Greetings from Altamirano, Chiapas, Mexico!
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| 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.
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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.
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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.”
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| 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
