Reflections on Access to Care in Rural Mexico

Anna Ruman

Resident in Pediatrics at Massachusetts General Hospital

PGY2

April 10, 2019

Hello again! I’ve just returned from my one month rotation in Chiapas, Mexico with Compañeros en Salud. I’d like to briefly describe my time in Soledad, the second community in which I worked as a resident mentor to the local pasante, as well as my overall reflections on the elective.

Mountains and red soil, Soledad from above

Soledad is another small community in the predominantly coffee growing region of the Sierra Madre. It’s a little bit bigger and slightly better resourced that Matazano, which made for a slightly different teaching experience for me. Seleni, the pasante working in Soledad for the year, certainly saw more patients per day, which resulted in some later nights for us. With our limited teaching time, we chose to focus my educational workshops on asthma, bronchiolitis, and malnutrition as I had in Matazano. However, a few cases and projects proved more interesting than others. I saw my second case of varicella ever (the first I saw in Matazano), and we were able to look up both photographs and clinical guidelines since the Soledad clinic has the advantage of Internet on site. With the middle school right next door, we spent a quiet afternoon setting up a very popular condom dispenser in front of the clinic. Sadly, our most time intensive project involved an elderly man with schizophrenia who had elected to forego his depot antipsychotic injection that month. Without his medication, he became progressively more aggressive, frightening both his family and neighbors. Apparently in the past, he had required injections by force, and we were left with the conundrum of whether to ply him with food and money or to again inject by force. We visited him daily with snacks, hoping that that day might be the day that he would take his medication, but we were unsuccessful after three consecutive visits. I do not know the ultimate conclusion of this situation, but I was so impressed with Seleni’s empathy and utilization of Compañeros en Salud’s mental health team as a resource throughout this difficult case. After a week in Soledad, I returned to Jaltenango for the conclusion of my elective.

Companeros en Salud Clinic, Soledad

With respect to my overall experience, it was certainly both challenging and meaningful. Although I have worked in low-resource international settings prior (including a year living and working in Mexico after college), this opportunity represents my first actual clinical immersion abroad as a supervising physician. I’m still not sure exactly what type of pediatrician I want to be after residency (am currently deciding between primary care vs. a more acute care subspecialty), and I’m not sure that this elective helped me figure that out. However, it reminded me that global and community health will continue to be the focus of my career going forward, regardless of the level of acuity at which I plan to practice. In addition, I found many of the systems issues really engaging, i.e. how to maintain an emergency backpack in each clinic, fully stocked, with procedures about how often and when to revise it, how to ensure the contained medications and materials don’t expire, and how to balance what to include in the emergency kit based on most common complaints, typical resources/transport time (6-8 hours via car on a dirt road to the nearest pediatric hospital), and just overall resource limitation. (More to follow on this project! Will be continuing to work on this). Or the lack of access to microbiology cultures in the region, meaning that obtaining a urine culture on a simple UTI is challenging and requires extensive travel on the part of a patient, and GBS screening during pregnancy is absolutely out of the question. Lastly, it also reminds me how much I love to teach.  I’m already using some of the techniques that I practiced in Matazano back on the pedi wards at MGH. For me, education will certainly comprise a significant chunk of my career focus going forward.

One final reflection: I’m also really fascinated by the intersection between education and typical development for children in low resource settings. Compañeros en Salud is currently launching an infant development/stimulation program for typically developing infants in its target communities. I love the idea, and I wonder what’s next. What does it mean that most children from these rural communities attend school fewer hours per week than recommended? How does that impact their development and, from a bigger picture perspective, their ultimate educational and economic opportunities? For the well child, how can we optimize their opportunity for success? How do we take the next step? Again, the bigger questions of the role of healthcare vs. medicine vs. public health – those of interdisciplinary development - we probably won’t be able to answer today, but I hope that someday I will be able to help answer these and many more for some of the most vulnerable families and children, both domestically and abroad.

Thank you for reading and to the Centers of Expertise in Global and Community Health as well as the Massachusetts Medical Society for their grant support of this project.