Primary Health Care and the Temptation of Excellence
No hay bien sin pero, ni mal sin gracia.
[There’s nothing good without a drawback, nor bad without some saving grace.]
—an old Mexican saying
For better and for worse, the Ajoya Clinic has come a long way since 1965, when it began as a few boxes of medicines and bandages on the front porch of the casa of blind Ramón, and its staff was no more than an ex-schoolteacher trying hard to play medic, assisted by a handful of over-eager village children. Then, to be sure, we had a strong sense of community—sometimes too strong—for we shared the open porch with dogs, chickens, pigs, cockroaches, a pile of pumpkins, a corn crib, a small table at which we ate in shifts, and five cots which at night were unfolded to sleep eight of the household and myself.
Today La Clínica de Ajoya occupies a large old adobe casa in mid-village. Although once a fine home, when we took it over in 1970 the place was in ruins. The roof was a sieve, the walls eroded and collapsing. It had been boarded up for five years, ever since the ancient widow who owned it died, and it was infested with bats, rats, fleas, pigeons, spiders and—according to rumor—ghosts. (The house was well over three-hundred years old. ed.)
We cleaned, patched and white-washed the old building as best we could, and to this day wage a never ending battle to keep it comparatively sanitary and vermin free. The village women cooperate by sponsoring a chore lady who daily scrubs, dusts, disposes of trash and steps on scuttling critters. But an old adobe house, like a small boy, blithely parries every attempt at cleanliness. It has too many secret niches. By day, things appear relatively kempt and under control, yet at night cucarachas materialize out of the walls to explore the medicine bottles, rats scamper and skirmish on the eaves, bats flutter through the patient wards, and occasional scorpion steals up a cot leg to cuddle in the warm bedding of a patient or volunteer. We are still not a high class medical facility.
Little by little, however, we have made “improvements." Over the years we have poured cement floors in the patient wards, fixed up an X-ray darkroom (which is not quite dark), built a workshop, put in a septic system, a flush toilet (which doesn’t always flush) and a cold shower. Last year we finished construction of an almost modern operating room complete with scrub room, fitfully running water, filtered air system and surgical lights, powered by our increasingly cantankerous 5 KW generator.
During the past few months, our biggest step forward has been to equip and get into operation a tolerably functional clinical lab. Many people have helped donate or scrounge supplies for it, so that we now have a fair range of equipment including two fine microscopes, scales, a macro and a micro centrifuge, and a simple but ingenious incubator for culturing bacteria. (This last item consists of a styrofoam box through which runs an exhaust pipe from our small propane refrigerator. The pipe has a thermostatic shutter valve, so that a constant temperature can be maintained in the box.) The incubator was contrived by the husband of a visiting medical technician. Three such technicians have made separate trips to Ajoya to help set up our lab and train our health workers to use it. During their short visits the volunteer lab techs have focused on training Kerry Travers, who has a degree in microbiology and therefore a head start. Kerry, in turn, has been training Ramona Alarcón, the grand-daughter of the village blacksmith, (who presented me with a white rooster when I first opened the dispensary in Ajoya 10 years ago), Ramona, after six months apprenticeship, is now able on her own to do many basic tests; to prepare, stain and examine slides of urine, feces, blood and wound exudates, to seed culture plates, and to identify common forms of bacteria and intestinal parasites. Our new lab service has greatly increased our diagnostic capabilities. Hats off to Ramona, to Kerry, and to our visiting medical technicians!
Inching Toward ‘Excellence’, or How Real-Life Complicated the Original Ajoya Clinic Mission
All in all, the Clinic of Ajoya is not only far better situated than it was a few years back, but the type of medicine we manage to practice, while still relatively primitive by U. S. criteria, has become increasingly advanced. Our village apprentices have gained experience, our American volunteers are better trained, our range of equipment is more extensive and our laboratory facilities are enormously improved. In short,one might say we practice “better” medicine.
But, is it really better medicine?
Yes and no. In terms of the widely accepted standards of Western Medicine, definitely yes. In terms of realistically getting at the root of the health problems in the mountain villages we intend to serve, perhaps no.
