A psychiatrist and researcher accustomed to helping people with OCD get relief from their symptoms through innovative treatments like deep brain stimulation, Benjamin Greenberg, MD, PhD, had a very different experience on a 10-day mission to San Lucas Tolimán, Guatemala. In a Q&A, Dr. Greenberg, chief of Outpatient Services at Butler Hospital and an associate professor of psychiatry and human behavior at the Alpert Medical School of Brown University, shares the challenges of working in an environment where modernized health care as we know it in the U.S. remains a goal to be achieved, and where, as recently as 25 years ago, people still lived in houses made of cornstalks and thatched roofs.
What was your role?
I helped provide basic medical care to local people, members of the indigenous Maya population. We went to outlying villages in the community, where we set up in schools, or a storehouse—only once in an actual clinic building. We would see 40 plus patients a day sometimes, making daily trips to the outlying villages with supplies from the 30-bed parish hospital in the main town, which many of the villagers are not able to travel to for treatment.
It has been a while since I practiced primary care, so I worked closely with an internist, Steve McCloy, MD, clinical assistant professor at Brown University, who played an integral role in delivering medical care and developing health promotion in the region for over 25 years. Over the same period, the San Lucas Mission helped people acquire land and improved housing, in addition to improving public health measures. For example, there are still residents who do not have working chimneys in their homes. So, when they light a fire to cook or stay warm, they are exposed to smoke that can cause respiratory illnesses, a common problem there.
What were some of the common health problems?
We usually saw mothers and their children (as many as seven), who would come in as a group. We also saw some older women, but usually the men were off working on the plantations ("Fincas") of large landowners or in their own small gardens or in Guatemala City, where they work for weeks at a time. My background in Neurology was helpful when seeing several people with epilepsy, and a young girl with recurrent muscle weakness. Health problems ran the gamut from pediatrics (scabies, tonsillitis, chicken pox, rashes, and respiratory syndromes) to internal medicine (diabetes, diabetic ulcers and gangrene, hypertension, and angina). We brought boxes of medicines and supplies to the outlying villages we visited from the main clinic in San Lucas Tolimán, and if we had something for a particular ailment, we would give it to patients, along with pictorial instructions in how to take it in case they couldn't read. For example, pains due to arthritis or bursitis were common, and we had some analgesics for those, which we dispensed in plastic baggies. In part these ailments seemed related to a lifetime of hard physical labor. For example, people carry heavy loads of firewood on their back supported by a tumpline on their forehead.We also had antibiotics, antiparasitics, antifungals, cough medicines, bandages, dressings, and sutures. Dr. Steve McCloy was struck by notable signs of progress, like the incidence of infant diarrhea or parasitic infections seeming to have decreased over the years.
What is the behavioral health/mental health situation like over there?
The people, and especially the health promoters associated with the San Lucas Mission, have a general awareness of mental illness, like depression and anxiety, and talked about it a bit. And people there take medicines for psychiatric symptoms. I saw a man selling unlabeled capsules for "nerves and anxiety" in a very colorful open-air traditional market. A couple of patients said they took such medicines, but they may also go to traditional healers. A major problem was how to get ongoing psychiatric care for people who need it. But we mostly saw cases of epilepsy, which were brought to me because I was a "brain doctor" on hand. Same issue with getting ongoing medicines - their seizures improved on medicines, but those were expensive (consuming a quarter of one family's $1,100/year income). We tried to come up with more affordable strategies when we could.We saw a case of mixed epilepsy and bipolar disorder, and a schoolgirl with psychogenic seizures which developed after she witnessed a classmate drown. Luckily, she was already improving, so we did some brief "normalizing" psychotherapy to further her recovery.
Sometimes people would describe episodes of temporary blindness that did not seem to fit the pattern of epilepsy or migraine. Another visiting psychiatrist, Michael Bostwick, MD, from the Mayo Clinic, who was trained at Brown University, and I wonder if some of these cases might have been cases of conversion disorder – neurologic symptoms that cannot be explained by medical evaluation. The population has risk factors for conversion symptoms: poverty, poor education (though it is improving), and because the Maya were in a sense foreign in their own country by virtue of being outside the economic mainstream.
It was challenging to assess mental illnesses there. It was difficult to get a complete medical and psychiatric history from everyone, even when they spoke Spanish (my Spanish was sorely tested, but luckily I had interpreters nearby). Some older people spoke the Mayan dialect Cak'chiquel. Villagers could also be slow to disclose information, or might focus on physical symptoms instead of psychiatric symptoms.
What were some of the bigger challenges to providing them with medical care?
A problem in treating any chronic illness, including psychiatric illnesses, is to help the patient get continued access to care. We had to assess whether they would be able to continue to afford a treatment or be able to travel to where they could get treatment.
How did experiencing those conditions contrast with modernized healthcare in the U.S.?
I've seen great poverty before. It is a question of, Can you do anything about it, and if so, what can you do? Virtually without exception, they appreciated that we were there to help them. We were repeatedly told that just being there, showing concern and trying to help, was very important, irrespective of what we might have done. Clearly, this decades-long project has been a great success overall in terms of development, helping them get jobs and land, and improving their health and education. But of course, continuing access to affordable care is also a major problem here in the U.S. too.
Dr. Greenberg was motivated to join this year's San Lucas Mission by his teenage son, Sandy, who accompanied him and did development work while there. Over the years, the San Lucas Mission has helped people acquire land, improve housing, and enhance public health measures. If you're interested in learning more visit the San Lucas Mission website.