Originally posted on Global Health Hub Here!
Over the last several years, through work with community-based health programs and research as a medical anthropologist, I have visited dozens of medical and surgical missions in Guatemala. These short-term trips are one of the most popular forms of medical volunteering for foreigners visiting Guatemala (and many other countries of the Global South). There are many variations on the theme, but the standard formula of the medical mission is something like this: a group of foreign volunteers flies to a developing country, sets up shop in a clinic or hospital for a week, and evaluates hundreds (or even thousands) of patients for medical and/or surgical issues. Consultations are typically free or relatively low-cost, and as long as the mission has been adequately promoted in the area, throngs of locals—some with urgent medical needs and others arguably without—arrive early in the morning and wait for hours, even days, in hopes of seeing the doctors. Some will be turned or triaged away, depending on the size of the crowd and the scope of the mission. Otherwise, medications are doled out, surgeries are performed, and referrals are made. Then the medical mission team packs up and flies home.
There are many critiques of the short-term medical mission model, relating to ethics of medical management in resource-poor settings, cross-cultural communication, mechanisms for follow-up care, and collaborations with local partners, among others. In spite of these issues, however, medical missions can help fulfill important gaps in health care delivery in LMIC. In Guatemala, for example, the national constitution guarantees free health care to Guatemalan citizens, but many surgical procedures are simply not available in under-resourced public sector hospitals. If they are, they have extremely long waiting lists and patients must cover the costs of basic materials such as gloves, surgical instruments, and blood donations. Relatively straightforward procedures that don’t require a lot of follow-up care, such as hysterectomies or hernia repair, are great examples of services that short-term medical missions make more accessible in Guatemala, as are specialized procedures like cleft lip/palate surgeries, when follow-up care can be coordinated with a local partner.
One extremely important issue in short-term medical missions, and the subject of the rest of this post, is language. Excellent communication is arguably at the heart of all good clinical practice, and it becomes all the more significant in contexts where health care providers see rural impoverished patients who have limited access to care. Short-term medical volunteers only have one shot with a patient: you’ll only see them once, and they may not have easy access to a trained health care provider again, so the need to convey a comprehensible and accurate message is all the more urgent. I’d like to share the story of a woman named Sucely to highlight these issues.
It was day two of a chaotic medical mission trip in eastern Guatemala when I met Sucely, a plump and pleasant indigenous Q’eqchi’ Maya woman in her late thirties. She had developed a mass in her right breast years ago, but as she was poor and lived in a rural village several hours from the nearest town, she had delayed in seeking out medical care. That day, Sucely had decided to travel into town after hearing radio advertisements about a visiting surgical mission trip (jornada)sponsored by a US-based non-governmental organization (NGO). She thought the American volunteer doctors might be able to operate to remove the mass.
“This could be cancer,” said Dr. Johnson, a physician from the United States who was volunteering with the mission trip for the week. A grave expression crossed her face as she guided my fingers over Sucely’s large breast mass. Dr. Johnson motioned to Sucely that she could get dressed.
“We really need a workup to know, and it’s too big for us to operate,” she said, confirming her assessment with the NGO’s surgical triage referral guidelines. “I think she needs to go to that hospital in Guatemala City,” she said, referring to Instituto de Cancerología (INCAN), the only oncology hospital in the entire country that attends to public sector patients. Getting to INCAN would be a six to seven hour journey for Sucely, and possibly longer, depending on how badly the seasonal rains ravaged the dirt road from her village to town.
“Can we send her to talk with Reina about this? It sounds like she’s dealt with this a lot of times,” Dr. Johnson asked me. Like many volunteer providers from the US visiting Guatemala, she spoke only a few words of Spanish (which is why I was pulled into her consultation room as a translator). Dr. Johnson was nervous about having a long talk with Sucely, given the unending line of patients waiting outside to be evaluated for potential surgeries, but recognized that someone needed to spend some time with the patient. Reina, the NGO’s patient care coordinator, often took on patient counseling about referrals to speed up the flow of the evaluation clinics. “Please come right back—remember, I can’t see patients without you,” Dr. Johnson reminded me as she sent us out the door.
