The Case of Chiapas, Mexico
Julio was wet from the pouring rain and frightened. He ran through the streets of Polho, a community in Chiapas sympathetic to the Zapatista rebels, to find Carlos, the health promoter. He explained to Carlos, in Tzotzil, that his young wife Ana had delivered their first child an hour ago and was still heavily bleeding at home. I ran with the student nurse to the clinic’s poorly stocked pharmacy to get the post-partum hemorrhage kit.
We put on our plastic ponchos and heavy boots and followed Julio and Carlos in a straight line an arm’s length from each other in order not to get lost in the thick nocturnal clouds. I tried to balance myself walking in a mudslide down the hill from the clinic but fell twice. Everyone but the nurse laughed at my mud soaked pants and inexperience with extreme conditions of poverty.
We arrived 40 minutes later. Julio’s tiny one room home was constructed from horizontal wood planks supported by four corner posts and draped with thick plastic sheets. A small fire in the center of the dirt floor used for light and heat produced a thick smoke that irritated my eyes and throat. Ana, covered with old colorful Mexican blankets was lying on her wooden plank bed holding her newborn girl, Esperanza. Anna’s mother, standing near a corner worried, directed two adolescent girls to mend the fire, get water, and keep the children out of the way.
I stayed by the door to protect Ana’s modesty as the nurse checked her vital signs and performed the exam. The blood pressure was stable and the bleeding stopped.
The entire family smiled at the good news and thanked us in Tzotzil. They said that a partera (traditional midwife) delivered the baby but left the complications for a doctor to handle. My stomach cringed as I asked myself what if the nurse and I was not there? If she continued to bleed would Anna have died? On my way out I gave on last good look at the house to imprint it on my memory forever. On the ground near Anna’s bed were three neatly tied bunches of herbs.
As a Harvard medical student with a Paul Dudley White and Andrew Sellard Traveling Fellowship, I spent eight months investigating the use of herbs by health promoters in Chiapas during low intensity warfare. I interviewed several directors from non-government health organizations, doctors, curanderos, and countless health promoters from the highlands and jungle. I worked at two clinics and helped the organization, Equipo de Atencion y Promocion de Salud y Educacion Comunitario (EAPSEC) – a sister organization of Harvard Medical School based Partners in Health – train health promoters in preventive medicine and primary care. I wanted to better understand the factors that influenced health promoters use of herbal medicine.
My initial understanding of herbal medicine as a viable substitute for Chiapas’s scarce health care services changed to a deeper understanding of the socioeconomic and political interplay between using the herb or the pill. Poverty, war, indigenismo, the culture of medicalization, and their lack of knowledge of herbal remedies influence the health promoters motivations and limitations in using medicinal plants.
Julio and Ana’s story illustrates the multifaceted dimensions of health promoters use of herbal medicine. It demonstrates the lack of health resources that leaves women like Ana needing to rely on traditional medicine such as parteras and medicinal plants. A study by El Colegio de la Frontera Sur in San Cristobal de las Casas revealed that only 14% of births are attended by doctors or delivered in a hospital or clinic. Chiapas has the fewest doctors and nurses with only one doctor for 18,900 inhabitants in the conflict zones. It also has the least number of hospital beds and operating rooms, with only one available for 3,000 and 83,300 people respectively.
In Polho, one doctor from the Mexican Red Cross and one temporary doctor from Doctors of the World, two Mexican medical students and a nurse on their mandatory rural year of service, and indigenous health promoters serve 8,000 people. Most villages I visited, however, were completely dependent on minimally trained health promoters. Most communities had no doctors, clinics, or pharmacies and in some, the nearest clinic or pharmacy was a six hour walk away.
Health promoters desperately seek resources. Herbal medicine, in Mexico’s most bio-diverse state, seems to be the only plausible available form of therapy. Health promoters say they use herbal medicine because they “cannot afford medicines.” One health promoter in broken Spanish said, “the government never attended our suffering. We struggle to find someone in our community who can cure with plants.” Another said, “we want medicines and clinics in the communities but there is no place to buy [medicine] and the doctors can’t send them. We are abandoned like the government’s trash. The problem is that we don’t have medicines because we don’t know how to organize. The rich make medicines from plants. We need to do the same.”
Furthermore, the low intensity warfare compels health promoters to use herbal medicine. Since the cease fire agreements in January 1994 between the Mexican Army and the Zapatista Army for National Liberation, the Mexican government militarized Chiapas with a third of its forces and promoted the formation of paramilitary groups to terrorize Zapatista sympathizers. Julio and Ana are two of 5,000 refugees in Polho displaced from their communities.
