By Mercedes Aguerrebere Gómez Urquiza
I have lived in non-indigenous rural Chiapas in southern Mexico since 2013, working with Compañeros En Salud (CES)—a Harvard af liated non-profit organization that partnered with the Mexico’s Ministry of Health to guarantee people’s right to health care in Chiapas’ Sierra Madre region.
Soon after starting its work in the region in 2011, CES staff realized that many patients came to the clinics because of mental health problems such as depression and anxiety. To bring mental health care to marginalized communities, CES launched the mental health program in 2014— which I helped design and for which I served as coordinator from 2014 to 2016.
After treating hundreds of women with depression I became aware of the psychological consequences of gender inequality. The narratives women told me about their illness were plagued with stories of violence by an intimate partner (including sexual violence) (IPV), sexual abuse by a someone who is not a partner (SA), or isolation due to gender norms that hampers personal freedom and restrict women’s activities to the household.
Women are twice as likely as men to suffer from depression (Kuehner 2016). Some biological differences between men and women could explain this phenomenon. For instance, biological differences in the stress response, in levels of serotonin and its receptors in the brain—a neurotransmitter closely related to depression— and effects of estrogen and progestin—hormones found in higher concentrations among females (Parry and Haynes 2000; Kuehner 2016). Still, other authors point to recent evidence that shows the gender gap in mood disorders stem from gender role traditionality (Seedat et al. 2009) and higher exposure to adversity among females, such as sexual abuse, and intimate-partner violence (Kuehner 2016; Heim et al. 2000).
Since many women and girls have only the consultation space to talk safely about their experiences, how could mental health services in primary care be leveraged as spaces of re ection on gender inequality? How could Compañeros En Salud adequately equip health service providers to adequately address acts of violence? What role could CES community health workers—more than a hundred women—play in promoting women’s human rights? How do gender norms and roles affect psychological distress, alcohol abuse and suicide among men? Questions like these saturated my brain while I was applying for the Harvard Masters of Medical Sciences in Global Health Delivery.
Shortly after arriving in Boston, I decided to focus my thesis on violence against women and mental health in CES’ catchment area. The project has not been easy for me as a physician and an idealist. Medicine is quite straightforward compared with anthropology, sociology, feminism and politics: disciplines I had not deeply explored until now. There is no magic bullet to prevent or address violence against women.
Still, violence against women is strongly associated with mental illness (Howard, Feder, and Agnew-Davis 2013), with high alcohol consumption by the male partner also associated with women’s experience of abuse (Abramsky et al. 2011; Heise 2011). In addition, while conducting the field work, I have learned that traumatic experiences since childhood are highly prevalent among men who suffer from alcohol use disorder.
My research project aims at measuring the scope of violence—both IPV and SA— in one of the communities where CES operates, and to understand social norms and structures that support excessive alcohol use among men, and support violence against women. The results will inform the ability of mental health services provided by CES and other Partners In Health sites, to deliver gender- sensitive mental health services and prevent and address intimate-partner violence, non-partner sexual abuse, and alcohol use disorder.
Although the project is ongoing, I am confident that CES can address these abuses and their mental health consequences, to work on several fronts: assure the mental health program is equipped to respond to cases of trauma in boys, girls, women and men, and to cases of alcohol use disorder; engage with the community leaders to provide healthy spaces for youth recreation, socialization and reflection on gender, development, and health; and guarantee that CES health programs—including community health workers, mental health, maternal health, and referrals—address gender inequality in the day-to-day practice.
Mercedes Aguerrebere, M.D., previously served as Mental Health Coordinator for Partners In Health Mexico (Compañeros En Salud), where she built a model for integrating mental health services in rural primary care clinics. She is currently a student at Harvard Medical School pursuing a Master’s degree in Medical Sciences on Global Health Delivery.