There is a self-healing mechanism always at work inside you … This doesn’t mean Osteopaths should sit at the side of the table, hands lightly hovering over the patient, doing nothing, as some critics of this gentle style of [medical] practice accuse us of doing. –Bonnie Gintis, DO, Engaging the Movement of Life—Exploring Health and Embodiment Through Osteopathy and Continuum

Roosters crow, golden streaks of light lick the sky, dogs bark, a woodpecker taps, the jacaranda trees blush in purple splendor, a bird whistles, the waters of the swimming pool are still. No car, truck, or diesel growls, whirs, whines. Medical students, doctors, and volunteers are awakening to dawn at Hotel Dos Mundos in the village of Panajachel in the Highlands of the Sierra Madre mountain range in Guatemala. 

In a few hours the open-air market and stores that line the village’s main street will be ablaze with the vibrant tapestry and clothing of local weavers. Women whose arms are draped in fabric that they have woven will call out and brush up against passersby, “Buy from me? Onedo-LAR scarves. You like? I make—no machine! Ochenta quetzales por éste!” 

Two hours later Dr. Camille Bentley rousts a medical team of thirty-two volunteers as she walks in the courtyard of Hotel Dos Mundos. Medical supply bags are being loaded onto tuk-tuks, the three-wheeled motorized taxis that will drive them to the pier overlooking Lake Atitlán. When Dr. Bentley says everyone is to be ready by 8 am, she does not mean 8:03 am.  

 In her clipped, no-nonsense Brooklyn accent, Dr. Bentley, director of global medical outreach at Rocky Vista University in Parker, Colorado, has briefed the group. She calls their service in Guatemala a “triple win,” good for the Guatemalan patients, good for the students who will practice medicine under the guidance of an attending physician, and good for medical professionals who will practice “the true art of medicine without the restraints we have in the United States—reinforcing why we are in the profession.”

“If you’re seeing a mom with three kids, listen to each one’s heart, lungs, belly,” she tells the students. “If your findings are all negatives, assure the mother her child is fine. The local doctor may sit on other side of the desk and see 200 patients a day, and they might not lay a hand on a patient. Instead you touch them, find the soft tissue, drop a stethoscope under clothing, under the thick brocade. Find the little person underneath.”

Guatemalans are small in stature, tracing their roots to indigenous Mayan peoples and sixteenth-century Spanish conquistadores. Most come to the clinics festooned in long hand-woven skirts and tunics or dresses known as huipils. Like their ancient foremothers and forefathers, these peoples use natural dyes from plant, animal, and mineral sources. The women’s long, lustrous hair may sparkle with sea shells, pearls, metallic discs, seeds, pods and other headdress.  A backstrap loom may be used to weave patterns of glyphs, geometric shapes, plants, and flowers. The thick brocade worn by patients in the clinics presents a challenge to the medical team, since they often work in one large room without privacy partitions.

Dr. Bentley instructs, “Pay attention and do your best. If you're afraid, let me know. If you don't know much about medications or dosing, work in the pharmacy under the supervision of someone who does—our registered nurse Barbara Crawford.  When you're examining a patient, and you think they might be malnourished or you aren't sure what is going on, consult with one of the attending docs.”

She advises the students to keep a log of each patient they see—age, sex, diagnosis. “If it’s a healthy child, that's a diagnosis.  Write down your positives and negatives on our medical form. What in the history led to your diagnosis? What is pertinent that supports it?  It could be something positive, like laughing. As part of your assessment, write down your plan—it could be education or medication or follow-up with a local doctor. If you prescribe a drug, consult the formulary—don't simply list ‘antibiotic’—which antibiotic?”

Dr. Bentley sums up the mission: “We are here in Guatemala as a team. During the workday or after our work at the market or a restaurant, never forget: you represent Rocky Vista, the medical profession, the United States.  Always keep that in mind.”

A triple win? Really?

After the briefing Allison Nelson tells a fellow third-year medical student Anna Austin, "I'm not a real doctor. I'm afraid I'll miss something.” Anna, who had persuaded Allison to make this trip, admits that maybe she herself “doesn’t have enough fear of things.”  Nonetheless, together and with the help of the attending physicians, they will figure things out.

Key to figuring things out is a cardinal principal of osteopathic medicine that Dr. Bentley has cited: “Work on the skin whenever you can.” Dr. Andrew Taylor Still, who founded the practice of osteopathy in 1874, described fascia as “pure living water,” “the framework of life,” and “the dwelling place in which life sojourns.” He developed techniques that use hands-on manipulation of joints and bones to diagnose and treat illness. He wrote, “I know of no part of the body that equals the fascia as a hunting ground. It surrounds each muscle, vein, nerve, and all the organs of the body. By its action we live and by its failure we die.”

