosocial counseling are usually scheduled for one interview per week, while more serious cases involving psychoneurosis or psychosis may be treated more often. Clientele The clinic is open to anyone in Guatemala who is_in need of neurological, psychiatric, or psychological services and who cannot afford to receive treatment from a private practitioner. Due to economic conditions in Guatemala, practically all of the peOple are eligible for services at this clinic. Patients may refer themselves or they may be referred from other individuals or organizations. There are generally two classes of patients who receive treatment at this clinic: 104 l. Outpatients who have not or will not receive similar treatment from another institution. 2. Outpatients or individuals who will be inpa— tients at some other institution. All patients with neurological, psychiatric, or psychological problems Who do not require hospitalization may be treated. Patients may have functional or organic psychosis, neurosis, brain damage of various types, marital or social problems, or simple transitory frustration states. ,Table 24 shows the number and types of adult patients treated during the years of 1960-62. Table 24. Adult Patients Treated at the Mental Health Clinic in 1960-62 _ . Numbers of Cases Type of Disability 1960 1961 1962 Brain damage and diseases: Acute, rapidly developing 180 169 133 Chronic 383 395 420 Mental retardation 34 22 32 Psychogenic disorders: Psychotic 72 74 103 Psychophysiological 33 42 28 Psychoneurotic 75 82 113 Personality disorders 27 16 22 Totals 804 800 851 105 Approximately 900 patients are treated at the clinic in one year, and as can be seen from Table 24 most of them are adults. About 50 to 100 children (age fourteen or below) also receive treatment, but no statistics were available. Children are treated for various neurological, emotional, intellectual, school, family, behavior, and psychosomatic problems. Efforts are also made to treat the parents or relatives at the same time the children are treated, since it has been found that many of the etiological factors in the children's problems involve their immediate environment. Comments This clinic was organized to provide limited serv- ices for the outpatients of the Neuropsychiatric Hospital. Although additional services are being provided to other clientele, moving this clinic from the hospital did not materially change its purpose and function. It is still an outpatient clinic for mentally or emotionally disturbed individuals. While it is true that the services offered in this clinic are important and necessary for the rehabilitation of mental patients, its effectiveness as a rehabilitation unit by itself is limited. It may be advisable for this clinic to work in conjunction with other rehabilitation type agencies and institutions in the community. ***** 106 Robles Institute The Robles Institute is an eye clinic owned and oper-w ated by the Committee for the Blind and Deaf (Comite Nacional Pro Ciegos y Sordomudos). The Committee is a private enter- prise established tO provide preventive, medical, and rehabil- itation services for the blind and deaf in Guatemala. It consists of a central committee and a group of service organ- izations whiCh provide special services for the blind and the deaf. The function of the central committee is to procure money, coordinate, and administrate the various service organizations. The Committee operates a very successful lottery called "Santa Lucia" which provides most of the rev- enue for the support of the service organizations.- Additional income is Obtained through the sale of baskets, rugs, and other articles manufactured at a workshop for the blind oper- ated by the Committee. However, this is not the usual reha- bilitation workshop because its primary purpose is to manufac- ture articles for resale and not to provide vocational train- ing for the blind. .Efforts are made to retain the productive employees after they have been trained, rather than to find them employment in the community. With the exception of the Robles Institute, the serv- ice organizations of the Committee are of an educational, or social welfare nature. The Committee has recognized the need 107 to provide vocational training for the blind, and they are presently in the process of planning and constructing a vocational rehabilitation center. It was not possible to obtain detailed information about the Committee and its organizations because-of the apprehension created by the survey. The survey may have been perceived as an "investigation" that might harm the Committee or reduce its competitive advantage with other agencies and institutions in Guatemala. History and Development The Committee Opened an Ophthalmological clinic in 1956, for the purpose of providing medical treatment for the blind and partially sighted. During the first year of its Operation, 125 patients were treated, and the following year the number increased to 167. The operation of the clinic was considered so successful that in 1957 similar services were established in Quezaltenango and Antigua. Thirteen months after the opening of the opthalmolog- ical clinic in Guatemala City, it was moved to its present location in order to provide more room for facilities and services. In 1959 the clinic examined 1,245 patients, and by 1960 the number of patients examined or treated reached 4,053. In 1960, the Committee decided to centralize some of its services located'in Guatemala City. The opthalmological 108 clinic was selected for expansion and other services were moved to the clinic. This amalgamation of services marked the foundation of the present "Instituto Rodolfo Robles." According to the administrator, services in odontology, gen- eral medicine, laryngology, otology, ophthalmology, pediat- rics, psychiatry, psychology, social services, and speech therapy are currently available at the Robles Institute. Administration and Organization The Robles Institute is administered by an executive director in charge of all institutional operations. Major policy decisions involving the kinds of programs and serv- ices, eligibility requirements for service, selection of administrative personnel, creation of new staff positions, capital outlay, and preparation Of the budget are made by the central committee personnel. The Director is respon- sible for the administration of all examinations, treatments, and operations conducted at the clinic. He works closely with the central committee and his staff in the preparation of reports and recommendations regarding services and clinic operations. These reports and recommendations are submitted to the central committee for consideration and approval. The Robles Institute is a member of the Committee's coordination system and it works cooperatively with the other service units. Since this institute has centralized many services, the other committee units are dependent upon this clinic for certain services. There is little or no 109 coordination or service exchange outside of the Committee's organizations. Finance The budget is prepared by the Director and the admin- istrative staff and is then presented to the central committee for review and approval. The Robles Institute receives most of its operating funds from the Committee, with minimum fees being received from the clientele. All of the clientele must be interviewed and approved by the social service department before they may receive clinic services, except in cases of emergencies. The social service department makes judgements as to which clientele should pay a service fee. The charge for the first consultation is fifty cents and twenty-five cents for all subsequent visits. However, approximately 90 per cent of the clientele receive services at no charge. Clients have the Opportunity to