It is my second week working with the local pasante in Soledad. One of the most striking challenges in this rural community is the care of patients with mental health issues. Depression, especially amongst women, is rampant in the community, and driven in large part by the social structures un which they live. Machismo reigns strong and many women start having children between 14 and 16 years of age, becoming financially dependent on their husbands. While by no means the rule, in many relationships, women are treated as second class citizens and ruled by their husbands. Domestic violence is prominent. I have met several young women this week whose husbands do not let them leave the house without them, depriving them of what we know to be a fundamental human necessity for happiness – to socialize and form bonds and friendships with family and peers. I met one women who we tried urgently to get to go to a nearby for an abdominal ultrasound who would not go because her husband was not home. I met another woman who we treated for sexually transmitted infections who was trying to extricate herself from an abusive husband who also maintained two other families. Many of these women certainly meet the DSM-5 criteria for major depression however their depression is so intimately tied with their social factors, their sometimes abusive relationships, their role as mother and keeper of the home, and their social isolation. Individual psychotherapy is not available. But through the clinic and through the support of the local physician and PIH, the community tries to combat this epidemic. Community health workers visit these women weekly. Support groups and women’s basketball teams try to combat social isolation. The physician supports them with medication and monthly medical appointments.
Even more startling perhaps is the challenge of confronting psychotic mental health disorders, primarily schizophrenia in a resource-limited setting and without significant access to psychiatric hospitalization and day programs. The unfortunate reality of this situation is that families, often ill-equipped to combat the sequelae of a serious psychotic disorder, are forced to be the primary caretakers of their family members with schizophrenia. They are supported by the local pasante with medications and home visits as much as possible. Yet, it is an enormous struggle for patients with serious psychotic disorders to live amongst their communities. The patients with schizophrenia that I visited often live separate from their families in a shack nearby and chained to a post that does not let them wander further than a few meters away. Yes, these patients are marginalized and live in less-than-ideal situations, yet they are integrated into their communities in a fundamental way. The community is small enough that these patients are well-known and in many ways protected by their communities. When a patient several weeks ago developed neuroleptic malignant syndrome and had to be sent urgently to a tertiary care center several hours away, the community came to the support if the young man and his family. Again, I am struck by the simultaneous challenge of providing medical care in a resource limited setting and the ability of the community to organize to support itself, and the role that a small community can play in improving its health.