The Politics of Health: A Retrospective

Project Piaxtla: A Villager-Run Health Program

When the Piaxtla Project started in 1965, the “diseases of poverty” dominated the health scene. One in three children died before reaching the age of five, primarily of diarrhea and infectious disease combined with chronic undernutrition. Seven in ten women were anemic, and one in ten died during or after childbirth.

This adverse situation stemmed in large part from an inequitable distribution of land, wealth, and power. Most campesino or poor rural families owned little or no land, and what land they did own was of inferior quality. In contrast, a handful of rich local families held large tracts of fertile, river valley land, owned large herds of cattle, and were quite wealthy. These few wealthy families completely controlled Ajoya’s community council. They repeatedly blocked all attempts by poor farmers to organize or demand their constitutional land rights, resorting to violence when they felt it was necessary in order to maintain their dominant position.

Land distribution has long been a critical issue. The 1910 Mexican Revolution was largely triggered by the feudal land policies of the president-turned dictator, Porfirio Diaz, who had given huge tracts of land to wealthy cronies. As the best farmland had become concentrated in giant plantations, or latifundia, the landless peasants had few options. Either they worked for the powerful landholders as serfs or sharecroppers, or they retreated into the hills to grow scanty crops on steep slopes using slash-and-burn farming. Either way, survival was difficult.

In the Mexican Revolution—with the war cry: “Tierra y Libertad!" (Land and Liberty!)—landless campesinos throughout the countryside united behind popular leaders such as Pancho Villa and Emiliano Zapata. At last, the Diaz dictatorship was overthrown and a new revolutionary Constitution was drawn up.

At the heart of the Mexican Constitution was, until recently, its agrarian reform legislation, which included the famous ejido system. According to this system, a group of villages could join to form an ejido or communal land holding. The local farmland was divided equitably among all families. Each family would receive provisional title to their parcel, and they could farm it and benefit from the produce as they chose. But ultimate ownership stayed with the ejido. The family could not sell its parcel nor have it seized for unpaid debt. This protected small farmers from losing their land. To further prevent the return of huge plantations, legal limits were placed on the size of property holdings.

Some social analysts say the ejido system contains the best of the political Right and the Left, encouraging the personal incentive and high production of private ownership, while guaranteeing the equity of land use intended by socialism. However, the ejido system has worked better in theory than in fact. Since the Mexican Revolution, the biggest problem has been institutionalized corruption. Although the Constitution calls for a democratic multi-party system, for 60 years a single political party—the Institutional Revolutionary Party (PRI) backed by brutal military and police force—has remained in power. In spite of growing inequities and hardships for the poor, it has clung to power by resorting to vote fraud, intimidation, torture, and strategic assassination of human rights leaders. The killing of outspoken journalists has been wryly dubbed “the ultimate form of censorship.”

Under such a corrupt regime, both the ejido system and the laws limiting the size of land holdings have often failed to protect small farmers' land rights. The rich and powerful routinely pay off government officials to break the rules and to silence those who protest. Nevertheless, the land reform statutes of the Mexican Constitution have, until recently, provided a legal and moral base whereby poor farmers could organize to defend their revolutionary rights to Land and Liberty.

Piaxtla’s Evolution: from Curative Care to Social Action

In this setting, Project Piaxtla’s strategies to improve health evolved through three phases. In its earliest phase it had no political agenda, but focused on curative care, the immediate need of the people. Village health promoters were trained using participatory, learning-by-doing methods, and became relatively competent in the treatment of common illnesses and injuries. But as time went on, the health team and the villagers it served became aware that the same illnesses and injuries kept recurring. In response, they gradually shifted the program’s focus to preventive and promotive measures such as immunizations, latrines, and water systems. As a result, during this second phase of the program, certain illnesses became less common and health improved noticeably. Fewer children died of tetanus and whooping cough, and fewer were left disabled by polio and complications from measles. Nevertheless, many children and women were still malnourished and sick, particularly in years when harvests were not good. The Under-Five Mortality Rate remained high, especially among children of the poorest families, who were landless, underpaid, underserved, and in many ways taken advantage of by a small minority with land, wealth, and power. So the program’s main focus changed again: this time to organized action to defend people’s basic needs and rights. In this way, the village health program evolved from curative care to preventive and promotive measures to sociopolitical action.

