Chiapas 15

(If this is the first time you see this blog I suggest starting to read from “Chiapas 1″ and onwards so that it all makes more sense.)

Graveyard of Las Abejas massacre. See: http://en.wikipedia.org/wiki/Acteal_massacre

Graveyard of Las Abejas massacre. See: http://en.wikipedia.org/wiki/Acteal_massacre

Look at a community in which there is Oportunidades, the government program we discussed earlier that pays you to send your kids to school and seek healthcare. Look how the entire town is gathered around looking for their money.

Look at a community in which there is Oportunidades, the government program we discussed earlier that pays you to send your kids to school and seek healthcare. Look how the entire town is gathered around looking for their money.

Compared to the previous photo, look at how different a Zapatista community is with a slogan at the entrance to town "Here the people order, and the government obeys."

Compared to the previous photo, look at how different a Zapatista community is with a slogan at the entrance to town “Here the people order, and the government obeys.”

A photo of where the pacifist resistance group Las Abejas was killed and buried.A photo of where the pacifist resistance group Las Abejas was killed and buried.

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A Zapatista school

A Zapatista school

Lucky 13 will be my final post, and as I sit in the Jaltenango office waiting to fly home in a few days–doing hardcore Excel and Access manipulations to support the pasante’s information technology system and researching Chiapas history, I am enjoying a light 38C fever and stomach ache. After the course the team have each gone their separate ways, some back to work in their communities and some to vacation, and I am locked up in the office trying to accomplish something productive to contribute to the team.

This final post will focus on the Zapatista movement and its influence, and a brief note on the threat of mining corporations.

On January 1, 1994, rumors of war traveled throughout the Sierra Madre. It was said that “indigenous brothers” had taken over the municipal capitals of Altamirano, Chanal, Huixtan, Las Margaritas, Oxchuc, Ocosingo, and San Cristobal.1 That day the local radio station did not broadcast, and people would later learn that the indigenist radio station had been occupied by Zapatista troops and that technical problems had prevented them from broadcasting to borderland inhabitants “The First Declaration of the Lacandon Rain Forest,” a beautifully written document that summarizes some of the history we reviewed together in my posts:

TO THE PEOPLE OF MEXICO:

MEXICAN BROTHERS AND SISTERS:
We are a product of 500 years of struggle: first against slavery, then during the War of Independence against Spain led by insurgents, then to avoid being absorbed by North American imperialism, then to promulgate our constitution and expel the French empire from our soil, and later the dictatorship of Porfirio Diaz denied us the just application of the Reform laws and the people rebelled and leaders like Villa and Zapata emerged, poor men just like us. We have been denied the most elemental preparation so they can use us as cannon fodder and pillage the wealth of our country. They don’t care that we have nothing, absolutely nothing, not even a roof over our heads, no land, no work, no health care, no food nor education. Nor are we able to freely and democratically elect our political representatives, nor is there independence from foreigners, nor is there peace nor justice for ourselves and our children.

But today, we say ENOUGH IS ENOUGH.

We are the inheritors of the true builders of our nation. The dispossessed, we are millions and we thereby call upon our brothers and sisters to join this struggle as the only path, so that we will not die of hunger due to the insatiable ambition of a 70 year dictatorship led by a clique of traitors that represent the most conservative and sell-out groups. They are the same ones that opposed Hidalgo and Morelos, the same ones that betrayed Vicente Guerrero, the same ones that sold half our country to the foreign invader, the same ones that imported a European prince to rule our country, the same ones that formed the “scientific” Porfirsta dictatorship, the same ones that opposed the Petroleum Expropriation, the same ones that massacred the railroad workers in 1958 and the students in 1968, the same ones the today take everything from us, absolutely everything.

To prevent the continuation of the above and as our last hope, after having tried to utilize all legal means based on our Constitution, we go to our Constitution, to apply Article 39 which says:

“National Sovereignty essentially and originally resides in the people. All political power emanates from the people and its purpose is to help the people. The people have, at all times, the inalienable right to alter or modify their form of government.”

Therefore, according to our constitution, we declare the following to the Mexican federal army, the pillar of the Mexican dictatorship that we suffer from, monopolized by a one-party system and led by Carlos Salinas de Gortari, the maximum and illegitimate federal executive that today holds power.

According to this Declaration of War, we ask that other powers of the nation advocate to restore the legitimacy and the stability of the nation by overthrowing the dictator.

