A healthy approach to medical care in Guatemala means providing services in indigenous languages. Dr Peter Rohloff on the work of the Maya Health Alliance
Access to healthcare in one’s native language is an important human rights and healthcare quality issue. In higher income countries and settings, healthcare institutions address the needs of clients by hiring professional interpreters for the languages that they commonly service. However, increasing international migration can strain these arrangements when patients speak less common or indigenous languages, and when contracted or in-house language services are unable to locate a qualified interpreter. As a Guatemalan language specialist, I am contacted almost weekly by hospitals all over the United States trying to locate speakers of Mayan languages.
This reality also raises a larger question: if it is so difficult to provide linguistically appropriate care to speakers of less common languages in high-resource settings, what is the situation like in their countries of origin? Let’s explore the case of Guatemala. One of the largest countries in Central America, Guatemala has a population of just under 17 million. There are 23 distinct indigenous languages in addition to Spanish, most of which are in the Mayan language family. Just under half of the population speaks a Mayan language, and several of these languages have communities of 500,000 or more speakers.1
Since 2003, the government has officially recognised the right of speakers of indigenous languages to receive all public services, including education and healthcare, in their own language.2 However, there is no funding and little political will to implement this law, so in practical terms, speakers of indigenous languages are unable to access any services (with the exception of basic primary school education) in their preferred language. A recent national healthcare survey illustrates this point well. Respondents were asked to report the language used at their last visit to a public hospital or health centre; more than 95% said Spanish was used.3
In 2007, I helped to found Maya Health Alliance (also known as Wuqu’ Kawoq), a unique primary healthcare organisation which is dedicated to providing services in Mayan languages and changing the national discourse around the use of these languages in service provision. Although a small organisation, with around 50 healthcare providers, we are one of only a handful of bodies working to develop and disseminate best practices for work in Mayan languages and healthcare in Guatemala. We have learnt some important lessons along the way.
An affirming institutional culture
When Maya Health Alliance was founded, the main goal was to create a healthcare institution which prioritised service delivery in Mayan languages. To do this, it was critical to make deliberate personnel choices, taking the time to ensure that the people we recruited were able to speak Mayan languages. We are proud that more than 90% of our healthcare providers are themselves indigenous Maya and therefore able to provide linguistically appropriate care to their patients.
Within the organisation, we prioritise the use of Mayan languages in other ways, such as encouraging their use in casual and office conversations, and by making excellence and innovation around language use one of the criteria for promotion and advancement. Given our connections to both Guatemalan and global academic health communities, many of our staff are able to attend regional and international professional meetings to share their work and receive recognition.
The work of our nursing staff on using smartphones to provide care in Kaqchikel was recently featured on the front page of Guatemala’s most important newspaper.4 In this project, nurses work closely with lay midwives, who attend the majority of home births in rural parts of the country. Midwives can use their smartphone interface to alert on-call nurses to any complications they are encountering in the field with their patients. The nurses can then help the midwives to triage and make a decision about whether an emergency hospital referral is required. If so, the nurses work to coordinate emergency transport and facilitate receipt of the patient by hospital staff. This arrangement has more than doubled the number of patients delivering within the hospital setting.
A lack of native vocabulary
It is not enough to simply employ Mayan-speaking staff. The Guatemalan universities and technical schools that train healthcare workers provide instruction only in Spanish, so many of our workers are initially very uncomfortable providing services in Mayan languages, despite being native speakers. This has to do mostly with the fact that Mayan languages lack native words for most of the technical medical vocabulary.
This is a commonly encountered problem for minority languages, and one which language revitalisation specialists have spent a lot of time thinking about. The most common solution is to work with a community of language speakers to develop – and then disseminate – neologisms to cover the missing lexical items.
