Access to Care in Rural Mexico

Anna Ruman, MD

Resident in Pediatrics at Massachusetts General Hospital 

PGY 2

I’ve just finished the first half of my global health elective with Partners in Health/Compañeros en Salud in Chiapas, Mexico and am very excited to report back. To briefly introduce myself, I am a second year pediatrics resident at MGH. I’m very interested in global and community health and hope to work with predominantly Spanish speaking communities in the US and abroad after residency. I decided to do my first of hopefully two international electives during residency to learn more about working in low resource settings, managing tropical diseases, teaching and learning from international colleagues, and of course understanding the Mexican healthcare system.

CES Clinic Matazano

As a bit of an orientation to my work, Partners In Health (PIH) is an international organization committed to improving the health of the poor by partnering with communities to delivery high quality health care. PIH’s Mexican partner organization, Compañeros en Salud (CES), operates out of 10 rural clinics in Chiapas, Mexico. As Resident Mentor with CES, my primary responsibility during the month long elective is to provide full-time bedside teaching for social service year physicians (pasantes) working in these rural sites. In addition, I plan to spend time at the Casa Materna, a house staffed by clinical providers in the larger city of Jaltenango. Essentially, women can come down from parts of the Sierra where there’s little access to obstetric care and spend 1-2 weeks prior to their due date at the Casa Materna to await their delivery, which would also occur in the Casa itself assuming it remains low risk. Overall, I’ll be spending about 90% of my time “in community” and the remainder at the Casa Materna or on various research or capacity building projects.

After arriving in Chiapas the first week of March, my first community assignment was Matazano, a community of approximately 600 people in the Sierra Madre. After an approximately 5-hour drive on mostly dirt roads, we arrived, and I met my colleague Doris, Matazano’s pasante, for the first time. For the next two weeks, we saw patients together Monday-Friday 8 AM-5 PM and Saturdays 8 AM-1 PM, although there were frequently emergencies in the evenings that kept us in clinic sometimes as late as 9 PM. Approximately 40% of all visits were children, which is of course where I had the most to offer in terms of teaching. With respect to the overall patient population, the most common reasons for visit included acute illness (respiratory, gastrointestinal), maintenance of chronic disease (asthma, diabetes, hypertension, mental health), routine obstetric visits, or urgent/emergency cases, mostly minor to moderate trauma. The pediatric cases trended more towards cough (allergic vs. postviral vs. asthma), acute vs. chronic diarrhea, fever (mostly viral illnesses), failure to thrive/malnutrition, adolescent mental and sexual health, routine newborn care, and minor to moderate trauma.

To step back for a moment – why does Compañeros en Salud work in Chiapas specifically, and why would a pediatrician be interested in working there? Well, I knew coming in that infant and maternal mortality in the Sierra region of Mexico had been identified to be much higher than the national average. Most female patients who I met had lost at least one child, often during infancy. The tradition in many rural communities in Chiapas is to leave a child unnamed until around the age of six months, that is to call them simply “niño” or “niña,” due to the reasonable possibility that the child would pass away. Similarly, new mothers don’t typically leave the home until 40 days postpartum due to fear of complications. This means that a provider doesn’t see a newborn until after one month of age, especially if they are born at home (a terrifying thought to most providers who care for infants). And lastly, children are rarely brought to physicians unless an acute care need arises due to the incredible difficulty and expense of transportation and overall poverty in the Sierra.

With these barriers in mind, Doris and I learned a lot together about neonatal fever, how critical congenital cardiac disease presents, which bronchiolitis baby is not like the other, when to start inhaled steroids in a dusty town with indoor wood burning stoves for cooking, how to use the nutritional supplements and rehydration solutions typically available in Mexico, when to clinically suspect varicella vs. measles vs. other red rashes of childhood, how to diagnose and manage UTIs without the availability of urinalysis, how often to suspect pediatric rheumatological diagnoses, how to clinically evaluate for fracture, and many other topics of discussion related to the patients that we saw. Incredibly busy, incredibly fulfilling, and just overall hard to describe.

Dona Mari's Tortillas

Of course, there was more than being in community than seeing patients. Each day, we ate two meals with Doña Mari. Fruit and vegetables are very hard to find in Matazano due to lack of reliable transport from the larger city, Jaltenango. However, Doña Mari always made amazing food with very limited ingredients. A typical breakfast included fresh eggs from her hens, black beans, hand made tortillas, and often a mild red sauce made from a local variety of tomato. We also always drank coffee prepared from the family’s coffee trees. For lunch, Doña Mari surprised us with a lot of treats, but probably the most unique was a crab and shrimp soup. Someone from the coast had driven up fresh seafood (about a 6-7 hour drive minimum) to sell in the community, and Doña Mari was so excited to have these ingredients to use. My favorite dish of all was a very traditional preparation of lentils from the Chiapas region in which fried plantains are mixed in. And the best part was learning about the community’s past and present from Doña Mari herself. Amazing!

In summary, I am so thankful for the learning and teaching experience I have had over the past few weeks. This week, I will be heading to another community, Soledad, to continue my teaching role with the pasante stationed there. In my next post, I’ll be describing both Soledad as well as my overall takeaways from this global health experience. Wish me luck!