The shift in the program’s focus from more conventional health measures to organized action was partly the result of a learner-centered, discovery-based, problem solving approach to health education. Workshops led by health promoters with farmers, mothers, or schoolchildren would start off with a “situational analysis” or “community diagnosis” in which participants identify and discuss health-related problems in their community and how these problems interrelate. Rather than looking at the death of a child as having a single cause (such as diarrhea), they would learn to explore the chain of causes that leads to that child’s death. The links would be identified as biological, physical, cultural, economic, and political, or (in simpler terms) having to do with worms and germs, things, customs and beliefs, money, and power.

In the early phases of the program when the focus was mainly curative and preventive, the links people identified in the chain of causes tended to be mostly biological, physical, and cultural. The chain traced back from a child’s death from diarrhea might have included death, dehydration, diarrhea, gut infection, germs carried from feces to mouth, and lack of latrines, hygiene and sufficient water. But as people began to explore more deeply, the chains of causes they discovered tended to include more economic and political links. For death from diarrhea, the chain might now include: death, frequent bouts of diarrhea, undernutrition, not enough food, no money, father works as a sharecropper, good farmland held by a few rich men, land reform laws not applied, payoffs to government officials, institutionalized corruption, lack of participatory democracy, insufficient organization and action by the people. After common problems and the root causes were defined, the group would explore possible solutions. Sometimes this was done through story-telling or role plays, or—to involve a wider audience—by publicly staged “campesino theater.” Finally, when the group agreed that the circumstances and timing were right, a strategy for action might be developed.

Actions to Defend the Health and Rights of the Least Advantaged

As the health promoters and community looked deeper into the underlying causes of poor health, they began to look for ways in which, through collective action, they might break some of the links in the chain of events leading to sickness and death. They started with some of the links which they thought might be easier to do something about at the local level, and which carried less risk of violent response from the power structure. However, they soon discovered that any attempt by the poor to correct inequities of the status quo can precipitate a heavy-handed response from those in positions of privilege.

Early actions organized through the Piaxtla health program mostly related to the ways in which poor campesinos were systematically cheated, mistreated, or exploited. Some of the activities initiated to address these issues included:

  • Demanding the owner of the local bus route to lower fares to the legal rates;

  • Starting a farmworkers-run maize bank;

  • Initiating a cooperative fencing program;

  • Organizing, led by village women, to shut down the public bar in order to reduce drunkenness and violence; and

  • Organizing a protest to take control of the village water supply away from a wealthy man and to introduce a public water system controlled by the community.

We will briefly describe a few of these initiatives.

The Farmworker-Run Maize Bank

One of the first, most entrenched forms of exploitation which the small farmers decided to tackle was the land-owners' usurious system for loaning maize. By the start of the planting season (the summer monsoons) poor families had often exhausted their stores of maize and were forced to borrow some from their wealthy neighbors. At harvest time, six months later, the poor farmers were required to repay three sacks of maize for every one borrowed. After payment, many families had almost no grain left. If they were unable to repay the debt, their creditors would seize their possessions, often pushing poor families into complete destitution. Many were forced to give up farming and migrate to urban slums in search of work. (This sort of exodus from the rural areas by land-deprived peasants has caused a whole new dimension of urban health problems which further jeopardize child well-being and survival, see Questioning the Solution: The Politics of Primary Health Care and Child Survival, page 77.)

To combat this exploitative loan system, the Piaxtla team helped the poor farmers set up a cooperative maize bank. This bank charged much lower interest than the rich farmers, and the interest collected was used to increase the bank’s lending capacity. This community-controlled loan program eventually spread to five villages. It helped to improve the economic position of the poorer families, and with it their nutrition and health. It also fostered greater cooperation and accountability among the small farmers, helping them to develop organizational, management, and even accounting skills. Most importantly, people began to gain confidence in their ability to improve their own situations. In the course of establishing the cooperative maize banks, the subsistence farmers were learning to fight for their rights. Within a few years, in Ajoya and the surrounding communities, the poor farmers' organization became so large and strong that it began to break the control that the few wealthy families had over the community council.

The Cooperative Fencing Program

The next problem the poor farmers took on to improve their economic base was to find a cost-effective way to keep the rich farmers' cattle from entering their mountainside maize fields and from eating their crops. Among the poorest farmers are those who plant the steep hillsides by the slash-and-burn method. Each year they would timber a new patch of land, and fence it to keep the rich farmers' cattle from eating their crops. To buy fencing wire, they had to borrow from the rich cattle owners. In return, they were forced to grant the rich families grazing rights on the land they had cleared, fenced and harvested. Thus the cattle owners got new grazing areas timbered, fenced, and planted with fodder, all for only the cost of the wire.

