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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