Concerning Project Piaxtla, a personal endeavor to foster a campesino-run health care network
in the mountainous reaches of Sinaloa, Mexico.
Dear Friends of Project Piaxtla,
The substance of this Newsletter has been prepared by Victor Miller, a 28 year old Californian who, as a volunteer for Project Piaxtla, spent the last two years in the back country of the Sierra Madre helping villagers set up their own "clinics" or health outposts, and in training the village workers to take them over. Over the past year in the Pueblo Viejo area, he has done a superlative job in helping the villagers to pull together in the construction of their own health facilities. Teresa, who has trained as a promotora de salud or village health promoter, is an exceptionally gifted and sensitive young woman who is becoming increasingly competent in the provision of primary health care. When Victor leaves for the USA in June, he will not be abandoning those he has worked with, but rather leaving them with a modest but ongoing health care program run by the villagers themselves and linked to the Ajoya Referral Center for supplies, supervision and follow-up training.
Last summer Victor was joined by Paula Haller, 23, who worked with him in helping train some of the villagers. Paula focused primarily on family planning and in organizing classes for mothers for child care. Victor and Paula have done an outstanding job in helping the people of the Pueblo Viejo area learn to cope more effectively with their own health needs.
Before passing this Newsletter over to Victor, I would like to add a few words about the role of American volunteers in Project Piaxtla. Project Piaxtla went through a period in its evolution where young Americans played an important role as "backwoods medics". These young Americans saved many lives, earned the love and esteem of the villagers and "had one Hell of a an adventure" while they were at it. But the days for the young American to "play doctor" are we hope, over. Far better than to have health care "delivered" by outsiders, is to have it come from the community itself. The role of the young American volunteer today, therefore, is not to deliver health care but to help foster it. This is a far more difficult, frustrating and challenging role. To handle it well, fluency in Spanish is essential, as is the capacity to work and relate to people. Some previous background in health care is, likewise, important. In the future, we will be asking young Americans who consider volunteering to commit themselves for a two year period, with the understanding that the last three months may be devoted to helping train the next generation of volunteers. The number of American volunteers that we can effectively use is smaller than it has been in the past, now that we have a growing number of competent village workers. Persons who have special skills which they can help teach -- doctors, dentists, veterinarians, laboratory technicians, agricultural experts, continue to be welcome even for shorter visits. We do, however, encourage a working knowledge of Spanish as well as a willingness to focus on teaching rather than practicing of respective skills.
Those interested in volunteering with our project should contact Allison Orozco, 419 Webster Street, Palo Alto, CA 94301. Final approval will depend on the village staff in Ajoya.
I would like to thank all of you who responded to my request for financial help in the "Note From the Sierra Madre" which we put out last month. Thanks to the assistance of our own personal friends and the supporters of Project Piaxtla, our study team, which consists of Martín Reyes, Lynne Coen, George Kent and me, will embark on our "Project to Facilitate Rural Health Care in Latin America" as scheduled this April. (In fact, we will already be on our way by the time you get this Newsletter.) However, we are still sorely in need of additional funding for the development of the guide books, work manuals for village health workers and rural health planners which we hope will be the outcome of this project. If you would like to know, more about this "Project to Facilitate Rural Health Care", please contact Trude Bock, PO Box 1692, Palo Alto, CA 94302.Your assistance either to this project, or to our ongoing work in the Sierra Madre in Sinaloa will be greatly appreciated. Thank you.
And now from Victor . . . .