After discussing and analyzing the implications of this situation to people’s well-being, the Piaxtla health team, together with members of the small farmers' organization, began to explore possible solutions. They organized poor farmers to join together to cooperatively fence in a whole hillside. Within this large enclosure, all could plant their small plots of land. To buy the large quantity of barbed wire needed, the health team obtained start-up money from a nongovernmental organization. Once the fencing project was completed, by charging the wealthy cattle owners for grazing rights, the poor farmers' were able to pay back the loan for the fencing wire within two years. From then on, grazing fees produced an income which could be used for the food and health needs of their families.

When the first group of poor farmers succeeded in paying off their loan, the same money was lent to a new group. Through this revolving fund, a growing number of poor farmers became more self-sufficient. The gap in wealth and power between rich and poor narrowed somewhat, and the health of some of the poorest children began to improve.

Through these and other organized actions, people began to gain confidence and experience strength through unity. This empowering process proved contagious and soon neighboring communities began to join the informal but cohesive organization of poor farm workers. As the numbers and solidarity of the peasant farmers grew, they and their health team began to combat bigger, potentially more dangerous issues.

Women Unite against Men’s Drunkenness

The women of Ajoya and the surrounding area also began to discover and exercise their power. One way they did this was to take collective action to address the problem of male alcohol abuse. This has long been a major cause of interpersonal and domestic violence in the region, with women and children often on the receiving end. Apart from direct physical violence, the drinking habits of men also indirectly damage the nutrition and health of women and children, because men often buy alcohol with money needed to feed their families.

In previous times there had been several bars in Ajoya, but many years ago they had been officially closed because of alcohol-related violence. For some twenty years the village was free of bars, although some illegal sales of alcohol continued. In 1982 the son of the municipal president announced that he was going to open a cantina, or bar, in Ajoya as a private business venture.

With help from Piaxtla’s health workers, the women organized to fight this move. They put on a public farmworkers' theater skit dramatizing how the drinking habits of men bring harm to women and children. All parts were played by women and children, with women bedecked in pants and mustaches to act the roles of men. The skit showed how, if they worked together, women could do something about this “men’s problem.”

[CAPTION]Village women band together to stop drunkenness.[/CAPTION]

In response to the skit and other awareness-raising activities, the village women of Ajoya took united action to protest against the opening of the bar. As a result, several health workers who had helped organize the women were jailed. But the women held a protest rally at the jail until the last health worker was released. Next, they persuaded several newspapers to publish editorials criticizing the municipal president’s use of public office to advance private business interests. The women were ultimately successful in blocking the bar’s opening, and soon women’s groups throughout the state were making similar protests and closing down local bars.

The Invasion and Redistribution of Large Land Holdings

After gaining greater confidence, organizational skills, and unity through combating other problems, finally the poor farmers were ready to tackle the most basic problem contributing to hunger and poor health: the inequitable distribution of the fertile, river valley farmland. They began to systematically invade and cultivate some of the large holdings of rich families—land to which they knew they had a constitutional right. They divided up the land fairly and then demanded ejidal land titles from the government. When the authorities at the state level ignored their demands, the poor farmers sent a committee to the Ministry of Agrarian Reform in Mexico City. The villagers persisted until the officials finally relented, and ordered the state authority to grant title to the poor farmers' land claims.

To date, the peasant farmers have reclaimed, won legal title to, and parceled out nearly half of the local riverside farmland. To increase food production, they purchased water pumps and began to irrigate the land during the dry season. This enabled them to harvest two crops a year instead of one. As a result, their families were able to eat better, to earn income by selling some of their produce, and to save some money for medical emergencies and other needs.

The impact of these various actions toward greater fairness—between rich and poor and between men and women—has had a significant impact on health, especially that of children. When the villager-run health program began in 1965, the Under Five Mortality Rate for this remote mountainous area was around 340 per thousand. Today it is down to between 50 to 70 per thousand. Equally important, there are now far fewer malnourished, sickly, and stunted children. More youngsters are healthy, growing well, and bursting with energy and life.

