Daniel Palazuelos on community participation in Mexico

Daniel PalazuelosI. The power to move mountains?

The commotion pealed like thunder in the distance.  It was unmistakable.  We turned the corner of the mountain dirt road and came upon over 40 farmers heaving in unison on four ropes that dropped off the side of the cliff’s edge.  The roads in this part of the Sierra Madre Mountains in southern Mexico are nothing more than an acute angle shaved into the crumbling earth.  They hold up well in the dry season, allowing the farmers access to the local city where they can sell their coffee harvest; but now it was the rainy season, and some unfortunate driver had come too close to the edge and slipped off the overhang.  Mud does not support sloppy driving.

cliff edge, MexicoWe waited patiently, marveling at how each coordinated heave revealed that much more rope.  Suddenly, a mangled mess of twisted metal and broken glass emerged from the mist.  A few more tugs of the rope, and the truck now faced us head on, one headlight bent down as if shamed, the other bright and boasting.  Everyone who had come out to watch or help, from the women and men to the chamacos and viejitos, erupted into spontaneous applause, hoots, and hugs.  Even the driver, who miraculously was unharmed from tumbling halfway down the mountain, smiled a satisfied smile.  A group of women had prepared pozol (a sweet crushed corn drink) to celebrate the success, and once everyone had a glass, we lingered for hours, chatting, retelling the story, joking about who was pulling the hardest, and who was just faking it.  The car would be repaired, but something bigger had been fixed.  I marveled at how powerful a community of concerned individuals could become if given a common purpose and the belief that with tools and effort, anything was possible.

Men pulling ropesEven though we are from very different worlds, I felt viscerally at that moment that these are my people.  They are mountain coffee farmers whose grandparents escaped from the brutal life on the coffee fincas to form collective farming communities (called “ejidos”) once the Mexican revolution made it legal for those who work the land to also own it.  I’m a Mexican-American, born to a Mexican father and a New Yorker mother. Raised in New York, educated at Brown, and now at a faculty at Harvard Medical School, I work with the Boston-based NGO Partners In Health in their supported projects in Mexico and Guatemala.  As a physician, I began to volunteer after Hurricane Stan devastated much of the state of Chiapas in 2005.  Once the disaster response was over, the medical brigades completed, and the acutely ill patched up, our Mexican colleagues and the affected communities made it clear to me that they didn’t want me to be their doctor anymore; instead, they wanted me to accompany them in the creation of a local community-based system of community health workers.  This was my first important lesson: in Chiapas, autonomy is everything.

This made sense to me.  The idea of communities taking control of their health care and public health was not a new one.  In 1978, in fact, the world recognized this possibility in one of the most influential global meetings of its kind, Alma Ata.  Called this for the city in which it was hosted, the WHO held a conference in which all attending countries unanimously voted to ratify a declaration vowing to achieve “health for all by the year 2000.”  This was to be done through the provision of Primary Health Care, but with a twist: article 4 of the Alma Ata declaration asserts, “the people have the right and duty to participate individually and collectively in the planning and implementation of their health care.”  This entails “full participation” in a “spirit of self-reliance and self-determination.”

Hopes were high back then: it was the 70’s, China’s Barefoot doctors were seen as a huge success and Where There is No Doctor was quickly becoming a house-hold classic.  Even Ted Kennedy made a surprise visit to Alma Ata, and he had a great pair of side-burns!  The bar was set high.  What wasn’t set, however, was how these goals were to be accomplished specifically.  The Cold War shaped all international engagement, and even though representatives from all over the world could meet in Alma Ata, Kazakhstan, in the middle of the communist bloc, and sign an agreement declaring health a human right, they didn’t dare try to agree on how their goals would take form socially, economically and politically.  Perhaps this is part of the reason why, now more than 30 years after Alma Ata, community participation in health remains a “perpetual allure, persistent challenge.”[1]  Now a decade after the year 2000, when it is clear that we are ever further from health for all, some have quipped that perhaps the declaration had a typo and should have read “health for all by the year 3000.”[2]

A lot can be said about what else happened to comprehensive primary health care since Alma Ata, how it was sapped of its energy by the creation of a selective primary health care, and about how neoliberal economic reforms undermined the public sector.  I refer the reader to one particularly good review.[3]  Yet, on the ground at our project site in the Sierra Madre Mountains, the promise of this one element of primary health care, of working with the power of the community, has been the backbone of our work.  We’re exploring a number of questions: can assisting organised communities improve government health services?  Can it improve infant mortality, eliminate maternal mortality, lower domestic violence, increase food security, or provide first line care to the destitute sick who have never received care before?  And above all else, if these improvements come from within the community, can the initiatives be more sustainable, free from the whims of international forces because they are bolstered by the homegrown participation of end-users?

[1] Morgan, LM. Community Participation in Health: perpetual allure, persistent challenge. Health Policy and Planning. 2001 Oct 11;16(3):221-230.

[2] Walton DA, Farmer PE, Lambert W, Léandre F, Koenig SP, Mukherjee JS. Integrated HIV Prevention and Care Strengthens Primary Health Care: Lessons from Rural Haiti. Journal of Public Health Policy. 2004 Nov 2(25):37-158.

[3] Bryant JH, Richmond JB. Alma-Ata and Primary Health Care: An Evolving Story. Health Systems Policy Finance and Organization. Carrin G, Buse K, Heggenhougen KH, Quah SR, editors. USA: Elsevier; 2009.

Daniel Palazuelos is an associate physician at the Brigham and Women’s Hospital, and an instructor of medicine at Harvard Medical School. He is the clinical director of the Partners In Health-supported projects in Chiapas, Mexico and Guatemala. Partners In Health is a US-based NGO working to bring advanced medical care to the world’s sickest and poorest people.  In this role, he lives for half of the year in isolated communities in the Sierra Madre Mountains, training local community health promoters, providing medical care, conducting research, hosting medical student projects, and creating original curricula. For the other half of the year, he lives in Boston and practices inpatient medicine with the hospitalist group at the Brigham.

Competing interests: DP does pro-bono work for Partners for Health, a Boston-based NGO and they assist him with travel support to work abroad.