purchase eye glasses for $3.00. A large supply of lenses are kept in stock. If the particular lens needed is not in stock, it is obtained for the client at one-half cost. Facilities The Robles Institute is located in a former private house which has been modified to serve as a clinic. Most of the modifications were made to facilitate the installation of various apparatus. The institute is a one-story abode build-- ing about forty-five years old and is in fair condition. It 110 is of typical Spanish architecture with a large patio in the center of the building. The various service offices are located around the open patio. There are a total of twenty-two rooms in the build- ing of which nine are service offices or clinics. The insti- tute has a bed capacity for eighteen inpatients; there are fourteen beds for adults and four cribs for children. Because of the very limited inpatient facilities and the nature of the services provided, most of the clientele are treated on an out- patient basis. The following rooms, offices, and clinics are found in the institute: two administrative offices, a small professional library, two eye examination and treatment clin- ics, two operating rooms for eye and ear surgery, laryngology clinic, dental clinic, mental health clinic, speech and hear- ing clinic, laboratory, pediatrics and internal medicine office, social services office, four wards for inpatients, and four domestic and utility rooms. The eye examination and treatment clinics are used mostly for refraction work with outpatients and for the diagnosis and treatment of various eye diseases. These two clinics are equipped with relatively modern refraction, optical, and medical apparatus. The two rooms used for eye and ear surgery are not adequately equipped, as they consist simply of two rooms with an operating table in the center of each room. NO other modifications or apparatus have been installed such as instruments, cabinets, oxygen and other 111 gases, proper lighting, et cetera. Each surgeon must bring his own instruments for the particular operation he plans to perform, and many times he must bring his own drugs. The institute recently received $5,000.00 worth of surgical tools from the Cooperative for American Remittances to Everywhere, Incorporated (CARE); however, they had not been inventoried and put into use at the time of this survey. The dental clinic is well equipped except for the absence of X-ray facilities. When an X-ray plate is needed, the client is sent out to another private clinic. The speech and hearing clinic is composed of two sections. The main portion of the room is equipped as a small classroom and may be used for speech therapy. One corner of this room is walled-off to form a sound-proof cham- ber for testing the clients‘ hearing ability and for fitting hearing aids. It is equipped with an audiometer and head- phones, but no external controls. The efficiency Of the sound-proofing is poor, and extraneous sounds interfere with the prOper function of these facilities. Personnel The institute has twenty-three employees of whom only four are full-time professional staff. However, some of the personnel work part-time at other service organiza- tions Operated by the Committee. Table 25 shows the number of service personnel and their temporal status. All of the 112 personnel listed are paid employees, except one oculist who is a part-time volunteer. Table 25. Personnel Schedule of the Robles Institute in 1962 .Q._..1 w Title Number Full-Time Part-Time Psychiatrist l X Physicians 2 X Oculist 2 F Oculist 3 X Laryngologist l X Dentist 1 X Psychologist 1 F Social worker 1 F Speech therapist 2 - X Nurses or aides ‘ 9 F Fringe benefits for the employees include free insti- tutional services, social security benefits, and a Christmas bonus equal to two weeks' salary. Programs and Services The objectives of this institute are to combat blind- ness and deafness in Guatemala through prevention programs, clinical examinations, and medical-surgical treatment. The 113 institute serves as a central service unit for all of the other committee organizations. In addition to the regular examinations and treatments given to patients at the insti- tute, special services such as psychiatric and psychological examinations, and social services are provided to clientele referred only for these specific services. The physicians working at the institute determine the eligibility of the clients to receive services, and the social worker decides which clients should pay a service fee. Case closures are made at the institute when the patient's examina- tions or treatments have been terminated or when they have been transferred to another service organization. The following services are offered at the Robles Institute: Eye examinations and the issuance of glasses NH Ophthalmological examinations and treatment Ear, eye, nose, and throat surgery General medical treatment Hearing and speech therapy Issuance of hearing aids ,Dental services mfiO‘Ul-bw Limited psychiatric services 9. Limited psychological services 10. Operation of mobile units for field examinations 11. Social work services 12. Limited follow-up. 114 Clientele The services offered at the Robles Institute are available to individuals of all ages and socio-economic levels, but most of the clientele are adults and children from the lower income groups who are experiencing difficulty with their vision. Clientele are received from all parts of Guatemala and efforts are constantly being made to extend services to remote areas. A prevention program initiated in 1960 utilizes mobile service units which examine children in the city and rural schools. All of the third grade chil- dren in the various elementary schools are given visual acuity examinations each year. Children who are found to need eye services are referred to the institute. Table 26 shows the total number of inpatients and outpatients served during the years of 1960—62. Table 26. Clientele Served by the Robles Institute in 1960-62 Service Category 1960 1961 1962 Eye examinations or treatment . . . 4,503 8,229 78,431 General medical . . . . . . . . . . 153 940 1,091 Ear, nose, and throat . . . . . . . 257 883 870 Speech and hearing . . . . . . . . 214 1,046 506 Dental work . . . . . . . . . . . . 206 445 394 Psychiatry . . . . . . . . . . . . 68 112 60 Psychology . . . . . . . . . . . . 3 16 74 Operations ... . . . . . . . . . . 33 198 625: 115 Table 27 shows the number of children and adults of each sex who received services during the year Of 1962. Clientele up to the age of fourteen were classified as chil- dren. Table 27. Children and Adult Clientele Served by the Robles Institute in 1962 Children Adults Service Category Male Female Male Female Ophthalmological and Optical 1,515 1,719 2,273 2,924 General medical 215 197 300 379 .Ear, nose, and throat 213 132 247 278 Speech and hearing 117 82 131 176 Dental work 163 48 112 71 Psychiatry 26 22 9 3 Psychology 37 24 7 6 Comparison of the service figures presented in Tables 26 and 27, with the number of beds at the institute, indicate that most of the clientele were treated on an outpatient basis. In 1962, the institute admitted 141 male and 169 female inpatients. During the same year, 140 male and 165 female inpatients were discharged. These discharges refer only to the Robles Institute, as some of the clientele con- tinued to receive various services or benefits from other 116 organizations operated by the Committee. Comments The Robles Institute is primarily a medical examina- tion and treatment clinic. Apparently the Committee plans to consolidate their service units into a few convenient centers. The Robles Institute may serve as an admittance and general treatment center for prospective rehabilitation program clientele. After the clients have been treated