Rural Health Care and the “Problem” of Language

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Peter Rohloff has training in parasitology, internal medicine and pediatrics. He practices in Boston, MA at Brigham and Women's Hospital and Boston Children's Hospital. Since 2003, Peter has been working in Guatemala, where he serves as the medical director for a health systems NGO – Wuqu’ Kawoq | Maya Health Alliance. Peter’s interests include the management of chronic diseases of children and adults in resource poor settings and how indigeneity, cultural, and language barriers impact access to and utilization of health care. @wuqukawoq

Global health is big business these days. Many of the readers and contributors to this site and others like it have at least partially staked their professional careers on its continued growth. From the perspective of low and middle income countries, what this means is that there has been a surge in the numbers of health volunteers, development experts on the make, health policy analysts, and career health systems bureaucrats all around the world. In development hotspots like Guatemala (where I work), they can be found, literally, everywhere. For example, in the last decade alone, the number of nongovernmental organizations in Guatemala has catapulted from 1-2,000 to 10-15,000 (1).

And these are not all foreign health and aid workers on the make either. Indeed, one clever social scientist studying organizations in Guatemala coined the term “Astroturf NGOs” to describe organizations created by urban Guatemalans to compete for international and government health contracts. Astroturf NGOs have historically been quite successful at winning contracts, because they appear to be “local” — although, in fact, they are “not grassroots but, rather, grass-without-roots” (2).

The end result, from the perspective of a rural target community is that, suddenly, there are a lot of development workers (foreigners and urban nationals) around, all the time. And, in Guatemala, these outside workers speak Spanish or English, and because they are relatively new to the field they have little insight into local customs and culture. This is a problem, because rural Guatemalan communities speak mostly Mayan languages, not Spanish or English. However, the need to access development services is strong enough, that local communities do their best to “get by” with the little bits of Spanish or English that they do know. This has two effects.

First, it reinforces the mistaken perception by development workers that language/culture is a minor technical issue, one that can sort of be brushed by with sufficient good will and good intent. The insularity of development work is self-fulfilling in this context, as development workers talk mostly just to other development workers about the effectiveness of their projects. For example, a recent report on contraception utilization by indigenous women is typical; the socio-cultural analysis section concludes that language and culture were not barriers to care – based solely on interviews done with development professionals, asking them if their perception was that these were barriers (3).

Second, given the enormous differential in social capital between the development worker and the rural subject, the presence of Spanish/English-speaking authorities/benefactors sends the message that speaking these global languages is a prerequisite to accessing services. This sets up, in effect, a perverse choice between one’s own language/culture and plain survival. In short, in rural Guatemala today, development work is one of the largest contributors to language and cultural death.

And this is not a phenomenon that is limited to Guatemala. Rather, all around the world, marginalized languages and cultures are threatened, in part by development work. Wherever rural or minority linguistic communities are led to believe that they must make a choice between “development” and “traditional values,” language death is occurring. This is not a trivial issue, since, of the more than 6000+ languages in the world, UNESCO estimates that fully 50% will disappear within the next several generations (4).

Even for those who might not be terribly exercised by the prospect of mass language extinction – and the contribution of the global health and development community to this extinction – there is still the issue of quality in service delivery, which should matter to everyone. On this front, it is remarkably evident that language and cultural barriers are a significant factor in the failure of development schemes. For example, in rural Guatemala, the one variable which correlates well with utilization of life-saving obstetrical services by rural women is contact with a lay midwife – in other words, contact with a community-based health worker who shares the same culture and language as the patient (5). In our own ethnographic work on health care access with patients in Guatemala, abandonment and mistrust—all occasioned by linguistic disparities—are the most common themes that emerge (1).

In a remarkable study from another region of the world—Cameroon—researchers interviewed informants in their native language of Nugunu or in French. When informants were interviewed in Nugunu, they were 6 times more likely to report that “development” was something that came from outside the community and was external to it. On the other hand, when informants were interviewed in the colonial language of French, they were equally more likely to respond “correctly” and state that “development” was grassroots, coming from within the community itself (6). In other words, informants knew that French coded for access to development and social capital and, as a resulted, responded in a way they knew was consistent with what development workers wanted to hear. On the other hand, when interviewed in their native language, they responded honestly, betraying the gulf in trust and the impaired agency that actually characterized their experience of development.

If we really want our development to be grass-roots, locally-engaged, democratic, and effective, we’ve got to start taking language and culture seriously.

1. Rohloff, P., Kraemer Díaz, A., & Dasgupta, S. (2011). “Beyond Development”: A Critical Appraisal of the Emergence of Small Health Care Non-Governmental Organizations in Rural Guatemala. Human Organization 70:427-437.

2. Cardelle, Alberto. (2003) Health Care Reform in Central America: NGO-government
Collaboration in Guatemala and El Salvador. Coral Gables, Fla.: North-South Center Press.

3. USAID (2009). Guatemala: Estudio del Acceso a Servicios e Insumos de Planificación Familiar. Washington: USAID.

4. Matsuura, K. (2007). Languages Matter! Message from the Director-General of UNESCO on the Celebration of 2008, International Year of Languages. Paris: UNESCO.

5. Glei, D.A., Goldman, N. (2000). Understanding ethnic variation in pregnancy-related care in rural Guatemala. Ethnicity and Health 5:5–22.

6. Robinson, C.D.W. (1996). Language Use in Rural Development: An African Perspective. New York: Mouton de Gruyter.

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