David’s Hypothesis: Promote Primary Health Through Education
Since the above discussion with Mark last September, we have tried in a number of ways to move increasingly in the direction of primary care and preventive medicine. Yet we have more or less resigned ourselves to the fact that the Ajoya Clinic is, ipso facto, a treatment center. Rather than try to change this state of affairs, we have determined to use it in every way possible to promote preventive measures and better overall health.
To this end, we have set about turning the Ajoya Clinic into a school. To some extent, of course, it has long been one. For ten years we have been training local village youths, on an apprenticeship basis, to function as medics and dentics, both in the Ajoya Clinic and in our medical outposts (now four). We have also had training programs, both in Ajoya and California, for our young American volunteers, who range from pre-med students to high school and college dropouts. In fact, the continuity of medical and dental care in our health centers is provided by the work force made up of these conscientious young amateurs and apprentices, both Mexican and Gringo. The primary role of visiting doctors and dentists, when we are fortunate enough to have them, has not been so much to practice their respective skills, but to teach. We have long felt it is the doctor’s responsibility to assist the auxiliary, not vice versa, and that it is the auxiliary’s job to assist—and teach—the patient.
Our latest effort, then, has been to expand our teaching program in the direction of primary care and public health. One of our most important adjuncts at the Ajoya Clinic has been to train “health promotors” from isolated villages.
A village health center should first and foremost be a school.
The Ajoya School of Boondock Medicine
The purpose of our new training program for Promotores de Salud is to disperse primary health care over a wider area. Thus we give settlements beyond reach of our immediate services the chance to select persons from their own communities for study at our central clinic. On returning to their villages, they are able to set up health stations and serve their fellow campesinos by providing simple treatment, vaccinations, programs for better hygiene and diet, health education and family planning. To encourage reciprocal responsibility between “promotor” and his village, each village is asked to come up with half of a modest scholarship or living allowance for their trainee while in Ajoya. Our Project provides the other half.
In late November, two weeks before the training program was to begin, I set out on a dash excursion of more than 200 km. on muleback through the remote barrancas of Sinaloa and Durango, to do final recruiting for the course and announce the starting date. As it happened, this expedition nearly cost me my life, and did cost that of my personal mule, ‘La Coloradita.’ Climbing a narrow, treacherous stretch of trail into the high sierra, my mule’s hind hooves unexpectedly slipped on the decaying granite and she fell on her belly, half off the trail. For a brief moment she teetered on the brink, her hind quarters dangling in space. In that moment I was able to carefully but quickly dismount. I scrambled up ahead of the wide-eyed mule, and pulling hard on her halter rope, tried to help her back onto the trail. She made a courageous lunge, and slipped again. The rope burned through my hands as she keeled over backwards, pawing at the air, and plummeted 200 feet to her death. After salvaging what there was to salvage (the saddle was smashed to smithereens) I hiked back to the rest rancho, my saddlebags over my shoulder, my hands badly blistered; yet I hurt most for the loss of my valiant companion. I managed to borrow another one for the continuation of my journey.
The training program began on December 10th as scheduled. The 12 students made up a heterogeneous but rambunctious crew, They ranged from 14 to 57 years old and had from zero to eight years of schooling. The average age was 23; the average education, 3rd grade. Mencho was the oldest and had the least schooling. The youngest was Nando, a 14 year old lad on crutches who, having come to Ajoya from a distant rancho for treatment of chronic osteomyelitis, had decided to stay for the course. One of our best students was Leandra, a jovial 33 year old mother of six. Although she has completed only the 4th grade herself, she has been serving her remote village (Caballo de Arriba, 60 km. by mule trail from Ajoya) as both schoolmarm and folk healer. Perfect qualifications for a village “promotora de salud.”
One of our most earthy and energetic students regretfully dropped out after only two weeks. This was Doña Goya, a stout-hearted middle-aged midwife from Carrisal, an hour’s walk from Ajoya. It turned out that her young husband—who is as unreasonable when drunk as he is irrational when sober, which is rarely—opposed her taking part in the course and beat her as often as he learned she had attended. Stoically, Doña Goya endured the beatings, arriving each day with new bruises; but when her man took to mistreating her 11-year-old son by a previous union (one day he hung the boy briefly by the neck), she stopped coming. When we asked her why she didn’t simply leave her insufferable consort, whom she supports, she answered laconically, “He’ll kill me … . and besides, I like him.” Suac que Voluptas.