for the acute stages of their disability and inititated into the primary phases of rehabilitation, they may be referred to the newly-planned vocational rehabilitation center. The Robles Institute, plus the newly-planned vocational rehabil- itation center and the other service organizations Of the Committee, may create an effective rehabilitation program for the blind. It might also be advantageous to the Commit- tee and the community if the Robles Institute and other service units of the Committee would seek cooperation and coordination with agencies and institutions outside of the Committee for the Blind and Deaf. ***** 117 The Neuropsychiatric Hospital History and Development The Neuropsychiatric HOSpital, was referred to as the "Mental Asylum" when founded in 1890. Previous to 1890, mentally disturbed patients in Guatemala were confined in prisons. The institution was founded by two physicians, Drs. Manrique and Azurdia, and Mr. Isidro Gandara. These men formed the first staff of the newly—founded institution, whose Objectives were to provide free treatment and housing for all mentally ill individuals. Legally, the institution came under the charter of the General Hospital, and was administered and financed through it with government funds. The asylum remained a part of the General Hospital until 1945, when it became an agency of the Ministry of Public Health. The objectives of the institution today are the same as they were when founded, and its legal basis has not changed since 1945. When founded the Neuropsychiatric Hospital consisted of a large two-story masonry building with ten rooms on the first floor and four large rooms on the second floor. It had nine wards, five for men and four for women, with a capacity for 700 patients. The institution has suffered from two natural catas- trophes. The building was destroyed by the earthquake of 1917 after which it was rebuilt to its original size. The 118 building was later enlarged by the addition of new wards and boarding facilities. In 1960 the entire plant was destroyed by a fire, in which several hundred patients lost their lives, and all of the records were burned. Institutional operations were temporarily moved to the Instituo Nacional de Avrones and Escuela de Comercio. During this period, a yet unfinished section of the San Vicente T.B. Sanatorium was modified for the new location of the Neuropsychiatric Hospital. Services When the institution was founded, services consisted mainly of confinement and some general medical treatment. It was not until Dr. Mora, a psychiatrist, became Director in 1926 that some psychiatric treatment was provided. Later in 1931, Dr. Molina, a staff psychiatrist, was appointed Direc— tor of the institution. He reorganized and improved services and for the first time, patients were classified according to their disability. Dr. Campo, the present Director, is attempting to make further improvements in the quality of services, but he is hampered by a low budget/patient ratio. In spite of these difficulties, the institution presently Offers relatively modern but inadequate services to its patients. Staff At the beginning the institution‘s staff consisted of two self-trained psychiatrists, eight male and eight 119 female nurses. Although the staff was enlarged in subsequent years as the influx of patients demanded, it has never reached a satisfactory or desirable staff/patient ratio which could provide effective treatment and rehabilitation to the patients. Clientele At the time of its founding, the clientele consisted of 80 patients who had been removed from the various city jails. The number of patients rapidly increased and exceeded the 700 patient capacity of the institution and by 1960, be- fore the fire, there were 1,500 patients in residence. On January 31, 1963 facilities at the Neuropsychiatric HOSpital provided for 500 inpatients; however, there were actually 1,103 adult patients and 48 children in residence. Since this is the only neuropsychiatric institution in Guatemala, patients are received from all parts of the country. Administration and Organization The Neuropsychiatric Hospital is a governmental in- stitution which is authorized by the Ministry Of Public Health. All institutional Operations are under the control of an appointed Director who personally directs the serv- ices provided by the institution, assisted by an administra- tive officer. The administrative officer has charge of finances, office management, records, personnel services other than professional, purchases, and general institutional 120 Operations. Under the administrative officer is a chief of per- sonnel who is in charge of the graduate nurses and the Sis- ters of Charity. The Sisters of Charity in turn direct the domestic staff and the nurses aides (see Figure 3). The administrative staff is chosen by the administrative officer through interviews, and practical on-the-job examinations. Policy Determination Major policies are always approved by the Director and in certain instances, the Director must obtain the ap- proval of the Ministry of Public Health--e.g., the budget, major changes in the physical plant, services, et cetera. Programs and services are generally determined by the Direc- tor, with the advice of his professional service staff. (As far as possible, services offered are based upon the needs of the patients. Eligibility for services is determined by the Director, who also determines professional personnel needs and standards. Other policies may originate from the various members of the administrative staff. Training The training and experience of the administrative staff are generally limited to on-the-job experience at the Neuro- psychiatric Hospital. Budgetary limitations make it very difficult to hire trained and experienced personnel. 121 MidiSter of Public'Health [ Director Professional Medical Administrative Special Services Interns Officer Education Chief of Administrative Personnel Personnel Graduate Nurses Sisters of Charity Nurses'.Aides Domestic Servants Fig. 3.--Organization chart of the Neuropsychiatric Hospital. 122 Finance The administrative officer is responsible for the financial affairs of the institution, assisted by the chief of personnel and the accounting department. Personnel are paid directly by the administrator and his chief of person- nel. All other accounting of expenditures are handled through the accounting department; however, the auditing is done directly by the office of the Minister of Public Health. The fiscal year runs from July lst to June 30th, and most institutional business is conducted on‘a monthly basis. The budget is formulated in May, at which time the Director discusses it with the administrative officers and the department heads. After the budget is generally ap- proved, it is submitted to the Ministry of Public Health. This office reviews the proposed budget and obtains an appropriation from Congress which is invariably lower than the amount requested. The money allocations to the hospital are usually delayed, running about six months behind the stated schedule. All funds for this institution, except occasional donations which are administered by the Sisters of Charity, are received through the Minister of Public Health. The institution received $420,156.00 from the Ministry during the fiscal year of 1961-62, an amount very close to that received for previous years. 