Healthy people, healthy planet

Self-Care In a Mexican Village

Biologist-educator David Werner has spent the last fifteen years organizing Project Piaxtla, a self-care network run by the campesinos (farm people) among the villages in the rugged Sierra Madres mountains of Sinaloa and Durango in western Mexico. The community-based health program, now run completely by local villagers, none of whom have any formal medical training, provides care for more than ten thousand persons at a cost of about one dollar per person per year.

The main referral and training renter is in the small village of Ajoya, which is accessible only by dirt road. Most of the other hundred settlements are accessible only by mule trails. There are no doctors in the area.

The network now operates an out-patient (and occasionally in-patient) center in Ajoya, complete with laboratory and X-ray facilities. Locally trained dental technicians extract, drill, and fill teeth, and make dentures. All this work is done by the villagers themselves, few of whom have received any formal education beyond the sixth grade.

The network also includes a large number of promotores de salud, village health workers. These workers, like the Chinese barefoot doctors, are selected by their communities. They then come to Ajoya for two months of practical health training in preventive and curative medicine, with a strong emphasis on community organization and concientzacion (consciousness raising), communication, and teaching techniques. When they return to their remote ranchos and villages, they continue to earn their living as farm workers while acting as part-time health workers.

David Werner, who is forty-three, received his bachelor’s degree at the University of New England in New South Wales (Australia) in ecology and entomology. A confirmed world traveler, David had come to Australia from Cincinnati, Ohio, because he wanted to study its natural history. He returned home after his schooling in Australia to pursue a newly kindled interest, dramatics, at the University of Cincinnati.

A trip to the Orient followed and a period of study with Gandhi’s successor, Vinobhave, “the walking saint of India.” During his time walking with Vinobhave, a leader in the land-reform movement in India, David was impressed with the possibility of organizing the poor of the Third World to have some power over the factors that influence their well-being.

Landing back in California, David joined the staff of Pacific High School in Palo Alto and soon began taking the students from this alternative school Infield trips to Mexico. In Mexico he found vet another vocation: medicine.

TF: How did you get involved in medical work?

DW: I took a walking trip by myself in the Sierra Madres one Christmas vacation. One evening I’d been delayed and was passing a little shack about dusk, and the family living there asked if I was hungry.

Well, I was hungry. So I stopped and they pulled a couple of eggs out from under the chicken and cooked them up for me—they were all eating beans—and asked me to stay the night.

It got very cold that night, and the family had only a couple of blankets for seven or eight people. Around two in the morning it got too cold to even try to sleep, so they got up and built a fire in the middle of the floor and sat around it, the older kids holding the younger ones, until dawn came.

When it got light, I noticed that one boy had a badly swollen foot. He’d stepped on a thorn three months before and by now the foot was seriously infected. I was struck by how unnecessary it was for him to have to suffer like that—all he needed was some antibiotics and some knowledge about hot soaks. Also, some of the kids were beginning to develop gaiters, and I knew that iodized salt could prevent that.

I went back to my students at Pacific High School and shared these experiences. We started talking about putting together some useful medical information and supplies and going back to the mountains to distribute medical kits and teach some basic medical skills.

So we made up some little kits in old coffee cans and went down to Mexico. We made about a hundred-mile loop through the mountains, passing out the kits and talking with people about health problems.

After we got back, I decided to go back down for a year to help the people there obtain the medical skills and supplies they needed.

And you ended up staying ever since.

Just about, though the program is now completely run by the community, and I’m just an advisor,

When was that first visit?

That was in 1964.

When you went down there to live, how did you get started ?

I started out making the mistake I think all experts tend to make, that is, trying to provide care instead of helping people care for themselves. Luckily, there was much more than I could do by myself, so I started recruiting the children who had begun to hang around out of curiosity, getting them to do things like washing wounds, suturing cuts, giving instructions. This group of kids, thirteen, fourteen, fifteen years old, became paramedical workers right from the beginning.