Undoubtedly a number of factors have contributed to the impressive drop in child death rate. Most families agree that the Piaxtla health program has played a key role in reducing child death and improving health. But if you ask “What actions brought the biggest improvements?” few people will say curative or preventive medicine. Many will mention organized action to reclaim their rights and their land. Most families realize that the main reason why so many of their children used to get sick and die is that often they didn’t get enough to eat. With their collective efforts to set up a peasant-controlled maize bank and cooperative fencing program, to combat excessive use of alcohol, and above all, to more fairly distribute the best farmland, the families of the village have been able to increase their economic base and to put more food on the table. All in all, they have gained more control over their health and their lives through cooperative action.

Since the early years of the health program, there has been a visible shift in power at the local level. In the first years, village council meetings had been strongly controlled by a few forceful land barons and cattle owners, but as the poor gained strength and unity, the few wealthy men who previously dominated decisions were so disempowered that they seldom attended ejido meetings. Outnumbered, they could no longer swing votes by threatening to evict sharecroppers or refuse them loans. In this way, the local struggle for health, which had turned into a struggle for land and liberty, also led to a more democratic and equitable community with greater accountability of leaders.

However, the process remained local and incomplete. The campesinos realized that if improvements in health were to be sustained, more good riverside land needed to be invaded and redistributed: not only in the Piaxtla valley but throughout the country.

Of course, this struggle for land, liberty, and health in the Sierra Madre was not an isolated event. In many parts of Mexico, grassroots groups were beginning to organize and demand their rights. As these groups gained in numbers and strength, high level attempts to silence them became more frequent and repressive. On occasion, Piaxtla health workers were jailed. And in a program which the Piaxtla team had helped to start in the neighboring state of Durango, two health workers were killed by the state police for organizing local residents to stand up for their timber rights. (An American plywood company was paying the corrupt leaders of the local ejido for the timber they removed. When the health workers organized their local ejido to demand fair disbursement of this money among all the families, the lead health workers were assassinated by the State Police.)

In response to this and other misfortunes, grassroots groups felt the need to unite in mutual self defense. To stabilize their tenuous gains, the health team joined with other grassroots programs to organize educational interchanges. This eventually led to both a national and a regional network of community-based health programs, covering Mexico and Central America. These grassroots networks share the conviction that the struggle for health is a struggle for liberation from hunger, poverty and unfair social structures.

New Threats to the Peasants' Gains: Free Trade and the Global Economy

During the 1990s a new and bigger obstacle has threatened to reverse the gains in land and health achieved over the years through the Piaxtla initiative. This new threat stems not so much from the local or state levels as from international and global forces. It is a consequence of the post-Cold War New World Order with its pervasive push for liberalization of national economies (see Chapter 11). In the 1980s this liberalization process was to a large extent implemented in Mexico through structural adjustment policies dictated by the World Bank and International Monetary Fund (IMF). In the 1990s this neo-liberal agenda has been further expanded through the North American Free Trade Agreement (NAFTA), an accord between Canada, the United States, and Mexico.

In preparation for NAFTA, the United States pressured the Mexican government to eliminate the progressive land reform statutes from Mexico’s Constitution. It argued that these statutes–primarily the size limit for private land-holdings and the ejido system that safe-guards small farmers from losing their land through sale or debt—are barriers to free trade. Since these constitutional clauses were preventing US agribusiness from buying up huge tracts of Mexico’s land to grow winter vegetables for export into the US, the White House insisted that the Mexican Constitution be changed. As it turned out, then President Salinas de Gotari was quite willing to disembowel the Mexican Constitution of its progressive land policies. The ruling party (PRI) was (and still is) controlled by a powerful club of bureaucrats, businessmen and big land owners who for decades have sought ways to sidestep the equity-enforcing statutes of the country’s Constitution. The US pressure for free trade provided a perfect excuse to dismantle the revolutionary statutes that protected the needy from the greedy. So, even before NAFTA was passed, President Salinas and his Congress gutted the Mexican Constitution of its progressive land statutes. The ejido system was dismantled and laws limiting the size of land holdings were repealed. In effect, these regressive changes in the Constitution catapulted Mexico back to the pre-revolutionary feudal system with its latifundia or giant plantations.