As we all know, Western Medicine has tended to pay far more homage to Panacea, the Goddess of Healing, than to Hygeia, the Goddess of Health. It has poured a vast amount of money, training, research and prestige into the treatment of illness, yet a proportionately trifling amount into its prevention, which logically and pragmatically should come first. The reason is simple: it is the sick who holler loudest. And of the sick, those who can pay most are often the most readily heard.
Over the past 40 years or so, the Science of Healing has made extraordinary advances. The discovery of antibiotics, the introduction of transfusions and transplants, the proliferation of devices for testing, monitoring, measuring and you name it, have taken the sting out of many illnesses and prolonged life for many who can afford it. Yet the fact remains: on this Earth today, there are numerically more persons lacking even rudimentary health care than ever before in human history. And every day the number of such persons is growing.
Ever since the days of Hippocrates, the sworn intention of the Medical Profession has been to serve the people; not just those who can afford it, but those whose need is greatest. Yet the very excellence, as well as exclusiveness, of today’s Medicine, with its increasingly high standards, elaborate technology and exhaustive training, has pushed its cost and availability far beyond the reach of the common man, and perhaps beyond reason.
There are numerically more persons lacking even rudimentary health care than ever before in human history. And every day the number of such persons is growing.
It is time that the Medical World went less in the direction of “excellence” which can only be for the few, and strove more toward “adequacy” for the many. This requires lowering our standards; or more accurately, lowering our standards for technology and training, and raising our standards for foresight, magnanimity and common sense. This won’t be easy. I can testify from my personal attempts.
Clearly, the chief concern of a primary care center should not be sickness, but health first. The original intention at the Ajoya Clinic was to provide primary care only and to concentrate our major efforts on broad-scale campaigns of preventive measures and public health, for we realize that only in this way will we ever make any significant or lasting inroad on the overall health of the community.
By no means have we neglected preventive measures completely. As those who have been following our activities well know, we have plunged into programs of vaccination, family planning, pure water systems, experimental crops, food cooperatives, corn banks, health education, medical self-help (including my villager’s medical handbook, Donde No Hay Doctor) as well as conservation of game, fish, timber, beauty, etc.
But for all these sundry programs in community health and preventive medicine, the end at the Ajoya Clinic has been to become increasingly embroiled in the curative side of medicine. The temptation of ‘excellence’ has been too strong for us to resist. It is only natural that one likes to provide the “best” medicine to those who clamour for and appreciate it the most, namely the sick. And so we have brought in X-ray and E.K.G. machines, centrifuges and microscopes, built an operating room, expanded our clinical library, picked the brains of visiting doctors, and done everything in our admittedly limited power to upgrade the scope and quality of our diagnostic and curative services. In short, we have come a long way from the primary care center we once set out to be.
“But, what’s wrong with taking better care of the sick?” you may ask. What is wrong is that we have put ourselves on the map. In Sinaloa and beyond, we have gained a certain “fame” for being able to cure difficult and heretofore incurable ailments. This fame is, of course, unwarranted; the fact being that in 90% of our more awe-inspiring successes, the difficulty which has made the illness in effect “incurable” has been economic: Our medicines work wonders simply because, for once, they are within the reach of the people. Yet, however undeserved our success, the word is out. More and more patients flood in from farther and farther away. Some have already sought medical help elsewhere, and present with obscure or recalcitrant maladies which we are often at our wits end to figure out. Patients come from the slums of Mazatlán and from as far away as Hermosillo, Tepíc and the Tarahumara territory of Chihuahua and nearly all are indigent. Some we can help, some we can not; some we refer to doctors we know in the coastal cities who are conscientious and may even give them a break; and a few—especially children with correctable deformities—we bring to California for treatment at Stanford, the Shriners Hospital for Crippled Children, or elsewhere.
True, all this fills a great—in fact, an endless—need, but not the need we set out to fill. This kind of stop-gap, helter-skelter, cure service is all right for a start; it helps limit the suffering of an ever-lengthening queue of sick individuals; but it makes no headway, gains no ground. On the contrary, the continual flood of “outside” patients has put a tremendous drain on the time and energy we would like to be putting into long-range community health and preventive measures in the mountain villages we came to serve. We have tricked ourselves into plugging so many leaks with our fingers, we don’t have enough free hands left to build a better dike. Contrary to our stated intentions, we have focused on sickness, not health.