The Pueblo Viejo area is an ejido (cooperative farming community without large landholders) of approximately 800 people, nearly 40% of whom are 12 years old or under. The ejido contains three distinct geographical regions: dense pine forests growing on slopes that rise to 9,000 feet, a broad verdant mountain valley at about 7,000 feet and deep jungle canyons (barrancas) that provide a variety of savory fruits such as guavas, mangos, oranges and bananas. The clinic is located in the central rancho of Pueblo Viejo near the underground origin of a stream that runs between two massive ridges of the Sierra Madre. The rugged pine covered southern ridge holds the three high sierra ranchos: El Potrero (the corral) Las Azoteas (the rooftops) and La Sierrita on its crest. The northern ridge is a series of jagged peaks with a convenient pass bordering the rancho of Pueblo. A twisting rutted trail of loose rock and 100 foot deadfalls leads from the pass (El Puerto del Pueblo Viejo) to the lush and fertile canyon ranchos of Rincón (the corner), Casa de Tejas (house of Spanish tiles) and Candalero (candlestick). Here and there a daring family, finding rich soil, has erected a house away from the ranchos and strives alone against the elements and solitude. The heads of these lonely households are usually iconoclastic but likeable patriarchs.
January and February have many near freezing nights and days of gray overcast or drizzly rain. March, April, May and early June are extremely dry months, with days of intense high altitude sunshine. Late June to mid-October is the time of year known as las aguas, when violent daily rainfalls dictate all of life's activities and dominate human conversation. The rains make the narrow rocky trails leading to the world "below" very treacherous, due to the constant threat of landslides, flashfloods and falling trees. Rattlesnakes in the altos, coral snakes in the valleys, and scorpions almost anywhere are more abundant during las Aguas. As the time of harvest approaches, the last year's corn and beans become less palatable, less nutritious and less plentiful. There is little time to hunt wild game, but much competition for the wary deer, wild boar and pheasant. It is a brutal and demanding time. For gringos who have not experienced las Aguas of the Sierra Madre, it is almost impossible to imagine the severity of the rancheros' hardships or the magnitude of the courage they demonstrate in raising their families. Nature is continually assailing them with its furious, yet beautiful, seemingly omnipotent outbursts of power. November and December provide the final act -- harvest time. The trails are open to travel. The pressure is off.
Building the "clinic" or backwoods dispensary was the most frustrating experience of my life. My knowledge of construction stood at absolute zero when I arrived in El Pueblo in March of 1975. With a backpack of medicines and a vague understanding with the people as to what was going to happen, I attempted to organize the building of the first medical facility in Pueblo Viejo.
It was agreed at several hastily held meetings that the head of each household in the ejido would either work one day, pay 100 pesos or provide 100 pesos' worth of material. In exchange, their families would be provided with low cost medical care and I was to train a local person to, eventually, replace me as médico.
During the first month of work, Murphy's law reigned. Everything that could possibly go wrong went wrong and the nearly finished walls collapsed. After that it was merely a matter of seeing that the same errors were not repeated. Fortunately they were not and, as it turned out, there were no more mistakes left to be made.
Forty people worked on and off at making adobe, cutting beams, roofing, cementing the floor and similar tasks. These ranged from amounts of time varying from twenty minutes to ten days. For every job there were never fewer than five opinions on how it should be done and what tool it should be done with, by whom and when. Arguments and discussions on these points would continue sporadically for days and, in fact, still continue to this day, a year after the clinic has been finished. There was never enough material except for the soil used to make the adobe, but the first bricks were made of the wrong kind and shattered easily, making even that a source of irritation. By early May, the walls were up again, or almost. About three hundred 20 pound adobe bricks remained on the opposite side of the arroyo. The people that had made the bricks said that they had already done their part and it was the responsibility of the people putting up the walls to carry the adobe across the arroyo. The people building the walls disagreed. When I was near collapse trying to haul the bricks by myself, the school teacher let all niños ages 5 to 12 loose on the mountain of adobe which was causing so much ill feeling. This so embarrassed their fathers in the two rival work crews, that the adults continued working at a begrudged but faster pace without further turmoil. The clinic was habitable in two weeks and operational in a month.
Everyone is extremely proud of the fact that the whole community built the place. Anyone in the ejido can come by and recognize a piece of work done personally, or by someone in the same household. That person then proceeds to point out his piece of work as the one thing done exactly right, while everything else should have been done somewhat differently.