We also ask that international organizations and the International Red Cross watch over and regulate our battles, so that our efforts are carried out while still protecting our civilian population. We declare now and always that we are subject to the Geneva Accord, forming the EZLN as our fighting arm of our liberation struggle. We have the Mexican people on our side, we have the beloved tri-colored flag highly respected by our insurgent fighters. We use black and red in our uniform as our symbol of our working people on strike. Our flag carries the following letters, “EZLN,” Zapatista National Liberation Army, and we always carry our flag into combat.

Beforehand, we refuse any effort to disgrace our just cause by accusing us of being drug traffickers, drug guerrillas, thieves, or other names that might by used by our enemies. Our struggle follows the constitution which is held high by its call for justice and equality.

Therefore, according to this declaration of war, we give our military forces, the EZLN, the following orders:
First: Advance to the capital of the country, overcoming the Mexican federal army, protecting in our advance the civilian population and permitting the people in the liberated area the right to freely and democratically elect their own administrative authorities.
Second: Respect the lives of our prisoners and turn over all wounded to the International Red Cross.
Third: Initiate summary judgments against all soldiers of the Mexican federal army and the political police that have received training or have been paid by foreigners, accused of being traitors to our country, and against all those that have repressed and treated badly the civil population and robbed or stolen from or attempted crimes against the good of the people.
Fourth: Form new troops with all those Mexicans that show their interest in joining our struggle, including those that, being enemy soldiers, turn themselves in without having fought against us, and promise to take orders from the General Command of the Zapatista National Liberation Army.
Fifth: We ask for the unconditional surrender of the enemy’s headquarters before we begin any combat to avoid any loss of lives.
Sixth: Suspend the robbery of our natural resources in the areas controlled by the EZLN.

To the People of Mexico: We, the men and women, full and free, are conscious that the war that we have declared is our last resort, but also a just one. The dictators are applying an undeclared genocidal war against our people for many years. Therefore we ask for your participation, your decision to support this plan that struggles for work, land, housing, food, health care, education, independence, freedom, democracy, justice and peace. We declare that we will not stop fighting until the basic demands of our people have been met by forming a government of our country that is free and democratic.

JOIN THE INSURGENT FORCES OF THE ZAPATISTA NATIONAL LIBERATION ARMY.
General Command of the EZLN2

Where did this movement that burst forth in 1994 come from? Apparently in the 1970s indigenous people from all over the state were gathering together to colonize a rain forest East of the Sierra area where our medical team works. Immigrant Guatemalans and mestizo peasants converged with indigenous people of many ethnicities along with a Maoist organization called Popular Politics. The exchange of experiences has allowed many global perspectives and political and religious ideologies to coalesce into a political-military movement.3 After the Zapatista uprising the government set up a huge military base nearby, but this did not deter local communities who now felt a radical sense of empowerment. On January 27, 1994, the Mam Supreme Council of the lowlands led a demonstration in front of the local office of the Ministry of Agrarian Reform, demanding restitution of the lands of Finca La Patria (remember Fincas are the old farms that began during plantation times, 1910-1930s): “If you are not going to grant us the rights over our ancestral lands, then make the necessary formalities so that our fifty families can have passports to go work in the United States, for we are already foreigners in our own territory, being displaced by finqueros from other countries who have become lords of the Soconusco.”4 (Recall the finqueros that started in plantation time 100 years ago were American, German, Swiss, Italian, Ladino, and of other international origins, and apparently the people see this as unchanged to this day.) A flurry of peaceful civil protests supporting the Zapatista cause began throughout Mam and Sierra populations, causing friction in indigenous organizations when some members chose to support the cause while others preferred to stay out of the conflict. “The organization, the religious group, the community, and even the family are now crossed over by a line dividing those who favor the Zapatistas and those who favor the government[!]“5

Since the first violent conflict with the government, which became a ceasefire within weeks due to international pressure, the Zapatistas have operated peacefully and are actually running the government instead of the federal government in several municipalities in the area. In December, 2012 a silent march demonstrated to the world that the Zapatista are still active, still working hard in their communities. To quote Roar Magazine: “The Story of the Sword” is an ancient parable that demonstrates how the indigenous peoples of Mexico can finally defeat the European invader. “The tree”, says Subcomandante Marcos when narrating the story, “tried to fight the sword, but was defeated. The stone likewise.” But not the water. “It follows its own road, it wraps itself around the sword and, without doing anything, it arrives at the river that will carry it to the great water where the greatest of gods cure themselves of thirst, those gods that birthed the world, the first ones.”6

I asked a friend I met who had visited Zapatista areas to get a personal account of a Zapatista’s life:  “The Zapatistas are campesinos. They work in their lands. They suffer a lot because they are separate from the system. Both men and women work hard, and they share food–they barter e.g. jam for coffee. They feel that they are a different community because they have dignity–and this comes from having autonomy. They have a hospital and clinics in each town served by health promoters. The level of education of these medical personnel is not the highest but they are open to any volunteer who wishes to teach. Preventive care did not seem to be prominent, but they seemed to have the same medications as the government hospital.”