On his first quiz Mencho scored only 19%, but it didn’t upset him much. For Mencho at 57, has remained as innocent of percentiles as of schooling. Until this last December, when he joined our new training program for village “promoters of health,” he had never been to school a day in his life. Yet in his youth he had somehow taught himself to read and write.
Mencho is from Jocuixtita, a long-defunct mining village crouched far back in the “barrancas” or wild ravine country of the Sierra Madre, 30 kilometers by muleback from our central clinic of Ajoya. From age six until his early forties, Mencho worked as a farmer, sowing with a planting stick small clearings hacked out of the jutting mountainside above his village. At age 42, Mencho’s life abruptly changed. One stormy evening after he had returned home from weeding his high fields, a band of “federales” burst into his adobe but and accused him of having given shelter to Tino Nevarez. (Tino Nevárez is the hero of many a folk song and legend today because he was a sort of Billy the Kid or Robin Hood of the Sierra Madre, who reputedly stole from the rich and gave to the poor. In the huge manhunt for the wiley and elusive thief, the baffled soldiers tried to starve him out of hiding by brutalizing anyone suspected of lodging or feeding him. In this tray, according to legend, they killed more than 100 innocent persons).
When Mencho denied having hosted the celebrated bandit, the soldiers threw him onto the earth floor and jabbed him so hard with their rifles, they permanently injured his spine. Unable from that day forward to work his steep cornfields, Mencho looked for other means of supporting his wife and hungry children. He began to shuttle “wonder drugs” and knick-knacks from the distant-coastal cities, transporting them on burroback to peddle in the villages of the barrancas. It was only natural that he prescribe and administer the medicines he brought, and in time he became highly regarded as the local medicine man. For know-how, he depended on the Good Lord and Good Luck, applying with a less than sterile syringe and blunt needle either penicillin, liver extract, or both for virtually every malady. He had no training and no resource material. In fact, the first book of medicine he ever laid hands on was a copy of my villagers medical handbook, Donde No Hay Doctor, which I gave him a year ago. For Mencho, the handbook was the doorway into a new and challenging world. When, last Fall, he learned that at the Ajoya Clinic we were offering a two month training program for village paramedics, he jumped at the chance.
Another of our trainees was Roberto, a youth from Campanillas, about 16 km. northwest of Ajoya. Like Nando, Roberto first came to us as a patient. Four years ago he was carried into Ajoya on a stretcher, severely emaciated and totally crippled by juvenile rheumatoid arthritis. Previously he had been taken for treatment to the coastal cities, where the last doctor to see him had told his grandparents that if he didn’t get better with the final course of medicine, his case was hopeless. To this day Roberto vividly remembers the chilly January night when his grandmother took off of him his one blanket to put it over the other children, since “he was going to die anyway.” As the wasted boy huddled shivering in the darkness, he made up his mind that if he survived that one night he would somehow manage to get better…
At the Ajoya Clinic, with the help of courage and corticosteroids, Roberto in fact began to improve. When he was able to use crutches, we began to give him jobs around the clinic. Today, although some of the joints in his hands and feet are irreversibly fused, Roberto not only walks almost without a limp, but does a good job pulling teeth. For the last three years he has worked with us as an apprentice dentic and as keeper of the clinic mules. He joined our new training program with the idea of serving his native village as a “promotor de salud,” and already makes calls there. His first love, however, is for animals.
Roberto has a real knack with animals and his ambition is to someday become a veterinary paramedic, If any of you readers might be able to help make arrangements for him to apprentice with a large-animal veterinarian in the U.S. or México, please try. Roberto has spent several months in California visiting with one of our former volunteers and speaks some English. He is 22.
Our Staff, Teaching Approach, and Principles
Our teaching staff for the new training program was every bit as motley as our coterie of trainees. The brunt of the teaching eras done by Mike Travers and myself, both of us former high school teachers of sorts. A couple of other American volunteers also presented some classes, and so did Martín Reyes, our chief village medic.
Miguel Angel Alvarrez, our youngest village dentist, trained some of the promotores how to pull teeth and tutored others, like Mencho, in simple math. Ramona Alarcón, our village apprentice lab tech, taught the trainees how to measure the hemoglobin content of the blood and slow to do simple urinalysis and other basic tests.
