I’m glad to be out of Antigua. Witnessing (and contributing to) contemporary phenomena of colonization in the former imperial capital of Central America was an instructive but grating experience for me. I was anxious to get to San Lucas Tolimán—where the real work would be and where I needed to go to begin the process of accessing poor, rural indigenous communities. And sitting in the central park practicing glottal sounds and memorizing vocabulary while trying to ignore loud tourists (all seeming to be expounding on volcano excursions, local restaurants or iPods in annoying West Coast vernacular or nearly incomprehensible Southern drawls) was helping only somewhat with learning Kaqchikel. Now that we are in San Lucas, I feel less anxious (and less like a waste of space), and, as anticipated, things are slow in getting started here, so I am glad we came here a week earlier than we had planned.
So far we’ve been here 4 days and have spent them mainly introducing ourselves to individuals involved in the preventive health program. At the moment, I have more to reflect on from last weekend, when we accompanied Peter on his patient visits in Santiago Sacatepéquez.
...
Two house calls in particular stand out in my mind. The first was to the home of an elderly diabetic woman, whom, after walking down a path of cracked cement and (in my case, anyway) nearly tumbling down a short dirt incline, we found sitting in a dark back room with a piece of blue cloth wrapped lightly around one foot. As we entered and took the seats that were invariably offered us by our gracious hosts during house calls, I noted an oddly pungent odor that, when the blue cloth was gently removed by the patient’s daughter, turned out to be the smell of rotting flesh. Her great toe was almost entirely detached from her foot by black gangrene, and her other toes appeared similarly infected, swollen or dying; particularly concerning was the redness and swelling in her foot and ankle, suggestive of soft tissue involvement and evolving osteomyelitis. The second was to the home of an elderly couple—the day before, Peter had been telling me about the woman, who has Parkinson’s, but ultimately it was the case of the man that captured my attention. He watched us from bed, his gaunt frame and features appearing at least 10 years older than his stated age of 63. He told Peter that he had been experiencing up to 15 bright red, bloody bowel movements a day for several months now and described dizziness and fatigue, both symptoms of anemia which indicated the severity of his bleeding. Bright red blood per rectum, as it is known in U.S. emergency departments and hospital wards, has a fairly extensive differential, but the subacute onset, progressive symptoms and accompanying anorexia and weight loss in this elderly patient made colon cancer the leading diagnosis. In both of these cases, the patient had endured fairly concerning symptoms for astonishing periods of time, and, despite Peter’s insistence that there was little that he could do, both patients resisted the idea of going to one of the regional public hospitals.
These examples spurred a cascade of thoughts about structural violence and the multiple manifestations of resultant marginalities in the lives of these two people. The first was an older woman with diabetes that, due to the lack of access to medical care generated by socioeconomic and cultural marginalization, remained undiagnosed until Peter recently began taking random finger-stick blood glucose measurements in the community. I am almost certain that the metabolic derangements associated with the disease had already wreaked havoc in the form of end-organ damage prior to this most recent, and more evident, complication. Similarly, this same socioeconomic and cultural marginalization generated a well-founded reluctance to go to a hospital where doctors would communicate in a difficult language (that is, if they communicated at all) and explain little about unfamiliar and thus frightening therapeutic options (that is, if they did indeed present them as options, or if they presented any possible therapies at all, for that matter). Moreover, if the patient did ultimately make it to the hospital, the inaccessibility of the antibiotics that would be the standard of care in the United States (either due to absolute absence or relative lack of access due to cost) would necessitate a more extensive surgical debridement (and subsequently increased disability) to effect a lasting cure. Moreover, the significance of disability in this context—a context that itself is generated and conditioned by poverty—was apparent in my own difficulty getting to her room. Similarly, the second patient was a 63-year-old man who, not having received a single screening colonoscopy, flexible sigmoidoscopy, or even a simple rectal exam and fecal occult blood test (strongly recommended by the US Preventive Services Taskforce for anyone 50-years-old and above), now had what was probably flagrantly symptomatic colorectal cancer that had, given the severity of his bleeding, likely metastasized already and become virtually untreatable. Moreover, because he had never had a cardiovascular work-up or even a lipid panel (cholesterol, etc.), for that matter, and because he had never been on lipid-lowering or other cardioprotective therapy (other than the antioxidants that Peter gives many of his patients), it was possible that he had underlying coronary artery disease that put him at high risk of a heart attack given the degree of his symptoms of anemia. If he did overcome his understandable resistance to going to the hospital, he would be treated by surgeons and medical doctors who definitely lack the proper resources and who probably also lack adequate training to be treating him. When people here say they are afraid to go to the hospital because that is where one goes to die, that assessment may be very accurate indeed.
