The vitality of practice, the importance of language

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.

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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.”

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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.