Monday, May 8, 2017

Providing Primary Care Supervision in Rural Mexico

Madeleine Matthiesen
Med Peds Resident at MGH

Providing Primary Care Supervision in Rural Mexico

My work here in rural Mexico has been incredibly eye opening and fulfilling. I have gotten to work for nearly three straight weeks with Rene, one of the pasantes. Rene has finished his medical school obligations, but he has to spend a full year in social service to a community. He chose to work with Partners in Health, to directly serve a rural area.
The pasantes at one of their monthly courses 
where they all come together
 from their various communities to learn

Of the three weeks I’ve spent here in Reforma, Chiapas, Friday, my last day, was one of the toughest. I have been struck several times by the injustice of the system: the developmentally-delayed kids who are left behind because there’s no way to support them (see my first post), the prejudice against the lgbt community, the services that exist only for those who can afford them, and so on.

Friday reinforced many of these challenges with one final knock-out punch. First, it was the woman with melanoma. This woman had brought a classic melanoma nail lesion to a doctor six months prior, and he had removed her nail. Soon after, a mass began to grow. And grow and grow. Until finally she showed up in our clinic with a fully fungating mass consuming her thumb. As she took the covering off her finger, the mass reared its ugly head, and I knew we were in trouble.

Not only was this patient at seriously high risk of already having metastases, but she was also Guatemalan; she was a migrant who had moved to Chiapas nine years ago, married, and had two Mexican children. She had no insurance.

Her husband sprung to action. A few hours later, he returned, having secured three months of public health insurance (better not to ask questions how but let's just say some pasante advocacy was involved). We would make a referral immediately and she would be seen within weeks.

She was followed closely by a man with a history of BPH (we think). He'd needed a suprapubic tube prior to a prostatectomy (complete? Partial? Quien sabe?), and it had been taken out two months ago without issue. Then suddenly he'd started urinating blood the day before, then stopped being able to urinate at all, and now he was oozing blood from his previously healed suprapubic tube site.

He refused to go to the hospital (likely due to cost) and asked us to put in a Foley catheter. After two attempts clotted, I knew we were in trouble again. We told him he needed to go to a hospital. Unfortunately, I don't know what happened to this gentleman, as when we went to see him at his home later in the day, he wasn't there. I can only hope he went into town to seek help.

Now an hour and a half behind, we forged ahead. Still, I couldn't shake these two patients from my head. What would happen to them?

As I finish this post, the house has just voted in favor of a new health care bill. In the pit of my stomach, anger and fear are swirling: will I soon face this horrible reality, that my patients will not go to the hospital or even be evaluated by their primary care doctor due to the fear of cost or being labeled as having a pre-existing condition?

Don Andres, the clinic nurse, with Liliana, a pasante,
 leading me through one of the rural communities
One of the many lessons my time in Mexico has reinforced is that despite the dysfunction of the US health care system, we can provide access on a level that the third world would dream of. Despite varying access to care, rarely does someone suffer the same fate as the patient with cancer who must wait weeks to have her diagnosis confirmed and treatment begun. At least for now.

I've learned a lot from the pasantes, especially the way that they advocate for their patients when no one else can or will, often pushing the envelope. I fear this is something I may become even more familiar with in a way I had never imagined.

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