My medical and public health education takes on new meaning here. Ironically, the importance of what I have learned thus far becomes vividly apparent in a context where much of it cannot (yet) be put into practice. The insights from my meager personal study of social theory and anthropology take on a special vitality here. It is sometimes difficult, even for someone who strives to think and act in terms of social justice, to make sense of perspectives like that presented in the essays in Pathologies of Power if one is sitting at a desk in downtown Chicago, blocks away from a world-class hospital; this difference, I think, is what Paul Farmer refers to as “the vitality of practice.”
...
Wicha is the Kaqchikel woman from Santiago Sacatepéquez who has taken it upon herself to organize, facilitate and otherwise assist Peter’s clinics and house calls there. She is an interesting person, and I hope to say more when I have spent more time around her—and when I speak enough Kaqchikel to understand her better.
This last point is an interesting one. When I had originally emailed Peter, I had introduced myself as a medical and public health student interested in learning a bit of Kaqchikel—he replied with what he describes as an “unforgiving” email that I absolutely had to learn the language before pretending to do any good, lasting work. I have argued similarly at Northwestern about the importance of health care practitioners in the U.S. learning Spanish, so I could understand where he was coming from, even if I did not understand the details of the situation that informed his perspective. The two days in Santiago Sacatepéquez and our interactions with Wicha made evident—even though I was a bit reluctant to admit it at first—the fact that I need to learn Kaqchikel.
When we had walked around on Saturday making house calls, there were numerous occasions when we were walking up a hill and Wicha would break the relative silence in Kaqchikel. Peter would smile and say something in response, and a brief conversation would ensue. Only on occasion did we speak in Spanish—and when we did, it was really just me asking Peter questions in a language that Wicha would understand; she would walk a few steps ahead, listening but saying little. On Sunday, when we were sitting in the cofradía, Elena leaned over and asked Wicha a question in Spanish. Elena’s Spanish is not yet perfect, but, nonetheless, on the basis of my experience with gringos and shoddy translations in other contexts, I found the question to be entirely intelligible, both in terms of grammatical structure and pronunciation. Wicha listened to the question twice, and turned to me, asking, “¿Qué dice?” (“What did she say?”) Similarly, on our last house call for the weekend on Sunday, Peter had Wicha and me go down to the square to buy gauze at a pharmacy—Peter first asked Wicha, who hesitantly pointed at me to ask if I could go with her. On our long walk down the hill to the pharmacy, our conversation was notably absent—I asked a question or two and Wicha responded with yes or no answers, and I got the sense that my Spanish was difficult for her and that it would have been much easier in Kaqchikel. On our bus ride home that afternoon, Peter noted that Wicha hates speaking Spanish. I understand now what Peter means when he says the dynamic and perspective rendered in Kaqchikel are completely different. I have quite a bit of work to do if I hope to do meaningful and useful work here.
Monday, August 13, 2007
More thoughts from "the field"
The major causes of morbidity in Central America and the Caribbean are maternal and neonatal problems, depression and violence. This fact, as Peter explained to me while we were awaiting a bus back to Antigua from his clinic in Santiago Sacatepéquez, calls into question the imposition of the appellation, “tropical medicine,” in his words, “wherever it is warm and there are mosquitoes.” Peter’s assessment, that “tropical medicine” is a mythical creation and a relic of imperialism, shed some light on my confusion about the eligibility requirements for the American Society of Tropical Medicine and Hygiene’s certification in tropical medicine: one must work in an impoverished country for at least two months before sitting for the certification exam; this is puzzling because it is implied that the “tropics” are an epidemiologically homogenous zone—somehow, working south of the U.S.-Mexican border is supposed to prepare certificate recipients to manage malaria, even if this work is conducted in the Guatemalan central highlands, where mosquito-borne diseases, as far as I am aware, are essentially nonexistent. This use of the word, “tropics,” reminds me of the equally perplexing use of the word “field” by a certain human rights professor at Northwestern in reference to what amounts to any and all non-First World settings. Such terminology obscures the diversity of different impoverished locales and their inhabitants and, perhaps more importantly, creates the potential for objectifying marginalized peoples and conceiving of their world as laboratories where very real and actively generated death, destruction and disability are rendered “facts of life” that fail to implicate the comforts enjoyed by us who descend from our universities and institutions to work in “the field.”
