Cultural Competency

14 Aug 2012

Catering to the foreign market of Spanish learners is a leading industry in Xela where there are over 20 Spanish schools.  A small minority are non-profit cooperatives whose proceeds benefit the community.  Pop Wuj is the only one with a medical program.  The program has an interesting beginning.  Soon after the school was founded in 1992, the administrators noted that many students were on the healthcare track and looking for medical experience as well as Spanish classes.  They began to collect contacts at local clinics that were willing to take volunteers.

It did not go well, at first.  In a few short months Pop Wuj went from having seven clinical contacts to three to one.  Ronnie, one of the school’s founders, tried to figure out what was going wrong.  He had many theories.  The truth is probably a combination, best illustrated with the story of ‘Bernadette’.

This young lady was a star medical student.  Intelligent and driven, she was eager to build her proficiency and experience.  She was placed in a clinic with a Guatemalan doctor.  While seeing their first patient, she cut the doctor off to take over the interview.  Her first question to the patient was “¿Cuál es tu problema?”  This translates into “What’s your problem?” and has the same impertinent implication that it does in English.

This particular patient was complaining of “dolor de estómago” which literally means “stomach pain”.  However, she was pointing to her liver/gallbladder which are on the other side of the belly.  There is no good word for belly or abdomen in common usage in Spanish, yet Bernadette harshly told the patient, “That is not your stomach”.  Finally, Bernadette chastised the patient for using traditional Mayan medicine and putting off coming to a (western) clinic.  When Ronnie saw Bernadette the next day, he asked her how her first day in clinic was.  She replied that it could have been better, as she had seen gastritis, high blood pressure, different infections, malnutrition, but “nothing interesting”.  He was taken aback.

Bernadette is an extreme example, but themes hold true for why the medical program almost failed.  There was a lack of cultural understanding between the young American medical students, the Guatemalan doctors, and the patients.  There were inexperience issues as well.  Most of these early students were in the beginning stages of medical training, pre-meds or first-year med students who had spent little time in clinical settings.  A lot were starting with minimal Spanish.  Even more troublesome were problems of motivation.  Many students came with a minimal desire to be of use, but a strong desire to strengthen their résumés.

A final obscuring shadow is the undertone of post-colonialism.  Ronnie explains to incoming medical students that patients sometimes respect fledgling Gringo medical students more than the practiced Guatemalan doctors.  In former colonies there is a long and bleeding history of whiter people having more.  From this is born a stereotype of superiority that continues to be part of the collective unconsciousness.  It is a natural conclusion that the tired mind makes:  “they have more” therefore “they are more”… more successful, more intelligent, more everything.

After this epic fail Pop Wuj was unsure about whether it should continue its medical program.  The need was clearly there, for both patients and students.   The administrators felt that, perhaps, they had not explained the cultural dynamics of Guatemala and the philosophy of the school well enough to new students.  They decided to have a week of cultural competency training before students start work in a clinic.  The project grew to be successful, and eventually the school found a partner in a global health organization and was able to start its own clinic staffed by two Guatemalan doctors.

I came into cultural competency week expecting mostly vocabulary lessons:  this is what to say, this is what not to say.  I was mistaken.  Imagine a Guatemalan anthropologist and a teacher who started a school, wanting the proceeds and the volunteer efforts to benefit his community.  This is Ronnie, and he taught our classes.  He opened with, “Why are you here?  What does it mean to be a volunteer?  You don’t have to answer, but think please about the question.”

For the next few days we were brought through hundreds of years of colonial history, economics, politics, anthropology, and yes medicine.  The central theme was that colonialism wasn’t solely physical and economic occupation;  it was complete domination, with divine sanction.  Europe took on the “project” of taking over civilizations using god to do so.  It was more traumatic than prior wars and conquests because of the concept of the (one) right.

The collective memory keeps and guards the things that affect everyone.  On this, the echoes of colonialism are a traumatic scar.  Before 1524 Mayan history had a collective memory of nine thousand years.  Overnight, a bearded white man atop a giant horse changed everything.  These men and their horses bred for war did not exist in the Mayan collective memory.  Neither did explosions outside of nature, controlled by man to bring about death.  Ronnie described a decisive battle where – after fewer than three-hundred Spaniards felled over two-thousand Mayan fathers, husbands, sons, and brothers – the remaining quickly surrendered.

The Spanish went on to shape their colonies with the mantle of Christianity.  Suddenly Mayan clothes were unacceptable, their intellectual history witchcraft, and their biggest library collected over millennia burned in a fire that lasted for days.  Mayan medicine was outlawed for centuries as sorcery, devil worship.  “Do not be surprised if a patient lies to you about taking traditional medicine.  They will lie because of centuries of being scolded and ridiculed.”

The learning focus was to begin a process of decolonization – to have us begin to understand the mental, emotional, and spiritual repercussions on identity that exist to this day.  It is an identity crisis I am familiar with;  You can’t look up in the Philippines without seeing an ad for a skin whitening cream.  We have a long history where the Gringo gives and the brown person receives.  But it will serve a volunteer to remember that the only difference between these situations is a historical accident.

My coming to Guatemala started with an idea.  I wanted to learn medical Spanish, not just enough to get by but enough to communicate well.  Eventually the idea became a necessity.  I felt that I had to go, that I wouldn’t be whole without this connection and exchange.  Ronnie’s closing words were, “I hope that you are here not only because you want the experience, not because you have more, but because you’ve listened to the crisis of your species and you need to help.”  I hope so too.


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