Rebuilding a Primary Health Care System in Rural Mexico

Social service year physician Dr. Valeria Macias and Dr. Patrick Newman from Brigham and Women's Hospital conduct a patient consultation. Credit: Eva Quesada, S4C

“I didn’t know what to expect,” Dr. Abelardo Vidaurreta says. “I didn’t know where I was going.”

Such uncertainties were rare for the 27 year old. But after finishing medical school at Tecnológico De Monterrey, an elite university that produces some of Mexico’s finest physicians, Vidaurreta ditched the urban commodities he was accustomed to and went to work with Partners In Health’s sister organization Compañeros En Salud (CES) in southeast Chiapas. It’s among the poorest and most isolated regions in Mexico, nestled at the tip of the country along the Guatemalan border. 

The move wasn’t entirely impulsive. In Mexico, newly graduated medical students are required to spend a year working in a public health clinic to earn their professional license. Often they’re assigned to far-flung outposts with few resources and even less oversight. This baptism-by-fire approach can be overwhelming. It can also be frustrating, especially for the community members who are left seeking medical care from a rotating cast of fresh-faced doctors who’ll stick around for only a year. 

Vidaurreta had heard of CES when his social service year arrived, but he didn’t know much about the group, let alone its plans to revitalize a primary health care system in a long-neglected region. Doubts loomed when he agreed last February to be among the first doctors to spend a year working alongside CES in Chiapas.

“I thought I was going into the jungle,” Vidaurreta says. “I thought I was going to be alone.”

Dr. Abelardo Vidaurreta, among the first social service year physicans to work with CES, stitches up a patient's kneee. Credit: Balam-ha' Carrillo, S4C

Now, as CES—whose work is supported by Vermont-based Green Mountain Coffee Roasters—celebrates its first anniversary and more than 10,000 patient consultations, Vidaurreta jokes that he was wrong on both counts. The landscape is more Martian than jungle, marked by towering mountains and a startling lack of infrastructure. And while he would encounter countless challenges in the field, he wasn’t going to be tackling them alone.  A core mission of CES is to alleviate that daunting sense of solitude by pairing the new doctors, known as pasantes, with resident physicians from Brigham and Women’s Hospital in Boston. 

“They’re doing all the work,” says Dr. Patrick Newman, 29, one of the first resident physicians from Brigham and Women’s to take part in the program. “But we see their consults with them, answer their questions, help guide their thinking, help to challenge their thinking, and encourage their ongoing growth.”

Learning Exchange

Newman is quick to point out that the exchange of insight flows both ways. For instance, he recalls visiting a family whose newborn had a cleft palate. His instinct was to hospitalize the baby, insert a feeding tube, and perform surgery when the child reached an appropriate weight—standard procedure in the U.S. 

“That was my first suggestion. But it was obvious after talking with the pasante and visiting the family that doing so would result in absolute and total financial ruin for the family,” Newman says.  “You have to understand that there are cultural aspects to care that the pasantes are going to understand better than we ever will.”
 

Dr. Abelardo Vidaurreta, one of the first social service year physicans, checks a patient's eyes at a clinic in Chiapas, Mexico. Credit: Balam-ha' Carrillo, S4C

In the area where CES works, patients might travel more than an hour for a simple blood test. Getting to a hospital could take half a day. And though there are brick-and-mortar clinics, it’s been years in most cases since a full-fledged physician has staffed one. To make sure the pasantes are equipped to provide the best possible care in this difficult setting, they receive monthly visits from CES staff and attend regular workshops.

“Accompaniment is present at all levels throughout CES. It’s really the backbone to what we do,” Newman says. “This project is unique in that it was set up to tackle a different set of health issues than many other Partners In Health sites. We are very much focused on establishing a primary health care system in the same way you would think about going to your primary care doctor here in the U.S.”

As a middle-income nation with ample doctors, Mexico presents as many opportunities as it does obstacles. While infectious diseases such as HIV and tuberculosis exist, they don’t pose the same burden as chronic ailments such as diabetes, metabolic disease, and high blood pressure.

An Epidemiological Transition

“I expected to find more patients with infectious diseases,” Dr. Jafet Arrieta, CES’ director of operations, says. “But we started finding these diseases that are supposed to be first-world diseases. Then I realized Chiapas is already facing an epidemiological transition. They live in third-world conditions, but they are facing first-world diseases. That is a challenge because there is no comprehensive primary care system.”

To lay the groundwork, CES partnered with local Ministries of Health to pilot its program in two clinics last February. By August, the program had expanded to six clinics. Now CES is seeing an average of 1,500 patients per month. As the pasantes and other members of CES gained credibility in the communities, new opportunities to engage residents on health issues opened up.

“We have offered 35 workshops that have covered 20 different topics, from dental health to family violence to chronic disease,” Arrieta says. The workshops have attracted more than 3,500 attendees. “Even when people live in this level of poverty they want to learn about their health. They’re eager to learn, they just haven’t had the chance.”

Dr. Patrick Elliott from Brigham and Women's Hospital accompanies social service year physician Dr. Valeria Macias through a patient consultation. Credit: Balam-ha' Carrillo, S4C

With a year down, Arrieta can reflect on CES’ successes. News that those who spend their social service year in Chiapas with CES work closely with resident physicians trained at Harvard spread quickly. It’s a good selling point that helps attract new medical talent to what might otherwise seem like an undesirable location. But ensuring that the positive outcomes of CES are sustainable and replicable will take time. The pasantes, Arrieta hopes, will be compelled to stay in Chiapas and help break the cycle of poverty rather than heading to a major hospital or big city when the social service year ends.

There’s progress toward that direction: Vidaurreta’s year as a pasante has come to an end, but he’s continuing to work in the region as a CES program supervisor. He still encounters new uncertainties and difficult cases in the field. But when he has to, Vidaurreta knows he can reach out to his colleagues in Boston for advice.

“They now know how we work, how we live, and how the people here live. We have learned a lot from them, and I think they have learned a lot from us,” Vidaurreta says. “This experience touches everyone.”