When I asked this friend about a critique of the Zapatistas, that the community is very hierarchical, that Sub Commandante Marcos and his colleagues are very controlling of the population, he responded: “In fact I was told that the government is a direct democracy: all decisions are made by every member of the community, both men and women. In Zapatista communities the women’s voice is more heard and respected, and they are leaders in feminist thought. Zapatista feminist claims have trickled into other communities of Chiapas. When the decision requires coordination between many municipalities a representative is chosen to represent the opinion of the town. If this representative gives his own opinion instead of the communities opinion she or he is immediately deposed.” When someone asks them “Can I work with you?” The answer was “We are not looking for people to join us. We are asking people to join the revolution. We don’t need more people.”

A final challenge to the Zapatista model is their application of communism. So if someone works hard he or she does not receive more, he still needs to distribute his production to his neighbors. If a Coca-Cola is being drunk, everyone has to drink it together… Some people have emigrated to the United States when given the opportunity because of their distaste for this system. Let me end this summary of the Zapatistas by saying that first, to be clear Companeros en Salud is not affiliated with this group, that the Zapatista communities work very hard and suffer, and that their lives are not a romantic vacation in the jungle. Perhaps this is the cost of human dignity, and perhaps it is too high a price for most people to pay. The comforts that the mass market and multinational politics can bring are tempting.

Before ending I will describe a new controversy with the government pushing privatization of ejido land (land that began to be distributed by the government starting in the 1930s) that would allow multinational corporations to buy pieces of land in the community. When you purchase any piece of land in Chiapas the first 20m are owned by the land-owner, but deeper than that the land is owned by the federal government. Thus if a single piece of land is purchased and mining rights are given the company can dig deep under other community lands until the soil is polluted and entire communities stop being able to produce coffee. This is scary, but so far the communities in which we are working are fiercely opposed to these mining operations, which limits the government’s ability to give mining rights.

Although violent gangs still exist, the communities in which Companeros en Salud operates are peaceful and not sites of active conflict. So do not start panicking with all these stories of guerrilla warfare and mining.

I am going to end these thoughts with an invitation to support the wonderful team here doing excellent preventive medicine and primary care in isolated communities throughout Chiapas, to do so with a deep knowledge of the people and their experiences, their feelings, thoughts, and beliefs. In the month I was here I did no more than learn how little I know. If your experience is anything like mine, you will laugh often, eat well, work too hard, be touched by the stories of people’s lives and a shared humanity that has been oppressed in the most inhumane ways. This is one of the places where I can express my solidarity with those who wish to work the land free from oppression, as I work to fulfill my childhood aspiration to become a member of an international community of people that sustainably live off the land.

1: Histories and Stories from Chiapas; Border Identities in Southern Mexico. R Aida Hernandez Castillo. 2001. pp.204
2: http://flag.blackened.net/revolt/mexico/ezln/ezlnwa.html
3: Histories and Stories from Chiapas; Border Identities in Southern Mexico. R Aida Hernandez Castillo. 2001. pp.206
4: ibid. pp. 208.
5: ibid. pp. 214.
6: Roar Magazine: http://roarmag.org/2012/12/zapatistas-march-chiapas-mayas/

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Chiapas 14

We are back in Jaltenango, the city where Companeros en Salud is based for 3 days of coursework on topics in global health, case presentations, and support of pasante’s research projects in the communities. These 3 days have been one of the most incredible learning experiences of my life. In addition to learning about how to design a public health project and learning about challenges pasantes face in navigating their health care system, I had the opportunity to present the Lebanese healthcare system and get feedback on ideas for public policy, I was impressed by how quickly, with only my brief introduction, the team picked up on subtle problems Lebanese face and proposed many of the solutions I have been thinking about for months. With many warnings about things to watch out for, it was a productive exchange of ideas about how the model they are working on in Mexico would translate to Lebanon, and I am confident that it is a promising way forward to developing primary care in my country.

Presenting Lebanon

Presenting Lebanon

We watched “Rojo Amanecer” to end the conference, a movie describing the daily life of a family that died in the Tlatelolco massacres of students that I previously described as undermining the people´s trust in the national government. A difficult discussion occurred during the feedback as several pasante´s expressed a variety of concerns about the student´s lack of interest in coursework, a reminder of how to maintain respect for the members of the communities in which we are working (don´t speak in English in their homes, don´t treat people that host you in their homes as if you have any entitlement for their service and also with deep humility and gratitude,) and other concerns regarding division of responsibility for cleaning as we are 15 people living in this home.

