A Short History of Project Piaxtla

by David Werner with contributions from the HW Editor

Project Piaxtla in western Mexico was a rural primary health care program run entirely by local villagers. Named after a nearby river and located in the foothills of the Sierra Madre mountain range, Piaxtla was started in the mid 60’s to serve a large, rugged, sparsely populated region in the state of Sinaloa. When the program started the area was traversed only by mule trails and footpaths. The program was based in Ajoya, the largest village (population l,000) in Piaxtla’s area of coverage. David Werner has been involved with this program as an advisor and facilitator since its inception. Project Piaxtla gave birth to Where There Is No Doctor, a village health care handbook, and also to Helping Health Workers Learn, a handbook on participatory, discovery-based methods of health education.

Here is David’s description of the early Ajoya clinic, from Newsletter #6, dated October 1970:

Project Piaxtla provides virtually the only medical and dental care within a 400 square mile sector of the Sierra Madre. This past year our clinics had more than 5000 patient visits. The project is active in introducing more nutritious food crops, starting corn banks and food cooperatives, sponsoring further education for gifted youngsters, and training village youth in medical and dental skills, we manage to accomplish on an annual budget of about $8,000 the equivalent of what other medical aid projects and up to $80,000 to do. To do this we tap numerous resources for donations of medicines, equipment, and volunteer assistance. We learn to live and operate on a shoestring – and in so doing we feel more in harmony with the villagers with whom we work.

By June 1994, David could report:

It has been said that one of the best indicators of the overall health of a population is the “under-five mortality rate” (U5MR) of its children. In 1965, when the villager run health program called Project Piaxtla began in the mountains of Western Mexico, 34 out of every 100 children died before reaching their fifth birthday. Today between 5 and 7 children per 100 die: more than is acceptable but a big improvement over the earlier rate. Equally important, now there are far fewer malnourished, sickly and stunted children. More youngsters are healthy, growing well, and bursting with life.

In a 1994 interview, the Piaxtla clinic had to a certain extent been pushed aside by a government program:

The health program now is not anything like what it used to be because the government has come in with its own health programs. The village-controlled health programs are seen as a potential threat. One positive outcome has been that the health workers are freed up to put energy into community organizing and land issues, which in the long run have more to do with improving health than preventive or curative care.

As the 1990s progressed Ajoya itself began to pass through increasingly difficult times. The economic crisis in Mexico—and the widening gap between rich and poor that resulted from the North American FreeTrade Agreement (NAFTA) and the “global casino” of speculative investing—has led to a tidal wave of joblessness, falling wages, crime and violence throughout the country. As we have described in Newsletter #18, the village of Ajoya, a strategically-located exchange point for illegal drugs grown in the mountains, has suffered more than its share of robberies, assaults, and kidnappings. As a response to so much crime and violence, many families have fled the village. In the last two decades the population has dropped from 1000 to just a few families and elderly folks.

As the result of the violence in Ajoya and the surrounding Sierra Madre in the last decade Program Pixatla, very sadly, has ceased to exist. The healthcare needs of those who remain in this part of the Sierra Madre are no longer being met by any organized program. There is great hope that in the future drug demand (herion and marijuana) in the US and elsewhere will fade and thus production/trafficking will also fade and Program Piaxtla could be reborn. But as of the beginning of 2011 the situation remains to violent and insecure in Ajoya and the mountains beyond.

Key Personnel



COMING SOON: In this section we will trace the major events of Project Piaxtla, sourced from the Newsletters and elsewhere.

A Portrait of Project Piaxtla

by David Werner

From About Project Piaxtla and the Authors, from Helping Health Workers Learn (1982).

To revive the memory of Project Piaxtla we turn to David’s account provided at the back of Helping Health Workers Learn, published in 1982. The Project was then 17 years old, bursting with charisma, growing capabilities and global influence.

Many of the ideas in this book came from a small community based health program in the mountains of rural Mexico called Project Piaxtla. This health program has been run and controlled by local villagers, some of whom have worked with the program since it began in 1966. The project has served over 100 small villages, some of which are 2 days by muleback from the training and referral center in the village of Ajoya. This mud-brick center has been run by a team of the more experienced local health workers, who trained and provided support for workers from the more remote villages. This book discusses details of selection, training, follow-up, and referral of the 2-month training course developed in Ajoya (see the Index).

Project Piaxtla began in an unlikely but very natural way. In 1964, David Werner, a biologist by training and a school teacher by trade, was wandering through the Sierra Madre observing birds and plants. He was impressed by the friendliness and self-reliance of the mountain people, but also by the severity of their health problems. Although he had no medical training, he felt that his scientific background and the people’s resourcefulness and skills might be combined to meet health needs better. So, after apprenticing briefly in a hospital emergency room in the U.S., and painting bird pictures to raise money, he returned. David stayed for 10 years, until he was no longer needed. It seemed that the most helpful thing he and the other outsiders could do to allow the program to evolve further was to leave. So in 1976, the program changed and was run entirely by the local villagers, with no ongoing presence of outsiders or professionals.