Teresa -- La Doctora Donde No Hay Doctor
I cannot make any claim to having been responsible for Teresa's medical education, nor for the high level of understanding which she herself achieved living in an area with seventy per cent of the population illiterate. Teresa has maintained a marvelous capacity to learn from books and apply her knowledge to practical situations. When I first met her two years ago, the had read all of David's book Donde No Hay Doctor, and was using what she had learned to treat her own family. She did this in opposition to the community's strong belief in the effectiveness of such things as enemas and sever dietary restrictions for most infectious diseases. She has continued to use local herbal remedies whose effectiveness she knows from experience, making her practice of medicine more adapted to community needs than would be possible for any outsider. Her mastery of both approaches to healing has made her the one person indispensable to the Pueblo Viejo Clinic. As far as the actual treatment of disease is concerned, we gringos are no longer necessary here.
On a solo visit to El Pueblo in 1974, I found that my bumbling Spanish was a far cry from the local idiom. Teresa was one of the few people who understood me immediately and thoroughly. Together, we saw about one hundred and fifty people during my first two visits. I was, therefore, able to give her practical experience in the things she had learned from David's book and she was able to show me how to derive the diagnosis of urinary tract infection from a woman presenting with a headache and nervous giggle.
Teresa is 25, married and has four children ranging in age from six months to five years. Paula and I delivered her youngest boy, Lino, on the day of the vernal equinox. Her husband, Carlos, while a firm believer in almost every superstition known to man, is also an inventor and "electrician". Forced to work at fixing such mundane items as radios and rifles, Carlos has found time to plan and build a turbine generator powered by the water of the arroyo. This year he laid 1/2 mile of pipe, set up the turbine and actually lit up an electric light bulb. Then he went broke when the local skeptics refused to finance a larger version of his creation. Terry and Carlos are a truly exceptional couple here, as they would be anywhere else.
Their home is always full of people waiting for their radios or dropping off defective firearms. Teresa used to hate the crowds, but lately she has been able to do a lot of health education with the Spanish medical pamphlets and books with which we furnished her. This is another thing which is difficult for an outsider to do. People here are unwilling to enter into a dialogue with gringos, or even Mexican professional people, for fear of offending them because they believe that they will be told something they are sure they will never understand. But Teresa has lived here all of her life, so that there exist feelings of equanimity and mutual understanding between her and the patient which are necessary for any real exchange of ideas.
In January, Terry took Lino in her arms and made the two day mule trip to Ajoya. She attended the classes for promotores de salud at the clinic there. Everyone was pleased with her dedication and surprised by her ability. When she returned to El Pueblo, people treated her with a new respect. There remained those who insisted that no one who had grown up as they had could ever do anything but have kids and grow corn. Naturally, these are the same people who will go to her most quickly and hysterically when they are sick. Overall, the community has accepted the inevitability of the changeover and has now begun to give her its full trust and confidence.
One of the most frustrating aspects of treatment here is the never ending array of vague aches and pains originating in the very active life the people lead. These either go away by themselves or respond dramatically to soaks and aspirin. However, every patient is convinced that his/her particular ache is the herald of some dread disease and requires the miraculous healing power of injectable vitamins or the panacea of intravenous fluids. Simple remedies are scorned. Nothing is worse than the flu season. The forcefulness of the symptoms lead to unending demands for injections of penicillin, liver extract and a variety of curious Mexican pharmaceuticals -- all ineffectual against the lowly virus. Keeping the peoples' trust in these cases is almost impossible. Despite careful explanations as to the cause and cure of these common ailments, it seems that someone's cousin in Culiacán has always sent up a few vials of some unlabeled substance that is muy fuerte. Refusal to inject this wonder drug will, in most cases, leave the patient disappointed or irate. He or she will then seek out a local person skilled in the art of puncturing the buttocks and they will enact this ritual until either the symptoms are gone or the medicine is expended.
