"At the Crossroads" symposium focuses on how to deliver culturally sensitive surgical services to indigenous communities.

SYMPOSIUM REPORT

by Jeanne Marie DiNovis and Peggy McInerny

International Institute, February 14, 2014 — “At the Crossroads: Medicine and Anthropology in Mesoamerica,” a symposium spearheaded by UCLA anthropologist Bonnie Taub and UCLA pediatric plastic surgeon Dr. Reza Jarrahy, took place January 31, 2014, at the Semel Neuroscience Auditorium at UCLA.*

Speakers at the symposium built on the themes of convergence, planting seeds for future growth and building bridges between health mission teams and indigenous communities in Mesoamerica. Those in attendance included faculty, undergraduate, graduate and medical students, as well as community leaders — all expressed great interest in the interdisciplinary symposium on global health issues.

Professor Tom Coates, director of the UCLA Center for World Health, a joint program of the David Geffen School of Medicine at UCLA and the UCLA Health System, began the conference with a discussion of world convergence in the medical field. Although the world is shrinking and we are becoming intricately more connected, he noted, we should not disregard the importance of respecting each other’s ways of life.

“Every culture has its constructs,” said Coates, “and the convergence of modern medical technology with those thoughts, cultures and constructs is really important.” His hope is to create a horizontal, rather than top-down, approach to integrating modern biomedicine into areas of the world with limited access to health services. 

Impact of community building

Dr. Reza Jarrahy spoke about his experience of moving from his comfort zone — the operating room — to the homes of the families of his patients in Guatemala through a nonprofit program that delivers concrete and ceramic stoves to families (see previous article). Jarrahy emphasized that it was essential for medical practitioners working in a foreign country to be sensitive to local culture, as “true partnership comes from cultural sensitivity and humility.”

In an environment where patients are underserved and undertreated, creating personal connections establishes a model for growth and development. Jarrahy drew a particular distinction between medical missions that “parachute” in, perform surgery and leave, and those that seek to create sustainable interventions that work effectively with local conditions and cultural values, which he called a “gardening” approach.

Professor Bonnie Taub gave a passionate description of her work as a medical anthropologist with Dr. Jarrahy in Guatemala. She spoke of the resilience of the indigenous people there, saying that being involved in the project has taught her how much there is to learn from the patients they treat. Taub also stressed the need to build bridges with indigenous communities, both physically through surgery and metaphorically through the creation of connections and intercommunity growth.

Birth as a biosocial process

Medical anthropologist Nicole Berry (Simon Fraser University, Canada) conducted significant research on the preference of indigenous women in Sololá, Guatemala to give birth at home instead of in a hospital, even when risk factors were high.

Medical anthropologist and professor Nicole Berry. (Photo: Jeanne Marie DiNovis/ UCLA.)

Her goal was to determine why the Safe Motherhood Initiative (SMI) created by the Guatemalan Ministry of Health, which sought to reduce maternal mortality among indigenous women, had been unsuccessful in Sololá. The large majority of women who die during childbirth in the region die either at home or en route to the hospital, so SMI sought to increase their use of the local hospital during labor.

Berry discovered that women in the region did not view birthing at home as a significant risk. In fact, they viewed themselves as “willing users of hospital services if they needed them.” Nor did they view the incidence of maternal mortality as a crisis.

The disconnect, said Berry, seemed to lie in differing notions of what qualified as an emergency and therefore required hospital admittance. For example, neither the women nor local midwives identified prolonged bleeding after birth or delivery of more than 24 hours duration to be danger signals.

Women in Sololá generally deliver their babies with traditional midwives, who, unlike biomedical staff, are understood to be called to their profession by God. Although they do not receive formal training, these women are trusted providers and spiritual advisors whom families depend on to help women bring their babies into the world.

Whereas the Ministry of Health saw midwives as “potentially trainable skilled birthing attendants,” said Berry, these women and their clients understood their role differently.

SMI targeted local midwives and provided them training sessions on how to recognize birthing risk factors for which hospitalization is recommended. Unfortunately, the initiative was unsuccessful because midwives rarely perceived the biomedical warning signals they learned as genuine risks for a mother during labor and rarely referred their clients to the hospital.

Berry found that midwives distinguished between “birth” and “sicknesses” that prevent normal births, considering only the former their responsibility. Thus, if a woman experienced a complication such as seizures prior to labor, a midwife interpreted this as “sickness” and did not refer her to the hospital. In the same way, they did not view mothers’ symptoms after birth as part of their purvey.

Midwives expect variations in the normal birthing process and do not believe such variations necessarily indicate an emergency, noted Berry. On the other hand, they said they would not hesitate to send a woman with an extremely unfamiliar birthing situation to the hospital. “Unfortunately,” Berry stated, “it’s familiar variations that most women are dying from,” such as extensive bleeding after birth or a miscarriage.