As a textbook for the course we used Donde No Hay Doctor (Where There Is No Doctor). One objective we had was to help the students learn to use the book effectively. Emphasis was put not on memorization, but on how to look things up. We also stressed the “importance of uncertainty,” of never saying “I know,” but only “I suspect,” for in folk medicine, like politics, there is a dangerous tendency to come up with answers before questions. In our class discussions we covered the pros and cons of folk remedies, as well as the proper use and misuse of modern medicines popularly used as cure-alls. In general, we tried to de-emphasize the use of medicines, especially injectables, and to focus on aspects of supportive care and preventive medicine. We encouraged the promotores to use every occasion of sickness or injury as a chance to teach the patient and his family the preventive measures necessary to avoid the return or spread of the particular ailment.
To bring home the fact that a good medic must first be a good teacher, we not only encouraged the trainees to teach each other, but arranged for them to give classes to the Ajoya school children on topics of personal hygiene, how to avoid intestinal worms, etc. In addition, our future “promotores” helped the school children set up public garbage pits, and led them three afternoons a week in pandemonious clean-up brigades, the outcome of which has been to make Ajoya a far more attractive and slightly more sanitary village.
We stressed the importance of uncertainty, of never saying ‘I know,’ but only ‘I suspect’.
One concept we tried hardest to get across—largely, I hope, by example—is that medicine and health care should primarily be seen not as a business, but a service.
The village medic is of course entitled to modest remuneration, but his chief satisfaction should come from giving, not taking. Above all, we tried to impress on the trainees that the health worker should be kind. He should try to put himself in his patient’s sandals, regard him first as a person, and take interest in his life, family, back ground, joys and fears. Finally the medic should admit openly his limitations, and “Do no harm."
The brunt of the students' training took place not in the “classroom” (actually an old attic over the bakery and blacksmith shop) but in the clinic, where from the first day they began to soak and dress wounds, practice suturing on fetal pigs, provide simple nursing care, and sit in on patient consultations. In the second week, the trainees began to consult and examine patients under the supervision of our more experienced paramedics. Thus each consultation became a learning/teaching opportunity for paramedic, trainee and patient.
In these three-way learning sessions, conducted as of necessity in the simplest possible language, it was interesting to note how many patients, far from taking offense at having their problems used for teaching, expressed appreciation at being included. Several patients who had formerly sought medical help elsewhere commented with relief that this was the first time they came away with an inkling as to what their malady was all about. Even when an illness is grave or incurable, we have found that most patients find it less frightening to be given some insight into their problem than to be left completely in the dark. Of course the medic must feel his way with each patient.
Mencho’s Practical Genius
On the final quiz of the course, Mencho scored 64% still—like Einstein—at the bottom of his class. Fortunately, we’d had the chance from the very beginning to appreciate Mencho in the practical as well as the academic setting. If in the classroom he proved the dunce, in the clinic we soon realized he was special. He has a certain “touch” with patients which, I believe, comes less from being brillant than from being humble. He is above no one, approaching each patient as a peer and equal. Being himself rustic and a farmer, his interest in the daily lives of his patients is not “professional” but real, and campesinos—like patients anywhere—are quick to sense the difference. He gains their confidence and cooperation because they feel he cares. Patients often “open up” to Mencho who won’t to other medics or visiting doctors. He has a way of gently drawing out the true problems which hide behind the apparent ones. Above all, Mencho is unhurried. No patient is too dull, nor problem too trivial not to claim his warmest sympathy and undivided attention. As a result, whether or not Mencho is able to do anything medically for a given patient, the patient almost invariably comes away feeling better. And that’s what the art of medicine is all about. (The science, of course, is another matter.)
Still and all, Mencho had great difficulty with some of the classroom work, especially the math. One afternoon he stayed behind to get special help on calculating doses of medicine according to patient weight. After much repetition he was still perplexed. At one point he shook his head wistfully and said, “Why waste your time on me, David. It’s pointless putting new shoes on a worthless old mule.”
“Mencho!” I asked him sharply, “Do you know what you’re worth?”
“About so much,” he replied, grinning sheepishly.
“Look here,” I cried, “You’re worth more to your own people than all the doctors in México, or for that matter in America or the whole Earth'.”
Mencho blinked at me, “What in Heaven’s name do you mean?”
“Tell me,” I said, “How many doctors are there in your neck of the barrancas, up there around Jocuixtita?”
“Why you know there aren’t any,” he replied mildly. “It’s too remote. The people are too poor.”
“That’s exactly what I mean,” I said.
“I still don’t follow you,” said Mencho with an embarrassed smile, “but if you don’t mind, let’s get back to those doses. I reckon I’ve just about got the hang of them.”