Dr. Karla Sanchez stood in the middle of a rural public clinic in Chiapas, Mexico, and surveyed the mess. The rooms were dusty and disorganized. Patient files were non-existent or incomplete. And thousands of vials of medication in a nearby storage room were spoiled.
It was February and Sanchez was the first clinician Compaňeros En Salud (CES), PIH’s sister organization in Chiapas, had sent to Letrero, a mountainside community located several hours over bumpy roads from headquarters. She would be the first of hopefully many young doctors to come and provide care for the 2,100 people living in and around the village.
But her yearlong task was Herculean: she was to set up the clinic, identify patients with chronic illness, provide everything from primary to emergency care, and—most importantly—earn the trust of her new neighbors, who historically had unreliable access to a doctor.
The situation would have been daunting for the most seasoned doctor, but it was especially so for Sanchez, a recent medical school graduate who had just arrived for her social service year. During her first days in the community, CES clinic supervisor Dr. Enrique Valdespino organized a meet-and-greet with community representatives to talk about CES’s mission, introduce Sanchez, and explain what she would be doing in Letrero.
Apparently, his message piqued their interest. “Afterwards, everyone wanted to go to the clinic,” Sanchez said. Her patients told her, “’I just want you to check me. I’m fine.’” Days later, nearly 50 people from a village an hour’s walk away showed up for visits. She and Valdespino dove in, seeing one patient after the other and triaging serious cases for follow-up appointments.
The “first functional doctors”
CES partners with Mexico’s Ministry of Health to recruit and train young doctors like Sanchez, who manage public clinics throughout Chiapas during their social service year. The first-year doctors, or pasantes, have conducted more than 45,000 patient visits in eight communities throughout the southeastern state since CES began providing services there in 2012.
Each of the sites (Capitán, Honduras, Laguna del Cofre, Matazano, Plan de la Libertad, Reforma, Salvador Urbina, and Soledad) is located within a four-hour drive of the central office in Jaltenango. In February, CES expanded to two additional communities—Letrero and Monterrey—pushing its reach farther into the surrounding Sierra Madre mountains.
Chiapas is one of the poorest states in Mexico. Half of its population lives below the poverty line. In the Sierra Madre region, where CES operates, most rural people are coffee farmers whose income relies on the fickle ebb and flow of the international market. While all Mexicans receive universal health insurance, public clinics in Chiapas are often under-equipped or closed. That’s partly because there are 94 physicians per 100,000 people in Chiapas—roughly half the number found in the rest of Mexico and nearly a third of the number in the United States. Plus, the two nurses and one doctor assigned to each government clinic are not always reliable.
People die from things they shouldn’t have died from.
“The problem with this operation is that most doctors and nurses are not from rural Chiapas,” said Dr. Hugo Flores, executive director of CES. “They have to travel from far distances to get to their job posts.” While many arrive at health centers on Mondays and return home Fridays, absenteeism—or, simply not showing up for work—is not uncommon and is a challenge for health systems in rural areas around the world.
“That really does not translate into adequate care,” Flores said. “The truth is that in most of the places that we work, we are either the first doctors or the first functional doctors” based in the community.
It’s difficult to pin down a list of common health problems in Chiapas. As is true everywhere, people battle common colds and flu, struggle with asthma and indigestion, and need to guard against infection from simple wounds. But the prevalence of infectious and chronic disease is high. And serious cases have gone without treatment for years.
There are women in advanced stages of breast cancer, men who have nursed hernias for half a century, and adults with untreated psychotic conditions who—because they lack access to proper treatment or medication—have spent 10 years locked in cages alongside their family homes to protect themselves and others from harm.
“People die from things they shouldn’t have died from,” Flores said. “Because they’ve never had access [to health care], everything becomes a problem. … When we’re there, we see that change dramatically.”
Opening Letrero and Monterrey
Within her first couple weeks in Letrero, Sanchez came across cases of the flu and diarrhea, but also met people with fractures they’d had for four years.
“It’s been so horrible to hear that every single family has one child that has died,” she said. “They’ll say, ‘He died of fever when he was born.’”
I want them to see what a real doctor is like, to have them trust me.
Preventing such tragedies has become Sanchez’s main goal. She plans to speak with midwives to help ensure safe deliveries. She wants to identify patients who struggle with chronic illnesses, such as hypertension and diabetes, and get them on medication. And she hopes to visit neighboring communities to provide mobile clinics and to triage patients in need of more intensive care.
“I want them to see what a real doctor is like,” she said, “to have them trust me.”
Fatima Rodriguez hopes for the same in Monterrey, the new CES site she’s running during her social service year. Community members told her they hadn’t seen a nurse arrive in several months, which was consistent with the meager stock of medications and the cobwebs and dust coating every surface.
CES clinic supervisor Dr. Jimena Maza helped Rodriguez set up the site with supplies and proper medications and introduced her to the community. Residents were happy to hear she would be there for a year and asked if vaccinations would be available—a clear concern in a region where the majority of children hadn’t received their shots.
Within days, Rodriguez was seeing her first patients. Many children had diarrhea due to improper hygiene and sanitation or asthma because of poor air quality, and respiratory infections were common among women and children regularly exposed to the smoke of indoor wood stoves. She was surprised to find both men and women were interested in birth control, since her patients also spoke about their practice of Catholicism or other forms of Christianity. And she identified several patients who suffered from epileptic seizures, which can be controlled with proper medication.
Rodriguez is learning how to tackle these everyday issues, but emergency cases push her limits. A 13-year-old boy suffered an eye injury while splitting wood and needed to be transferred to a hospital immediately, but public transportation doesn’t exist. She managed to find a resident with a car who volunteered to drive the boy two-and-a-half hours along bumpy gravel roads to the nearest hospital.
The experience taught Rodriguez the importance of having an emergency plan in place. It’s something the community doesn’t have, but will by the end of her stay.