'One Year is Not Enough:' A Doctor in Rural Chiapas

Dr. Gerardo Murillo didn’t get what he wanted when he came to the remote town of Reforma in Chiapas, Mexico. He got more.

When the 24-year-old applied to do his social service year through Compaňeros En Salud, as Partners In Health is called in Mexico, Murillo thought he would be practicing medicine in a clinic where running water and electricity were distant dreams.

Instead, the easygoing first-year doctor from Puebla with a shock of thick, black hair landed in Reforma, a community of 1,440 people about 45 minutes from PIH’s base in Jaltenango. His clinic and living quarters—which are in the same compound—have running water, electricity, and even wifi. Most residents’ homes have electricity as well, although not all have easy access to water. A single phone serves the entire community, and public announcements echo every couple of hours from a loud speaker located in the center of town.

This was the first dose of reality among many Murillo would receive during his service. His is one of the busiest of 10 clinics throughout rural Chiapas that PIH supports in partnership with the Ministry of Health. He sees as many as 350 patients every month, many of whom deal with chronic illnesses such as hypertension, diabetes, and depression. In fact, he cares for a quarter of PIH’s patients living with high blood pressure. He closely follows everyone’s progress with the help of nurse Andrés Ríos, nurse’s assistant Adriana Martínez, and nine dedicated community health workers.

Patients line up at the clinic’s metal gate before it opens and come knocking with emergencies late into the night. Many are locals. But patients regularly come from surrounding rural communities and urban areas like Tuxtla-Gutiérrez, the state capital located three hours away—where hospitals and clinics are hardly in short supply. They arrive in Reforma because they know they will receive quality care and get connected with specialized services in larger cities.

Eight months in, Murillo sat down over a lunch of vegetarian tacos at his host family’s home to reflect on how he now views medicine, to share lessons learned, and to discuss his plans for the future.

Before coming to Reforma, you had an idea of how daily life would be. Did the reality match up?

Among PIH’s sites in Mexico, Reforma is one of the most privileged and most urbanized. Honestly, I had a completely different idea of how it would be. I imagined fetching my own water, using an outhouse, that there wouldn’t be electricity and I would be doing everything by the light of an oil lamp. But no, that idea was based on myth and prejudice, because in reality Reforma has most modern conveniences. But this is specific to here, not to all PIH sites, and not to all of rural Chiapas.

I was also thinking I’d arrive in a place where no one would know anything about health. I would talk about how to have a balanced diet, the importance of vaccinations, and things that would be completely innovative. And it wasn’t so. Instead, they know all the health indicators perfectly well—probably better than me. And they know how to follow a balanced diet even better than I would indicate. However, the problem is that there aren’t the means to achieve it. It’s not that they don’t know how, but that the barriers to achieve it are too big. So it’s not just about arriving and presenting an idea, but about seeing how that idea could possibly function.

Murillo reviews the progress of patients under the care of  Eudeli Velasquez, a community health worker in Reforma. (Photo by Leslie Friday / Partners In Health)

Has your perspective on your profession changed at all?

I began to think of medicine as focused on the patient and not on the doctor. I began to realize that it’s not just about giving instructions and waiting for the patient to follow them, and then scolding them if they don’t follow your instructions. On the contrary, you need to explain to patients why it’s important that they do something, validate their opinion, and make them completely participatory in their treatment. Because if they feel that you are only giving instructions, then they aren’t going to follow them. They have to feel that it’s in their best interest to get better, and that it’s their decision to take care of themselves.

Have you had a patient who taught you a specific lesson about medicine or life in general?

Less than a month ago, I had a baby come who had had many problems since the moment he was born. The problems were about more than health. Many were due to structural violence, discrimination, or not having the funds to access the health system.

His parents had had a bad experience at the hospital when he was born. When the boy later became malnourished and required surgery to swallow and digest milk, they didn’t want to take him to the same hospital, even though we ensured them access to the procedure. It was very difficult to convince them to go, because they had been mistreated by other clinicians and they couldn’t afford care in the private sector.

Each time we achieved a small victory, there were still all the other conditions that made him fall behind. In the end, the boy died. And he died for a reason that he shouldn’t have—because of malnutrition. A child with all the economic means and ability to access better health care would have been able to conquer this problem.

He wasn’t able to get better precisely because the boy lived in conditions of poverty. We have to work harder to solve these inequitable situations. He was a boy who shouldn’t have died from a situation that was completely fixable. He died because of his economic situation, social position, and marginalization.

What do you hope to achieve in your remaining months here?

I wouldn’t like it if patients lost any advances they’ve made. So my interest now is in leaving the clinic with the best possible amount of information about the patients who have come and try to pass along the vast majority of outstanding issues to the new doctor.

I have my diabetic and hypertensive patients whom I would like to help get to controlled numbers. I don’t want to leave any patients in limbo, but to see that they are already receiving some type of care and only require follow-up.

I would also like to do more prevention campaigns on topics such as family planning and nutrition. Reforma is a clinic that functions at a decently high level. So I don’t feel as if I’d have to start addressing any of these issues at the ground level, but perfect them so that I leave the clinic in a better condition than before.

Murillo visits with Maria Roman, a patient living with diabetes and hypertension who can no longer walk to the clinic for care. (Photo by Leslie Friday / Partners In Health)

What did you want to do after your social service year and have your plans changed?

I swore that after my social service year I was going to start my specialty and do my residency to become an anesthesiologist. That was my immediate plan. It continues to be my plan in the long term. But I don’t plan to do it this year, because I would like to dedicate a bit more time to working in a community and continue working with PIH. It would be a great opportunity. And if that opportunity presented itself, I’d take it.

I feel like one year is not enough. Maybe an entire lifetime is not enough to be able to make all the changes that need to happen. It’s something that I fell in love with, and I know it wouldn’t be easy to return to the life I had before.

Have you gone home to Puebla during your service year?

Yes, I went one time.

And how was that?

It was an emotional shock to arrive and return to see medicine as it shouldn’t be practiced, centered on the doctor, and thinking about where to lay blame, completely throwing it all on the patient as the sole person responsible for their own health.

And you begin to see more frivolous things and think that they are overvalued monetarily. For example, there are people who could eat for an entire week on what someone is spending in the most ridiculous way. Or that there are people who think and say that they are “so poor” because they don’t have money to travel abroad. Poverty is perceived as not getting everything that you want, while there are people who literally are dying of hunger, who don’t have money to even eat. You begin to have these emotional shocks from the world that you knew and thought was normal and the new reality that you now know. I missed being here more than I did being there.

Anything else you wanted to add?

Truly I feel that I am still learning a lot, and that there is still so much to learn. I don’t think that my experience can compare with whomever has been in PIH for a long time, especially those who’ve been in Haiti or have been in Africa, where the health disparities and economic barriers are much larger than those that I encounter.

But that also says something. It means that I can keep working in this. I can keep throwing all my effort into making a change and continuing to improve the situation. And if I can handle a little now, I will be able to handle more difficult situations in the future.