Tuesday, April 15, 2014

Child Health & Human Rights in the Autonomous, Indigenous Communities of Chiapas, Mexico

Greetings from Altamirano, Chiapas, Mexico!

The entrance of Hospital San Carlos on Palm Sunday.
Whether providing clinic care on the pediatric ward or outpatient clinic at Hospital San Carlos, conducting neonatal resuscitation training for nursing students and other hospital staff, or working with Dr. Juan Manuel Canales in surrounding autonomous, indigenous communities, my time in Chiapas has thus far been full of rich, rewarding, and thought-provoking experiences.  At every turn, I am struck by the challenges of providing high quality and accessible healthcare and promoting the health and dignity of children and families here, amidst powerful socioeconomic, political, and systemic determinants and stark health disparities. 

First, a bit of a history lesson … On the day of NAFTA’s signing in 1994, the Zapatista uprising began in Chiapas to defend and demand indigenous rights.  After negotiations with the government stalled, the Zapatistas vowed resistance, refused government services, and created their own autonomous systems of health and education. Thousands were displaced and decades-long militarization and low-level paramilitary violence followed. While Mexico’s human development index has been on a consistent rise over the past several decades, Chiapas has seen little of this progress, despite nationwide development efforts such as Opportunidades.  The state faces Mexico’s highest infant mortality rate and mortality from gastrointestinal infections.  Half of children under five remain stunted, highlighting the high prevalence of chronic malnutrition and the concomitant increased risk of child death.  Notably, most of the children I have cared for in the hospital have been at least moderately stunted (< -2SD ht/age) and wasted (< -2SD wt/ht). Furthermore, paramilitary attacks against the autonomous communities, most recently at the end of January this year, have occurred with impunity and the blind eye of the government. 

Dr. Canales and a promotor on their way to a
vaccination campaign. No photos were taken
in the communities, to protect their privacy.
As I learned on my trips to several autonomous communities with Dr. Canales, the autonomous health systems can include basic clinics run by promotores/promatoras as well as vaccination campaigns. With the support of Doctors for Global Health (DGH), Dr. Canales works with various Zapatista communities, providing training to these promotores/promatoras and helping them plan preventative activities.  Per Zapatista philosophy and official policy, the health promoters are not compensated for their services to their communities. Importantly, vaccinations are always transported and given by the community health workers in order to maintain trust.  While vaccination coverage is strong in these communities, there are often supply shortages.  During the pediatric vaccination campaign that I attended two weeks ago with Dr. Canales and MGHfC Division of Global Health’s, Dr. Jennifer Kasper (who was able to join me for a portion of my trip), HBV, PCV7, and BCG were not available.

In the distance, families walk along the gravel road;
travel to the hospital can take many hours to a day.
Last week, I had the opportunity to conduct a newborn health / warning signs capacity-building session in one of these communities.  We used videos of ill newborns from the Global Health Media Project to challenge them to identify various such signs.  None of the health promoters had ever seen a newborn with sepsis or severe jaundice, as ill newborns self-triage and make the long trek directly to the hospital.  Typically, this is Hospital San Carlos, a non-government-affiliated safe haven run by an impressive group of Mexican nuns, which I’ll describe more in my next entry.  Though the health promoters I met had not recently experienced any physical violence, they did speak about verbal threats on their homes and land and their day to day struggles, farming corn and coffee, and feeding their families.

Never having worked in the context of autonomous, indigenous communities, I wondered how one would apply a health and human rights framework.  Namely, considering that human rights, including child and adolescent rights to health and education, refer to government obligations to their people, who then is to be held accountable to the children and families in the autonomous communities? In the absence of an accessible and acceptable alternative, the autonomous communities have chosen to have their own autonomous systems of healthcare.  At the same time, they continue to call for the fulfillment of their rights, including their right to health and healthcare.  It seems that this is in line with the United Nations Declaration on the Rights of Indigenous Peoples, a standard to which Mexico is a signatory.  Article 5 of the Declaration states, “Indigenous peoples have the right to maintain and strengthen their distinct political, legal, economic, social and cultural institutions, while retaining their right to participate fully, if they so choose, in the political, economic, social and cultural life of the State.”  Per Articles 21 and 23, and of course other, equally relevant human rights doctrines such as the Convention on the Rights of the Child, this includes, among others, education, sanitation, and health.

Certainly, the Mexican government has the obligation to respect (to not directly violate) and protect (to prevent violation by others) the rights of these indigenous communities.  Impunity in response to paramilitary violence marks an ongoing and unacceptable failure to protect.  Perhaps the obligation to progressively fulfill or realize the rights of indigenous children and families in fact lies at once in the hands of the Zapatista leaders and the Mexican government.  While the State bides its time and turns a blind eye, Dr. Canales and Hospital San Carlos continue their slow and steady campaign in solidarity with the self-determining, indigenous communities of Chiapas, an effort that DGH would call, Liberation Medicine: The conscious, conscientious use of health to promote human dignity and social justice.”  

The beautiful, rolling green landscape of Chiapas.

And I am so grateful to have this opportunity to share in and bear witness to their journey.

Ashkon Shaahinfar, MD, MPH
MassGeneral Hospital for Children
Pediatrics, PGY3

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