disease symptoms and to the curandero to remove the cause of the disease. A study of recent migrants to Guatemala City found that they were uninterested in preventive health care and only demanded curative measures when an illness reached an advanced stage. Even then they seldom followed medical advice and failed to use prescriptions or even return for checkups. Yet they would rely heavily on the advice of pharmacists, neighbors, and other nonmedical personnel. A hypothetical sequence of responses exemplifies a mother's delay in time of family illness:
First, she will try all remedies she herself has found to be effective. These will most frequently be herbs, but will also include common patent medicines such as aspirin, zinc oxide, and cough syrup. If these are unsuccessful, she will ask her neighbors, especially older women, who are usually more than glad to give advice. After trying a number of similar recommended home remedies, she will finally consider seeking a specialist. At this point, she will either call in a local curandero, if one lives nearby, or she may consult a pharmacist in the neighborhood. Only after trying the cures suggested by these people is she likely to seek a doctor. 8
During a single illness as many as twenty-five remedies or treatments may be tried, with the only criterion for judging their quality being their immediate effectiveness. When the ill person becomes well, the last medicine or treatment used is assumed effective, and is heartily recommended to others having similar symptoms. In cities, delay in seeking modern health care may be lengthened because of the increased number of non-medical sources of health advice.
These examples show two basic features of health behavior in Guatemala. First is the typical progression from the cheapest and most accessible care to treatment that is more expensive and harder to make use of. Second, given the greater social distance (though not necessarily physical distance) between users and public health providers, use of their services occurs only when more familiar sources prove ineffective.
A hierarchically arranged system of public health services is common in Latin American countries. The basic inequality in health care availability to various social classes is demonstrated by the proportion of national resources that are invested in the upper levels of this pyramid. These sophisticated and specialized services consume great amounts of financial and human resources, and are limited in their spatial impact. Although claims are often made that such facilities administer to "referrals," in fact such referrals are few. These specialized facilities provide care to the foreign and indigenous elites; they are "showcases" often used for prestige purposes and are inaccessible to most of the population. Greater effort must be made to broaden the base of the health care hierarchy--to apply "appropriate technology" to health care demands. Social welfare considerations