Abusing Abelardo

Abusing Abelardo

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Everyone at the beach!

Everyone at the beach!

Pasantes brought everything from candy to these blowing things to spice up their presentations

Pasantes brought everything from candy to these blowing things to spice up their presentations

Late at night Gaby and I decided to play the “put toothpaste on your hand and tickle your ear prank” on a couple of the pasantes who had to wake up at 6am the next morning. Almost everybody found it funny. ;-)

Last time we talked about religion in Chiapas and the cultural changes that began in the 1970s with participative indigenism. Today we will talk about the COPLAMAR program, the first program to support rural development in marginalized communities. You will see IMSS-OPORTUNIDADES if you visit a Chiapas clinic, and this is a direct descendant of COPLAMAR. To quote from the government’s website:1

“IMSS-Oportunidades is a Federal Government Health Care Program administered by the Mexican Institute of Social Security (Seguro Populare). The Program provides health services to the uninsured population, promoting the comprehensive development and equality of opportunities for all Mexicans, as well as fulfilling their Constitutional right to health care.

The Program operates thorugh a Comprehensive Health Care Model (CHCM) based on Medical Care and Community Action. Medical Care functions by means of 3,594 Rural Medical Units, 225 Mobile Health Teams, 270 Urban Medical Units, and 79 Rural Hospitals and is responsible for providing health care services and mounting epidemiological vigilance programs. Community Action (CA) incorporates individuals and communities in the practice of healthy habits to improve their long-term quality of life. CA work is done through medical staff and more than 309 thousand health volunteers originating from within the populations served by IMSS-Oportunidades.”

To quote Wikipedia:

“It is designed to target poverty by providing cash payments to families in exchange for regular school attendance, health clinic visits, and nutritional support. Oportunidades is credited with decreasing poverty and improving health and educational attainment in regions in which it has been deployed.

Key features of Oportunidades include:

  • Conditional Cash Transfer (CCT) – To encourage co-responsibility, receipt of aid is dependent on family compliance with program requirements, such as ensuring children attend school and family members receive preventative health care
  • “Rights holders” – Program recipients are mothers, the caregiver directly responsible for children and family health decisions
  • Cash payments are made from the government directly to families to decrease overhead and corruption
  • A system of evaluation and statistical controls to ensure effectiveness
  • Rigorous selection of recipients based on geographical and socioeconomic factors
  • Program requirements target measures considered most likely to lift families out of poverty, focusing on health, nutrition and children’s education.

Many pasantes like the program, especially because it improves chronic patient’s clinic attendance, but others mentioned some challenges:

“Rigorous selection of recipients based on geographical and socioeconomic factors”: “One problem is that people who need Oportunidades do not receive it. Why? Because people who need it sometimes don’t receive it–the criteria for selection are having a big house or not–sometimes people go to America and make money and build a big house but now they don’t have money.”

“Rights holders” – Program recipients are mothers, the caregiver directly responsible for children and family health decisions: “Some mothers are expected to buy food to secure children’s nutrition, but many spend the money on other things and end up having more debt. They then use Oportunidades money for paying their debts.”

Program requirements target measures considered most likely to lift families out of poverty, focusing on health, nutrition and children’s education:Another problem is rural communities have Oportunidades–they have to get their children to school and to a health center, but then their is no health center or doctor. So what is the point of making these payments if there is no teacher or doctor?

To quote a report I found on the World Bank website from “the Shanghai Poverty Conference” that describes the program:2

The program design was based on the idea that poor families do not invest “enough” in human capital and are thus caught in a vicious circle of intergenerational transmission of poverty. According to Oportunidades’s vision, poor families are aware of the benefits of investing in their children but cannot afford the monetary costs of attending school or the opportunity costs of sending children to school (the income or value of income that children would earn if they were working, rather than attending school). Since families need this income for current consumption, they take their children out of school at early ages and send them to work. Thus, the idea of Oportunidades is to provide parents the equivalent of that income to send their children to school instead.

The amounts of the monthly grants range from about $10.50 (105 pesos) in the third grade of primary to about $58 (580 pesos) for boys and $66 (660 pesos) for girls in the third year of high school. The health component provides basic health care for all members of the family, with a particular emphasis on preventive health care. This service is provided by government public health institutions. The nutrition component includes a fixed monetary transfer, equal to about $15.50 (155 pesos) monthly, for improved food consumption, as well as nutritional supplements for children between the ages of four months and two years, malnourished children aged 2 to 4, and pregnant and lactating women.