This was Maya Health Alliance’s early strategy, and we worked to develop many medical words in collaboration with community and academic partners, including Guatemala’s Academy of Mayan Language. However, this approach turned out to be very problematic because most of the neologisms were completely unintelligible to patients and ended up creating more communication barriers than they solved. They also tended to reinforce class differences between our providers and their often much poorer patients, with many patients saying things like, “I guess I don’t speak Mayan as well as you do.”
We reevaluated and came up with an unorthodox solution. Essentially, we began encouraging our providers to codeswitch between Spanish and Mayan languages. The instructions go something like this: “If you don’t know the word in Mayan, your patients won’t either; just use the Spanish word.” Our primary goal, after all, is to understand and be understood, and codeswitching freely is a distinguishing characteristic of natural discourse in Mayan languages in all but the highest register of academic or ceremonial speech.
This approach has also allowed us to be much more focused and strategic in our use of selected neologisms. If a Spanish loan word is well understood and commonly used in everyday speech, then we encourage our providers to use it. Pulmón, for example, is the most commonly used word in Kaqchikel for ‘lung’, whereas almost no speakers recognise the native word pospo’y. However, there are other Spanish loan words which few people understand, and we target these words for replacement with native neologisms. Although many patients use the Spanish word diabetes to describe their illness, some do not understand what diabetes is. In contrast, our new word rukab’il ri kik’ (‘sweet blood’) is readily intelligible to most speakers and conveys important information about the disease.
Innovation and consistency of care
Another area of language-based innovation involves the development of a ‘care navigator’ role. Although patients may receive linguistically appropriate care within our organisation, when they are referred to a different institution they likely will not. We collaborate with several large hospitals to provide cancer and cardiovascular care, and none of these facilities has interpreters on staff or access to contracted interpreter services. This means that there is no access to interpreters for indigenous patients in any of Guatemala’s major medical facilities.
To address this, we train care navigators, who are native Mayan language speakers and professionals, typically with a social work background. Training begins with formal didactic sessions reviewing the social and cultural barriers to healthcare access in Guatemala, assessing dialogic strategies taken from motivational interviewing and shared decision-making theory, and discussing conflict resolution. Subsequently, new navigators ‘learn by doing’, working in tandem with an experienced navigator who models behaviours. They then gradually assume responsibilities, with direct observation and feedback.
When patients require referral, care navigators accompany them to the hospital, providing logistical and emotional support and, most importantly, acting as interpreters so that patients can understand what is going on. Unfortunately, formal training programmes for interpretation are a long way off in Guatemala, and we recognise that our navigation staff still have much to learn. In fact, a long-term goal is to develop more formal standards and a training programme for Mayan language interpretation. Nevertheless, at this time, the arrangement works well, since patients express a high degree of satisfaction with – and confidence in – their navigators. In particular, overcoming the language barrier means that they are more likely to complete their treatment. For example, in our experience of providing navigation services for indigenous women with cervical cancer, more than 80% successfully complete their entire treatment course compared to less than 50% previously.
More than 10 years after starting this work, we continue to advocate for the use of Mayan languages in healthcare and to show that it is possible to provide high-quality care in these languages. By raising the visibility of Mayan languages in healthcare – by providing accompaniment and interpreting services in public referral hospitals and training other institutions in our approach to language use – we are also contributing to a national discussion about language rights and healthcare inequality.
1 Richards, M (2003) Atlas Lingüístico de Guatemala. Guatemala City, Guatemala: Editorial Serviprensa
2 Government of Guatemala (2003) ‘Decreto Numero 19-2003’. Guatemala City, Guatemala: Government of Guatemala
3 Ministerio de Salud Pública y Asistencia Social (MSPAS) (2015) ‘VI Encuesta Nacional de Salud Materno Infantil’. Guatemala City, Guatemala: MSPAS
4 Ola, AL (26/8/18) ‘App Salva Vidas’. In Prensa Libre
Dr Peter Rohloff is the Chief Medical Officer for Wuqu’ Kawoq (Maya Health Alliance) in Guatemala and a physician at the Brigham and Women’s Hospital in Boston, USA.