123 Expenditures Table 28 shows the expenditures at the hOSpital for the month of July, 1962. Since the budget does not change appreciably from year to year, it represents the institution's usual monthly Operating costs. Table 28. Expenditures of the NeurOpsychiatric Hospital for July, 1962 EXpense Category Cost Per Cost Per Month Patient-Day Food $12,000.00 $0.356 Drugs 2,110.00 0.062 Clothing 1,700.00 0.050 General eXpense 1,800.00 0.053 Fuel 550.00 0.016 Prof. equipment reserve 300.00 0.009 Furniture and other equipment 150.00 0.004 Maintenance 550.00 0.016 Salaries 14,730.00 0.436 Day labor (planillas) 2,303.00 0.068 ' Total $36,193.00 $1.070 Table 29 presents the salary schedule by departments, hours worked, and hourly wage of all hospital employees. All of the personnel, except day laborers (planillas), are on a monthly salary. Table 29. 124 Personnel and Salary Schedule of the Neuropsychiatric Hospital in 1962-63 .1 Number Type Monthly Hours Wages of of Salary Worked Per Personnel Position Per Person Per Month Hour Direction 1 Director $300.00 96 $3.12 Administration 1 Administrator 210.00 176 1.19 1 Typist 90.00 176 .51 1 Chief of personnel 110.00 176 .62 1 Inventory clerk 90.00 176 .51 1 Office clerk 90.00 176 .51 1 Statistics clerk 80.00 176 .45 1 Office clerk 80.00 176 .45 1 Office clerk 70.00 176 .40 l Store-keeper 80.00 176 .45 9 Sisters of Charity 30.00 336 .09 Technical Staff 15 Physicians 100.00 96 1.04 2 Inpatient physicians 100.00 96 1.04 l Neurosurgeon 100.00 48 2.08 l Dentist 100.00 48 2.08 l Radiologist 100.00 48 2.08 l Pediatrician 100.00 48 2.08 l ~Chi1dren's psychi- atrist 100.00 48 2.08 l Anesthetist 85.00 48 1.77 8 Graduate nurses 110.00 176 .62 l Pharmacist 60.00 96 .62 4 Interns 115.00 176 .65 1 Blood bank chief 150.00 96 1.56 _X-Ray Service 1 X-ray technician 70.00 176 .40 Laboratory 1 Laboratory assistant 60.00 32 1.88 125 Table 29--Continued Number Type Monthly Hours Wages of of Salary Worked Per Personnel Position Per Person Per Month Hour Physical Therapy 1 Physicalatherapist aide $ 60.00 32 $1.88 Infirmary 6 Male and female nurses 60.00 288 .21 26 First class nurses 50.00 288 .17 22 Second class nurses 40.00 288 .14 Teaching Staff 2 Teachers for men— tally retarded 80.00 40 2.00 Anti-Alcoholic Services 1 Chauffeur 70.00 176 .40 1 Nurse 60.00 176 .34 1 Nurses' aide 50.00 176 .28 Social Service 1 Chief social worker 175.00 176 .99 2 Social workers 150.00 176 .85 Pharmacy 1 Pharmacy aides 30.00 176 .17 Service Staff 21 Cooks 30.00 176 .17 20 Washers 30.00 176 .17 13 Seamstresses 30.00 176 .17 14 Maids 25.00 176 .14 Other 2 Chauffeurs 70.00 336 .21 2 Barbers 40.00 176 .23 126 Table 29--Continued Number Type Monthly Hours Wages of of Salary Worked Per Personnel Position Per Person Per.Month Hour 10 Porters $40.00 176 .23 2 Telephone Operators 50.00 176 .28 1 Chaplain 30.00 176 .17 1 Messenger 50.00 176 .28 3 Night watchmen 75.00 336 .22 Facilities The physical plant of the Neuropsychiatric Hospital was designed and built four years ago as a TB sanatorium. The utilities are modern but the building is in poor condi- tion. It contains thirty rooms divided into three large wards. .The physical plant is inadequate because it was not designed for its present use or for the number of patients now occupying it. It contains eight administrative offices, a social service office, a special education classroom, four medical treatment rooms, one physical therapy-type room, as well as rooms for the pharmacy, laboratory and X-ray services. There are no Special rooms for dining, vocational training, conferences and recreation. Patients eat in the courtyard and hallways. There is no accurate count of the number of beds in the hOSpital, as 510 are listed while there are over 1,000 patients in residence. Some patients sleep on straw mat- tresses on the floor, and in some cases two patients share 127 a single bed. Special Service Facilities The admiSsions clinic, observation clinic, and the ward clinics have adequate heating and lighting and, except for the ward clinics, have adequate ventilation. They con- sist of single rooms which are functionally inadequate-for lack of partitioning and equipment. The admissions and observation clinics are open six hours per day, while the ward clinics are open twelve. The admissions clinic processes twenty-five patients per day, averaging fourteen minutes each; the observation clinics treat fifteen patients per day at an average of twenty—four minutes each, while the clinics in the wards, handling three patients simultaneously, can care for thirty a day. The admissions clinic is used for admission examinations of all patients in the hOSpital, as well as for outpatient treatment. The observation clinics for women and men are located adjacent to the appropriate wards and are used for diagnosis and inpatient classification before patients are assigned to permanent wards. Three clinics in the women‘s wards and four in the men's are used to provide medical and psychiatric treatment to the patients in the respective wards. These clinics are also used for some occupational therapy type activities. The "operations division" consists of the following 128 Spaces: operating room, an adjacent electroencephalograph (EEG) room, a post-operative recovery room, and a surgical supply area. .The operating room is used primarily for gen- eral surgery related to the treatment of the hospital pa- tients or for emergency treatment. The room and its facil- ities are adequate for this function, but the equipment is somewhat less than minimal. There is no adequate facility for neurological surgery, and an additional operating Setup for this purpose is therefore needed. The EEG section seems adequately equipped and appropriately placed to perform needed diagnostic services. Both the post-Operative recovery room and the surgical supply room seem quite adequate for the purposes for which they are used. Personnel There are no formal written criteria for the employ- ment of personnel. However, ability and a desire to work in the institution are given high priority in personnel selection. Prospective employees apply in writing to the Director and are then given a practical examination in their field of interest. Selection is based upon the examination and the Director's opinion. Appointments for executive positions come directly from the Ministry of Public Health. There is very little turnover in personnel. Fringe benefits for the employees include social security and free treatment of common illnesses. 129 Personnel needs as perceived by the Director are as follows: a. Four resident psychiatrists b. Two psychologists c. Two occupational therapists d. Two rehabilitation counselors e. ,Eight graduate nurses f. Four post-graduate nurses in psychiatry Twenty nurses aides h. Twenty orderlies. Monies for additional staff are regularly requested in the budget, but the Minister's office has not been able to grant it. A complete personnel list may be found in the finance section in Table 29. Programs and Services Objective There are no written Objectives or other descriptive literature since all documents were destroyed in the fire of 1960, and have not been replaced. ‘The objectives are to give medical-psychiatric treatment to inpatients with mental dis- turbances in order that they may again become functional members of society. 130 Eligibility Requirements Any person in Guatemala is eligible for services, provided he is ill and that his mental disorder predominates over any other disability. Actual admissions depend upon the seriousness of the disorder as determined by the admissions personnel. Referrals are received from other institutions, especially from the Mental Health Clinic. Patients who are not seriously ill may be treated as outpatients. There are no fees for services, nor are there any private patients treated at the hospital. Outpatients Patients not admitted to the hospital are treated as outpatients and in addition, many patients released from it are retained as outpatients for a period ranging from one to six months. About five to fifteen minutes are spent with each outpatient per visit. The number of treatments vary, some receiving treatment three times a month while others come whenever they wish. _Many of the outpatients are epilep-u tics and alcoholics. The outpatients are usually seen by the social worker who counsels them and administers the pre- scribed drugs which she requisitions through the admissions clinic. Some of the outpatients are treated at the Mental Health Clinic instead of at the hospital. Inpatients The admission procedures for inpatients is illustrated 131 by Figure 4, which is a schematic diagram of the hospital service structure. ‘Admission Clinic l Classification Ward TB Ward Ward No. 1 (Women) Mental dis- orders Nursing Ward No. 3 Ward No. 2 Care (Men) (Men) Ward Mental dis- Epileptics orders and and epileptics Alcoholics Fig. 4.