This is the briefest of introductions and doesn’t sufficiently analyze the program, read a few books and visit the communities to make your own educated judgments.

1: http://www.imss.gob.mx/english/Pages/IMSS_Op_Introduction.aspx

2: http://info.worldbank.org/etools/docs/reducingpoverty/case/119/summary/Mexico-Oportunidades%20Summary.pdf

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Chiapas 13

This brief post describes pasante’s responsibilities in Motozintla, the capital of the county in which they are working. Each month they go to a central health administration office in their county and deliver information on child and maternal health, chronic diseases, and the number of patients they’ve seen and other clinical statistics.

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A gang of kids had a chain raised in front of the car and asked for money (a common practice done when someone repairs the road, but these kids wanted a freebie!)

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Apparently the town name means “squirrel”

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Motozintla’s hilly streets

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The health center where people clamor for benefits and doctors fill their paperwork in the government bureaucracy upstairs

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One of 16 offices that the pasantes enter to get their paperwork signed. This is a half-day process every month.

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Motozintla town square

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Stark contrast of a high-end supermarket with the rest of the area

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Stark contrast of a high-end supermarket with the rest of the area. Buying the ingredients for mango ice cream!

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Chiapas 12

Today was palm Sunday and we did a procession through town to the church, after which the priest delivered one of the most beautiful masses I have heard. The two most beautiful ideas were developed from the passage in the last supper where Jesus talks about being served at the dinner table. He asks his disciples “who is more important, he who is at the table being served or he who is serving?” And he responds (these quotes are rough, from memory) “I am sitting at the table, I am the greatest, and yet I sit in the middle of you serving you.” And in our hearts this is an idea we reject, because we do not tell the person who we pay to work for us in the fields (and many members of the congregation hire Guatemalans to harvest coffee): please, let me serve you. Instead we say “do your work and I will compensate you.” Serve me first! But if you are tired one day then you say “ok, this is where I draw the line of serving others.” But then the priest held up the ideal of Mother Theresa as someone who begged in her right hand for her own bread, and then begged for the poor with the left hand. She had this Christian balance–how wonderful would it be to be able to hold up both the ideal of self-service and community-service? And beyond the theory, he gave a few practical examples–the good husband is the one who on Sunday says “honey, today the housework is mine,” as well as the wife who says “after a long day of work I cooked you a special dinner.” Service in a relationship, the priest described, is love. Challenging patriarchy, he emphasized the importance of service as leadership in the tradition of “the Promisekeepers,” a religious group worth googling that I studied back in the undergraduate days. And this is a radical Christian idea–when everyone in society says “this is good,” the Christian always has to go through the hard work of defying the norm and saying–actually, I have a different ideal.

Honduras Catholic church

Honduras Catholic church

Flowers for Palm Sunday procession. (Everyone carries leaves or flowers)

Flowers for Palm Sunday procession. (Everyone carries leaves or flowers)

The second place where he developed the concept of service as described in the last supper was in government. When the government does something good for the community they say “I am doing you a favor. Look how good I am.” When in fact leadership, as we discussed, is a type of service. Again, who is greater, he who serves or he who is being served? And if one can balance the two entities, the servants and Jesus and his disciples, one sees those in government not as the most important, but rather to provide for the basic human needs of the community is their right. Health as a human right, I was later told in coursework on Mexican public health, was written into Mexican law in 1977 into Article 4 of the constitution. What a beautiful message in advocacy drawing on the rich tradition of the Bible. We are driving to Motozintla, the government offices where paperwork is completed every month by Juan Carlos and Valeria to document all the work they are doing and inventory and order the medications they use in the communities.

I went online to learn more about religion in Chiapas and found an interesting article1 by a writer from the Casa collective, a local NGO:

“To begin to understand religion in Chiapas or Mexico at large, it is essential to realize the central role it plays in community life. In small communities or neighborhoods in urban areas, the festival of the Church’s patron saint is the most important time of year, and organizing and paying for the party, the most important cargo (communal duty, service). Typically, the people who fund and host the saint festival are among the wealthiest and most powerful in village and municipal political bodies. That is to say, religious, economic, and political power in small communities often overlaps. When a family removes themselves from the Church by converting to a different faith it is an affront not just to the religious uniformity of a village, but also to community social and political life. In some areas, these tensions become very real power struggles in which converted Protestants are expelled from the community, or if Protestants reach a majority, Catholics are expelled. In Chiapas, religion is an explosively divisive issue and religious refugees in the state’s major cities number in the thousands.

