Intentions Aren’t Enough

By Nora Moraga-Lewy

The summer before I came to college, I went on a month-long trip to my family’s hometown in Nicaragua with a few friends to help start an after-school camp with a sexual health-based curriculum through an organization called Fundacion San Lucas. Although we took our mistakes lightheartedly at the time, my friends and I made plenty of errors as foreigners. My friend Alex didn’t speak any Spanish and couldn’t get any of the kids to take him seriously. It took Jesse four days to realize that her short athletic shorts were inappropriate and distracting to the adolescent boys she was trying to lecture on respecting women’s bodies. Jon kept his expensive watch on and complained when the hired driver didn’t arrive on time in the mornings.

We all had good intentions. My friends and I had a wonderful time and completed some concrete foundational tasks that were of great help to Fundacion San Lucas. But I also recognize that our impact was diminished because of our lack of preparation. And when I look back at the trip, it’s easy to see that good intentions are, while essential, a minimal part of what makes a global health field experience successful.

Student Partnerships for Global Health has worked with healthcare providers at the Subcentro Valdivia to administer HIV tests and carry out research for the past several years. (Moraga-Lewy/TYG)
Student Partnerships for Global Health has worked with healthcare providers at the Subcentro Valdivia to administer HIV tests and carry out research for the past several years. (Moraga-Lewy/TYG)

My friends here at Yale also have good intentions when they decide to pursue service trips, summer research, fellowships and other opportunities in health work abroad. Global health is appealing because of its interdisciplinary nature and because of the visible impact associated with relatively simple interventions. Sometimes, students work on projects that are directly requested by healthcare providers from sites abroad. Needs assessment surveys, which help identify the needs of a particular community or population, are another way to ensure that projects at least address a problem worth solving. Still, the work is challenging, especially when sensitive issues like sexual health are involved. Linguistic, cultural, and logistical barriers might disrupt careful planning or make it harder for students to reach as many people as expected.

The importance of a volunteer’s language ability varies with each project. Education, outreach, and face-to-face research require personal interactions (and thus, near-proficiency with the language), while lab research might not demand such extensive skills. Fluency might be more trouble than it’s worth, and sometimes we are told that we can hire translators or learn as we go. Still, we often underestimate the benefits of linguistic ability. One student from the Yale School of Forestry* admitted that, after he gradually picked up Creole while doing research on environmental health in Haiti, he began to realize that his translator was tweaking the results of the research. The translator conveyed the questions to the subjects with a different tone than intended and gave responses to the student that were more “what he thought [the researcher] wanted to hear than what was actually being said.” The quality of the student’s research was ultimately lessened by these linguistic barriers. Still, the miscommunication might have been avoided had he trained the translator before beginning interviews or found a translator with more research experience.

Language skills can shape the way in which Yale students approach service work abroad. Members of an organization called Student Partnerships for Global Health (SPGH) dedicate a significant portion of their time in Latin America to sexual health education and outreach. When asked why she chose to volunteer at an Ecuadorean HIV testing clinic in 2013, SPGH Campus Coordinator Rachel Wilkinson (SM ’16) explained that one draw was to “continue to use Spanish.” For her role in the project, being able to connect with patients in their language was important. Part of the group’s success was based on the experience of members from previous years, who passed down advice on appropriate vocabulary and tone to use during the charlas (brief lectures) given to patients at the clinic. For example, Wilkinson’s team learned to avoid technical terms in order to be more accessible for the audience (and also learned that “preservativo” is the colloquially correct term for “condom”).