To convince poor farmers to accept the spaying of their Constitution, which could cause millions of small farmers to lose their land, the Mexican government launched a massive disinformation campaign telling farmers that, with the end of the ejido system, at last they could become full owners of their own land, to do with it as they chose. This official media blitz—broadcast day and night on radio and TV—for a time caused a split within poor farmworkers' organizations throughout Mexico. Even within the Piaxtla program a division arose. Some farmers swallowed the government line and said, “For the first time the land is completely our own!” But those who were more astute understood that, with the loss of the ejido system, small land owners would soon begin to lose their land, either selling it in hard times or forfeiting it for debt.

Nevertheless, the constitutional changes instigated by NAFTA have effectively terminated the legal reclamation and redistribution of large land holdings. Before NAFTA, the campesinos in the Sierra Madre had proudly invaded large holdings as citizens defending their constitutional rights. Now, under the modified Constitution, if they invaded large holdings they would be common criminals, and treated as such.

Free Trade in Poverty, Racial Violence, Repression and AIDS

The changes in the Mexican Constitution in preparation for NAFTA were officially hailed as a progressive step toward national economic growth and prosperity. But many social analysts correctly predicted that these measures would have devastating human and environmental costs. Indeed, thousands of small farms are being bought up by big land holders or confiscated for debt. The concentration of farmland into fewer hands, together with the flood of tariff-free US farm products into Mexico as result of NAFTA, have caused the mass exodus of more than 2 million landless peasants to the mushrooming city slums, where they have swelled the ranks of unemployed persons competing for jobs. Mexico’s courtship with foreign speculative investment contributed to the crash of the peso at the end of 1994. In the first six months of 1995, the unemployment rate more than doubled; more than 1.4 million Mexican workers lost their jobs. Independent unions estimate unemployment and under-employment to be around 50 percent. The inflation rate reached 39.91 percent in July, 1994, while the sales of basic food stuffs decreased by 25%, a harbinger of widespread malnutrition.

With such a huge surplus of hungry people ready to work under any conditions, wage levels have dropped and the already minimal bargaining power of organized labor has been further weakened. The combination of falling wages and rising unemployment inevitably takes a high toll on people’s health, especially that of children.

Along the US/Mexico border, many poor Mexican workers toil in the maquiladoras (manufacturing plants), which now number over 2,700. These sweat shops employ over 605,000 workers who have fled to the colonias (unincorporated areas) on both sides of the border in search of a better life. Including worker’s families, more than 1.5 million men, women and children live in these slums in which “there is a pressing need for basic sanitation [and which] have no potable drinking water, sewer systems, garbage collection or adequate medical facilities. In many colonias, garbage is left in open dumps or scattered in urban streets, attracting and proliferating vermin and contributing to surface and groundwater pollution.”

As landlessness, poverty, disease and unemployment in Mexico increase as a result of NAFTA and structural adjustment, more and more braceros illegally cross the US border in search of work. With increased job competition and unemployment in the United States, more people will resort to prostitution, drug peddling, and drug use. At the same time, fewer illegal immigrants will get the health care they need, since new legislation is threatening to reduce the opportunities for undocumented workers to receive public health services. If, as predicted, the US army is recruited to assist the Border Patrol, expulsion rates back to Mexico will increase along with the numbers of illegal workers. Thousands who have acquired sexually transmitted diseases, HIV and/or drug habits will carry their new afflictions home with them. The incidence of AIDS in Mexico is beginning to skyrocket as it has in Africa. For the poor of Mexico, however, concern about combating AIDS is at present eclipsed by the more immediate need to combat landlessness, joblessness, and hunger.

In the United States, NAFTA’s effects are precipitating an upsurge of racism and human rights violations. As more US industries move factories south of the border to take advantage of low Mexican wages and weak enforcement of workers rights and safety, thousands of US workers have lost their jobs. According to an article by journalist Patrick Buchanan, “In the first eight months of [1994], 224 US factories—a factory every single day—laid off workers or shifted production overseas as result of NAFTA. NAFTA has put American workers into competition with 80 million Mexicans labor there is only 15% of the cost of US labor.” Correspondingly, in the US the real wages of workers has continued to fall.

Because US workers are poorly informed about the root causes of their loss of jobs and falling wages, they tend to put the blame for their economic hardships on the influx of Latinos. This appears to be sparking racial violence.

