Rural Primary Care in Chiapas, Mexico

For the past week and a half, I have been in the community of Soledad, a small rural community in the mountains of the Sierra Madre in Chiapas.  The road up to Soledad is windy and unpaved and takes about 4 hours to navigate from the closest city.  Driving into Soledad, you are greeted by the expansive view of rolling mountains and deep red earth of the Soledad roads.  Here, I have been spending my days in the community’s health clinic, accompanying the Mexican pasante, or Mexican doctor recently graduated from medical school and completing a year of social service work as the community’s only physician.  The breadth of patients we see here is incredible from pregnant women to adults with chronic medical issues to neonatal sepsis to patients with schizophrenia.  The treacherous roads to the community preclude the entrance of ambulances and other emergency personnel and thus it is also the pasante’s job to be the first responder to local emergencies such as the fatal motorcycle accident this week that killed one young man and seriously wounded two others. 

Given the lack of access to studies and diagnostics I have considered routine thus far, the practice of medicine is fundamentally different and has forced me to develop and hone a different skill set.  The closest EKG machine is 5 hours away. Basic labs are at least 1-2 hours away and out of financial reach for many.  There is almost no way to order certain more specialized labs such as a TSH.  Financially and logistically, it is challenging to refer to specialists, although there is a significant referral system that PIH has organized that is much more robust than that seen in other rural areas of Mexico.  Here, we have a set of medications to use and our challenge is to be creative with what is available.  We listen attentively to the patient’s story, knowing that it is the most fundamental diagnostic tool we have available.  I am forced in a way that I am not in my own primary care practice in Boston to rely my diagnostic impression from the patient’s story.  We use treatment trials as diagnostics.  We see patients with hypertensive urgency and and dangerously high hyperglycemia on a daily basis to tweak their medications.  We go searching for patients we are worried about in their homes to check on them and bring them refills of medications.  We work closely with acompanates, local community health workers that are fundamental in helping to manage patients with diabetes, hypertension, depression and schizophrenia.  While challenged by the limited access to resources, we rely on the strength of the community to organize to support itself.  Here, we are engaging in community health in a way that I have yet to experience in my time as a young physician.