In This Issue:

DGH has been accompanying communities in Chiapas, Mexico, in two important ways: providing volunteer health professionals to rural Hospital San Carlos and supporting a Community Health Worker (CHW) project. The CHWs are from 35 isolated, indigenous, autonomous communities that have decided not to accept services from the Mexican government because of its maltreatment of the indigenous people, and are struggling to manage their collective resources. A DGH-supported Mexican physician coordinates the CHW training in nutrition, vaccination, parasite treatment and giving vitamin A to prevent night blindness. They are also starting community vegetable gardens and constructing environmentally-friendly stoves. This issue has three articles that provide a glimpse into both types of work being carried out in Chiapas.

My Six Months in Chiapas By Lleni Pach, MD

After over 30 years of teaching and practicing general, child and adolescent psychiatry as a Clinical Associate Professor at Upstate Medical University in Syracuse, NY, I decided that my next professional and personal stage would be working with underserved populations through the practice of general medicine, since it is difficult to reach such populations through the practice of psychiatry alone.

As a Peruvian and having done my Medical Education at San Marcos University in Lima, Peru, it seemed that the best place to pursue such an endeavor would be in a Spanish-speaking country. I thought that it would be easy to attain such a goal, since I had the academic credentials, experience and Spanish fluency. Yet it took me about two years to find an organization that supported and facilitated my re-tooling in clinical medicine. Those two years were marred with frustrations as I found myself blocked by the fears of different medical environments about legal constraints. Fortunately I found Doctors for Global Health, an organization made up of supportive, flexible and forward-minded people whose main goal is serving the needy, rather than getting snarled by misplaced fears that undermine the original purpose of the Socratic oath.

My quest finally took me to Altamirano, a town in Chiapas, Mexico, where I came to work as a volunteer in Hospital San Carlos. The Sisters of Charity from Saint Vincent de Paul have administered and worked in Hospital San Carlos since 1976. They have received many volunteers from DGH, and they accepted my coming under the condition that I would stay for six months and be supervised the first two months by Linnea Capps, MD, a DGH board member who coordinates DGH's Chiapas projects and has worked in the hospital several months a year for many years. She is also the Residency Program Director of Internal Medicine at Harlem Hospital in New York.

“It took me about two years to find an organization that supported and facilitated my re-tooling in clinical medicine. Those two years were marred with frustrations... Fortunately, I found Doctors for Global Health, an organization made up of supportive, flexible and forward-minded people whose main goal is serving the needy.”

Present-day Altamirano has a few primary schools, one secondary school with about 300 students, and two Prep Schools (one for technical training, CONALEP, where the majority of students come from both Tzeltal and Tojolabal indigenous-group communities, and the other, COBACH, which most of the town children attend). During my time there I stayed at the home of Juan Manuel Canales, MD, a member of DGH and its in-country project coordinator. He was a most gracious host, who helped ease my transition to the hospital.

A new Hospital San Carlos was inaugurated in November 2004. It has 60 hospital beds: 30 for adults with an area for isolation, and an Obstetrics and Gynecological floor; and 30 for children with a prenatal and intensive care component. There are five outpatient offices, a pharmacy with donated medications, a very basic clinical laboratory (no cultures), and two operating rooms.

The hospital, which is open 24 hours a day, seven days a week, is oriented to providing care predominantly to the poor indigenous population in the surrounding villages. The outpatient service has five nursing auxiliary-translators, and the various floors have nursing staff that speaks the different native languages.

The hospital also provides milk to families in need. The old hospital building is partially dedicated to attend to a limited number of convalescent patients. It has a humble Inn for family members that need to stay overnight and it also provides food for many of them. In the inpatient services the hospital allows up to two relatives to stay overnight with each patient, giving them blankets for the night.

Besides the predominance of respiratory infections, the hospital also sees typhoid fever, malaria, tuberculosis and, recently, an increasing incidence of HIV. There is also a lot of alcoholism in the area, but most of those patients are not seen at the hospital.

The design of the new hospital is such that it is easy to go quickly between the outpatient and inpatient service areas. This facilitated my ability to consult with the other physicians, who were most receptive and helpful. The situation encouraged me to start seeing patients independently after just three weeks. Soon afterwards I was asked to help out with the on-call schedule, initially during the weekdays and later on weekends. Their support and trust in my recovered clinical skills was of much value and I am very thankful.

I also was asked to give psychiatric consultations, and provided therapy to individuals and families. The psychiatric problems most commonly seen are related to alcoholism, family violence, depression and psychosis. There was a consensus by several people that the problems of alcoholism, violence and prostitution exploded as a result of the presence of the Mexican military station that had settled in the outskirts of town after the Zapatista uprising in 1994.

I was confronted with the suffering and injustice of the economic disparities that caused the uprising in my daily work in the hospital. I will never forget the patient who came to the hospital because he had been loosing his vision. One eye was already blind and we wanted to save the other. Unfortunately, we could not do what we needed to in the hospital and the cost of such an intervention elsewhere was too high. The patient and his family decided that they could not spare the little money they had on the operation, so they started the long trek back to their village with the knowledge that one of their family members soon would be completely blind.

Still, I quickly settled into a comfortable routine. In the early morning when there was still mist and fog in the mountains that surround Altamirano, I would take my daily walks towards the forested areas. I found laborers holding their machetes, schoolchildren walking or riding bicycles. There was an abundance of greetings. "Good morning, Sister or Brother," was the typical greeting. I would cross the streets watching the roosters, dogs, horses, goats, sheep, pigs and cows. I could hear, from early on, the sounds of the radios playing both Mexican and American music coming from the households or the stores.

Towards the outskirts of the town I found the campesinas carrying wood on their backs with a strap that they held on their forehead. Others carried baskets with white lilies, amaryllis or alcatraz (the calla flowers that one sees in many of Diego Rivera's paintings). They brought all these to sell in the market. In the region they also grow chrysanthemum for wholesale distribution.

There is a remarkable abundance of bird life here as well-blackbirds, magpies, hummingbirds, vultures, finches, blue bird, warblers, flycatchers, herons, egrets, oriole and more. Their songs kept me company while I walked, their melodies competing with the noise of the chainsaws - the deforestation in Chiapas is of alarming proportions.

In February the town celebrates its Patron Saint, Caralampio. I have been told that this holiday was instituted by the merchants who wanted to take advantage of the coffee profits that occur at this time of the year when residents have money to spend on household goods.

My time in Altamirano was an invaluable experience. I was able to recover my diagnostic skills in general medicine, see a diversity of unique clinical presentations and experience the generous support of other professionals. And, most importantly, I had the privilege of experiencing the Chiapanesca culture and its people in all their historic-social richness.

I plan to continue on this new path I have been lucky enough to embark upon. I foresee continuing to work with other marginalized populations under the auspices of DGH and being supported in this aim by DGH's philosophy of Liberation Medicine-the conscious, conscientious use of health to promote human dignity and social justice.

OTHER ARTICLES IN THIS ISSUE