The road to San Rafael, Mexico, is not long, but it is steep, with twists and turns that carry ominous nicknames like “Espinazo del Diablo,” or the “Devil’s Backbone.” To get to San Rafael from Reforma, the small community in which a Partners In Health/Compañeros En Salud-supported clinic is located, you have to ford a river, which often becomes impossible during the rainy season. If you can cross the river and navigate the tortuous road, you’ll bump out of the woods and into San Rafael, a small town nestled atop one of the Sierra Madre Mountains’ many peaks. Fewer than 400 residents live there, many of whom are coffee farmers.

Among them is 55-year-old Don Fausto Velasquez, a big man with crystal blue eyes and grey hair tucked under a cowboy hat. It was nearly a year ago when Velasquez started having chest pain. The pain was so bad he could barely walk a block without resting. Frightened for their father, Velasquez’s sons took him to a series of clinicians that were hours away, but none provided a clear diagnosis.

Finally, the sons took Velasquez to the state capitol of Tuxtla Gutierrez, four hours from their home in perfect weather, significantly longer should the mountain sky open up. There, a cardiologist diagnosed Velasquez with hypertension and stable angina. Thankfully, the conditions were manageable.

This heartbreaking tradeoff between care and economic security is one faced by the rural poor around the world.

The family, however, was devastated to learn that to receive care, the coffee farmer would have to make the costly four-hour-long trek to Tuxtla once a month. This heartbreaking tradeoff between care and economic security is one faced by the rural poor around the world. As death and disability from noncommunicable diseases increases in low-resource countries, more and more families are facing this predicament.

PIH-supported physician Dr. Enrique Valdespino first met Velasquez in January 2013, several months after the hypertension and angina diagnoses were delivered.

Dr. Valdespino recalls that Velasquez’s dual heart conditions were completely uncontrolled. “He came in and he was taking two medications—one a diuretic and the other for people who’ve had a heart attack or a stroke,” recalled Dr. Valdespino. “Nothing really to treat the symptoms of his angina, to treat his chest pain.”

Velasquez explained that he had stopped making the monthly trip to his cardiologist after only two or three visits because “there just wasn’t any money.” Coffee farmers in Chiapas often earn a meager living. But 2013 has been particularly brutal as a plague called the Roya (coffee rust) devastated local coffee crops. “I was spending a thousand pesos [around $80] to buy 20 pills. I couldn’t keep doing that, so I stopped going [to the cardiologist],” Velasquez said.

Dr. Valdespino listened intently to Velasquez, taking in the clinical and social challenges the patient faced. Soon after, PIH/CES started traveling to San Rafael so that Velasquez and other residents of the tiny town could consistently access high-quality care. Now Dr. Valdespino and at least one other PIH staff or volunteer physician make the treacherous trip, ford the river, and traverse the “Devil’s Backbone” once a month. “During the rainy season, we sometimes have to go on horseback or donkeys,” Dr. Valdespino says.

Velasquez started receiving aspirin and beta blockers, which quickly led to clinical improvements. His hypertension is under control as well; he can now walk four blocks without resting and can tend to a small crop of corn.

For Velasquez and the 24 other citizens of San Rafael with chronic diseases, PIH’s presence has not only provided the medication and treatment to prolong and improve the quality of their lives, but it has also saved them catastrophic spending in search of medical care. As the Roya plague continues to decimate crops in the area, PIH’s commitment to accompany the patients of San Rafael is stronger than ever. “We have our corn and our beans, so we’ll survive,” Velasquez says. “But it’s going to be a hard year. At least we no longer have to go down the mountain to find medical care.”

Emma Goodstein has been collaborating with the PIH team in Chiapas, Mexico, since June 2012. Originally from Portland, Oregon, she graduated from Wesleyan University in 2010 with a degree in history and has since worked in various positions in the health care field in Portland and New York City.

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