DGH in Chiapas By Linnea Capps, MD |
I recently returned to the US after spending a year as a DGH volunteer in Mexico. I worked in Hospital San Carlos, a small Catholic hospital in Altamirano, a town of about 10,000, in the highlands of Chiapas, a beautiful area of mountains and pine forests.
The hospital has been there since the 1960’s and is run by the Daughters of Charity. It has 60 inpatient beds and a busy outpatient clinic. It also has a large program to train auxiliary nurses.
| “Working there as a physician was an experience in using basic doctoring skills without the high-tech testing we always rely on in the US...I found myself relying a lot more on intuition than I would have at home.” |
Patients come with every imaginable type of medical problem. There is a small medical staff comprised of a mixture of Mexican physicians and foreign volunteers. There are presently no surgeons or obstetricians and anything complicated has to be transferred to a hospital in the state capital, which is about four hours away by car. Also, the diagnostic testing capacity is fairly limited.
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| The hospital tries its best to accommodate the special needs of its patients. Since most have to come from very far away and are very poor, the hospital allows family members to stay in the room with their sick relative. |
I have been interested in health and human rights since my days in medical school. During my residency in Internal Medicine at Harlem Hospital, I participated in the movement to keep the public health care system in New York City accessible to the most vulnerable patients. I continued to work in Harlem after training to pay back a National Health Service Corps scholarship.
In 1984, while studying public health, I became acquainted with a small humanitarian organization, Aesculapius International Medicine, which was just starting a project (along with the Catholic Archdiocese of San Salvador) to train rural health promoters in an area where many people lacked basic health care due to the civil war. I lived and worked in Chalatenango from 1985 to 1987.
After returning to New York, I continued to work on health and human rights in El Salvador, where I met volunteers recruited by DGH and visited the project in Morazán. When DGH began looking for a volunteer to work in Chiapas, I decided to try to devote a year to working at Hospital San Carlos and exploring how DGH could support community-based health care there. I was fortunate to be able to arrange a one-year leave of absence from my work at Harlem Hospital and Columbia University. I went to Chiapas in January of 1998.
It was a wonderful experience, which I found very rewarding although sometimes frustrating. Working in a completely different culture—with patients whose understanding of illness and treatment is profoundly different from the concepts of "Western" medicine—is sometimes difficult. The vast majority of the patients are Mayan Indians. Doing a medical history and physical exam can be a slow process because of the need for translation and the cultural differences in describing the symptoms and course of an illness. Although the majority of the patients are from the Tzeltal group, many are from one of three other ethnic groups: Tojolabal, Tzotzil or Chol. They don’t understand each other’s languages, so just finding the right translator can be time consuming. And it can be almost impossible to get what we think of as an adequate history, especially when there is a chronic symptom like abdominal pain (a very common one), in which the diagnosis often relies heavily on the history. The auxiliary nurses are really good workers, but they are not professional nurses, nor do they have any real training in medical translation. I often found myself relying a lot more on physical findings (or lack thereof) and "intuition" than I would have in the US.
Many of the medical problems seen in the hospital are diseases of poverty and the lack of the most basic housing, nutrition, clean water and sanitation. We saw epidemics of several infectious diseases during my year there. At the beginning of the rainy season in May and June, there were dozens of cases of typhoid fever (or at least that’s the best diagnosis we could make without blood cultures). It seems that typhoid is a common seasonal problem, which isn’t confined to any one region. Most small rural communities don’t have running water and, since many less serious cases never get treated, there are probably many infected people with no symptoms, which leads to a lot of contamination of the environment.
| “The only real problem for me personally during my stay in Chiapas was the continuous scrutiny of foreigners by Mexican immigration authorities.” |
Tuberculosis (TB) is another problem. At one point in June there were 10 cases in the hospital’s 30-bed adult inpatient ward. There are usually at least one or two patients hospitalized with TB and the hospital diagnoses a new case about once a week. Many patients arrive with severe symptoms and one or both lungs already partially destroyed by the infection. Most never complete their treatment because they live in very isolated areas where there is no follow-up care. The hospital gives them a two-month supply of medicine, but some can’t even come for an appointment every two months since it is such a long trip and/or they don’t have money for bus fare. During the latter half of the year, there was also an epidemic of whooping cough due to the low rate of childhood vaccinations in most communities. Two young infants died in the hospital.
To make matters even more difficult, the hospital is plagued from time to time by electricity shortages, which means sometimes having to do without radiology, which makes diagnosing TB particularly difficult. In addition, the hospital lives on a shoestring budget. They occasionally run out of certain medications and other supplies, due to both the tight budget and the distance from the larger cities where the supplies can be purchased. The most essential medicines are usually available, however, and that is more than can be said of some of the government hospitals, where the patients’ families have to go out and buy medicines out of their own pocket before they can be administered.