…
On Saturday, I followed Peter and Wicha, a Kaqchikel woman from Santiago who organizes and supports his activities there, on several house calls. Needless to say, the opportunity to enter the intimate sphere of people’s homes and to watch Peter work was unlike anything I had experienced previously, in Guatemala or elsewhere. Despite the relatively slow pace of the work—which is partly due to what Peter calls “the hospitality mechanism”—the relationship-building and patient-centered health education that is made possible through these house calls has allowed the gradual deconstruction of well-founded negative conceptions and assumptions about Western allopathic medicine and its providers. The perspective that comes from this mode of practice, in conjunction with critical analysis, is markedly absent when a physician blames an impoverished HIV-positive patient’s antagonistic posture towards healthcare providers completely on denial (failing to see that physicians are often representatives of oppressive power structures) and when medical students fail to recognize how heavily the Tuskegee syphilis experiments influence some African Americans’ contemporary mistrust of physicians.
...
I had asked Peter when we were in the market buying medicines if he and his colleagues had been collecting any quantitative data to demonstrate positive outcomes achieved through their treatment methods. Of course, the collection of such data requires a great deal of time and money, both of which are in short supply for any incipient NGO. Ample anecdotal data, however, directs his work. Again, the limited resources available require definitions of “treatment success” that differ from what would be considered the “standard of care” in resource-rich settings. Peter talks about using what he can to bring a patient’s random blood glucose from 300-400s down to high 100s/low 200s, and, while he admits that this is not “perfect” management and that there are other important treatments and outcome measures to be considered in diabetics, he points to the change in quality of life that he has observed in many of his patients. If the best available care is the ultimate lofty goal, and if the needs of many individuals must be at least temporarily balanced with the needs of a few, then helping a patient progress from a bedridden existence to planting his first maize crop in 3 years can be considered an exciting and unequivocal success—even if his fasting glucose is above 126 mg/dL.
...
Today, Monday, I began instruction in Kaqchikel! I learned letters and sounds and some rudimentary conversations (“Good morning. How are you? I am fine, thanks. Where are you from? I am from Chicago.”). Learning a new language is difficult, but it is also a lot of fun. There is nothing more fulfilling than the way one’s head throbs after spending a few hours in the kind of transcendental levels of concentration required by the effort to internalize a completely new vocabulary and grammar. The arrangements for lessons are still a little up in the air, and I’m taking things on a day-to-day basis in terms of teachers and times of day that they are available. The majority of the teachers at the language school are working with a summer class from the United States until the end of this week, which means that things may be a bit disjointed and disorganized this week. In any case, I got a new textbook that Peter suggested and that is a more extensive version than the English language one I got in the United States—this is quite exciting for a Bengali with a book fetish! I also learned from the teacher that I worked with today that the fair rate for personal tutoring with a teacher who lives closer to where we will be spending the rest of the year (that is, on Lake Atitlán) is relatively compatible with our small budget. So, good things, so far—now all I have to do is put in tons of hours and much effort. Ack!
…
On Saturday, I followed Peter and Wicha, a Kaqchikel woman from Santiago who organizes and supports his activities there, on several house calls. Needless to say, the opportunity to enter the intimate sphere of people’s homes and to watch Peter work was unlike anything I had experienced previously, in Guatemala or elsewhere. Despite the relatively slow pace of the work—which is partly due to what Peter calls “the hospitality mechanism”—the relationship-building and patient-centered health education that is made possible through these house calls has allowed the gradual deconstruction of well-founded negative conceptions and assumptions about Western allopathic medicine and its providers. The perspective that comes from this mode of practice, in conjunction with critical analysis, is markedly absent when a physician blames an impoverished HIV-positive patient’s antagonistic posture towards healthcare providers completely on denial (failing to see that physicians are often representatives of oppressive power structures) and when medical students fail to recognize how heavily the Tuskegee syphilis experiments influence some African Americans’ contemporary mistrust of physicians.
...
I had asked Peter when we were in the market buying medicines if he and his colleagues had been collecting any quantitative data to demonstrate positive outcomes achieved through their treatment methods. Of course, the collection of such data requires a great deal of time and money, both of which are in short supply for any incipient NGO. Ample anecdotal data, however, directs his work. Again, the limited resources available require definitions of “treatment success” that differ from what would be considered the “standard of care” in resource-rich settings. Peter talks about using what he can to bring a patient’s random blood glucose from 300-400s down to high 100s/low 200s, and, while he admits that this is not “perfect” management and that there are other important treatments and outcome measures to be considered in diabetics, he points to the change in quality of life that he has observed in many of his patients. If the best available care is the ultimate lofty goal, and if the needs of many individuals must be at least temporarily balanced with the needs of a few, then helping a patient progress from a bedridden existence to planting his first maize crop in 3 years can be considered an exciting and unequivocal success—even if his fasting glucose is above 126 mg/dL.
