Friday, April 3, 2015

Compañeros en Salud – a model for rural primary care in Chiapas, Mexico

Week 3

Compañeros en Salud

The Mexican branch of Partners in Health, also known as CES or Compañeros en salud is based in Jaltenango, surrounded by a number of rural communities in the sierra of Chiapas, where new Mexican medical school graduates (pasantes) are placed to fulfill their one year obligatory service posts. Currently there are 10 pasantes in 10 communities, each about 1 to 3 hours from Jaltenango on rough rugged roads. CES maintains a relatively lean budget, using it to supplement the government support of the pasantes so that they do not need to rely on the goodwill of community members to host them free of charge (the government provides US$150/month and CES effectively doubles this stipend). The budget also supports several supervisors, all of whom recently completed the CES pasante program, who travel between communities to support, precept, and teach the current pasantes. Many of these supervisors will be living in Boston in the upcoming years to complete master’s degrees in global health and public health. Additionally, the budget allows CES to supplement the often inconsistent and meager medication supplies provided by the government, and to help ensure that the pasantes have the basic medical equipment they need to provide care. Several short and long-term volunteers also support CES, mostly from the U.S., with a medical director who recently graduated from Brigham and Women’s medicine residency program.

My role over the coming weeks is to offer support to several pasantes in two communities (Laguna and Monterrey), accompanying during visits and providing feedback and suggestions throughout the course of clinical visits. A major goal of the CES program is to improve the training of Mexican doctors, through direct clinical practice and observation, as well as through monthly didactics that take place in Jaltenango. During this month’s course, we discussed topics of biopoder (biopower), nutrition, diabetes, and tuberculosis. One pasante presented an M&M case (morbidity and mortality) of neuroleptic malignant syndrome in a man with schizophrenia and another presented a morning report style case of possible Scarlet Fever in a child. A humanistic curriculum session to discuss the emotional aspect of medicine was also included.

Overall, the program seems to emulate some educational aspects of a U.S. medical residency (although on a much smaller level), while providing extra support to pasantes who otherwise would have a very isolated and resource-restricted experience trying to care for the local community. Hearing pasantes talk about the various urgent cases that they have managed, you realize that with a few key resources and a good understanding of when to triage to a higher level of care, there is a lot that can be done in a very resource-limited setting. Some of those key resources include materials to start and maintain IVs, fluids, oxygen with nasal cannula, oral and nasal airways with ambu bag, suturing materials, local anesthetics, saline flushes, bandages, tourniquets, inhalers and nebulizers, steroids, antibiotics, anti-hypertensives, insulin, aspirin, and other key medications.

One thing that I will have to get used to in the coming weeks is the difficulty in obtaining laboratory work. In the U.S., when you start someone on anti-hypertensives, in particular on diuretics and ACE inhibitors, a basic chemistry panel is a must to ensure that our patients are not becoming hyper or hypokalemic. In the communities, however, the nearest lab may be over 2 hours away, a trip that many patients may not be able to afford or fit into their week. In the U.S., we order TSH screening tests like candy - if someone has constipation or fatigue or palpitations, failing to order a thyroid screening test would be neglect. However, in order to get a TSH in the communities, one not only has to travel to the hospital in Jaltenango, but one also has to pay an additional fee to the lab. For this reason, it is so important to be critical about what labs are actually likely to change management in a significant way. More on patient care in future posts, as I have yet to spend a significant amount of time in any one community.

Finally, one last observation that I have been struggling with is the fact that none of the pasantes are actually from Chiapas. The large majority of pasantes have graduated from one of the top Mexican medical universities, in particular from Instituto Tecnológico de Monterrey. On the one hand, CES is able to work with the best medical graduates to build their potential to function at a higher level and in that way bring up the overall quality of medical care in Mexico. These pasantes will go on to complete residency programs in various specialties, some will pursue degrees in public health and look forward to a career in research and program development, others will remain as general practitioners and work to educate the upcoming classes of pasantes after them. These individuals will be leaders within the Mexican medical system in the coming years. One day, CES can and should be run by Mexicans, who have a stake in improving their own health care system.

Nevertheless, Chiapas remains one of the poorest regions of Mexico, and the patients being seen in the community clinics are very different from the pasantes themselves. The difference in class and education and culture are marked. In some ways, the pasantes are almost as gringo as we are (of course, not really, but sort of). Some of them love camping and REI and American films as much as we do. Yet, the experience of serving these rural, impoverished communities must be striking and indeed quite impactful. In the U.S., programs like these (Teach for America, Americorps, National Health Service Corps) change the way individuals understand the inequalities in our society, and may help to change perspectives and policies down the road. Of course, what is ultimately needed is development of educational and employment opportunities and upward mobility for people in Chiapas. The goal is to have doctors from Chiapas who will stay in Chiapas and who understand better the needs of the community. What I have been told is that the universities in Chiapas are not good, and for this reason, CES has not had pasantes from Chiapas. However, how might the program change if these folks were sought out and recruited and mentored to their full potential? Certainly there would be challenges, but it would also bring a richness and perhaps greater accountability and responsiveness to community needs.