Other consultas are emergency cases for such things as gaping wounds, acute asthma, births and severe pains of any type. With these patients, the amount of injections or paraphernalia or frantic effort on our part leaves the family more than satisfied regardless of the outcome. In these cases, careful counseling in home care is all too often disregarded since the family members believe in the awesome power of those technological talismans -- shots, pills and ointments. The child with fever and bronchitis, when treated with aspirin in the clinic, may be less likely to get the vaporization we prescribed for home treatment. It is painful to admit that after the clinic has been operating a year, the local attitude towards home care is most often, "He's had the shot (or pills). Why do anything else?"
A complete absence of health education here in the past, very heavy handed and mindless radio advertising campaigns for medicines and unprincipled wandering vendors of useless, sometimes dangerous, pharmaceuticals has led to unhealthy overmedication. With minimal understanding of how medicines work or what they contain, a new folklore, a pharmaceutical mythology has arisen. Woe be it unto the medico who doesn't inject penicillin for pain or Vitamin B12 for stomachaches: The considerable herbal lore the people once had was at least based on their own experience and was a part of their everyday environment. So called "western" medicines have no such basis and are subject to rumor, ritual and conjecture. Despite the recent origins of these folkways, they are nonetheless powerful and well entrenched, thus making education the most crucial and demanding aspect of the consulta.
We have tried to deal with these problems by sheer jawboning, but whenever we have succeeded, I am uncertain whether the explanation given is going to generate any new thoughts or habit patterns in the person. Has s/he understood or has s/he merely accepted a series of arbitrary procedures recommended by the "all-knowing" medico? The continual struggle to counteract fallacious ideas about health and to stimulate change has been our greatest challenge. Here and there a person has been won over to the point where s/he will challenge a neighbor who wants to put excrement on a cut or give a purgative to a feverish child. This is all too rare, but the fact that such a dialogue is commencing among villagers themselves is a significant step towards a self-operating system of health care and health education. If we can bring this about through the consultas, we will have been able to treat the community as well as the individuals within it.
It is a long broken trail that connects Ajoya and Pueblo Viejo. It runs for thirty miles across uninhabited canyons, immense ridges and lofty forests, without good water along the way. I made the first of several trips along this trail from Ajoya in early February. We vaccinated two hundred children (DPT and polio) and one hundred adults (typhoid) from six of the villages. I started out on a bitter cold night and made the trip which usually takes two days by mule, in twelve hours. Arriving at the first ranch house, I divided the vaccines and ice in my thermos so as to send a batch to Teresa in El Pueblo and another to the local volunteer vaccinators in Rincón. I then headed up the La Sierrita-Azoteas ridge. February's lone rainfall, a violent half-hour affair, hit me half-way to the crest. I finished vaccinating the last kid at midnight and went down into El Pueblo to compare notes with Teresa. The people from Rincón had not shown up to carry the vaccines down the valley. Some people hadn't come out because of the rain and darkness. Many kids had la gripa (flu) and high fevers, making vaccination contraindicated. Many adults had acted damned silly about injections. We hadn't created a large enough reservoir against infection because on this round not enough people were vaccinated.
Uin, a local campesino, boasted of being able to reach El Pueblo from Ajoya in 8 hours by a high sierra trail transversable only by foot. Two days after the first vaccinations, he was off. He proved his boast in spite of the fact that a mountain lion severely mauled his dog on the return. "Better him than me", said Uin philosophically. Not wanting to be left out of what seemed to be the only excitement in the area, the Rincón folks got themselves another marathon runner, Uin being temporarily disabled. Alberto vowed to beat Uin's record, lion and all. Arriving half an hour shy of the mark, Alberto claimed the legendary onza (a monstrous cat with glowing eyes and supernatural powers) had cornered him in a box canyon for two hours. He showed everyone some recently expended shells from his pistol to prove his story, leaving himself open to some good natured ribbing.
