By Rebecca DiBiase
I wrote this blog post as I was flying to Peru to volunteer at a traveling medical clinic. In preparation for my trip, I read an insightful book called When Helping Hurts by Steve Corbett and Brian Fikkert that addresses the challenges and pitfalls of relief and development work in low-income countries. The authors didn’t tailor the book for a medical audience, and the lessons it offers apply to any global humanitarian intervention.
One of my favorite concepts they present is called the “participatory continuum.” This phrase describes the relationships that can arise between local people and those seeking to provide charitable assistance. The authors posit that healthy relationships often involve cooperation and co-learning, where the local community and foreign relief teams form a mutually beneficial, collaborative liaison to drive positive change.
This powerful and relevant concept reminded me of my undergraduate thesis, in which I used interviews, field data and literature reviews to examine medical care delivery in the indigenous Mayan communities of rural Guatemala. I concluded that the following factors influence health care practice and utilization in every country, and practitioners should study them prior to beginning global health work.
No. 1: The Provider Hierarchy
In the United States, health care team members have clearly delineated roles. Nurses and physician assistants have their own unique skills, and an attending physician leads the team. Primary care providers are gatekeepers, referring patients to specialists if necessary. Pharmacists, social workers and dieticians supplement care with their specific skillsets.
In Guatemala, the roles are largely ambiguous. The folk sector consists of traditional healers, including those who employ purely spiritual means, and others who incorporate aspects of biomedicine. The professional sector includes formally trained practitioners such as doctors, nurses and pharmacists. Many patients see an array of these providers and combine their advice to create treatment plans. To enter this system and practice medicine without first understanding and adapting to the existing structure would be detrimental for both patients and providers.
No. 2: The Historical and Social Context
In the United States—and elsewhere—racism, homophobia, sexism and socioeconomic disparities are social problems rooted in history and still permeate multiple systems, including health care. Every culture has firmly established social nuances that inherently influence health care delivery.
A civil war in the late 20th century devastated many highland Mayan communities of Guatemala, killing many and forcing survivors to leave their homelands. The Mayans channeled the loss of culture and feelings of betrayal into a massive effort to restore ancient culture and tradition. This movement has strengthened Mayan healers’ authority. Therefore, to dismiss a village’s local healer and replace her holistic methods would not only be disrespectful, it would also make a larger negative statement about Mayan social politics.
No. 3: The Economic System
Economics play a significant role in U.S. health care. The system is overburdened, and even when a patient has health care coverage, the emergency room copay is still a deterrent to seeking necessary care.
Similarly, financial disparities pose a major problem to Guatemala’s medical system. The traditional sector, with its more flexible barter payment system, is vital in providing access to care. Therefore, maintaining traditional medicine alongside biomedicine helps overcome the system’s economic hindrances. Further, to ignore the economic context and assume medicine operates in a moneyless world would be as unproductive in the mountains of Guatemala as it is in Baltimore.
No. 4: The Education System
The U.S. education system strives to keep its curricula relevant to prepare students to care for their future patients in a changing world. For instance, while medical students have always learned basic gynecologic knowledge, many medical schools recently added material in their curricula about proper screening measures for transgender adolescents.
Similarly, Guatemalan medical schools integrate important cultural topics into training. Medical students learn about traditional healing principles and techniques commonly used in indigenous populations. While recognizing the “evil eye” as a cause of the flu might not be endorsed as proper diagnostics, Guatemalan doctors must be able to understand a patient who brings her child to the clinic saying he is plagued by the evil eye. The bottom line: Providers educated in Guatemala know more about their patients than we do and can connect with them at a more meaningful level. It is important to recognize this and learn from them rather than adopting a superiority complex and refusing their guidance.
No. 5: Spirituality and Organized Religion
While each person’s specific religious beliefs vary, faith is often a universal source of therapeutic support. For example, many patients and visitors leave gifts and prayers at the base of the large statue of Jesus at the entrance of The Johns Hopkins Hospital.
For Mayans, spiritual health is as vital as physical health, and the two are integral and interdependent. Well-trained Guatemalan practitioners recognize this and adopt a multidimensional approach to treatment. Clearly, a fundamental understanding of these concepts is important for providing the most helpful health interventions possible.
In conclusion, it is imperative to study these five factors to determine the best means of helping people from cultures different from your own. Exploring these topics inherently requires cooperation and co-learning, which Corbett and Fikkert so adeptly point out in their book.
This material is also relevant when helping people who live right down the street. I believe that if people embrace this holistic approach to medicine and public health, it can help make our work—both in the United States and abroad—more productive and sustainable.