I led Sucely to Reina’s station down the hall, and when I explained the situation to Reina, she assured me that she would talk to Sucely. As I walked away, however, I overheard Reina say, “Señora, we can’t operate on you here,andyou have to go to this hospital in the capital.” I turned around, saw Reina hand her a referral slip with INCAN’s address and quickly return to her desk, where she continued to review patients’ charts and make frantic phone calls to coordinate patients’ upcoming surgeries. Sucely clutched the sheet of paper, confused. Whether Reina, like many other Guatemalan providers, believed that it was harmful to tell a patient that she might have cancer, or whether she was overwhelmed by her standard duties, I was not sure, but I suspected it was some combination of both. While I had expected Reina to sit down and have a heart-to-heart conversation with Sucely, she hadn’t had the time for it either.
At the risk of holding up Dr. Johnson’s clinic, I decided to sit down and talk with Sucely myself. But it quickly became apparent to me that she, like many other women who had come to the jornada, was a monolingual Q’eqchi’ Maya speaker who had just enough command of Spanish to bluff her way through a short medical consultation. The beginning of our conversation had gone something like this:
“What is your name?”
“Welcome, Doña Sucely. How old are you?”
“What brings you here today, Doña Sucely?”
“This, right here.” [points to her breast]
With some reflection, I realized that Sucely’s responses to many of the more specific follow-up questions were somewhat vague. I had originally presumed that this was due to shyness, as Sucely had never attended a medical consultation before, and suddenly there she was on the exam table with two American strangers poking and prodding at her. In fact, Sucely had been attempting to speak a second language she didn’t know that well.
There are twenty-three indigenous languages are spoken in Guatemala. While Spanish is the national—and colonial—language of Guatemala, about 30% of the population is monolingual in a Mayan language. But many short-term medical missions don’t anticipate a need for translators for indigenous language speakers, for a variety of reasons.
First, many foreign volunteers who come to Guatemala for the first time (and sometimes the second…and the third…) are simply not aware that local populations speak indigenous languages. In part, this seems to be because short-term volunteers do not have to do a lot of preparatory work (i.e. learning about the country they’ll be visiting) to participate in service trips (perhaps this is part of the appeal). Of course, some groups do hold orientations or meetings for volunteers prior to departure, but this has been the case for the minority of mission trips I’ve encountered. As such, most trip organizers and participants assume that Central America is a purely Spanish-speaking territory. Accordingly, visiting groups tend to be at least somewhat conscientious about offering English-Spanish translation services—at least when volunteers are forthright about not being able to proficiently speak Spanish. However, this tends not to be the case regarding indigenous languages.
A second issue is that even those who have been on the ground for years sometimes wrongly assume that their indigenous patients—or accompanying family members—are bilingual. This is because they’ve had conversations like the one I had with Sucely—using the most basic words. When I’ve asked NGO and mission directors about indigenous language use over the years, they often tell me that “language is not an issue” for them because monolingual patients bring their bilingual family members to the clinic to translate for them. It is true that sometimes relatives are bilingual: older indigenous patients’ children may have learned Spanish by going to school for a few years or working in dominantly Spanish-speaking areas of the country. But it is also true that relatives are sometimesnot bilingual, and cobbling together meanings from medical consultations becomes a joint effort between several family members, none of whom are really comfortable in Spanish.
Another problem is that missions and NGOs may underestimate the value of providing care in the preferred language of a bilingual patient. “They can speak Spanish, they just don’t always want to,” many health care providers have told me. Based on limited clinical interactions in Spanish—such as the one Dr. Johnson and I had with Sucely—I’ve heard many clinicians generalize that indigenous people are reserved or “closed off” to outsiders without recognizing the role that a common language can play in establishing rapport. I’ve had many experiences, for example, where I repeat a question originally phrased in Spanish in Kaqchikel Maya—a language I’ve been studying for the last several years—and a new person emerges before me. Patients often start smiling; they become animated, talkative, and more comfortable with physical exams.