Within eight months of the passing of NAFTA, the Southern Poverty Law Center reported that, “Hostility towards immigrants and efforts by white supremacists to exploit fears about immigration are at their highest levels in 70 years, causing a rash of violent bias crimes against anyone who is perceived as ‘foreign.'” This anti-immigrant paranoia is so severe that in November of 1994 the voters of California—a state which has a large immigrant population—passed the so-called “Save Our State” initiative (Proposition 187). This draconian initiative, if implemented (its constitutionality is being questioned in the courts), would prohibit undocumented children from utilizing public education and health services (except in cases of emergency). This is in blatant violation of the International Declaration of Children’s Rights.

The Chiapas Uprising to the Rescue

The ratification of NAFTA was a devastating blow to Project Piaxtla and the farmworkers organization. With it came the imminent danger of losing the land and the health gains for which they had struggled during the last 20 years. Throughout Mexico, campesino groups staged protests against the dissolution of the ejido system and the signing of NAFTA. But as usual, the PRI and President Salinas turned a deaf ear.

However, at the beginning of 1994 an unprecedented turn of events was triggered by the uprising of the Zapatista National Liberation Army (EZLN) in Chiapas, Mexico’s poorest and most southern state. The uprising was symbolically launched on January 1, 1994, the day that NAFTA went into effect. Described as “one of the most unexpected, brilliantly staged peasant uprisings in living memory,” the mini-revolution has forced Mexico’s ruling party to respond seriously to popular demand for social justice.

It is too early to know the long-term results of this mini-war waged by Mexico’s poorest, most exploited indigenous people. But as things look now, the uprising may have done more to defend the rights and health of the country’s people than any event since the Mexican Revolution 80 years ago. For one, the Chiapas insurrection has helped the Piaxtla health team and farmworkers in far off Sinaloa to retain the gains of their 20 year struggle for land and health.

At the start of the Zapatista uprising, the Mexican Army responded with brutal collective punishment, attacking, bombing, and destroying entire Indian villages. But throughout the nation, the majority of citizens (70% of the population according to polls) and much of the national press sided with the rebels. The EZLN’s clear demands for land rights and social justice, voiced eloquently by the mysterious sub-comandante Marcos, struck a sympathetic chord with millions of campesinos. Fearing a possible national revolt (or possible overturn of the PRI in forthcoming national elections), the Mexican government was forced to call off the army—and eventually to capitulate to some of the Zapatista’s demands.

The Zapatistas’ demands called on the government to uphold the statutes of the original 1917 Mexican Constitution, especially those that protect the rights of the common citizen. This included both restoration and honest implementation of the agrarian reform program which, due to institutionalized corruption, had never effectively reached the indigenous peoples of Chiapas. They called for reinstatement of the ejido system to protect the land rights of small farmers. They demanded fair, genuinely democratic elections and an end to discrimination against indigenous people and the poor. And they called for a minimum wage high enough for poor people to adequately feed their children and for an end to institutionalized corruption and graft. The EZLN made it clear they did not want to take over and run the government. They simply wanted it cleaned up, to make it more representative of and accountable to the people.

At the bargaining table, President Salinas offered to pardon the Zapatistas if they gave up their weapons and called off the insurrection. However, sub-comandante Marcos—his face, as ever, masked in a ski-cap—publicly replied:

Why do we have to be pardoned? What are we going to be pardoned for? For not dying of hunger? For not being silent in our misery? For not humbly accepting our historic role of being the despised and outcast? For carrying guns into battle rather than bows and arrows? For being Mexicans? For being primarily indigenous peoples? For having called on the people of Mexico to struggle, in all possible ways, for that which belongs to them? For having fought for liberty, democracy, and justice? For not giving up? For not selling out? > Who must ask for pardon and who must grant it? > Those who for years and years have satisfied themselves at full tables, while death sat beside us so regularly that we finally stopped being afraid of it? > Or should we ask pardon from the dead, our dead, those who died ‘natural’ deaths from ‘natural’ causes like measles, whooping cough, dengue, cholera, typhoid, tetanus, pneumonia, malaria and other lovely gastrointestinal and lung diseases? Our dead—the majority dead, the democratically dead—dying from sorrow because nobody did anything, because the dead, our dead, went just like that, without anyone even counting them, without anyone saying “ENOUGH ALREADY,” which would at least have given some meaning to their deaths, a meaning that no one ever sought for them, the forever dead, who are now dying again, but this time in order to live?