“Midwives learn empirically,” stressed the speaker. If they have not experienced a problem with a condition that biomedicine defines as a danger signal (e.g., a scar from a previous caesarian section), they consider it a waste of time to send a woman to the hospital. Given existing distrust of hospitals among indigenous people, continued Berry, “midwives figure if they [western medicine practitioners] are lying about this, they are probably lying about the rest of it.”

One program that seemed successful in bridging the gap between midwives and biomedical staff was implemented by a local doctor who invited midwives to actively participate alongside doctors and nurses in providing care to women in the obstetrics and gynecology ward. Intended to build relationships and trust between midwives and medical staff, the program helped reduce the fear and mistrust of many indigenous women about entering the hospital.

With trusted midwives working in the hospital, these women were more comfortable and confident that they could communicate, as most do not speak Spanish. Of note, the program was not funded by the Ministry of Health or local mayors because it did not directly correlate with the Safe Motherhood Initiative. In fact, the doctor paid for the program out of pocket for several months. After attempting to secure funding without success, the program was discontinued, even though it appeared to be a more successful effort to integrate midwives into the biomedical world. 

Ultimately, Berry argued that pregnancy and birthing are not just biomedical processes, they are also biosocial processes that become very complicated by social and familial relationships. When creating plans to address biomedical problems, addressing the perceptions of the target community is a crucial element of whether medical interventions achieve success or end in failure.

The limits of “parachute” missions

Dr. Andrew Moyce, a general surgeon (and specialist in otolaryngology) with 20 years’ experience participating in surgical missions to Central and South America, began by providing a general overview of how such missions are organized and implemented, then discussed the conditions under which surgeons on these missions work.

Dr. Andrew Moyce. (Photo: Peggy McInerny/ UCLA.)

In family oriented societies such as those in Central America, noted Moyce, a disease or disability often causes two family members to cease working: the patient and the family member who cares for them. Reducing a disability can therefore return two or more people to productive life.

Visible deformities, such as cleft lip and cleft palate, have both economic and social consequences, he explained. Such deformities are usually seen as a social stigma, sometimes even as a curse. Moyce noted that in the case of a cleft lip and a cleft palate, he has learned to operate on the cleft palate first (rather than vice-versa, as in the United States), in order to ensure that the family will return for the second surgery on the more visible deformity.

Although U.S. doctors generally see the same pathologies on missions abroad that they see at home, the pathologies are typically much more severe. Modern equipment and early diagnosis have made a significant impact on modern surgery techniques, said the speaker, meaning younger surgeons may not have experience with more advanced and challenging conditions. Because of this, Moyce has a rule that one member of a traveling surgical team must have grey hair!

Moyce emphasized that the expectations of American surgeons and rural patients in developing countries differ. Patients in these countries have usually been treated very poorly by their own health systems and believe U.S. surgeons can work miracles. Frequently, they seek operations for problems that cannot be resolved by surgery. On the other hand, U.S. surgeons often have unrealistic expectations of what they can do on the ground; many also tend to believe American surgery is superior to local options, an opinion with which he did not concur.

The speaker stressed that doctors on surgical missions must make hard decisions based on: the facilities available (e.g., lighting, instruments, access to anesthesia and blood banks); their own experience with specific procedures; and issues of post-surgical care, including patients’ living conditions, a doctor’s ability to communicate home-care instructions and the availability of medical supplies and complementary health services (e.g., dental care in the case of cleft palate surgery).

For example, explained Moyce, a goiter (an enlargement of the thyroid gland) is frequently treated in the United States by suppressing growth with thyroid hormone. Surgery to remove the gland is generally done only when there are symptoms of obstruction; and the patient must then take thyroid medicine for the rest of his or her life.

Since a lifelong regime of thyroid medication is simply not possible in poor rural regions, he explained, a thyroid cannot be removed entirely from a local patient — the surgeon must leave part of it, a procedure that causes much greater blood loss.

Given these circumstances, Moyce advised surgeons on medical missions to slow down and think about what they are doing before they decide to operate. Surgeons must ask themselves:  Do I normally do this procedure at home or refer it to a specialty center? How long has it been since I have done this procedure? Do I have the right equipment for it? Is my inexperienced surgery better for the patient than no surgery at all?

“There is a limit to what you can do,” he remarked. “You will do more good for the patient if you understand this.”

Moyce then discussed whether it made sense to build a hospital in areas typically targeted by surgical missions. For him, the decision principally depends on two things: whether a hospital will compete with existing health care providers in the area and whether it will increase the population’s access to health care. He then compared two hospitals, one built in an urban town in Mexico and another in a remote rural region of Guatemala (of which he is currently chairman of the board).