These conflicts are in the minority, however compared to the religiously divided communities that coexist with little or no discord. Furthermore, the healing and empowering aspects of religion are sometimes overlooked. For example, many women attribute their conversion to Protestant faiths to the prohibition of alcohol, which for many means the recovery of an alcoholic husband, more family stability and less domestic abuse. A Mayan Christian movement (resurrecting traditional Indigenous theology within a Catholic context, exploring the syncretism in the faith of present day Indigenous Catholics) is a growing force for ethnic empowerment, spiritual healing, unity and dignity in communities. Liberation theology (a reorientation of the Catholic Church in the late 60s and 70s to the empowerment and spiritual needs of the worlds oppressed peoples) and its’ defender in Chiapas, Bishop Samuel Ruiz, was incredibly successful in creating Indigenous leadership, mobilizing communities for dignity and justice and allowing space for an Indigenous theology that renewed cultural traditions and pride. It is thought that the religious and leadership training that Indigenous catechists received laid the groundwork for an Indigenous movement demanding rights, justice and dignity in the mid-80s; the fledgling Zapatista Liberation Army.”

1: CASA Collective, accessed March 30, 2013. http://www.casacollective.org/story/analysis/analysis-believing-a-better-tomorrow-religion-chiapas

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Chiapas 11

Saturday evening Valeria and I did two home visits: the first was to a patient with suspected pulmonary fibrosis, a disease where the lungs basically become non-functional for a variety of reasons, most still not properly understood. There was also a suspicion of right heart failure, and the patient had been complaining of a night-time cough that was making it impossible to sleep. In addition to following up on his medications and adjusting dosages, we suggested raising the head of the bed or putting pillows under his back to avoid pulmonary edema (water in the lungs) that can be caused by the heart failure that might be causing the cough. We also diagnosed what appears to be an oral candidiasis from his prednisone and promised to deliver a nystatin gargle in the morning.

The second patient was a difficult patient that had been prescribed anti-depressants which he did not like to take, and who was confusing because he had episodes of depression and insomnia by history but was completely normal on the depression screening test we use (the “PHQ9″). He also had an addiction to sleeping medication (clonazepam) without which he did not sleep for several days at a time but had normal function. His insomnia, pressured speech, and his history of depression with a normal to elevated mood on admission put both anxiety and bipolar disorder high on the list of diseases I suspected he might have. So we went to see his wife and family to see what they knew–and indeed after about an hour of patiently probing conversation his wife spontaneously started telling us about a history of grandiosity associated with hyperactivity that lasted for several months–he was going to build a ranch (despite being economically challenged), and have lots of horses and buildings on it, and indeed woke up in the middle of the night to work on this project getting little to no sleep. He also talked about episodes of how he would speak a little too openly to other men’s wives and spent money freely, disinhibitions that, along with his other symptoms, were enough for me to consider the diagnosis of bipolar disorder. Typically bipolar disorder is a diagnosis that is referred to psychiatry, but this may not be possible in the context in which we are working. We left with the proposal that we switch to a mood stabilizer instead of his addictive / not recommended for long term use sleep medication, and will probably refer to the healthcare team for advice about the case before making any definitive decisions.
 
Today we will introduce the Instituto National Indigenista, and elaborate on the discussion of the 1970s cultural changes pushed by the government and discussed in my post “Chiapas 7.” In the 1970s, after the Tlatelolco massacre (the killing of students by the police forces at a demonstration,) and a series of land distributions that favored a few wealthy families, the Confederacion Nacional Campesina [CNC] created in 1938 to defend peasant rights and end plantation conditions began to lose its credibility. A political vacuum developed between the government and indigenous community, and so after the Indigenous Congress in San Cristobal sixty regional congresses were organized to represent the different communities of the region. It is in this context that we see the emergence of government initiatives to recognize “ethnic groups” as state interlocutors and to create institutional spaces for their representation.1 The shift to a multicultural Mexico where the government would encourage a certain conception of ethnicity began in the Instituto National Indigenista, the government organization that was composed of anthropologists and other academics and previously responsible for salvaging the traditions of a dying indigenous culture while simultaneously promoting integration into a unified Mexican culture. This changed in the following way: before the government wanted to integrate; now they wanted to promote a certain conception of ethnicity that could be used to communicate with and, arguably, use to have a hegemonic influence on indigenous culture: participative indigenism. In this model the state related to ethnic groups through programmed investments in cultural activities. 
 