Physicians for Human Rights (see related article, p. ) documented multiple violations of the neutrality of health care. Health promoters concurred that the Mexican government cause divisions amongst community members by providing aid only to non-Zapatista sympathizers, use state police and soldiers to assist the Mexican Red Cross deliver medicine, and interrogate clinic patients suspected of being Zapatista sympathizers. Moreover, military and immigration checkpoints are located in strategic entry sites creating fear and limits on community members ability to travel and organize. They also harass international human rights observers and providers of humanitarian aid, according to Physicians for Human Rights and local non-governmental organizations.
To avoid the risk of interrogation and harassment, health promotors see herbal medicine as a means to be independent from government services. One promoter said, “we need to be prepared with medicinal plants [and] train more people in other collective work in order not to depend on the government.” Another questioned, “if there is war and we don’t know how to use medicinal plants, how will we treat the indigenous?”
Indigenismo, a movement to increase awareness and pride in the accomplishments and cultures of indigenous peoples, also motivates health promoters to use medicinal plants. To many health promoters, herbal medicine is a form of identity and connection to their history. This is evident in when a health promoter said, “our culture like our ancestors who cured with medicinal plants are really important and need to be respected.” A health promoter in Polho added, “… that’s what our ancestors used. [Allopathic] medicine have side effects and can not cure everything.” Others said that the herbal medicine was better because their ancestors were healthier and lived longer. They mentioned certain culturally specific ailments such as empacho, alteracion, and susto that western doctors could not treat. Health promoters seemed to justify their use of herbal medicine and intended to claim value in their traditional practices.
Historically, Christian missionary doctors and government personnel from the Indigenous National Institute in the ’50s and ’60s tried to undermine traditional beliefs to assimilate indigenous Chiapanecans to western philosophies and the mestizo culture. As a result, a competitive and unfriendly interaction between allopathic doctors and traditional healers was reported in the interviews with health promoters. Graciela Freyermurth, a medical anthropologist in Chiapas, confirms these observations.
Some health promoters however, prefer pills to herbal medicine; they associate allopathic medicine and the pill with modernization and prestige. That is the manifestation of the assimilated culture of medicalization. A health promoter said that “the people do not believe [in traditional medicine] because private doctors give pills and devalue traditional medicine. Most people request the pill.” A health promoter in Polho said that it was “difficult using herbs because the people want medicine.” His idea of a bad doctor was one “that disrespects us and does not give medicines.” Some health promoters simply believe that pills work better than herbal medicine.
Moreover, many health promoters, like Carlos in Polho, do not know how to use medicinal herbs. Ana’s partera used the three bunches of herbs I saw on the floor; Carlos observed he knew little about herb usage. Some health promoters are refugees or migrants unfamiliar with local plants. Their minimal knowledge was learned from family members and non-governmental health organizations such as EAPSEC or the Catholic Church, but rarely from curanderos. Some claim that curanderos are not willing to teach their trade since it is their source of income and hierarchy. “In these days,” a health promoter said, “curanderos charge 200 to 300 pesos in the community and even ask for a chicken.”
Rafael Alarcon, the director of the Organizacion de Medicos Indigenas in Chaipas (OMIECH) said that herbal medicine is a dying knowledge that needs to be rescued. One health promoter observed, “we need to rescue and practice our traditional medicine and customs to better our health because if we don’t we will lose our tradition.” In response, curanderos from OMIECH hold workshops to train health promoters how to use herbal medicine and make medicinal syrups, tinctures, and salves.
Nevertheless, the creation of herbal gardens and remedies requires resources that health promoters do not have. Time attending herbal gardens or making remedies is time away from their work in the harvests. Money is needed to buy gardening tools, containers, syrup, and vaseline to make medicinal syrups and salves and to build adequate storage rooms.
Relying on herbal medicine to curve Chiapas’s adjusted infant and maternal mortality rates, which are amongst the worse in Mexico, is an overly ambitious goal and as Anna’s partera, neglectful. Chiapas will still lead the nation in deaths due to diarrhea and have the second lowest access to immunization coverage and the fourth lowest life expectancy. Therefore, given Chiapas’s poor health indices, and its immediate need, priority and resources should wisely be directed towards adequate and effective allopathic systems of care and treatments. Only then will herbal medicine be a true “alternative” and infants like Esperanza can hope for available health resources. Otherwise, herbal medicine will remain to be the only dying option.
Raul Ruiz, a member of the Partners in Health Chiapas Health Project, is an MD and MPP candidate class of ’01, Harvard Medical School and Harvard University’s John F. Kennedy School of Government.
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