Among the various concessions that Salinas made to the EZLN, at least two may have a substantial impact on the people’s health:

First, Salinas agreed to a fairer, more open election process with greater accountability to the public. Although the PRI won the national elections again in August, 1994, the electoral process is now under more critical public scrutiny, and the possibility of a more accountable and representative government in the future is somewhat increased. Already opposition parties have won elections in some municipalities and states.

Second, Salinas agreed to partly reinstate the land reform and ejido system which he had dismantled in preparation for NAFTA. He signed a presidential decree whereby the members of previously existing ejidos could decide by vote to keep or dissolve their ejidal structure. The government, of course, continues its propaganda to induce campesinos to dissolve their ejidos. But throughout Mexico, many small farmers—inspired by the clear thinking and just demands of the EZLN in Chiapas—are electing to keep their ejidos.

Among these, in the Sierra Madre of Sinaloa, the community of Ajoya and many surrounding communities have voted strongly to keep the ejido. Roberto Fajardo, health activist of Project Piaxtla and leader of the farm workers' organization, is delighted. He and others had feared that the villagers' 20 year struggle for land and health had been irrevocably lost. Roberto is first to acknowledge that the “barefoot revolutionaries” in Chiapas have given a new lease on life and possibilities for a healthier future to the children of Sinaloa’s Sierra Madre.

Village and Global Health are Now Inseparable

Roberto and his fellow campesinos are relieved that in their corner of Mexico the people’s land rights have, at least for the present, been partially preserved. They know that their right to land is crucial to freedom from hunger which is key to health. Yet Roberto and the Piaxtla health team also realize that their gains are tenuous. Like many community workers, he has learned that the biggest threats to health are now on a global scale. The small farmers of Mexico’s Sierra Madre may for the moment have partially recovered their land rights. But the inequities of the world economic order persist. NAFTA remains in place, legally binding Mexico to the corporate interests of the United States. Already many small farmers in Mexico are being forced off their land. With the tariffs lifted by NAFTA, the United States is now exporting tons of surplus maize into Mexico. Subsidized by the US government, the selling price of this maize is half that of Mexican maize (although the buying price for families has not dropped). Unable to compete, countless campesinos who are giving up farming and moving in desperation to the growing slums of the cities, are finding that, as a result of the competitive market forces of free trade, the prices of food staples rise faster than wages.

Many health workers, including Roberto, are already suffering from NAFTA. During 20 years and at considerable sacrifice, Roberto had gradually built up a small herd of eight cattle. The cattle were an investment, the proceeds from which with which he planned to send his oldest son to college and then medical school (in the hopes his son would become one of those rare doctors who return to serve the villagers). But now with NAFTA, the US beef industry is shipping hybrid cattle into Mexico at wholesale prices, thus undercutting the value of local cattle. Almost overnight the selling price of Roberto’s cattle has dropped to half of what it was. Thus, NAFTA has slashed Roberto’s life savings and his son’s dream of medical school.

Yet things could be worse. Whatever his losses, Roberto knows he is relatively lucky. His family still has a plot of land to plant. His children for the time being do not go hungry. He knows that millions of families in Mexico and throughout the world are much worse off.

While many critics predicted grim outcomes from NAFTA, few foresaw the plummeting of the peso, starting in December, 1994, which has suddenly converted Mexico from the success story of trade liberalization into a global economic basket case. To keep the wolf from the door (and foreign investors from losing vast sums) Mexico has already borrowed billions of dollars from the US government, the World Bank, and the IMF, and has a line of credit for billions more. Even if the peso can be kept from slipping further—and so far there is no certainty of this—the burden of repaying the debt, along with the hardships of the devaluation itself, have fallen largely on the backs of the poor, whose real wages continue to plunge.

To keep servicing its increasing debt, Mexico has had to escalate the austerity measures already demanded by the World Bank’s structural adjustment programs (see Chapter 11). Already, the Mexican people have suffered further reductions in public services, further declines in real wages, increased taxation, and more user fees for health, education and other social services. By mid-1995 the price of oil had risen 35% and a federal sales tax on most goods had been raised from 10% to 15%.

Mexico provides a stark example of the global trend we examined in Part 3 of this book. With NAFTA and other free market strategies designed to favor the privileged, the plight of the poor is worsening in both poor countries and rich. In 1991 Mexico had only 2 billionaires. Today it has 28. Reportedly, one of these billionaires, Carlos Slim, controls as much wealth as 17 million of his poor compatriots.

