Changing the Face of Health Care for Latinos/as
Every seat in the waiting room is filled and even some of the floor is occupied as children sprawl with crayons and coloring books. The patients at the Spanish clinic are waiting for Dr. Manuel Guillermo Herrera Acena, and when they see him walk in, the room lights up with a collective smile. He smiles back as he hurries to check in with Lucia Cardenas, the receptionist, and don his white coat.
Herrera Acena, a long time professor in the Harvard Medical School (HMS) and the Harvard School of Public Health (HSPH), runs The Spanish Clinic of Brigham and Women’s out of the ambulatory building of the Harvard teaching hospital. In the late 1960s Herrera Acena observed that Latinos/as in the Boston area had trouble accessing adequate health care. “The barrier was not just linguistic,” he notes. “It was attitudinal, it was social, it was cultural, and the lack of congruence between the culture of the patient and the culture of the care giving institution really prevented good health care and humane and effective medicine.”
In 1971, with the approval of the director of Ambulatory Medicine, at what was then the Peter Bent Brigham Hospital, Herrera Acena began to hold one session a week of the outpatient practice in Spanish. “I wanted to give patients a kinder and more receptive ambience when they approached this enormous building,” he says. The Spanish clinic offered services in primary care, social services and mental health care. “The demand was there,” Herrera Acena says. “The clinic just took off.”
Today the clinic is open three evenings a week with a staff comprising five primary care doctors, a nurse practitioner, a nutritionist, a psychiatrist, a social worker, a receptionist, and medical students. Spanish is the official language, and staff are required to have an affiliation with Latin America as well. They see patients from Central and Latin America, mostly immigrants, mostly middle-aged, who have come to this country to improve their standard of living.
Social worker Julia E. Rodriguez says that Herrera Acena “is like a godfather to these people. That’s the first word that comes into my mind,” she adds laughing.
“When it’s the patient’s turn,” says Rosemary Byrne, the nurse practitioner, “it’s the patient’s turn. It’s their health issues, how’s the family, what’s going on at home. He’s not high tech and the patients really appreciate that. Dr. Herrera Acena is the last one to leave the clinic. Always. Time with patients is first and foremost.”
Byrne and the physicians on staff consistently see the same health problems among the patients — high blood pressure, high cholesterol, depression, and diabetes. Many of these problems can be traced to the host of issues they deal with as immigrants, which can either provoke poor health or worsen an existing condition. Herrera Acena cites the emotional stress patients experience due to loss of extended family, separation from familiar circumstances, and inadequate housing.
Rodriguez, a Dominican who lived in Puerto Rico, says she has a special affinity with the patients. She connects them to resources outside the clinic that may help them cope with their problems, especially housing issues, which she says are prevalent.
Herrera Acena, originally from Guatemala, received his medical degree from HMS in 1957. Early in his career he identified a lack of emphasis on nutrition in medical school curricula. His investigations led him to an assistant professorship at HSPH in the mid 1960s. Today Herrera Acena can take credit for work in several related areas: nutritional research in developing countries, a student exchange program at HMS, and the Spanish Clinic.
Herrera Acena’s work with nutrition has taken him around the world and led to collaboration with government agencies such as the National Institutes of Health (NIH) and UNICEF. In Sudan, he studied the effects of vitamin A supplementation on child mortality and morbidity, a project that involved 28,000 children. He was also the principal investigator in a joint study promoted by the Colombian government and the NIH, which studied the effects of malnutrition in pregnancy and early childhood.
“The hope is that some of our work gets translated into policy and action to solve the problems,” Herrera Acena states. “But those wheels turn very slowly, as you know. It’s difficult for agencies; many times for them doing research means diverting resources from their mission. So, I think it’s very important for organizations such as the World Bank and AID to fund medical research.”
Herrera Acena says he is especially pleased with the success of a student exchange program at the HMS he helped create in the 1970s. Fourth year medical students can sign up for Medicine 518, ‘Nutrition and Rural Medicine in Latin America.’ First they receive intensive instruction in Spanish; this portion of the course was developed by Professor Chad Wright, then at Harvard, now a professor of Romance Languages at Catholic University in Washington, D.C.