In both cases, he said, the groups behind such projects had no experience in hospital administration and maintenance and had to either learn on the job (Mexico) or find skilled local administrators (Guatemala). Yet he stressed that the most important issue was access. The hospital in Mexico competed with another hospital in the same town and ended up limiting access by charging outsiders higher prices and reducing the outreach conducted in outlying regions.

In Guatemala, by contrast, the remote location of the hospital and its emphasis on primary care (supplemented by visiting surgical teams) has greatly increased access, with many rural residents traveling days to reach it.

The ultimate goal of surgical missions is to support and nurture local resources so that these two-week interventions are no longer necessary, observed Moyce. “In the meantime, they are a blend of parachuting and gardening,” he remarked, referring to Dr. Jarrahy’s earlier analogy.

Holistic intervention: A rural hospital succeeds by becoming a social services provider

Dr. Gary Salomon. (Photo: Peggy McInerny/ UCLA.)

Dr. Gary Salomon, a plastic surgeon, and his wife Dianne Salomon, a nurse anesthetist, gave a comprehensive presentation on Hospital de la Familia in Nuevo Progreso, a remote rural town in southwest Guatemala with a mixed population of roughly 8,000 (Ladinos and indigenous people). Both speakers have worked with the hospital for 30 years.

Over half of Guatemala’s 15 million people live in impoverished rural areas, noted Dr. Salomon. Some 46 percent of the population is indigenous; 80 percent of this group lives in rural areas. Indigenous peoples have, moreover, the highest rates of infant mortality and malnutrition in the country.

With 75 percent of the nation’s health resources concentrated in big population centers (and health care expenses representing a mere 5 percent of the government budget), these communities have limited access to health care.

Hospital de la Familia was founded in Nuevo Progreso by an American and a dedicated Italian Catholic priest who worked in the town. The American, Jack Younger, was a member of The Family Club — a private, all-male club in San Francisco that sponsors charitable initiatives — and well poised to raise money and recruit doctors to the venture.

Young’s initial fundraising led to the creation of a medical dispensary, which over time became a hospital staffed by Guatemalan primary care physicians and nurses. Although it is not a Catholic institution, four local Catholic nuns run the hospital. Working closely with local staff, traveling teams of foreign surgeons regularly visit the hospital in two week missions to provide surgeries.

Dianne Salomon, CRNA. (Photo: Peggy McInerny/ UCLA.)

Already in existence for 37 years, the hospital annually treats 14,000 patients and provides 2,500–3,000 surgeries. It has successfully taken root in the town and earned the trust of its inhabitants for two main reasons. First, the foreign doctors who both participate in the surgical missions and serve on the hospital board have made a long-term commitment to the hospital. “We show up regularly, year after year, and the locals know that we won’t suddenly disappear,” said Nishikawa-Salomon.

Second, the hospital has responded to critical local needs by implementing programs in partnership with the town that have improved residents’ health and well-being. Because malnutrition was endemic among young children and increases surgical risk, the hospital created a feeding center where nurses helped infants and children become healthy through regular nutritional meals and nursing care.

When the hospital offered sewing classes to local mothers, it used the time to educate them on basic hygiene and nutrition as well. And because education is critical to effective medical care, the hospital eventually created a K–8 school for local children, which its own staff also attended.

To reduce trachoma, an endemic eye infection that causes blindness in very poor countries where poor water, poor hygiene and crowded households all contribute to transmission, the hospital conducted health education campaigns and helped the town create a clean water supply. Surgical mission participants provided funds and technical advice, while the local residents did the work.

Finally, to develop the local human resources needed to make the hospital sustainable, Hospital de la Familia created a nursing program and, more recently, a medical technician program. Although it is not possible to train surgeons during two-week missions, the hospital has established links with medical schools in Guatemala and their students now do residencies at the hospital.

Given its striking record of success, Hospital de la Familia offers a promising holistic model of health care delivery for indigenous populations.

*Jarrahy is a plastic and reconstructive surgeon at UCLA Medical Center and an associate clinical professor and co-director of the Craniofacial Clinic at the university’s David Geffen School of Medicine. Taub is chair of the UCLA Latin American Studies Graduate Program and on the faculty of both the Department of Anthropology and the Fielding School of Public Health at UCLA.

The two professors are the co-principal investigators of the Working Group on Indigenous Children’s Health in Central and South America of the UCLA Latin American Institute, which is funded by a Title VI grant from the U.S. Department of Education, with support from the UCLA Center for World Health. Their joint research has received a UCLA Clinical and Translational Science Institute grant. A co-authored paper on the “At the Crossroads” seminar series, now in its second year, will be presented at the upcoming “UC Global Health Day.”

The series will sponsor two additional symposia in the coming months: “Pediatrics, Surgery and Anthropology in Brazil” (March 11) and “Humanitarianism, Medicine and Anthropology” (May 2).

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Published: Friday, February 14, 2014