--Service organization chart of the NeurOpsychiatric Hospital. Patients are received at the admissions clinic which is the same clinic used for outpatient treatments. From the admissions clinic the patients are sent to the observation ward for classification. After eight to fifteen days of ob- servation and clasSification they are sent to the proper inpatient wards. 132 Services Offered Table 30 shows the types of services provided patients at the hospital. Table 30. Services Provided at the Neuropsychiatric HOSpital in 1962 Percent Receiving Service Category the Service Psychological testing . . . . . . . . . . 5% Psychological counseling . . . . . . . . 5% Psychiatric services . . . . . . . . . . 100% Social services . . . . . . . . . . . . . 14% Medical services . . . . . . . . . . . . 100% Occupational therapy . . . . . . . . . . 10% Follow-up (by social workers) . . . . . . 3% Avocational activities . . . . . . . . . 20% Clientele The institutional facilities are not adequate enough to permit the inpatients to stay a sufficient length of time to receive effective treatment. Alcoholics stay as inpatients for an average of three to eight days. Patients who stay for a period of years or for life usually have severe or chronic mental disorders or they'have no friends or relatives who can or will care for them if ° released. 133 No figures are available describing the national geographic origin of the clientele; however, it is estimated that most of the patients come from within the city or adja-' cent areas, while a minority come from other parts of Guate- mala. The Neuropsychiatric Hospital had an average of 1,123 inpatients in 1960; 1,010 in 1961; and 1,084 in 1962. The average numbers, ages, and classification of all inpa— tients treated at the hospital in 1961 are presented in Table 31. The classifications in Table 31 are the same categories used in reports submitted to the Ministry of Public Health. 134 Table 31. Classification of Inpatients at the Neuropsychiatric HOSpital in 1961 Disability 1 year _ _ 65 or Category or less 5 14 15 24 25-44 45-64 more Total Schizophrenia Psychotic and other related disorders 1 90 129 49 l 270 Psychoneurotics Mixed disorders and unclassi- fied related , diseases 1 3 39 82 10 135 Epileptics and other related diseases-- unclassified 2 3 27 46 9 87 Other disease of the brain 1 5 10 6 10 32 Arteriosclero- sis without gangerine l 23 17 31 Nervous System and convulsive disorders 4 38 34 3 1 80 Miscellaneous disorders . 375 *‘k*** 135 Social Security Rehabilitation Hospital The Guatemalan Social Security System The social security system in Guatemala (Instituto Guatemalteco de Seguridad Social, IGSS) was established in 1946 for the purpose of providing medical and other services to employed individuals. The Social Security Administration initiated services in the department of Guatemala in January 1948, and then gradually established clinics and hospitals in other parts of the country. Social security is rapidly being extended to provide "benefits and protection" for work accidents, maternity cases, general illnesses, invalidism, old-age, and death. However, due to economic limitations services are currently limited to work related accidents and illnesses, except for maternity benefits available in the department of Guatemala. The ultimate Objectives of the Social Security Administration are to extend coverage to all illnesses and to protect the total population of Guatemala. At the present time the pro- gram covers all government and private employees in the de- partments of Guatemala, Izabal, Escuintla, Quezaltenango, Suchitepequez, Retalhuleu, Chimaltenango, Santa Rosa, and the southern parts of San Marcos and Zacapa. In December of 1961, the Social Security Administra- tion owned and operated eighteen hospitals, eight clinics, and eighteen first-aid centers with a total of 1,122 beds. 136 At the same time IGSS had fifteen hospital wards and two private clinics under contract which increased the total number of beds to 1,292. Of the estimated 1,375,625 employed workers in 1961, approximately 275,125 or 20 per cent were covered by social security. Congressional legislation has established that the program be supported by contributions from the government, employers, and employees. However, in practice the govern- ment contributes only its percentage as an employer. _The income of IGSS for the year 1961-62 was $8,218,376.03 com- pared with expenditures Of $8,737,127.62. This resulted in an operating loss of $518,751.59 for the 1961-62 fiscal year. One of the hospitals owned and operated by the Social Security Administration is a rehabilitation hospital. This hospital was commissioned to provide rehabilitation services to affiliated members who had passed the acute state of their injury or illness. The rehabilitation hospital discussed below serves all patients discharged from one or more of the other IGSS hospitals or clinics. History and Development The Social Security Rehabilitation Hospital was founded in 1948 through the action of the Board of Directors to provide rehabilitation services for affiliated members. By their agreement, rehabilitation was defined as a physical 137 and/or psychological process that reconstructs and re-edu- cates a handicapped person for an active life of work. The process is comprised of medical treatments including physical training, provision of prosthetic or orthopedic devices, as well as vocational training and placement. “The hOSpital was founded to give complete rehabilitation services to disabled workers after discharge from other medical centers. When founded the hospital was merely a gathering place for the disabled and handicapped since there was no rehabilitation program. In 1953 the staff, facilities, and services were reorganized and some rehabilitation programs were developed. Programs and services continued to improve until today it has nearly a complete rehabilitation program. During its first year of operation, about 100 patients re- ceived meager treatment. The number of patients increased to 800 in 1953 and at the present time the institution pro- vides services for about 1,000 patients per year. The staff in 1948 consisted of five general physi- cians and a social worker. New positions were continually created until today the staff consists of specialists from most of the fields in modern rehabilitation. The physical plant was moved from a small private home to a rented apartment building, and plans are currently being made for the construction of a new rehabilitation hos- pital. 