One such investment spurred the creation of the Mam dance groups, a way in which contemporary Mam have imagined their history. Dramatizations by Mam dance groups serve as a collective reconstruction of a prohibited past that now includes memories of the “Law of Government,” the “burning of the costumes,” the suffering of the finca, and the years of the purple disease. All these historical discourses have been confined into a myth of origin with which the Mam identify themselves before large audiences.2
 
As of 2002, when the book I borrow heavily from in this blog was created, the following could be said: “One of the main weaknesses of the participative model was that policies were still being created in the country’s capital by urban intellectuals and civil servants with little knowledge of indigenous reality. As of 1994, out of the sixty Centros Coordinadores Indigenistas [regional congresses] that were created, not one was under indigenous management. The few indigenous personnel in the CCI were at best hired as “research assistants,” which meant basically being translators for the local anthropologist. Most INI employees were in fact drivers or janitors. These personnel policies, which in any other context would be called racist, have not been challenged, not even by the most critical sectors of Mexican society. Only since 1994, after the Zapatista uprising, has institutional racism been discussed in the political debate of the Mexican left. The Community Committees, which should have functioned as advisers for indigenist civil servants, were rather an administrative space in which local INI officials met “community representatives” monthly to inform them of the projects that were already being developed or decisions that had usually already been taken.”
 
The following link shows the different “centros coordinadores para el desarrollo indígena,” some of which exist in the communities served by the health centers I visited: http://sic.conaculta.gob.mx/index.php?table=centro_desarrollo_indigena&disciplina=&estado_id=7&municipio_id=0
Hopefully the modern reality is different from the textbook I am using, and I will leave it to you to explore this issue further.
1. R. Aida Hernandez Castillo. Histories and stories from Chiapas; Border identities in Southern Mexico; pp.103.
2. ibid. pp. 137
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Chiapas 10

Last time Valeria, the pasante with whom I am working and I went to a local hospital to care for a teenager with renal failure. At 12:30am the local doctor came to give his orders for the patient, and I was confronted with how to convey to this doctor the right medications for this patient so that he does not compromise the child´s renal function, which Valeria had been working to improve for months. At first in my mind I was panicking–how am I going to convey information to this doctor with my limited Spanish? If things go sour how am I going to call Valeria and from which phone? But I tried not to show this and tried to stay cool and confident: the first problem we have here is a power struggle; how am I going to convey that Valeria and I, despite being inferior in the medical hierarchy, know what is medically best for this child? Previously I hadn’t participated in any of the conversation, so I began by introducing myself to the doctor as “Kareem, a doctor from the United States who is assisting Valeria this week in her medical work.” (Saying from the United States was easier than explaining where and what Lebanon is.) I explained that she is a pasante (a medical graduate doing a mandatory public service year) working with Partners in Health, an international organization that supports rural medicine in countries around the world (again, PIH is not strictly a rural organization, but close enough…). This introduction with a few words of English thrown in seemed to impress my colleague, but I immediately followed up this introduction with a move to negate any upcoming power struggle: “We are here in this hospital as your guests and the decisions are yours. We are a team caring for this child, but my role is only to support and give advice–ultimately, the decision is yours. So what do you want to do?”

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Random images of Chiapas: road destroyed by mudslides

The doctor then explained each step in his plan and his reasoning (which prompted me to share the following ideas in brackets): an ACE inhibitor or nifedipine to lower the blood pressure (ACE inhibitors would decompensate and cause hypoperfusion in this child with creatinine of 1.7; Harriet Lane, a pediatric textbook, suggests that nifedipine causes too rapid a drop in blood pressure in children with urgent hypertension; and the blood pressure was only high (~150 systolic) because the doctor had told the mother not to give the child’s normal amlodipine dose in the first place, perhaps we could consider keeping the child on his regular medication to avoid reflex tachycardia of discontinuing a calcium channel blocker), to start diuretics, furosemide and spironolactone (the risk of direct damage from dehydration and the diuretics exceeded the risk of fluid overload in this child (he was 52kg with an ideal weight of 47kg–uptodate suggests dialysis when >15% ideal weight–but I don’t know what the right call is here), and discussed with the mother if the child could be monitored at the hospital for the next few days (since they couldn’t measure electrolytes here it would be better to refer to tertiary care).