The medical team will probe physical bodies and fathom culture in Guatemala, “land of forests,” the name derived from one of the Mayan dialects spoken at the time of the sixteenth-century Spanish conquest. Many of the people speak Spanish, but about thirty-five percent speak only their indigenous Mayan dialects, K’iche’, Kaqchikel or Tz’utujil.

 During their nine-day trip in March, the RVU group will set up clinics in villages bordering Lake Atitlán, a vast shimmering lake formed from the caldera of a volcanic eruption some 84,000 years ago.  From Panajachel in the southwestern Highlands of Guatemala, the team will go to San Antonio Palopó, San José Chacayá, Sololá, and Chuabaj. The last is a new site, farthest away from the national hospital in Sololá. 

The group uses a chartered turbo bus named Santa Rita. It’s a retrofitted school bus, no seat belts, thinly-upholstered narrow two-person benches that seem inclined to dump occupants into each other’s laps. The bus rollicks around steep, paved roads, countless switchbacks lined by leafy palm trees, terraced lands lush with maize, coffee, and beans, towns dotted with small concrete or plaster houses painted lime, aqua, and pink, shops topped with corrugated metallic roofs.

The fourteen medical students, one undergraduate, five physicians, three nurses, one dentist, one dental assistant, one firefighter, and six community volunteers will treat nearly 600 patients. Each clinic is set up from scratch in a multi-purpose assembly hall where staff of the Guatemalan First Lady and the local mayor have deployed townsfolk to assemble tables, chairs, and hand sanitizers. In late afternoon, villagers will serve fresh fare of beans, rice, chicken, thick corn tortillas, freshly-harvested fruit, and bottled water.

A clinic is born—adapting to fewer resources, different cultures

To reach the first clinic, the group boards a ferry bound for San Antonio Palopó, a rural village on Lake Atitlán’s eastern shore where the elevation starts at 5,124 feet. As the vessel nears the village, passengers gaze at corrugated tin roofs, small squat shops, and homes built on steep inclines. The medical team walks briskly if somewhat breathlessly from the dock onto cobblestone-lined streets that ladder their way into the sky.  

At the crest of the walkway is the town hall, and the team climbs winding stairways to the second floor where a clinic is assembled in an all-purpose assembly hall. Students and doctors don stethoscopes and reach into big canvas bags that they have carefully assembled at RVU.  They pull out medications, medical forms, disposable gloves, an eye-chart, reading glasses, sunglasses, soaps, shampoos, shoes, OTC pain meds, antacids, and vitamins. Stations are quickly arranged consisting of chairs alongside laminated tables. At each of five stations, two medical students will conduct exams under the supervision of a physician. Three other stations use examining tables for ultrasound, osteopathic manipulation, and dentistry. 

 Barbara Crawford, RN, staffs the last station, a pharmacy. Her outlook: “Practicing international medicine is the most important rotation a medical student can experience. Medical school training doesn’t necessarily focus on adjusting treatment plans based on culture, race or ethnicity, or providing care with limited resources, yet at the same time the US population is growing in diversity. Traveling to other countries, you become more accustomed to working with different cultures. You learn to treat with far fewer resources available to you. You become more capable of treating a person effectively because you see first-hand the impact of social determinants on health.”

Charlie Echeverria, a fourth-year medical student specializing in osteopathic manipulation, is treating a laborer with back pain. Another student doctor and physician have already examined him and referred him to Charlie for further diagnosis. They didn’t ask the patient to disrobe since this clinic is one big community room without privacy.  At age two, he broke his arm, and it atrophied. The humerus juts out beneath the skin, and he is wearing extra support for his back. 

Garbed in a traditional Mayan knee-high, woven skirt, thick high socks, and vest, this five-foot tall slender man lies on an examining table while Charlie begins rocking motions and manipulates his spine.  If they shared a common language, she would tell him that she’s working to calm the sympathetic nervous system. His pain most likely comes from a lifetime of not being able to use one arm. In his work as a laborer, he has built up muscles on one side of the body to compensate for impaired and weakening muscles on the other side. The resulting imbalance has manifested in hip dysfunction. Why would he feel acute pain in his low back if the dysfunction is the hip? “In osteopathy we say if you step on a cat's tail, where does the sound come out?”  One body part may squawk, and something adjacent may be compressed. When the man gets up from the table, he offers Charlie a big smile and a nod. 