138 Administration and Organization The hospital has an executive director appointed by the IGSS administration, who is responsible for all institu- tional activities. Under the Director is a Chief Administra- tor, who is responsible for the execution of administrative decisions made by IGSS, the Director, and the technical council. The Chief Administrator is recommended for appoint- ment by the hospital Director, but the actual appointment is made by IGSS. The Administrator is in charge of all finan- cial activities, statistics, budget, reports, and selection of the administrative personnel. Technical Council The technical council consists of approximately ten members, including the Director, Administrator, and all the service chiefs in the hOSpital. The meetings are used to discuss administrative problems related to organization, personnel, and services. They are also used for case con- ferences, utilizing the rehabilitation team approach. These latter conferences may include, in addition to the members of the council, any professional staff members involved in the treatment of the cases being reviewed. Major Policy Determination Major policies are subject to the approval of the IGSS administration, based upon budgetary limitations and the policies' relationship to the total array of services 139 performed by other IGSS service organizations. Personnel needs and standards prOposed by the technical council, sub- ject to the approval of the Director, are recommended to the IGSS administration. The budget and capital outlay are handled in the same manner, final approval being dependent upon service demands and funds available. Coordination The IGSS Rehabilitation Hospital is one service unit of a coordinated medical service program under the govern- ment's social security system. The patients served are referrals from the other affiliated medical units, except for approximately one dozen private cases per year. Types of Hospital Reports These reports include periodic summaries of expend- itures which are to be reimbursed, monthly progress and serv- ice reports, and an annual report which summarizes the year's activities as well as presenting needs and plans for the forthcoming year. The objective of these reports is to provide necessary information for accounting and statistics at the central IGSS offices. Administrative Officers The Director.--The Director is retained by the hos- pital on a half-time basis. He is also the Director of the Children's Polio HOSpital, Director of the School of Physio- therapy, part-time physiatrist at the Recuperation Center No. 1 7 140 and chief of services at the General Hospital. His training consists of eleven years work and study beyond secondary school; his Specialty is physical medicine and rehabilita— tion which he studied at New York University. He has been the Director of the Social Security Rehabilitation Hospital for nine and one-half years. Administrator.--The Administrator is responsible to the Director and conducts all hospital business. He is a full-time staff member, and has been in his present position for five years. The Administrator's training consists of approximately two years‘ work at the college level, focused specifically on hospital administration and rehabilitation administration—-including a three months administrative in- ternship in the United States. Finance Authorization of expenditures.--Expenditures are authorized at the hospital by the Director within budgetary limitations. These expenses include medicines, staff pay- roll (excepting administrative personnel), disability pay- ments, and other service-related materials and labor. Pay- ment of the administrative staff and other costs not directly related to services are handled either directly from a revolv- ing fund, through authorized invoices sent to the central IGSS offices, or in the case of some materials and equipment which are requisitioned from the central offices the payments are handled entirely by the central Offices. The last method 141 would apply to materials generally purchased in large quan- tities and used by various other service units. Except for items purchased through the revolving fund, all checks for payment of purchases, payroll, and benefits are made and accounted at the central offices with the use of IBM equip- ment. Figure 5 below is an organization diagram of the personnel involved in financial administration. The verti- cal dimension of the diagram denotes the level of authority in regard to financial control, and the connecting lines denote interaction regarding financial matters. Budget A tenative budget is prepared by the Director, technical council, and Administrator. This is usually re- vised by the budget department of IGSS in collaboration with the hospital Director before it is approved. Income The hOSpital is one service unit of the national system of social security services and it receives its operat- ing funds from the Social Security Administration. The sources of the IGSS funds are legally from government con- tributions equal to 2 per cent of the gross national pay- roll, employers‘ contributions of 5 per cent of their gross payroll, and an employees‘ contributions of 2 per cent of their gross pay. The legal machinery for enforcing the employers‘ and employees‘ effective; however, the government‘s contributions are usually not made because of some technicality. 142 contributions seems to be quite The IGSS central of- fices handle the collection and redistributiOn of funds col- lected to the various service units, as well as the auditing of each service unit. IGSS Central Offices Hospital Director HOSpital Administrator Technical Council Stenographer Assistant Administrator Secretary Fig. 5.--Financia1 administration chart of the Social Secu- rity Rehabilitation Hospital. 143 The only money received by the Rehabilitation Hos- pital directly is a revolving fund of $2,500.00. This fund is operated as a petty cash fund, and direct cash payments are made for various purchases on sales slips and invoices. When a substantial portion of the $2,500.00 has been spent, the Administrator sums up the sales slips and invoices and presents them to the central offices for reimbursement. These cash payments are made for items such as food, main- tenance, and various contingent expenses. The total amount of money allocated for the support of the Rehabilitation HOSpital (not including disability benefits and pensions) was $393,212.13 for the 1960-61 fiscal year, and $392,105.10 for the following year. Table 32 shows the expenses charged against the Rehabilitation Hospital by the central offices for the fis— cal years of July 1, 1960 to June 30, 1961 and July 1, 1961 to June 30, 1962. In addition to the cost of Operating the Rehabilita- tion Hospital, IGSS pays various disability benefits and special pensions to disabled clients, based upon the type and extent of their disability or handicap. Table 33 shows the usual maintenance and service costs per inpatient-day at the Rehabilitation Hospital. 144 Table 32. Expenditures of the Social Security Rehabilitation Hospital in 1960-61 and 1961-62 Expense Category 1960-61 1961-62 Salaries $159,713.04 $164,192.59 Medical supplies and equipment 19,176.58 23,358.48 Food 63,546.35 61,232.18 Private professional services 5.00 40.00 Operational costs 53,466.34 44,947.29 Administration expenses central offices 86,533.34 87,559.13 Depreciation costs 10,775.43 10,775.43 Total $393,216.08 $392,105.10 Table 33. Costs per Inpatient-Day at the Social Security Rehabilitation Hospital from 1958-62 Cost Per Number of Inpatient--' Year Patient-Days Cost Day July 58 to June 59 65,918 $65,484.00 0.993 July 59 to June 60 67,301 62,341.00 0.926 July 60 to June 61 69,464 61,595.00 0.955 July 61 to June 62 69,569 59,778.00 0.859 Averages 66,813 $62,299.50 0.933 145 Facilities The Rehabilitation Hospital is located in a former apartment building with sixty rooms, of which thirty-seven are used to provide services. The building is of abode con- struction, twenty-five years old and in poor condition. The utilities, lavatories, exits, stairways, and hallways are adequate for the needs of the hospital. Heating is inade- quate, and there is not enough Space on the grounds for recreational activities or parking. The hospital contains nine men‘s wards, one women‘s ward, three administrative Offices, six service offices, nine medical treatment rooms, fifteen physical therapy-type rooms, four vocational train- ing-type rooms, two dining rooms, one conference room, one adult education classroom, two libraries, and one lounge. The ten wards contain a total of 148 beds for.rehabilitation inpatients. The present plant is inadequate for the services rendered and plans are being made to build a new hospital at some future date. Occupational Therapy For patients with injuries of the lower extremities, therapy is provided through the Operation of looms and spin- ning wheels. The products manufactured are actually used throughout the hOSpital. The room is used by an average of ten patients at a time. It is adequately lighted but poorly ventilated. 