These are all reasons that medical volunteers, mission coordinators, and NGOs need to anticipate and budget for translators for locally-spoken languages in the clinic. And thankfully, the mission trip Sucely visited was one of the few I’ve encountered that did employ translators of indigenous languages. After some searching in the crowded waiting room, Sucely and I found Heidi, the NGO’s designated Q’eqchi’-Spanish translator.
Heidi and I spent about 20 minutes talking with Sucely, first slowly and delicately revealing to her that she might have cancer, then providing her with details about how to reach the hospital in Guatemala City. Attempting to assess whether Sucely would actually make it to the capital, I tried to tease out information about her social support network. As she related to Heidi in soft and crestfallen Q’eqchi’, her husband had abandoned her years ago and she was struggling to raise her four children alone. None of this came out when I had exchanged some pleasantries with her in Spanish in the consultation room, where she had responded with a simple “sí” (yes) to my question about whether she was married.
I knew Sucely would not go to the oncology hospital. And if she were to make it there, she would not be able to get through on her own. The hospital, like most health care facilities in Guatemala, does not have interpreters for indigenous language-speakers. In tears, Sucely stated that she did not have the resources to get to the capital, but she thanked us for talking her through her options.
As luck would have it, another volunteer physician from US caught sight of us speaking at length and took interest in the case. The physician arranged for follow-up care, and it turned out the mass was benign and operable.
Sucely’s story is exceptional in many ways, and it demonstrates one of the fundamental reasons that indigenous patients slip through the cracks of health care systems: language. At the majority of medical missions in areas where indigenous languages are widely spoken in Guatemala, there won’t be a translator of those languages. Of dozens of medical missions I’ve worked with in Guatemala, there have only been two that have employed translators. Sucely ended up at one of them. Sucely also managed to actually speak to the translator—oftentimes volunteer providers (like Reina, Dr. Johnson, and myself) might be too inundated with consultations or other work to recognize whether a patient comfortably speaks Spanish, and to request translation services accordingly. Lastly, resolution of Sucely’s health problem depended on the compassion of a sympathetic physician, as, according to the organizational protocol, her breast mass was outside of the mission team’s scope of practice. I’ve seen volunteers, on many occasions, use personal funds to provide follow-up care to patients even when the organization cannot, but patients in Sucely’s situation aren’t always lucky enough to be assigned to those volunteers who go the extra mile.
Short-term medical and surgical missions will continue to be common forms of engagement in service and international health work. Sucely’s story points to a few simple things that volunteers can do to prepare:
- Find out what languages are spoken wherever you are volunteering. You may be predominantly told that a colonial language is spoken—like English, French, Spanish, or Portuguese, for example—and it may take a little bit of digging to figure out if other languages are spoken. Take the time to dig!
- When you choose an organization to volunteer with, figure out if they provide translators for those languages. Encourage them to. And make the adequate provision of translation services to patients one of your criteria for working with a service group or NGO.
- Recognize that you’re not going to be able to help everyone you see on a clinical level, because patients will come in with medical problems too complicated for you to handle in the short-term. But you can still provide a valuable service that patients may not find in a public, government-sponsored facility, or in a private clinic where they will have to pay out of pocket: speak to them in their preferred language, on their own terms, about exactly what type of steps they’ll need to take to address their health problem, even if you won’t necessarily be there to walk through it with them. Sucely appreciated it. Many others will, too.
- For those who find themselves doing longer-term work or consistently going on mission trips: If you fall in love with a place and decide you’re going to keep going back, think seriously about learning the locally spoken language. It can improve the quality of care for patients dramatically. It will make your clinical practice or service work more fun, engaging, and rewarding. And it is a small step towards promoting and revitalizing otherwise marginalized languages and cultures.