Then we went through a phase where we depended on young American students—many of them Stanford pre-meds—to come down and spend blocks of time helping out. We’d organized an unofficial course at Stanford to train these volunteers. The course was run by the young volunteers with local doctors as resource people.

It was very interesting to compare the graduates of this three-month, very practical course with some of the new medical school graduates who also came down to volunteer. The pre-med students were better in every respect, including the strictly clinical areas. They had learned to focus on the problems of greatest need, while the med school graduates would want to do an extensively detailed medical work-up with a complicated differential diagnosis. They’d feel frustrated because we didn’t have the technology to do all the lab tests and diagnostic procedures.

How did the villagers respond?

That was very interesting. We realized that the better our volunteers got—and by that time we were really getting the cream of the crop of Stanford students, really dedicated and committed people—the more they tended to undermine the capacity of the villagers to assume responsibility for their own care.

When the paramedical village workers, many of them teenagers, had to compete with the volunteers, we could see a real falling-off of interest.

So we went into another phase in which we decided that no outsider should provide any direct service at all. They should be there as educators. Their goal should be to leave behind their knowledge and skills with the villagers. This didn’t come until eight years after the program had begun. We learned pretty slowly.

So there have been several phases of the project….

Yes. The first was me working with the young people from the villages. I think that was a good start.

The second was using the American pre-meds, which I see now as an unfortunate back-sliding toward the kind of dependency that professionals always seem to produce.

The third phase was limiting the outside experts to teaching functions, so that the outsiders were really coming in on the villagers’ terms.

The fourth phase began about three years ago, when the village team in Ajoya decided they wanted to take the whole thing over themselves, including the supervision and training of the village health promoters. So it was decided that there would be no ongoing presence of outside providers.

Including you.

Including me. They did decide to invite outside professionals in as they needed them, but strictly to teach.

How has your role changed through those four stages?

I was originally a direct provider of services. In the middle stages, 1 was an active teacher. More recently, I’ve been more of a consultant and advisor. I’m moving in the direction of making myself completely dispensable. Because of my role in the past, it’s difficult for me to be there without being an authority figure. I’m now spending about a quarter of my time in the community there, and always at their invitation.

Are the village health workers practitioners or educators?

They’re both. Half their training is in communication and education. They don’t try to be some big expert. Even if they already know all about a problem a patient has, they’re encouraged to look it up in our handbook with the patient, so that a patient gets a sense of what he can do for himself. They try to transmit the idea that this isn’t some magical knowledge, and you don’t need some special ticket to have access to it. It’s something easily understandable; let’s find out about it together—that sort of approach.

Do they use medical supplies brought in from outside?

Yes, but less than they used to. Dehydration in children—secondary to diarrhea—is a major problem in rural Mexico. When we started out, we were infusing these kids with intravenous fluids, because that’s what they do in hospitals up here. But we realized that this was creating a dependency on skills and materials that required outsiders. Now we almost never use IV treatment, because the long-term survival of these children is ever so much better if the mothers themselves are involved in the rehydration process, using oral mixes they can make themselves from things they already have in their homes. Infant mortality has dropped from 34 percent to about 6 percent since we’ve been there. I think that’s due almost entirely to the fact that mothers now know how to rehydrate their own kids.

You were saying that some of the villagers had learned to do simple eye surgery.

Yes, they remove cataracts. You know, so many medical skills consist of some very simple knowledge combined with dexterity and a lot of practice. Somebody with a limited amount of education can learn a specific skill. Our chief laboratory technician has never been to school a day in her life, but she can do stool analyses, differential diagnoses of different parasites, blood workups, urine analyses, and so on, and report her findings accurately and intelligibly.

The dental workers there can run circles around recent dental school graduates from the States— because they’ve had more experience. Having a title or a diploma doesn’t necessarily make you any good. Some of our village kids have pulled ten thousand teeth, while a new dental school graduate might have had a chance to pull two or three in his four years of dental school.