146 Occupational Therapy and Recreational Center This room is used for occupational therapy, speech therapy, recreational, and educational activities. It is equipped with modified pool and ping-pong tables. For rec- reational purposes, games and puzzles are provided, which also serve to encourage social interaction, particularly for some of the psychiatric cases. Educational activities are encouraged on a voluntary basis and include drawing, paint- ing, reading, and writing. The room is open for use six hours each day and is attended by an occupational therapist. The room can be used by approximately fifteen persons at one time and is used by an average of thirty patients per day. The room is adequately lighted and ventilated, but the noise level is high because of the adjacent looms. ()ccupational Therapy-— Bookbinding All aspects of bookbinding are taught in this room. iPatients learn to use the various devices involved in bind- iju; books, and actually bind materials for the hospital and «other IGSS centers. It is used seven hours each day by an .average of fifty patients, many with hand injuries. The .1ighting and ventilation are both inadequate, and the noise .Level is too high because of the adjacent looms. 147 Physical Therapy Room for Individual Treatments This room contains six bays of equal size, each used by a physiotherapist for patient massages, muscle exercises, et cetera, to prevent muscular atrophy. These bays are used six hours per day, by an average of seventy patients. Light- ing and ventilation are adequate, but the noise level is too high. While they are fairly adequately equipped, some addi- tional service apparatus is needed. Mechano-Therapy Facilities of this room are available to all patients of the hOspital for the purpose of muscle building, improve- ment of motor coordination, et cetera. They are available for use six hours each week day, and approximately twenty patients use the facilities at one time. An average of 150 patients with injuries of the extremities, shoulder, or back receive mechanO-therapy each day. The room seemed well- equipped and the equipment was in good working order. Manual Therapy Facilities in this room are used for manual therapy Of the fingers, hands, and forearms. The purposes Of the mq ADV mcfimucsom Hmumz ADV suaoanuooam Ans .uumno o>onm CH boumfla mmcflpafldn Ou Homou soaon mwxon CH muwnesz .m huuwmoum mo muflw .N r—{NMV‘LO How CocmeOb wasncaoaso soap -aonoo moH .Humcoo luoumwmo Oahu OOfl>me \mmmHO mEoou # mEoou mo # Hobos mcfloaflsm Aswan HOOHM Cflmunov F2 SS GENERAL FACILITIES CODE mEoou damp mcflcfimua .Oo> Amv mammonu Hooanssm mo noisy HH< Ros _ucoEummHu HMOHCOS AUV mooamwo OOH>umm AOV nooamuo .saeoa Ans mEOOHmmmao COHDMOSUM Hmwoomm Amv "RODEO: cam wEOOH mo momNB mbcsoum HMCOHummuomm Amv Amumo mo .02 may mcflxnmm AHV nsmaaanm Ans nuanum Ems nuflxm ADV .v F3 upon H m \wEOOH mo # "mumu SS IHUCH .moauou H 2 IHEHOU HO mbum3 Amy CODE on Acv GENERAL Ass FACILITIES - AHV .nomo Onwnomoo ommoam .mEOOH CODMHOH OOH>Hom stuo mEoou Oman coflumouoom Axv snounaq Aflv momcsoq AHV mEOOH OUCOHOMCOO Any mEOOH OCACHQ Amy FACILITIES - SPECIFIC SS - F4 use one sheet for each service room or class room CODE 1. Identification of room by number and/or name. 2. Relative location in building 3. Draw a sketch and indicate size and Openings. 4. What is this room currently used for? 5. What kind of activities take place in this room? 6. How many hours per day is this room in use? 7. What are the characteristics of the clientele/students using this room? (a) Age range (b) Kinds of disability (c) Largest number at any one time (d) Average number utilizing this room each day 8. Number and kinds chairs or desks: (fixed?) DEC 1962 Res Date 1963 Informant 10. ll. 12. 13. 14. 15. 16. FACILITIES - SPECIFIC SS - F5 use one sheet for each service room or class room CODE Types and amounts of equipment in this room. Lighting Ventilation Noise Temp. *What is the capacity for services in this room? What materials or equipment do you need or have in excess: (Indicate which?) *Is this room adequate for the services conducted? Explain FACILITIES - SPECIFIC SS - F6 use one sheet for each service room or class room CODE 17. Types and amounts of rehab. materials in this room? 18. List of teaching materials: (a) Types and amounts Of institutionally provided teaching aids. (b) Availability of common supplies (paper, pencils, etql (c) Books. (d) Types and amounts of teacher produced materials. PERSONNEL SS - Pl CODE 1. Administrative personnel: (get list of total personnel) Full-time Part—time TITLE Sex Pd. Vol. hrs/wk. hrs/wk. 2. Service Personnel: (indicate average hours per week) Total # Full-time Part-t TITLE Pd. Vol, # F # hrs, # hrs. (a) Prim. Teacher (b) Sec. Teachers (c) Speech therapists (d) Counselors (e) Social workers (f) Psychologists (g) Psychiatrists (h) Physicians (i) Physiatrists (j) Oculists (k) Phys. Therapists (1) Occ. Therapists (m) Prosthetist (n) (0) (p) Dec. 1962 Res Date_____1963 Informant PERSONNEL SS - P2 CODE 3. What additional staff do you presently need? (Indicate type and number) 4. Have provisions been made for additional personnel in your 1963 budget? (indicate type and number) 5. What is the rate of turnover among your service personnel, (paid and voluntary)? Explain 6. What criteria are used for employment of service personnel? (if written Obtain a COpy) PERSONNEL CODE 7. Are your hiring criteria difficult to follow? SS P3 8. What are your hiring procedures? (obtain copy) 9. What Opportunities exist for advancement? 10. Fringe benefits: (a) (b) (C) (d) Social Security Retirement Insurance Other SERVICE PROGRAMS SS - Sl CODE 1. What are the Objectives of this institution? (Obtain copy) 2. What are the elibibility requirements for service? (Obtain copy) 3. What are the referral methods to and from this institution? (List agencies and numbers also) Dec. 1962 Res Date 1963 Informant SERVICE PROGRAMS SS - $2 CODE 4. How are those admitted for services selected? 5. What is the criteria for case closure? 6. How do you evaluate student performance? (SE) (a) Grading system (b) Examination procedures (c) Testing programs (list types of tests used) 7. What is the criteria for grade placement? (SE) SERVICE PROGRAMS SS - S3 CODE 8. Indicate below the specific services provided by this insti- tution and the percentage of the clientele receiving each service. (a) Psychological testing (b) Psychological counseling (c) Psychiatric services (d) Social work (e) Vocational counseling (f) Medical services (g) Prostheses (h) Physical therapy (i) Occupational therapy (j) Speech therapy (k) Ophthalmological and/or Optical services (1) Vocational training (m) Educational training (n) Training in activities of daily living (0) Maintenance (p) Subsidies (q) Vocational placement (r) FOllOWbup (3) Transportation (t) Avocational activities (u) Services for parents, etc. (V) (W) (X) (y) (2) ClR SS CLASSIFICATION AND TALLY ucnsnomsH moms moon mom Nwmd DMD 1962-61-60-59-58-57 also Enter projected 1963 Tally CODE oow>uow mo mama omcmm omd #50 :4 m unoaao\osanm£oso 4 5;. snaaannnao muom moooz HOECD #50 CH muflommmu oua>uom soaoooauannnao snaaannnan .m CLASSIFICATION AND TALLY SS - ClS CODE 1. Approximate number of students applying or recommended for admission in: 1962 1961 1960 1959 1958 1957 2. Number of students in special classes or receiving special services in: 1962 1961 1960 1959 1958 1957 3. Number Of students graduating in: 1962 1961 1960 1959 1958 1957 4. Number of special classes taught in: 1962 1961 1960 1959 1958 1957 DEC 1962 Res Date 1963 Informant CLASSIFICATION AND TALLY SS - C28 CODE Students Served During 1962 5. Type Of Disability Number Type of class or service 6. Enrollment by grade level: (1962 only) M F M 7 F M F Pre school , I I! II I III M F _ M F M F III IV! II VI M F M F M F VI VII! Other 7. Number of students in age ranges from: (1962 only) 4to6 6t08 8tolO 10 to 12 12 to 14 16 to 18 I |. Other- J—J 14 to 16 LED 10. 