DGH Profile: Juan Manuel Canales By Linnea Capps

For Dr. Juan Manuel Canales, the regular trip to one of the most isolated communities where he works starts before dawn. It begins with a two-hour ride in the foggy darkness. By the time we reach the place where we have to start walking, the sun has come out and the fog is gone. The mostly uphill walk through pine forest and coffee fields takes another two hours, much of it on narrow footpaths. Juan Manuel is the Mexican physician Doctors for Global Health (DGH) supports to coordinate community health work at Hospital San Carlos in Altamirano, Chiapas. Juan Manuel's work consists of training health promoters from the communities and helping them carry out projects in their villages, such as vaccination campaigns. The agenda for this visit includes further work on a community vegetable garden he has helped them start. He is bringing a visiting agronomist with him to offer advice. I am joining him on this trip as the DGH project coordinator and as a physician who volunteers at Hospital San Carlos a couple of months every year.

“When I returned to Chiapas I found that most of the problems I had seen during my social service year 20 years ago still exist. There may be examples of modernization, but the illnesses that affect the poor in rural communities haven't changed much at all. ”

Juan Manuel's project involves working with indigenous Mayan communities surrounding Altamirano, many of which are small and geographically isolated. Most of them are supporters of the Zapatista movement and consider themselves to be "in resistance." They therefore do not accept any services from the Mexican government.

Not that the government ever offered them much. The lack of even the most basic of government services for the indigenous population was one of the reasons for the Zapatista uprising in 1994. Chiapas is one of the poorest states in Mexico, with rates of tuberculosis and malaria among the highest in the country. The Mexican government's own data show that immunization coverage in children in Chiapas is significantly lower than that in Mexico as a whole. Only 76.1% of children under one year of age had completed the basic immunization series in Chiapas in 1996, as compared to 91.8% in Mexico overall. Access to medical care is limited by the scarcity of physicians in some rural areas of Chiapas. In municipalities where the indigenous population exceeds 70%, the ratio of physicians to population is 1 to 25,000 (the United Nations recommends one physician for 1,000 people).

Juan Manuel with indigenous children in a community in Chiapas.

There is little other data on access to health services, but a study by Physicians for Human Rights found evidence of barriers to care experienced by indigenous residents. These include the continued militarization in Chiapas and the often poor quality of services in the government health system. Non-Spanish-speaking indigenous residents of Chiapas often avoid taking advantage of publicly-funded health services for fear of being misunderstood or threatened. This is one reason for the popularity of Hospital San Carlos which, unlike the government hospital, offers round-the-clock translation services to patients who do not speak Spanish.

“The model of community health that we want to build starts with how they want their community to develop, not what we think is best for them.”

Hospital San Carlos served over 13,000 patients in 2001. The hospital records reveal that these patients came from over 400 villages in 29 municipalities of Chiapas, meaning that many or most had chosen to bypass Mexican public hospitals in order to travel to this private facility. In addition, since the government has failed to implement the agreement it made with the Zapatistas during the negotiations of 1996, the communities that support the Zapatistas feel they have been deceived and that the government has no real interest in ending the impasse and bringing social justice to their communities.

The first day we spent with the promoters this trip included classes on better methods to prepare the soil and plant vegetables to improve nutrition, such as carrots and radishes. There was also practice actually working in the garden. The next day was devoted to discussions of medicinal plants. Juan Manuel is trying to help the promoters find effective plant-based remedies for some of the simple problems they see. Medications are very expensive and difficult to carry into the community because it cannot be reached by vehicle. We also met with a newly-organized women's collective that is trying to start some projects to produce things for their families (like bread and children's clothing), as well as possibly selling them to raise money.

Juan Manuel remembers seeing the enormous differences between the lives of the rich and poor in Acapulco where he grew up. His parents never got past primary school and earned a modest living running a small store and restaurant in their home. They earned just enough so that all their children could go to school. While a student, Juan Manuel worked occasionally as an assistant to a carpenter. He recalls going to work in the elaborate mansions of the wealthy and then passing by the make-shift homes of the very poor. This influence stayed with him during the early 1970's when he graduated from high school and was considering going to the university. Being sympathetic to the plight of the poor, he decided that he wanted to become a physician as a way to help them. He went to Mexico City to attend the university there in 1971.