Other challenges related to communication, especially with projects in sexual health, are much more sensitive. Sarah McAlister (TD ’16) is part of SPGH’s Nicaragua Team, and will be conducting research on antiretroviral treatment adherence among HIV positive patients in León, Nicararuga. She admits that one concern for her team is “learning how to […] feel comfortable while discussing private matters” such as sexual history, HIV status, or gender preferences. Successful communication regarding these issues is largely dependent on the relationship between visitors and those served by the project. Gregg Gonsalves, co-founder of the Global Health Justice Partnership between the Yale School of Public Health and the Yale Law School, emphasized the importance of “gaining trust” from the people volunteers are trying to teach, survey, and live with during their time abroad. Gonsalves said that starting points might include making a demonstrated effort to learn a language and adapting to sensitive topics in a given context. But this can be extremely difficult to do given the brief time span of most projects (often two months or less.)

Erinma Kalu (BR ’14), who served as co-director of SPGH when it was called the Yale-Ecuador HIV Clinic Initiative, encountered and studied a cultural challenge in one of her global health experiences. She took part in a group research project in 2012 trying to understand machismo – the aggressive masculine pride commonly seen in, but not exclusive to, Latin American culture. According to her team’s trip report, which can be found on the SPGH website, this cultural phenomenon seemed to play a role in how certain important subsets of rural Ecuador’s population understood and acted on issues regarding gender roles, sexual risk-taking, and HIV/AIDS. Transcripts for outreach and questions used in surveys “[had] to be very sensitive,” explained Kalu. “Especially in rural areas, where there is a lot of machismo”. Adapting project materials might be as simple as changing diction to avoid an accusatory tone, even for questions that might seem reasonable to us. At the time, SPGH was partnered with Fundacion VIHDA, an organization based in Ecuador. VIHDA provided some sensitivity training for subsequent SPGH teams in order to address various issues related to culture clash and misinformation.

Another challenge that students have faced is common to any field of study. Logistical planning can determine the success, efficiency, and enjoyment of a project abroad. “Though we accomplished our trip goals,” explained Rachel Wilkinson of her time in Ecuador, “I think we could have accomplished even more had we planned more thoroughly.” In Latin America, though, planning ahead is almost impossible. Adjustments have to be made, whether that means waiting for local officials’ approval to continue with a previously permitted project, finding out that an “hourly” bus only runs twice a day, or learning to suggest an 8:00 AM meeting time when what you really mean is 9:00 AM. Sometimes, subjects of a research project might not follow through with commitments because something comes up. Or perhaps a survey takes people twice as long to fill out as expected because of their level of education. It is important to understand that cultural and structural factors might require a change of plans.

Student Partnerships for Global Health members give a presentation on the importance of HIV testing to patients at the Manglaralto Hospital in coastal Ecuador. (Moraga-Lewy/TYG)
Student Partnerships for Global Health members give a presentation on the importance of HIV testing to patients at the Manglaralto Hospital in coastal Ecuador. (Moraga-Lewy/TYG)

Linguistic, cultural, and logistical challenges can frustrate the aims of almost any global health project. To obtain a workable set of data from research or fulfill deliverables for a project, volunteers must overcome challenges, but preparation and past experience can serve as a guide. An experienced group like Student Partnerships for Global Health has the benefit of receiving guidance from its alumni. SPGH also tries to maintain consistent contact with its partners abroad at a site they return to annually. Ideally, this continual presence will eventually make for a better working relationship between short-term visitors and the community they are trying to serve.

When approached with sensitivity and humility, the challenges of health trips abroad can provide invaluable learning experience and make a project feel more rewarding once completed. Many students who have undertaken projects in global health keep returning to the same foreign location year after year. However, to ensure that these experiences are as beneficial as possible for all parties invovled, we must make an effort to understand the challenges that other students have faced. Recognizing these issues might prevent some of the difficulties I encountered in Nicaragua a few years ago, and that thousands of students face in any given summer. In short: Do your homework, ask questions ahead of time, and you’ll extract more value from your time abroad than you’d ever have expected.

*Name was omitted to protect privacy.

Nora Moraga-Lewy ’16 is an Environmental Studies major in Branford College. Contact her at This year she is co-directing the Student Partnerships for Global Health program.