In its focus of action, Project Piaxtla evolved through 3 stages: curative, preventive, and social. It began with curative care, which is what people wanted. In time, the central team gained a high degree of medical ability. Although most of the group had little formal schooling, they were able to effectively attend (or help the people attend) about 98% of the health problems they saw. Because of the difficulties in getting good care for persons they referred to city hospitals, the team made efforts to master a wide range of medical skills. These included minor surgery (including superficial eye surgery), delivery of babies, and treatment of serious diseases such as typhoid, TB, leprosy, and tetanus. (With the help of village mothers, who give the babies breast milk through a nose-to-stomach tube, they have been able to save 70% of the newborns with tetanus.) For severe problems beyond their capacity, the team slowly developed an effective referral system in the nearest city (see page 10-1 8).

The health team, having been trained by a visiting radiologist, was also able to take X-rays using an old donated unit. A basic clinical laboratory for stool, urine, and blood analysis was run by Rosa Salcido, who had never been to school. Several village ‘dentics’, headed by Jesus Vega, would clean teeth, extract, drill and fill cavities, and make dentures—at a fraction of what these services cost in the cities.

Even as curative needs were being met, however, the same illnesses appeared again and again. So people became more concerned with prevention. The team began programs of vaccinations, latrine building, nutrition classes, child spacing, and community gardens. But in time the people began to realize that even these measures did not solve the root causes of poor health-those relating to land ownership, high interest rates on loans, and other ways that the strong profit from the weak. So little by little, the focus of the health team became more social, even political. Examples of actions they took are discussed in the introductory section (Why This Book Is So Political) and elsewhere in this book.

The health team came to feel that its first job was to help the poor gain self-confidence, knowledge and skills to defend their just interests. But this was not easy. Among other things, the health workers had to re-evaluate their own approaches to teaching and working with people, to develop new methods that help persons value their own experience and to weigh critically for themselves what they are taught and told. Many of the learning methods and materials discussed in this book have been developed by the team and student health workers through this process.

Project Piaxtla’s relationship with the government was mixed. When the village team became increasingly effective in helping people deal with illegal land holdings, high interest rates, corruption of local officials, and abuses by health professionals, local authorities made repeated attempts to weaken the program or close it down.

But Piaxtla also had its strong supporters—even within the government. Although the Health Ministry, in many ways, opposed the villager-run program, those in other ministries appreciated its value. The Ministry of Agrarian Reform contracted with the village team to train its first group of community health workers. The Ministry of Education—which has considered making ‘Health’ a full-time school subject—sought the advice of Martin Reyes, the Project Piaxtla coordinator. CONAFE, a government program that set up basic skills libraries in villages throughout the country, employed Pablo Chavez to help train village ‘cultural promoters’ in the use of Where There Is No Doctor. (Pablo is the health worker who helped illustrate this book.)

Also within the Ministry of Health, Project Piaxtla had its friends. For years, the malaria control and vaccination programs cooperated with the village team. At first, things were more difficult with the tuberculosis program. The district chief refused to provide the health team with medications for those living too far away to make regular trips to the city health center. So a leader of the village team, Roberto Fajardo, went to Mexico City and convinced the head of the national program to give an order to the district chief to supply the team with medicine for proven cases of TB. In this way, the Project Piaxtla team began to affect government policy, making it more responsive to the needs of the rural poor.

The Ajoya team valued economic self-sufficiency. The part-time health workers from outlying villages also achieved this in their work. They earned most of their living by farming, and charged a small fee for services. Self-sufficiency proved more difficult for the team of coordinators in the training and referral center. However, they experimented with a number of income-producing activities: hog raising, chicken raising, vegetable gardening, fruit orchards, and bee keeping. These activities not only brought in funds, but helped improve local nutrition and provided examples of improved small-scale production. The team also charged a modest fee for services. Persons unable to pay could send a family member to help with the farming instead.

The village team came to feel that health workers from different programs and countries have much to share and learn from each other. The team was active in a regional Committee for Promoting Community Health in Central America.The committee’s third international meeting was held in Ajoya. In this meeting, the number of professionals and outsiders was strictly limited, so that the health workers themselves could lead discussions and participate more easily. The Ajoya team also conducted a series of ‘educational exchanges’, inviting village-level instructors from health programs in Mexico and Central America to meet together and explore educational methods and materials. These ‘exchanges’ were valuable for gathering and testing many of the ideas in this book.

Project Piaxtla has evolved through trial and error, learning from both mistakes and successes. It struggled through many difficulties, many of which grew more severe as the team became active in defending the rights of the poor. The future of the project is as uncertain as is the future of the poor in Latin America.

The Politics of Health Emerging from Project Piaxtla (1994)

by David Werner

This essay is David Werner’s definitive statement on the significance of Project Piaxtla. It outlines the history of the political developments emerging from the project as the author grew to realize that the health problems faced by the rural people of the Sierra Madre were not purely medical—due to the absence of medical treatment—but socio-economic in nature—because the poor cannot eat.

In this essay, the struggle for health is explicitly linked to the struggle for land. Various phases of the political struggle led by the health workers are outlined, beginning with the maize bank and activism against drunkenness, culminating in the struggle for campesino land rights. Facing setbacks from NAFTA and global capital, David finds inspiration in the Zapatista uprising of 1994.

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.

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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.