11. Number of Number of Number of Number of CLASSIFICATION AND TALLY SS - C38 CODE residential students (1962 only)---- day students: (1962 only) ----------- I students from city: (1962 only) ----- students out Of city: (1962 only)-—- Anticipated applications and recommendations for enrollment in: 1963-1964 1964-1965 1970 Anticipated enrollment in: 1963-1964 1964-1965 ‘ 1970 RESEARCH ENDEAVORS SS - R CODE What research, if any, has been conducted by members Of the staff of this institution? INVESTIGATOR TITLE Publisher. A 7 A A A i A Date Where available _ I A Brief summary INVESTIGATORg TITLE Publisher Date Where available Brief summary DEC 1962 Res Date 1963 Informant 1. 2. 3. 4. 10. ll. 12. l3. 14. 15. l6. 17. 18. 19. 20. 21. 22.‘ 23. DOCUMENTS CODE SS - D Please obtain the following documents when available. Check the ones obtained and write in the number of pieces of materials. Legal Charter or by-laws . . . . . . . . . . Printed materials on aims, services, etc . . Budgets for years 1962-61-60 . . . . . . . . Auditors statements or financial reports for 1962-61-60 0 o o o o o o o o o o o o o o 0 Floor plan of building if service areas are extenSive O C O O O O O O O O O O O O O 0 Salary schedules . . . . . . . . . . . . . . Personnel liSt O O O O O O O O O O O O O O 0 Criteria for hiring professional personnel . Application forms for professional service personnel . . . . . . . . . . . . . . . . Criteria for admitting clientele . . . . . . Applications and admissions forms for clientele. Student/clientele classification . . . . . . Class/service schedules . . . . . . . . . . Fee schedules . . . . . . . . . . . . . . . Copies Of available statistics . . . . . . . Copies of various annual reports . . . . . . Institutional procedure guides or manuals . Research reports or! publications . . . . . . DUDHUHUUDDDHDUU DEED [1 BED APPENDIX C PERSONAL INFORMATION INVENTORY (English Translation) 231 .INSTITUTE OF EDUCATIONAL RESEARCH-ANQ_IMPROVEMENT (IIME) Survey of Special Education and Rehabilitation Programs Personal Information Inventory IIME is conducting a survey Of Special Education and Rehabilitation programs and facilities in Guatemala. An estimated twenty public and private institutions and agencies are cooperating in the study. Most of the infor- mation to be collected will be obtained through interviews and visitations. However, some of the most vital infor- mation can only be obtained directly from individual profes- sional workers in the field. Will you assist the Institute in this important study by completing all the information requested below? Your responses will be kept in strict confidence and analyzed only by IIME researchers. Thank you for your cooperation. INSTITUTE OF EDUCATIONAL RESEARCH AND IMPROVEMENT (IIME) SS - P4 Survey of Special Education and Rehabilitation Programs Personal Information Inventory A. PERSONAL DATA 1. Name of Institution in which you are employed: 2. What is the title of the position which you now hold? 3. Describe in about one sentence the nature of the work that you do. 4. For how many years have you been employed in this Institution? (Check one) a. Less than 1 year ( ) d. 4 to 6 years ( ) b. 1 to 2 years ( ) e. 6 to 10 years ( ) c. 2 to 4 years ( ) f. 10 or more years ( ) 5. Normally, hOW'many hours per week do you work? 6. Is this position considered to be full-time or part— time? (check one) a. Full-time ( ) b. Part-time ( ) 7. In what way are you paid? (Check one) a. by salary ( ) b. by hourly rate ( ) c. non-paid volunteer ( ) 8. If paid by salary, what is your regular monthly salary? Q 10. ll. 12. SS - P5 If paid by means other than by salary, what are your earnings per hour? Q What is your sex? a. male ( ) b. female ( ) Are you married? a. yes ( ) b. no ( ) Approximately what is your age? (Check one). a. under 20 ( ) c. 30-39 ( ) e. 50-59 ( ) b. 20-29 ( ) d. 40—49 ( ) f. 60 or more ( ) PROFESSIONAL TRAINING AND EXPERIENCE 1. Have you taken a course at the University of San Carlos in the last three years? If so, please identify the courses in the space below. (If more than three, list the three most recently completed). Name of Course Faculty Date Completed In general, of what value were the courses you took at the University Of San Carlos in your professional work? (Please check one) a. of great value ( ) c. of little value ( ) b. of some value ( ) d. Of no value ( ) Please identify the professional organizations to which you belong. To what professional publications do you regularly subscribe? P6 SS - CoonQEo £0fl£3 cofiumooq c0fiu5uflumCH OHUHB ca mumow m0 oemz A.ucooou ammoa ou ucooou umoE mo umbuo cw uquv .mumo> so» ummm 0:» mcHH5© paw: o>mn 50> coaumm5000 H0 mCOAuwmom map umfla oncoam .o PERSONAL INFORMATION INVENTORY Cmcumo coocouum ouMOHwHuHoo SOAQB E5H50HHH5O coaumooq coflu5uwum5H no 0562 H0 ooummn cfl whom? .bmz 0>m£ 50> coaum05po mo munch acmE 30: oumoflbcw mommam .m PERSONAL INFORMATION INVENTORY SS _ P7 .1; you are a teacher, omit questions 1 through 5 and CONTINUE DIRECTLY TO QUESTION 6. PROFESSIONAL ACTIVITIES 1. Approximately how many clients do you_see during the average day? 2. What is the average length of time you spend per visit with each client? a. Less than 30 min. ( ) c. l to 1% hour ( b. 30 min. to 1 hour ( ) d. more than 1% hour ( 3. DO you limit your practice to specific disabilities? Yes ( ) NO ( ) 4. Briefly state the type(s) Of disabilities you treat. 5. What additional training, if any, do you believe would help you to better perform your present duties? ) ) noanaflannnan .nosoosun m0 0H5umz mmmHO mu5005um no 5H u£m5mu omcmu mow nuooflnsm m 2 mucwvsum m0 H0QE5Z H0>0H ocmuw mou5cHE mo gamete cw mmmao mmmao no 0802 mm.) mm many ca uAU5Mp 50> £0fl£3 mommmHO cowum05bo amaoomm may mo 30mm How cofluMEMOMCH coumo5vou osu zoaon unmno on» Ca 00H>0Hm ommoam .Noma mcflu5© coflu5uwwwcfl .0 MAZO mmmmUGWB Mm 830 GmAAHh mm QADOZm manta mHmB PERSONAL INFORMATION INVENTORY SS - P9 1 A 7. Do you hold any other position in addition to your em- ployment in this institution? a. Yes ( ) b. No ( ) If yes please describe in the chart below. Title of Hours Salary or position Institution per week wage per month D. PROFESSIONAL OPINIONS 1. *What do you consider to be the four greatest problems or needs in the field of special education ( ) or rehabili- tation ( ) in Guatemala?. (Please check one) a) . . 19) C) SS - P10 D. PROFESSIONAL OPINIONS (continued) d) 2. In your opinion, how great are the Opportunities for pro- fessional advancement in the field of special education ( ) or rehabilitation ( ) in Guatemala? (Please check one) a. Many ( ): b. Some ( ); c. Few ( ): d. None ( ). 3. DO you have specific plans for additional training in your field? (Please check) Yes ( ) NO ( ) If yes, please describe below:g 4. DO you plan to remain in your present field Of speciali- zation? (Please check) Yes ( ) NO ( ) If not, please describe the reasons why you are choosing to leave this field of specialization.