Internationally there has been much high-level discussion about Universal Human Rights: the Rights of Children, the Rights of Women, the Rights of Indigenous Peoples, etc. But the New World Order—spearheaded by the international financial institutions (the World Bank and the IMF)—has denied humanity the most fundamental rights of all: the right to have enough to eat and, ultimately, the right to live.


It is hard to evaluate the success of a small, grassroots program like Project Piaxtla–especially when it comes to gauging its contribution to long-term social change, which is the ultimate determinant of health. Piaxtla and the organization of poor farmers that grew out of it have sparked a process of empowerment which has had a limited but significant impact locally. Child mortality has declined to 20% of what it was when the program began. Despite a drop in real wages in Mexico as a whole, extreme poverty in the program’s area of coverage is less common than it used to be. The gap between rich and poor in the distribution of land, wealth, and power has narrowed substantially. And the people’s election to conserve their ejido status for the time being helps make their gains in land and health more sustainable.

But the Piaxtla team knows it is playing with fire. The government has made several attempts to shut down the villager-run program. Members of the Piaxtla team and of the organization of poor farmers have been jailed and threatened. The government has also tried to put Piaxtla out of business by starting its own rival health services in the area (instead of turning its attention to the many areas of Mexico which are still without health services). Paradoxically, however, while the government clinic has seriously weakened Piaxtla’s actual health service (which is currently in disarray) it has also freed the program’s most motivated health workers to focus on addressing the more basic social, economic, and political causes of poor health. In the final analysis, the Piaxtla team’s work in these areas has done far more to reduce child mortality and improve people’s health–and overall quality of life–than a narrow medical approach alone could have accomplished.

Now in the 1990s, the villagers recognize that the future is less certain than ever. They foresee that the improvements in health won through years of community organizing and struggle may be lost tomorrow due to greed-driven global policies. They have seen the constitution that their forefathers fought for violated by foreign powers in conspiracy with their own self-seeking leaders. For them, the “free trade” agreement is not free; it has cost them their land, their health, their most basic human rights, and the dignity of self-determination. The plight of poor farming and working people in Mexico is not an isolated situation. Similar hardships are being wrought on disadvantaged peoples in every corner of today’s endangered planet. The global power structure–comprised of big government, big business, and the international financial institutions–has imposed its New World Order worldwide. It has tied most areas of production and development to the global market in a way that benefits powerful interests and weakens the bargaining power of the poor. Today no nation—and, indeed, virtually no village—has the liberty of self-determination.

Appendix: Summary of the Impact on Mexico of NAFTA and the Structural Adjustment / Austerity Measures Intensified after the December 1994 Crash of the Peso

  • Between 1994 and 1995 sales of major wholesalers dropped by 75%.

  • Food production fell by 80%.

  • Basic food prices rose faster than overall prices (by 43% in the first 7 months of 1995).

  • While cutting back on services and subsidies for the poor and taxing them more, the government increased subsidies for the rich. In 1995 it spent 13 billion (5% of the GDP) to bail out commercial banks, and 2 billion to assist private road-building contractors (who put tolls so high that few can afford to use the highways they built).

  • Over 60% of all Mexican businesses reduced their workers, and 1/3 of businesses have closed down.

  • In the first 9 months of 1995, over 2 million people fell into extreme poverty. Today over 40% of population lives in poverty.

  • Mexico’s foreign debt has swollen to suffocating size. Interest payments in the first half of 1996 were almost $18 billion, nearly double that in the first half of 1994.

  • Since December, 1994 the average wage lost 54% of its purchasing power.

  • During 1995, between 1 and 2 million more workers became unemployed, raising total unemployment to 10 million (26% of the active workforce).

  • In 1996, the President’s “secret budget item” (a discretionary fund for which he does not have to account) was raised to US$85 million—30% higher than the year before.

  • In response to growing poverty, crime has escalated. In response, Congress legalized gun ownership by private citizens. Gun-related violence, already extremely high, is predicted to increase.

Publication Information


A background paper first presented on the Project Piaxtla page, then rewritten and republished as Newsletter 29 in June 1993.

Note: An illustrated version of this essay was published as “How the Uprising in Chiapas Revitalized the Struggle for Health in Sinaloa” in Newsletter #29. However, differences between the two texts justify its presentation as an independent article.