After this, the students spend two months abroad in a clerkship designed to give them medical experience in a Latin American setting. “Here they can perfect the language, they learn culture, and they learn the roots of many Latinos/as who live in the US who they may later work with. The students come back transformed.” Herrera Acena beams. “They come back really conversant in the culture, able to practice medicine in Spanish.”
Five hundred students have participated in the program so far; it continues to be a popular elective at HMS. In 1999, the PBS program La Plaza produced ‘Doctors for Two Worlds,’ a documentary which profiled a student as she progressed through the intensive Spanish course and her subsequent clerkship in Guatemala.
Students can travel to Ecuador, Bolivia, Venezuela, Costa Rica, Guatemala or Puerto Rico for their clerkship, Some of these sites send their medical students to HMS, as well, where they work with their American counterparts in Boston hospitals and help each other with cultural and language issues.
In Guatemala, the Universidad Francisco de Marroquin operates a health clinic where students from HMS work alongside their Guatemalan colleagues, who are newly graduated doctors. Supervision from senior physicians is limited, and some of the population speak only the native indigenous Cakchiquel.
Students who go to Bolivia work for the Fundacion San Gabriel, started by ___, the first woman in Bolivia to attend medical school. The foundation supports an 80-bed hospital in La Paz and satellite clinics in the surrounding barrios. Students divide their time between the hospital and clinics.
“The students stay in touch,” says Herrera Acena. “What is even more rewarding is that most of them are now resources for Latinos in the community.” He is pleased that he can refer his patients at the clinic to former students practicing in the area.
One of his biggest challenges at the clinic is space, physical and temporal. Because they see more and more patients, he and his associates would like to expand, but don?t have the space or the resources to do so.
Byrne and Rodriguez echo his frustration. Both would like to see the clinic hours expanded. Rodriguez says that she must do her follow-up work during the day while she is at another job. Byrne says that she has seen patients reluctant to come for an evening session when the seasons change. As it gets darker earlier, and when the weather is bad, patients do not want to wait on a dark street corner for a bus. She would like to see some daytime hours.
Herrera Acena continues to study the patient/health care relationship and finds that his efforts are improving patient health. He cites a diabetes program in which 20 patients meet on a regular basis, with clinic staff, over lunch. The goals are not only to disseminate information on treatment but more importantly to allow the patients a chance to talk about their lives in a relaxed atmosphere.
Herrera Acena recounts the diabetes lunch session earlier that day. At the beginning of the session, as they do each time, everybody’s blood sugar was measured. He invited the two with the highest readings to accompany him on a brisk walk. When they returned and their blood sugar was measured again, the levels had dropped by 1/3. This made quite an impression, he says, on all the members in the group.
This program was begun with the aid of Mercedes Barnet from the Office of Minority Health in the Department of Health. Another such effort is ongoing with asthma patients, a joint effort between Spanish clinic staff and Brigham’s asthma clinic.
Herrera Acena attributes the successes of his career to the people around him. But the awards that grace his office at HSPH indicate that he has played a vital role. The honor which touched him the most was one the HMS graduating class of 1996 created, along with the William Bosworth Castle Society (???). They presented him with a huipil, a hand embroidered blouse from Guatemala, and a plaque which reads: “To Manuel Guillermo Herrera Acena; For your tireless efforts teaching Spanish to generations of medical students, and single handedly arranging clerkships at rural health centers in Latin America; For your creation of the Brigham and Women?s Hospital Spanish Clinic, which for the past twenty-five years has provided invaluable service to the Latino community; And for your warmth, generosity and advice; We are indebted to you.”
Susie Seefelt Lesientre is a publications intern at DRCLAS for the fall semester. She is enrolled in the Certificate for Publishing and Communications program at Harvard Extension. In 1990 she received a Master’s degree in TESL; she has taught ESL in the US and abroad.
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