“Últimamente me he sentido muy cansado,” starts explaining Genaro. He has been feeling tired, but also weak, and unable to concentrate on things. Since he arrived in Providence a couple of years ago from the highlands of Guatemala, he has been doing hard work — manual labor like construction and carpeting, working long hours for little pay. “Se me olvidan las cosas,” he continues. He has been forgetful, and has had trouble holding on to jobs. He is getting depressed because he doesn’t know what is happening to him.
“Did he have any head trauma? Does he have trouble with his vision? Has he had thoughts of hurting himself or others? Does he have any other medical problems? When was the last time he saw a doctor?” Dr. Boulel asks me. And I translate into Spanish. That is the purpose of my presence at the free clinic today. But I already know that today there is more to be translated than just language. Genaro is confused by all these questions. He wants to know what is wrong with him, why won’t the doctor just tell him? Surely there must be a pill he can take to go back to normal.
Dr. Boulel is from Syria. I know little about him but I think he has been in America for a long time, probably longer than Genaro and I combined. He knows Arabic, and his English, though heavily accented, is almost perfect. Genaro’s language isn’t Spanish, but Quiché. It’s a Mayan language spoken by only one million people in the Guatemalan highlands. My knowledge of Spanish is supposed to make ‘Latinos’ feel comfortable. Dr. Boulel thinks Genaro feels at ease with me because of the Spanish, but doesn’t know that Genaro barely knows it. Why should he, anyway? In Guatemala, it’s the language of oppression. I am wondering if my presence is making things any better — does it help at all to attempt this translation, from one foreign language to another?
Dr. Boulel wants to do a MoCA. The Montreal Cognitive Assessment Test (MoCA) is a screening tool for rapid detection of cognitive impairment. The provider asks the patient a series of questions — some math, some language — and scores his answers on a scale of 0 to 30. A score of 26 and above is normal. Anything below that is abnormal. The test has been translated into 38 languages. Spanish is one, and so is Estonian (spoken by 1.1 million people in Estonia). But Quiché isn’t. And what good would it be anyway, when neither of us speak it, and Genaro, most likely, doesn’t read it? Dr. Boulel prints a Spanish copy of the test from the Internet.
The first question shows a bunch of letters and numbers randomly spread around a boxed area. An arrow points from number 1 to letter A and then to number 2. “Mira,” I say. “Desde el numero uno se va hasta la letra A, y desde el numero dos …Y así sigue…” So it goes on. “Now you continue. What comes next?” Genaro stares at me. “After one comes two and then three and then four … After A comes B and then C and then D … No entiendo.” I repeat the instructions but he meets me with the same blank stares. By now I am certain he must be thinking that I’m crazy. Now, as I write, I’m wondering — why is that we always think that by repeating the exact same thing many times, people will eventually understand us? As if the problem was theirs, as if they hadn’t listened the first, second and third time, as if there was a switch they could suddenly turn on to understand us the fourth time? I wasn’t explaining this well, and I didn’t know how to. Dr. Boulel didn’t know how to help. Maybe there was no way to help, and the question just didn’t make any sense to begin with. If after 1 comes 2 and then 3, what do A and B have to do with it?
Genaro starts getting nervous because he realizes he is failing the test. Dr. Boulel is nervous because a) Don’t I speak Spanish? Why doesn’t the patient understand me? And b) Hasn’t this guy been to school, or what? He decides we should move on to the next question.
“Draw a clock that shows 11:10.” Genaro grabs the pen. “Once y diez?” he confirms. This time, he wants to get it right. Then he draws a rectangular digital clock display and carefully writes 11:10. He makes the numbers look like they would appear on a digital display with the one made out of two lines … “No, I meant a clock like this one” and point to my own watch. He stares for a second then draws a circle. “I don’t know these types of clocks” he says, and puts down the pen.
Dr. Boulel looks at me and sentences: “Okay, let’s give him half the points.”
Next come the animals. A lion, a rhinoceros and a camel are drawn on the page; they are staring at Genaro waiting for him to recognize and name them. The correct answer would be: “un león, un rinoceronte y un camello.” Genaro stares at the animals and thinks. He thinks for a few minutes. Dr. Boulel and I get increasingly anxious. I am really wondering if these animals have ever been seen walking around the highlands of Guatemala, and cursing whoever thought it was a good idea to pick exotic, African animals to test the cognitive abilities of people all over the world. Why not a chicken, a dog and a cow?