...
Today, Monday, I began instruction in Kaqchikel! I learned letters and sounds and some rudimentary conversations (“Good morning. How are you? I am fine, thanks. Where are you from? I am from Chicago.”). Learning a new language is difficult, but it is also a lot of fun. There is nothing more fulfilling than the way one’s head throbs after spending a few hours in the kind of transcendental levels of concentration required by the effort to internalize a completely new vocabulary and grammar. The arrangements for lessons are still a little up in the air, and I’m taking things on a day-to-day basis in terms of teachers and times of day that they are available. The majority of the teachers at the language school are working with a summer class from the United States until the end of this week, which means that things may be a bit disjointed and disorganized this week. In any case, I got a new textbook that Peter suggested and that is a more extensive version than the English language one I got in the United States—this is quite exciting for a Bengali with a book fetish! I also learned from the teacher that I worked with today that the fair rate for personal tutoring with a teacher who lives closer to where we will be spending the rest of the year (that is, on Lake Atitlán) is relatively compatible with our small budget. So, good things, so far—now all I have to do is put in tons of hours and much effort. Ack!
On Mayan medicine
A quick disclaimer: of course what is written here is the result of just 2 days in Guatemala, and some of the perspectives and information are liable to modification over time (and rightfully so, I think) as we gain experience and knowledge. So the following entry is really just a representation of where I am and what I’m thinking about right now on this journey. Thanks for your patience. Without further ado…
On Saturday morning I woke up early to make sure I had time to stop by an Internet café to print a copy of my proposal before meeting Peter, who is serving as an advisor on my project in San Lucas Tolimán, in Antigua’s central park. I arrived a bit early, so I sat and reread my proposal briefly. I spotted him after a few minutes, walking quickly to catch up with him and calling out to get his attention. We shook hands and headed to the market—we had spoken the evening before, and he had told me that he needed to stop by the market to purchase some medicines.
I followed closely behind him so that I could hear what he was saying and so that I wouldn’t lose him in the maze of shop stalls. Finally, he stopped in front of a large corner stall full of fresh produce, which he looked at and said, “This is the woman I usually buy stuff from.” I looked more closely at the stall’s wares, searching for strips of pills and bottles of ointment, but saw none; I looked around me at the other stalls, searching for a small stash of allopathic medications or medical supplies, but all I could see was more fresh produce. Peter got the attention of the woman who runs the store and, speaking to her in Kaqchikel, began asking her for things.
The only word I understood was “manzanilla”—chamomile—and I quickly realized that, given Peter’s avid interest in ethnomedicine, when he said he needed some “medicines,” I should have understood that he meant medicinal herbs. He proceeded to collect a sizeable bunch of different herbs and vegetables, and in between speaking in Kaqchikel to the storeowner and her assistant, he explained to me in English the rationale and principles for using alternative medicine. Medicinal herbs are cheaper and, for a physician who has not yet received what will be a nominal license to practice, more easily accessible than allopathic medications. The usual issue of cost and accessibility is compounded by the fact that generics are, according to Peter, virtually impossible to come by in Guatemala. I do not know the reasons for sure, and nor did Peter, but I have a bad feeling that this is the result of predatory, “neoliberal” policies akin to the stipulation that the sums of money recently promised by the United States for the purveyance of anti-retrovirals in sub-Saharan Africa be used to purchase only non-generic medications, converting what could have been a huge humanitarian gesture into a kick-back to First World pharmaceutical companies. (I use quotes around “neoliberal” because I think that cheap drugs should be the outcome of a neoliberalism that fosters and is based upon truly equal competition.)
Reasons other than cost (and Peter’s current student’s-stipend-budget) drive the use of herbs. First, the structural violence that has and continues to characterize relations between indigenous and non-indigenous peoples is manifest between practitioners of Western allopathic medicine and indigenous patients, and the use of medicines that are a part of indigenous Mayan medicine fosters trust and adherence to treatment regimens. On our walks between patients’ houses, Peter explained several examples of patients who quietly refuse to take allopathic medications but whose diseases have nonetheless been brought under relatively good control with only herbal medicines. Second, the use of Mayan medicines, in conjunction with activities such as Peter's financial sponsorship of Mayan religious ceremonies, serves the ostensive mission of Peter’s newly founded NGO, Wuqu’ Kawoq (see sidebar for Internet link), “strengthening Mayan culture and medicine”: the study and use of medicinal herbs contributes to the effort to preserve and revitalize Mayan knowledge and culture. In any case, after this interesting introduction, and after two days of continuing to learn from Peter about medicinal herbs, I am convinced that they should be appropriately incorporated as first-line treatments.