Once everyone realized what was going on, the community divided itself into two distinct groups, those who took their punctures with stoical good humor and those who hid out until they thought the ice had melted and the coast was clear. The former group consisted almost entirely of children, the latter group was made entirely of adults. Oligario got caught under his bed, making himself an easy target. Uin made a valiant effort to escape, but tripped over his ailing dog. Felipe, celebrating his saint's day with free beer for all, left himself and his groggy well-wishers easy prey to Teresa's enthusiasm. A few hung-over party goers wanted treatment for scorpion bites in the morning, forgetting the drunken bravado with which they had rolled up their sleeves the previous evening. Moto armed himself with a machete and defied anyone to try and vaccinate him. Unfortunately, his compadres had already been jabbed and, human nature being what it is, they saw no reason to let their amigo escape their fate. With a malicious glee, they disarmed and unshirted the flailing, cursing Moto who was then crudely but effectively injected. So ended the first wave of vaccinations.
In March, the newest runner, Pacho, again failed to equal Uin's mark, however he arrived with plenty of ice in the thermos at about 1:30 in the afternoon. This time a local family had decided that the vaccines were part of a plot by the United States government to kill off Mexicans. The rumor was circulated that, once vaccinated, a person had but five years to live: Some people were frightened and vowed not to be caught with their arms exposed. Teresa, Paula and I had to do the house to house educational talk all over again. All but a few people were convinced to get the second and last of the typhoid series. The older kids all came giggling to be first and stayed around to laugh at the mannerisms of the reluctant adults. The event ended at 9 pm. When Jose Luis decided it was too cold an evening to spend nearly naked down by the arroyo waiting for the bothersome vaccinators to get out of his house. Like the building of the clinic, the vaccination program was a community effort full of boundless good intention and chaotic execution, but all in all a success.
In April of this year the second of the DPT and Polio series will be given. The adults, now no longer targets of the needle, have decided the whole thing is a lot of fun and probably a good medical practice too. With help from the Ajoya Clinic, the people themselves can now organize future vaccinating programs for the outlying ranchos and those people missed this time around. Teresa is already making the plans.
The Bad Year
When the rains finally let up in October, tension is released and people begin looking forward to a full harvest and fuller bellies. But this year the rains ended early in mid-September. The corn stalks became brittle and dry in the fields and the corn failed to fully mature. Towards the middle of October the remains of a fierce coastal hurricane flattened most of what was left of the crop. Also, the beans and sugar cane were hit by frosts in November and December, making for a miserable harvest. In other years, several inches of rain in January have made crops of tomatoes, fruits and green vegetables possible, but except for a few gray drizzles, this January, too, was a dry month. In February, with nearly six months to go before the next good rains, the arroyo had already begun to dry up. Now, in March, the people began to sell whatever they had (cattle, mules, sewing machines and labor) to distant more fortunate areas. Some families left the Sierra to take their chance in the already crowded barrios of Mazatlán or Culiacán. To add to all of this misfortune, this month a U. S.-Mexican helicopter crusade, looking for marijuana fields, sprayed every cultivated patch of ground, orchards and grazing lands. Concentrations of the herbicides in the sluggish streams proved fatal to cattle in many cases. Inflation was the final blow. In the local stores, by mid-March, the price of every staple commodity which people needed to buy in quantity had at least doubled.
When I arrived in Ajoya for supplies in early March, I was told that the people of the Pueblo Clinic would need to somehow achieve the very difficult goal of self-sufficiency in the primary health care program in a period of a few months. All of us are working extremely hard to reach that goal, but now it seems more distant, more impossible than ever.
This year, for many of the campesinos as well as for us medical amateurs, it is a long cruel way to the next harvest. It is bad, but not too overwhelming, when one is faced with a single critically ill patient. Now, however, the health of the community itself seems to be endangered. We can share with these people the numbing presence of helplessness before the relentless natural forces that must be combated each and every day. We feel our common inadequacy to move events and shape our destinies. Yet we know that after all our effort, we cannot give up or succumb to the fatalism which has always afflicted these mountains. How we will work everything out, I don't know. But this village health program is needed more urgently than ever before, and it is going to remain here for the campesinos who work so hard and have so little.