Allison has been assigned to work under Barb’s supervision in the pharmacy. Soon a patient stands at the pharmacy table, a baby in a woven sling on her back, and another young child holding her hand. The diagnosis is scabies, a contagious skin infestation from a mite that burrows into the skin causing itchiness and a pimple-like rash. Permethrin has been prescribed. Allison looks the patient in the eye and calls her by name, as written on the script.  Holding up a finger, Allison says, “Un momento.”  She walks across the room to check with a student doctor to confirm that all three patients, mother, child, and baby, have been diagnosed with scabies. When Allison returns, the mother is standing quietly, the child at her breast, her four-year-old son at her feet playing with a truck given out by the clinic. As Allison gives dosing instructions, she watches the mother’s face to see if she looks confused. Gracias comes the soft reply.

 Mid-day during a break, Allison will declare, “My Spanish is better than I thought it was.” For those patients who speak an indigenous dialect, she may call on a local interpreter who speaks Spanish and Mayan dialects but little to no English. Allison observes that mothers with two or three children sometimes have to wait for a script to be filled while other patients are processed more quickly. During the wait, “There is a stillness there.”  Her friend Anna quips, “In America, they threaten to sue you if they have to wait five minutes longer than someone else.”   

By mid-afternoon Barb is thumbing through the medical forms for each patient. “We've seen joint pain, allergies, back pain, sore throats, vision problems. That’s not surprising. The people here use open fires in their homes to cook so they have respiratory illnesses. They walk up and down steep hills of the village, so they have joint pain. The impure water supply and [insufficient] hygienic practices make them more vulnerable to fungal infections, eczema, scabies, as well as stomach pain, diarrhea and other gastro-intestinal issues. The women work from an early age in textiles. Vision problems and arthritis are common.”

“Faith in the human body to heal itself”

Before dusk the group walks back to the dock and boards the ferry. 

Allison goes top-deck, sits on a bench, and leans back into the breeze. Does she still feel overwhelmed?  She grins. Nope. 

Charlie contemplates the lake, the deepest in Central America.  Does she think her osteopathic manipulations helped ease pain and treat the underlying conditions she saw today? Yes, she nods. Treatments don’t result in immediate healing, of course. She affirms the entire premise of osteopathy—“It’s a faith in the human body to heal itself.”

Bradley Cross, a third-year, squats on the deck and observes, “Even when we can’t offer treatment, a diagnosis can be reassuring.”  For example, “We told one patient who had an unstable shoulder, ‘It’s not going to get better unless you have surgery.’ The patient thanked us, said he didn’t have money for surgery, and said he was glad it wasn’t cancer.”

Instead of waiting for a translator, Brad deployed a strategy he uses to treat infants. “They can’t tell you what’s wrong, but you can do a physical. When the translator shows up, I ask questions based on my physical findings. If the belly is hard, I ask, ‘Does it hurt you when you eat, before you eat, in the morning, at night? When is the pain worse?’”

Considering this first clinic, he declares, “We’re already a team.” Leadership matters, and Brad is impressed with Dr. Bentley’s briefings and clear directions. “I don't think she ever said ‘might.’ Instead it was, ‘This is the way it is.’”

Dr. Bentley has coordinated the trip through Guatemala’s SOSEP—Secretaria de Obras Sociales de La Esposa del Presidente, a humanitarian outreach group organized and run by the first Lady of Guatemala, Patricia Marroquín. 

The trip itself is sponsored by a US non-profit, Hands for Health Inc. Founded in 2012 by Dr. Bentley and Dr. David Kanze, Hands for Health provides health care to persons living in developing countries, and it supports culturally sensitive and medically competent education of new physicians and medical students.  Dr. Bentley leads three trips each academic year to Latin American and African countries. Chair of RVU’s Tracks and Special Programs, she is investigating a longer outreach trip with Spanish immersion during the school’s spring break.

On the ferry Brad looks out at the volcanic mountains and escarpments encircling the lake.  Visible is a ridge known by its profile as Indian’s Nose. Brad wants to remember his experiences in Guatemala.  Recalling his thirteen years in the military, including two tours of duty in Iraq and service in Kuwait and Qatar, he says, “The stories I remember from the military are the ones I can't tell my family—like people’s legs blown off.  I’ve forgotten two-thirds of what happened, the good stuff, the awesome persons, helping Iraqis.”  In contrast, what is happening here in Guatemala is already shaping itself into stories that he can tell his three sons and wife.

At today’s clinic, the first of four, the medical team has seen 136 patients. “You did a great job,” Dr. Bentley tells the students. She’s been to San Antonio Palopó sixteen times, and this clinic was the smoothest. Her spouse Keven Meyer is dancing on the ship’s deck—he spent the day giving eye exams and dispensing eyeglasses. He reaches for her hand. They dance—he’s got the moves, and she follows. This day’s work is done. 

Carol Sullivan, PhD, wrote this story. A Denver writer, yoga teacher, former state legislator, and former adjunct associate professor at the Colorado School of Mines and other colleges, she is one of the community volunteers who made the trip.