During the years he was in medical school, there was a very strong student movement with demonstrations and strikes. At first he didn't get involved thinking that he had come to study and not to be involved in politics. In 1974, conditions for the students became nearly intolerable due to cuts in the budget for public education, so he went on strike with other students. He also became involved with students who had progressive political views and were interested in community health. It was with them that he started to work on a special project in community health in Chiapas. During his social service year at the end of medical school he worked with a group of 10 doctors, each of whom were assigned to give medical attention to five or six remote communities in the jungle near the Guatemalan border.

Dr. Juan Manuel Canales training community health workers in Chiapas, Mexico.

He then spent several months in Guatemala and was trained in surgery in the field and worked with health promoters in indigenous communities, teaching them first aid. After a few months, he went back to his family in Acapulco. His parents were worried about him and tried to persuade him to start a medical practice in his home city. But he soon went back to Mexico City where he was re-united with the same group of doctors he had worked with in Chiapas.

This was in the early 1980's at the beginning of the civil conflict in El Salvador. He worked with solidarity organizations and collected material aid. In 1982 he went to El Salvador and spent several years in the northern area, serving as a physician. "I learned so much from the campesinos we worked with," he says. "We all lived and worked for years in extreme deprivation, but the spirit of struggle was what sustained us." In 1988 he went to live in Santa Marta, El Salvador, a community made up of people who had fled their homes during the war and returned to their communities when conditions made it possible.

He decided to return to Mexico in 1999 to finish his studies for a masters degree in public health, which he had started years earlier. He was happiest doing work in rural communities and wanted to stay in Mexico and find community health work.

This was when he came across DGH and its work with Hospital San Carlos in Chiapas. "When I returned to Chiapas," he says, "I found that most of the problems I had seen during my social service year 20 years ago still exist. There may be more highways and other examples of modernization, but the illnesses that affect the poor in rural communities haven't changed much at all." In addition, the violations of human rights have only become worse. He notes that there are government institutions that are supposed to monitor the situation but there is rarely any punishment for violators of human rights. Paramilitary groups operate with impunity.

Juan Manuel sees a side of rural Mexico that is rarely noted by the many tourists who pass through. Most of the people in these communities depend on coffee for the little cash they earn. The dramatic fall in the world price of coffee has had a major impact on them. They are now getting about 50 cents for a kilo of coffee, which in some cases does not even pay for their costs of producing and transporting it. For many of them this means there is almost no cash income at all, and therefore no money for clothes, shoes, medicines or other necessities for their families.

"If you ask the campesinos the price they are paid for the coffee they grow and the price of the necessities for their families, then you will have an idea of how hard their lives are," he explains. "If you look inside their houses, you see the difference between what our government says and the reality. The social programs of the government don't do anything to stimulate development of the communities. They have a paternalistic attitude and try to limit the political growth and understanding of the people. In contrast, we are trying to work with the communities in a way that respects their autonomy. The model of community health that we want to build starts with how they want their community to develop, not what we think is best for them."

When asked about his association with DGH, Juan Manuel says, "It is important to me to be working with people who have the same world view. We all have to do something to make changes in the world. Too many people who see poverty don't have any opinions about what should be done. But we have to be a part of the movement for change and as a group we can work more effectively than any one of us alone." He also wants to encourage DGH members to continue to be part of the struggle to change the policies of the US government because its decisions have such a huge impact on marginalized people around the world.

As we were finishing the discussions with the promoter group, talking about their progress in improving health in their communities, Miguel, the coordinator of the group, said, "When Dr. Juan Manuel came to work with us, we had nothing. We didn't know how to start our health projects. We are still very poor and we have a long way to go, but now we can see how working together we can make our community better." One of the women added, "We are so grateful for the help of Juan Manuel and DGH. We know we are not alone."

Juan Manuel examining children in the remote indigenous communities of Chiapas, Mexico.