In spite of all these difficulties, the rewards of my time there were immeasurable. It’s hard to forget some of the individual patients and their stories. There were a few amazing successes. One was Elena, a young teacher whose family brought her to the hospital in a coma. She was so emaciated we doubted we could save her. They told us she had gotten sick a few weeks earlier. They had taken her to other clinics and hospitals, but no one could help her. We admitted her, gave her intravenous fluids and tried to correct her serious dehydration and electrolyte problems. We performed what few diagnostic tests we had available, but could find no specific cause for her illness. Her parents and siblings stayed with her many days. Just when we were about to give up, she woke up. Gradually she regained her ability to communicate and to walk. Later, she told us that her illness had begun with what, from her description, sounded like the mumps. She explained that she kept getting weaker until she was unable to get out of bed or eat. The best diagnosis we could come to was that she had some type of viral encephalitis [an inflammatory infection of the brain] and that she had recovered because of the supportive care she received from us and her family.
Others may face more difficulties. Patients with chronic diseases sometimes find it impossible to keep taking their medications. I remember a three-year-old diabetic boy who came to the hospital active and well, but would clearly need insulin every day for the rest of his life. His parents were very poor, living in an isolated village with no electricity, and couldn’t read, write or speak Spanish. We spent a great deal of time trying to explain the concept of diabetes and the need for life-long medication. They left with a month’s supply of insulin. We knew it would be very hard for them to keep the insulin without refrigeration and that it would be very hard for them to bring the child back for the necessary frequent follow-up appointments. I often wonder what has happened to him.
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| A father tries to keep his infant son entertained and preoccupied in the pediatric ward of Hospital San Carlos in Altamirano, Chiapas, Mexico. |
One of DGH’s goals in sending a volunteer to Chiapas was to work toward supporting the work Hospital San Carlos had started in community-based health care, which would allow us to follow-up with patients like that child. In recent years, this work has been difficult to maintain due to the political tensions in the area and, related to these, a severe shortage of the personnel and financial resources needed to maintain the hospital and its community-based programs. I couldn’t do much traveling to communities because of the government restrictions on foreigners, but I did have the chance to observe a little of the work and begin to help plan how to strengthen it. Shortly before I left this past December, I was able, for the first time, to attend a meeting of health promoters with the Mexican physician who works in community health.
The promoters come from one of the "autonomous municipalities" (indigenous communities trying to set up their own governance structure and not depend on the Mexican government). They were in the midst of learning how to do a survey of vaccine coverage in their communities. They reported that it was very poor—as many as one-third of children under five hadn’t received any vaccines and very few were completely up to date. In some of the communities this is because there is so much distrust of the government, people won’t even accept vaccines from public health workers.
The promoters were all enthusiastic participants in the class and seemed eager to learn. The education process can be slow, however, since many of them have very little formal education and Spanish is not their first language. Although all of them speak Spanish well, they are more comfortable in their native indigenous languages, of which there are two distinct ones in this group of 12 promoters. Occasionally, they had to pause so one of them could explain a point better to the others in one of their languages.
The only real problem for me personally during my stay in Chiapas was the continuous scrutiny of foreigners by Mexican immigration authorities. Earlier in the year there was lots of talk blaming foreign agitators for all the problems and that Mexico doesn’t need any observers or outside help of any kind. There are immigration posts at all entrances into the jungle areas that are strongholds of the rebel Zapatista army and immigration agents question anyone who looks like a foreigner whom they find in an area that is off the usual tourist routes. This has meant that it has been very difficult to travel to and from Altamirano and it has also meant that I have never really been able to do any community health work since the army and immigration authorities have made it very difficult for foreigners to travel to many of the more isolated places in the "conflict" zone. I was hoping to be able to travel to more of the communities and work with health promoters in the rural areas, but that proved impossible.
Conditions remain very difficult for many people living in Chiapas. There are still tens of thousands of Mexican Army troops stationed in many areas of the state and many of the indigenous communities feel very intimidated by their presence. Peace talks have been stalled for months. No one knows what to expect next, but there remain many people in the indigenous communities and people from various humanitarian organizations (Mexican and international) who persevere in looking for a peaceful way to end the conflict.
DGH plans to continue to work in the area by supporting and strengthening the community health work that is already being done. Primarily, DGH has begun by paying the salary of the Mexican physician who is currently in charge of the community health program since Hospital San Carlos didn’t have the resources to keep him on staff. DGH members experienced in setting up community-based primary health projects will visit Altamirano to help fine-tune the program. DGH will also be actively recruiting volunteers and gathering material support for Hospital San Carlos.
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