In the end Genaro points at the lion and says “Creo que es un tigre.” He thinks it’s a tiger. Close enough. Dr. Boulel smiles, he will give him the point. Then Genaro points at the rhino and says “ésta … Pues, no sé, pero creo que es una vaca.” I can’t resist and burst out laughing. It is completely unprofessional, I know, but too ironic to resist. There are few things the whole world has in common and one of those are cows. Maybe he’s thinking that in America, where everything is different, cows’ horns are in the middle of their faces instead of on top of their heads. I’m thinking that maybe in America, where everybody is different, they could have considered that some places don’t have rhinos, but all places have cows.
Finally, he looks at the camel and gives up. Its neck is indeed too long for it to be a horse, plus it doesn’t have a mane, its tail looks like a cow’s, and what is up with that strange bump on its back?
I turn to Dr. Boulel and translate. Not just the language and the animal names but what I can imagine came behind them. I don’t know much about Guatemala but I have been to Chiapas, Mexico, the region which borders Guatemala and shares many of its geographical features and ethnic groups. I think of the bright green hills and coffee plants and say “there are no rhinos, camels or lions in Guatemala. I don’t think this reflects his cognitive ability.”
“But didn’t he see them in school?” the doctor asks. I am not sure about Syria, but I am guessing that there are no lions there either. Nor are there any in Italy, but both Dr. Boulel and I remember seeing pictures of these animals in grade school. But the schools I saw in Mayan communities in Chiapas were one-room shacks with a chalk board and children of all ages sharing a single bench. There were no picture books or computers. The students’ notebooks were almost empty, and the few pages that weren’t were used to practice the alphabet, and numbers. I didn’t see a single rhinoceros.
I imagine that where Genaro grew up in Guatemala was somewhat similar to that. I explain this to Dr. Boulel. He gets it. Although he said earlier that this test “is supposed to be universal,” he knows it’s not, as nothing can be. He was just trying to be thorough, to quantify things, as we like to do in America. There is so much guessing going on when we try to understand where “people who are different from us” are coming from, what they are saying, what they want from us. Things like the MoCA are just a way to fool us into thinking we know something about somebody and their world, when really, we know nothing.
Genaro aces the next questions which are pure memory and math. I decide to change the words he has to memorize to things that make sense, picking “chicken” instead of “silk.” Dr. Boulel is generous with his grading and Genaro gets a 27. Normal. Despite all of this he made it pretty clear to us that he is not cognitively impaired; if anyone in this room is, it is more likely to be one of us in white, asking absurd questions.
Dr. Boulel refers Genaro for an MRI and he is sent over to those who can help him schedule it. Although with no insurance, who knows if he will get one? I try to reassure him that his test was normal, and translate Dr. Boulel’s explanations — “perhaps you are working too hard, perhaps you are feeling depressed, where is your family?” He wants to know what is wrong but we don’t know. So he goes.
I haven’t seen Genaro since but I have been thinking about him often, and about my role as an imperfect translator not only of languages but also of worlds. From Spanish to English, from Guatemala to Syria. I often think that because I myself am ‘diverse,’ because I am an immigrant, because I speak many languages, because I have traveled, I can provide better care than others could. But in this case, both Dr. Boulel and I, diverse as we are, failed Genaro. I can only guess, but we probably made him even more confused and distressed than he was when he came in. Will the MRI make any difference? Will it make him feel better? What if it comes out normal, as it most likely will?
Diversity means that people are actually all different from each other, not just from ourselves. So being diverse does not mean we will just ‘get it.’ There can be no manual for dealing with “diverse patients,” be they “Latino” or “African,” just like there can’t be one for “White Americans.” I do my best to take guesses and try to translate languages and worlds, but Genaro reminded me of the limits of language (and pictures), and gave me an important lesson in modesty.
Author’s note: This is a nonfiction piece but all names and identifying information have been changed.
Contributing Writer Emeritus
Warren Alpert Medical School of Brown University
Bianca is a Class of 2015 medical student at the Warren Alpert Medical School of Brown University. She graduated from Harvard College in 2009 where she majored in global health and African studies. Before medical school, she was a case worker in New York.