Peter also explained that at this point he is using about 20 or so such remedies, and that an important criterion for use of a specific medicine is scientific literature verifying its benefit—of course, not all of this evidence is from head-to-head randomized controlled trials comparing herbs to allopathic medicines, and Peter also noted wryly that it is a little imperialistic to make decisions based on Western allopathic standards, but that it is an easily rationalized way of selecting from the hundreds of herbal therapies for various ailments.
That's all for now. Thanks for reading! I'll post more soon.
On Saturday morning I woke up early to make sure I had time to stop by an Internet café to print a copy of my proposal before meeting Peter, who is serving as an advisor on my project in San Lucas Tolimán, in Antigua’s central park. I arrived a bit early, so I sat and reread my proposal briefly. I spotted him after a few minutes, walking quickly to catch up with him and calling out to get his attention. We shook hands and headed to the market—we had spoken the evening before, and he had told me that he needed to stop by the market to purchase some medicines.
I followed closely behind him so that I could hear what he was saying and so that I wouldn’t lose him in the maze of shop stalls. Finally, he stopped in front of a large corner stall full of fresh produce, which he looked at and said, “This is the woman I usually buy stuff from.” I looked more closely at the stall’s wares, searching for strips of pills and bottles of ointment, but saw none; I looked around me at the other stalls, searching for a small stash of allopathic medications or medical supplies, but all I could see was more fresh produce. Peter got the attention of the woman who runs the store and, speaking to her in Kaqchikel, began asking her for things.
The only word I understood was “manzanilla”—chamomile—and I quickly realized that, given Peter’s avid interest in ethnomedicine, when he said he needed some “medicines,” I should have understood that he meant medicinal herbs. He proceeded to collect a sizeable bunch of different herbs and vegetables, and in between speaking in Kaqchikel to the storeowner and her assistant, he explained to me in English the rationale and principles for using alternative medicine. Medicinal herbs are cheaper and, for a physician who has not yet received what will be a nominal license to practice, more easily accessible than allopathic medications. The usual issue of cost and accessibility is compounded by the fact that generics are, according to Peter, virtually impossible to come by in Guatemala. I do not know the reasons for sure, and nor did Peter, but I have a bad feeling that this is the result of predatory, “neoliberal” policies akin to the stipulation that the sums of money recently promised by the United States for the purveyance of anti-retrovirals in sub-Saharan Africa be used to purchase only non-generic medications, converting what could have been a huge humanitarian gesture into a kick-back to First World pharmaceutical companies. (I use quotes around “neoliberal” because I think that cheap drugs should be the outcome of a neoliberalism that fosters and is based upon truly equal competition.)
Reasons other than cost (and Peter’s current student’s-stipend-budget) drive the use of herbs. First, the structural violence that has and continues to characterize relations between indigenous and non-indigenous peoples is manifest between practitioners of Western allopathic medicine and indigenous patients, and the use of medicines that are a part of indigenous Mayan medicine fosters trust and adherence to treatment regimens. On our walks between patients’ houses, Peter explained several examples of patients who quietly refuse to take allopathic medications but whose diseases have nonetheless been brought under relatively good control with only herbal medicines. Second, the use of Mayan medicines, in conjunction with activities such as Peter's financial sponsorship of Mayan religious ceremonies, serves the ostensive mission of Peter’s newly founded NGO, Wuqu’ Kawoq (see sidebar for Internet link), “strengthening Mayan culture and medicine”: the study and use of medicinal herbs contributes to the effort to preserve and revitalize Mayan knowledge and culture. In any case, after this interesting introduction, and after two days of continuing to learn from Peter about medicinal herbs, I am convinced that they should be appropriately incorporated as first-line treatments.
Peter also explained that at this point he is using about 20 or so such remedies, and that an important criterion for use of a specific medicine is scientific literature verifying its benefit—of course, not all of this evidence is from head-to-head randomized controlled trials comparing herbs to allopathic medicines, and Peter also noted wryly that it is a little imperialistic to make decisions based on Western allopathic standards, but that it is an easily rationalized way of selecting from the hundreds of herbal therapies for various ailments.
That's all for now. Thanks for reading! I'll post more soon.
Subscribe to:
Posts (Atom)