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The town of Siltepec, where this story happened

Valeria’s suggestions for the management of this child were based on a phone conversation with a pediatric nephrologist who had gone over with her the indications for admission, best antihypertensives (terazosin or hydralazine), and so forth, and apparently this nephrologist was the professor of the young doctor at the hospital and commanded his respect. Eventually he agreed to hold off on prescribing medication till the morning since the child was stable so we could consult the specialist and refer to tertiary care so they could make these decisions, seeing as the child was stable. At 3am his blood pressure was 150 and we gave 5 drops of nifedipine, which in hindsight may not have been the best call since the rapid decrease in blood pressure could provoke more hypoperfusion and acute kidney injury than the problems the 150 systolic was going to cause. The next morning at 6am Valeria and the local doctor had a very conciliatory conversation and bonded, and the doctor shared the idea that it would be best to refer to tertiary care since there are actually no doctors at this health facility over the weekend, and that there are many lab tests that could not be done with the local laboratory. This gave us confidence that the doctor was going to put our patient in a tertiary care facility, and after exchanging numbers and information about the local health system Valeria and I ended up having an excellent relationship with the local doctor. We also learned that in the neighboring town we could send our pregnant patients for free ultrasounds, an important piece of knowledge for the three pasantes working in our area. We drove back to the Honduras clinic and Valeria saw her patients that morning while I slept… We are still concerned that the prednisone has been stopped [Update: it wasn't and so far patient doing great!] –which would be unfortunate seeing as it was keeping his creatinine under 2 –and know that the mother needs support to navigate the medical system which Valeria was providing but (of course) was unable to devote herself to full-time, but ultimately we cannot follow this patient at the expense of all the others and have to trust in the system. (No history this time as well…stay tuned!)

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Epic (and typical) breakfast while staying Jaltenango. Beans, eggs, tortilla, papaya juice

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Chiapas 9

Friday afternoon, while working with Juan Carlos on administrative paperwork for the government, Valeria came by and announced that I would be accompanying her to the neighboring town of Siltepec to the health center, where a boy with renal damage had been admitted after several episodes of vomiting and diarrhea while on prednisone (steroids). Any illness when someone is taking steroids needs to be taken seriously, and when a child’s kidneys are damaged and is losing a lot of fluids there is the potential to lose even more kidney function and to have imbalances in the amount of salts (electrolytes) in the body. We bought lots of snacks and headed out to Siltepec, and Valeria and I discussed the plan for this patient: lots of fluids are ok because he is dehydrated, no diuretics because we don’t want to dehydrate him further and damage the kidney, when would we consider dialysis, which drugs are recommended if he is hypertensive, and the indications for referral to tertiary care–most of this information had been acquired over a long phone conversation she had with a pediatric nephrologist before leaving.

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The hero of the story, Valeria (who looks a lot like my sister Nayla?)

When we arrived it turned out that the family was not being admitted by any of the public doctors at the health center and had to be admitted under the name of a private doctor with admission privileges. The Mexican health system is hierarchical, with primary, secondary and tertiary health centers to which a patient is referred in a very systematic way. Coming as community doctors to the health center in Siltepec which represented the “next level” of the hierarchy and discussing the case with the doctors at Siltepec in itself created a power struggle, a “status competition” in front of the family to show who knew more, although this happened in a very subtle way and with much mutual respect during the conversation. However, Valeria who had impeccably researched the plan for this child with her residents at the Brigham and was giving 50mg of prednisone to treat the child’s kidney disease (glomerulonephritis / nephrotic syndrome; suspected minimal change disease) was questioned by the doctors in Siltepec who thought that the dose should have been started more gradually and should be lower, supporting the argument by saying that the prednisone had created a Cushing’s syndrome in this child, but also with the phrase: “I use 80% intuition and 20% rationality to make my decisions,” a phrase that Valeria told me privately later demonstrated the importance of evidence-based medicine among her colleagues. Most confusing was the questioning of Valeria’s diagnosis with the suggestion that everything that had been happening over the last six months with this child that she had been following closely was a liver problem, not renal, despite overwhelming evidence to the contrary.

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Random images of Chiapas: children's parade on Spring festival

Since Valeria had a full day of work the next day with an average 20+ patients per day I suggested that she get some rest as it was around midnight by the time we finished discussing the case with the doctors and family. After our conversation we were worried that the Siltepec team were going to do all the things that the pediatric nephrologist said not to do–use the wrong antihypertensives, to give a diuretic with inadequate hydration, and not to refer to tertiary care (and since electrolytes could not be measured at the center this was probably a big mistake.) So it was my job to stand guard that night and to try to reason with the doctors about what we felt was in the child’s best interest. Indeed, around 12:30am the doctor on duty came by and wanted to prescribe all the medications that we were trying to avoid. (No history this post, this story continued in next post!)

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Random images of Chiapas: Coffee, which defines the local economy, coming out of the roaster

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Random images of Chiapas: Furniture from Lebanon store in Jaltenango...so random.

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