We have tried to resolve this dilemma in several ways, none fully successful. We have even made feeble efforts at refusing service to “outsiders,” especially those who come from areas where there are doctors or health centers. But we find that many patients have made long journeys, often at great sacrifice, because they are too poor to get the medical help they need elsewhere. They arrive with their hopes high and their pockets empty. In theory one can turn such persons away. Not in fact.
Soooo, what do we do?
Simplifying the Ajoya Clinic, in Theory At Least
“Simplify!” is the proposal of Mark Lallemont, a young doctor from Paris who spent three months helping at our clinics last summer.
Unlike many of our visiting doctors, who are either frustrated or charmed (or both) by the relative primitiveness of the Ajoya Clinic, Mark insists that the level of medicine we practice is “trés sophistique.” He thinks we should limit our services to those which villagers can learn to handle for themselves and can duplicate in other villages up the line. He is adamant that we focus on stopping sickness before it starts.
But sophistication, like crab grass, is easier to come by than get rid of. “How,” I asked Mark, “do you suggest we ‘simplify’?”
“First of all,” replied the French doctor, “Throw away some of your fancy equipment, the E.K.G. machine, for instance.”
“But it’s a useful tool!” I protested. “What do we do when we’ve got a patient with a baffling heart problem?”
“Admit you’re baffled,” replied Mark. “Be kind, be supportive, and let Mother Nature or the Great Reaper determine the course. They will anyway, regardless of whether you monitor the poor guy’s heartbeat. If you have an E.K.G. machine you’re automatically relegated to tinkering with outdated hearts when what you want to be doing is digging latrines, improving crops and de-worming kiddies.”
“Any other suggestions?” I asked.
“Yes,” said the French doctor. “Get rid of 9/10 of your medicines. The fewer kinds of medicines you have, the more people you’ll reach with them and the easier you can teach the people to use them correctly. You can make do with 10 or 12 basic drugs. This, of course, means you’ll be treating mostly the commoner ailments. But that’s fine. If you limit yourself to primary care you’ll have more time to devote to hygiene, nutrition, birth control, vaccination and all the other things which in the long run make for less sickness all the way around."
“That sounds great,” I agreed. “But when someone suffers from a not-so-common illness we could readily treat, it’d seem a shame not to lend a hand, just because we’d thrown away the specific medicine he needs. Suppose, for instance, a leper comes in, as happens now and then. Do we tell him, ‘Sorry, not today.’?
“Leprosy’s hard to cure anyway.” said Mark. “It takes years.”
“But we’ve cured it!” I pointed out. “Remember, it’s a dreaded, slowly progressive, disfiguring and crippling affliction with a huge social stigma. It’s a disease you want to help somebody with if you can.”
“Can’t you send such patients to the city for medicine?” suggested Mark.
“If they can afford it. And if they’ll go,” I said. “But we can get the sulfones they need much cheaper ourselves.”
“Hmmm” conceded Mark. “In that case perhaps you should include a sulfone on your list of basic drugs.”
“We’ve already included it,” I assured him, “along with a whole drove of other medicines which once in a while make a big difference in this or that patient’s life. That’s why ‘things just ain’t simple’ . . Believe me, Mark, our line of reasoning is pretty much the same. I’d love to put most of my time into preventing sickness instead of treating it. But theory’s one thing and life’s another. And when a patient who’s deathly ill comes to you because he believes you’ll do your damnedest to help him, by Jesus you do your damnedest to help him, all your theories about preventive medicine and keeping things simple be hanged!”
“True!” said Mark. “And that’s precisely why you should have only 12 basic drugs and get rid of some of your fancy equipment; so you won’t be seduced away from the work which in the long run will help the people most."
“Thirteen basic drugs,” I corrected him. “You just added a sulfone, remember?”
Mark laughed. “Okay! Okay! I get your point!” and added with a sigh, “Things just ain’t simple … but, Mon Dieu, they should be!”