Friday, April 29, 2016

Mexico (Chiapas): Medical Experience

Kaysia Ludford
Resident in Internal Medicine
PGY2, Brigham and Women's Hospital

This spring, I traveled to Chiapas, Mexico to work in rural communities cared for by CompaƱeros en Salud (CES), an NGO of Partners in Health. CES has been in the state Chiapas for about 5 years, currently supporting 10 rural clinics in the Sierra Madre region of Chiapas, located in the southern most part of Mexico, abutting Guatemala.  The organization has partnered with the Ministry of Health in Mexico to select 11 “pasantes”: physicians who have just completed their last year of medical school to work as primary care physicians in these clinics during their mandatory year of service. All medical school graduates are required to do this year. The pasantes tell me that oftentimes, most graduates (especially those with higher grades who have more luxury of choosing) opt to stay closer to home in urban areas if they are from big cities or try to go to work in big cities . Graduates from more rural locations also try to go to bigger cities as well as this opens more opportunities for jobs and fellowships after the year of service is over. As a result, communities like those in the sierras of Chiapas which are rural and poor have typically struggled to recruit highly qualified and eager pasantes to work there. All that has changed however since CES implemented its program there.  Among the many things the organization does are its provision of logistical, material and education to the providers. The organization sponsors 10 clinics, three of which I was fortunate to work in during my month there.

Lugana del Cofre, from left to right
 pasante extraordinaire Sebastian
 Each clinic has one pasante who is responsible for providing medical care for the local community (about 1500-2000 people in each place) for one year. CES supports the clinic with medications for a range of illnesses ranging from depression to infection. This supplements but does not overlap with the supply stock provided by the Ministry of Health. Additionally, CES has formulated a training curriculum for the pasantes. Every month all 10 providers come together at the organization’s headquarters for 4 days and receive courses in global health/social medicine and general medical topics and ones unique to practicing medicine in resource-poor settings. As part of that training CES also has frequent volunteers from different residency programs in the US who travel to the communities and work with the pasantes for 2-4 weeks providing additional support and help with reasoning through and making medical decisions of patients attending clinic. It was in this context that I traveled to CES and to Mexico. I worked in 3 communities Reforma, Laguna del Cofre and Soledad, each very similar but at the same time very different from the other.

Throughout my time working in these communities with the pasantes, I was most struck by the genuine care and tenderness with which each of these young doctors treated their patients. Because they lived in the communities 24/7, leaving only for the course with CES each month, they knew their patients intimately in a way I have not seen while practicing medicine in the US. Patients would routinely invite me and the pasante into their homes to share dinner (on one occasion we had a delicious posole chicken soup), to hang out with their children or just to chat. The beauty of having that sort of relationship is that it fosters a sense of trust and understanding that is hard come by behind the confines of an office desk. As a result, patients felt extremely comfortable going to the pasantes with even the most complex social problems, or knocking at their door at odd hours of the morning if someone became acutely ill. They were always greeted with a welcoming smile and kind words; the disadvantage to this being that the pasante is always on call and without ever having much opportunity get a mental and emotional break from the role of “doctor”.  The other thing that struck me was the great lengths to which pasantes go to advocate for their patients. When I was in Laguna del Cofre for instance, a 40 year old woman was taken to us by her family, lethargic, anorexic and insomnic for more than a week. The paperwork that accompanied her showed that she had developed acute and persistent renal failure over the previous few months with the kidneys functioning less than 5% of normal.

We suspected that her renal failure was the reason why she had no appetite, was lethargic and had swelling in her legs and fluid in her lungs and that she urgently needed to be hospitalized to undergo further testing. Recognizing this, the pasante re-scheduled all our remaining patients in clinic that day so we could travel two and a half hours to the nearest hospital with this patient. Once we arrived we were met with resistance by the hospital team there as they did not have the necessary tools to take care of the patient and felt they would not be able to offer much:  no equipment to check her basic labs , EKG to check her heart function or dialysis to remove the toxins that had built up in her blood from her failed kidneys. The pasante cajoled, argued and negotiated with the staff opting to pay out of pocket for the necessary lab tests for his patient that night. Together we came up with a plan for her care there, the pasante wrote the admission note and thankfully because of his herculean efforts, she was admitted and fluid diuresed off her lungs significantly improving her breathing.

Overall I was inspired by my experience in Mexico to see ways in which dedicated physicians are making strides in improving individual lives and the health of whole communities with limited resources. I feel encouraged and excited about my own journey to strengthen and improve care in marginalized places in my home country of Jamaica. 

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