As far as the skills of primary dentistry are concerned—drilling, filling, and cleaning—the village boy can be trained to a level of skill comparable to an American dentist in a matter of weeks and can provide those. services at about—oh, I’d say about one-fiftieth the cost.

So on the basis of that experience, how does the American system of health care look to you?

Disturbing. I think that a lot of our experience in Mexico could be valuable to people working in the States. Medicine here has become a priesthood complete with its whole hierarchy, with an ignorant populace down below on the receiving end. I think it’s a real tragedy that American kids go through as many years of schooling as they do and remain so shielded from an area which is of such importance to our own well-being.

Americans just don’t know that much about medicine.

No, and it’s a shame. So much medical knowledge is so simple to understand. If the things all our health workers in Mexico know were taught in the public schools here—all the stuff which has been the sacrosanct domain of the health professions—it would do an enormous amount to make people more aware of how to deal with their own health needs. It would be a tremendous boon to both prevention and treatment.

How might this come about?

It would take a big conceptual shift, a lot of consciousness-raising. The schools would have to place a lot more emphasis on the workings of the human body in health and disease—and that should include considerations of environment and social and political influences on health.

We need to set up situations in which people can share their experiences and come to recognize their mutual needs. Then they can focus on their power both as individuals and as a community to cope with some of those needs.

Health workers need to evolve in the direction of being better teachers, better communicators and sharers of knowledge and skills. I think a good many doctors go into medicine—or maybe they’re influenced in this direction by their training—because they want power and prestige. I think it’s going to take a major change in attitude for doctors to become more open about sharing their knowledge and skills.

I am impressed by your community-cantered approach in Mexico, having the communities who need a medical worker decide who’s going to get the advanced medical training.

That’s how they do it in China, too. Another thing they do there is graduate doctors up from the ranks, so that you start out as a barefoot doctor, then you can become a physician’s assistant, and finally a doctor, instead of going right to the top once you’ve received your M.D.

What’s been the effect on the young American premeds who worked in your program? Some of them must be doctors by now.

Yes. There are about twenty of them, most of them still in their training. They’re all committed to the kinds of changes we’ve been talking about. They’re all talking about trying to find a way to establish the same kind of special sharing-based relationship with a community that we’ve had in the Ajoya area.

You know, to me it’s a tragedy that people coming out of medical schools and the other healing professions are so often deprived of this real human closeness. It’s one thing to have a patient come into a hospital nice to him, and to have him be grateful, but it’s quite another to be a real member of the community where you live, to be involved with all the members of family from birth on up.

That doesn’t seem to happen with the way medicine is practiced here. The doctor relates to his colleagues, but in many cases there’s a great deal of social and psychological distance between doctors and their patients.

And that’s everybody’s loss.

Yes. The doctor’s as much as the patient’s. What I would encourage the young person interested in being a health worker to do is not to start medical school until he or she has lived in community with people, and established some sense of his or her ability to relate in human terms. It would be very good to have already developed a warmth and affection for a particular community before going to medical school, to have had a chance to engage in a wide range of community activities and involvements. Then if he or she does go on to medical school, to go through it with eyes open, critically, and with the plan of taking back to the community what will be of use to it.

You were saying that you thought a turn toward self-care in this country would have a beneficial effect on other countries, too.

Yes. As it is now, when students from undeveloped countries come here for medical training, we train them to depend on our highly technological way of medicine, and we socialize them to want to make a lot of money. As a result, they’re not trained to practice the kind of medicine their countries need, and they end up staying here or going to some other rich country.

When we support medical programs in these countries, we tend to build costly, elaborate hospitals in big cities, serving the elite, ignoring the majority of the people. We support programs to force birth control on the poor when they are so poor that they desperately need a big family to survive. What we should do is help them get a better standard of living, and they’ll regulate the size of their own families.

The health decisions we make in America will have a terrific impact on the health of people in the poorer countries. I don’t think we can afford to think of our health as something separate from the health of the rest.

Tom Ferguson MD Written by Tom Ferguson MD