The CES Radio Show

Every Sunday morning, one of the CES supervising physicians Héctor invites a guest speaker to a local radio station in Jaltenango (broadcast to many of the rural communities where CES works) to discuss a topic relevant to public health. Previous topics have included nutrition, alcoholism, diabetes, depression, antibiotic overuse, UTIs and others. This Sunday we talked about hypertension, and I was the “expert.” Some common myths that we covered included the idea that hypertension could be caused by a susto (a scare), an idea that many people in Guatemala also have regarding diabetes. Other myths included the fact that medicines for hypertension are caliente (hot), meaning that they interact with various vitamins and herbal remedies and may cause gastritis or other problems. Many people buy these medicines over the counter, sometimes without the evaluation and prescription of a doctor, and we had a caller who asked if I could prescribe something for her over the radio for her headaches that she felt could be caused by hypertension. (Of course I said no). Other people are prescribed anti-hypertensives, then stop taking them because they are told the medications interact with alcohol and they do not wish to abstain from alcohol. Others stop taking their meds when they start to feel better, not understanding that hypertension is a chronic disease. Still others spend their money buying medications from pharmacies in town, believing that the free medications offered at the community clinics must be worse because they are free. We addressed these concerns, while also discussing the enormous burden of hypertension in the world (9 million 400,000 people die from complications of hypertension every year) and in Mexico (according to a 2012 survey, 1 in 3 people live with hypertension, yet only half of them are aware of their diagnosis, and only half of those are controlled). Finally, we spent a good amount of time discussing dietary, exercise and other lifestyle changes to prevent and treat hypertension at the most basic level. We ended the radio show with one of my favorite songs by Marc Anthony  :)

On Government Programs

Later in the day, Héctor took me on a jog through Jaltenango’s Ciudad Rural, a government program throughout Chiapas to build sustainable communities for low-income families. The community in Jaltenango was built after an earthquake destroyed the previous settlement, and is quite lovely. There are 600 brick homes with tile floors and enough space for a family, with a lawn in the front with space for a garden. There is a central garden where theoretically vegetables and fruits can be grown for local consumption (not sure whether this is currently in use, as it was too dark to see the gardens). There is a church. There is a central park/plaza for taking walks, sitting, jogging. There are streetlights powered by solar panels, which unfortunately cost too much to replace when they break (10,000 pesos), so at least half of the lights are out. Unfortunately, of the 600 homes, at least a third or more of the homes are currently unoccupied, as people have had to move out of the community to find work, as there are few job opportunities in the surrounding neighborhoods. Many of the residents work as mototaxistas, shuttling people around town in hybrid motocycle / taxis for 5 pesos (~33 cents) a ride. The homes were gifted to families, and thus are technically owned by the families that originally settled in the community. However, it seems there is some barrier to selling the homes if a family must move out, so the homes lie unused when a family can no longer support themselves on the meager job opportunities available in Jaltenango.

During our jog, Héctor explained to me a bit about the Mexican public health care system, explaining concepts that had been brought up during the CES course for pasantes about biopoder (biopower, or the systems and hierarchies that affect people’s health on a broad institutional level). For example, all Mexican citizens have access to universal health care through Seguro Popular (the health safety net insurance for those who don’t qualify for other insurance programs through employment and income levels), with a list of at least 250 preventive and other medical conditions that are covered fully by the insurance. These include things like vaccines, diabetes and hypertension care, prenatal and postpartum care, and many common urgent care conditions like parasites, respiratory infections, ulcers, dengue, etc. The difficulty becomes when the government and their body of experts must decide which conditions are covered and which are not. Theoretically, the most cost effective interventions for common conditions are covered, while less cost effective interventions for rarer conditions are not. Through decisions like these, the government is able to maintain lower overall health care costs, with approximately 6% of the GDP dedicated to health expenses (compared to 17% in the U.S.). Nevertheless, it is difficult to place a cost on the value of a life and decide when it is not cost effective to try to save a life. Also, which conditions are covered may be influenced not only by objective measures, but likely also by politics and who is making the decisions.

A third program that is quite interesting and again partially problematic is the program now called Prospera, previously called Oportunidades. Effectively a welfare program, the payments are however tied to requirements such as attending prenatal appointments, following up with chronic disease care, ensuring that your children attend school, etc. Payments vary depending on income and family size, on the order of US$60-$100 monthly. The program becomes problematic when you think about the power that it gives to those supervising visits, who determine whether or not an individual has completed the requirements and thus qualifies for payment, and when thinking about the barriers to an individual or a family in fulfilling the requirements, and the fact that the most vulnerable individuals will have the most difficulty completing the requirements.

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