Coffee with Dr. Enrique Valdespino

Dr. Enrique Valdespino Serrato, 25, works for Compañeros En Salud, Partners In Health’s sister organization in Chiapas, Mexico. Last year, he worked for the Ministry of Health as a community doctor in Reforma, a remote coffee-farming village about a five-hour drive over dirt roads from Chiapas’ largest city, Tuxtla Gutiérrez.

This year, he’s supervising a new class of young Mexican doctors who are working in remote communities for their required year of social service.

We sat down with Valdespino in our Boston office last month to learn about his life and work. Of course, we talked over coffee. “What I like about coffee is the origin of it,” he said, sipping. “It reminds me of the sweat of the people of Chiapas.”

Where did you grow up?

I grew up in a small town of about 80,000 people in Michoacán. My grandmother mostly raised me, but I had an adoptive mother and a biological mother as well. My adoptive father died when I was 12 years old, and I was never close to my biological father.

Learning about PIH/CES opened my eyes, because it was the first moment I saw I wasn’t alone. There are others thinking the way I think.

At age 14, I left to continue my education. Michoacán is one of the worst states in Mexico for education, and I was looking for better opportunity. For the second part of high school, I went to Toluca, a state capital near Mexico City. At the beginning, it was hard to keep up because the education was much more rigorous, but I made it. When you have a lot of motivation to succeed, you push yourself, and there’s a lot of reward, both professionally and personally. When I realized that, I decided to continue investing in my professional development. I wanted to have a career that would be fulfilling.

At age 16, I decided to be a doctor. To apply for college, you have to decide your career path. It’s a decision that requires a lot of maturity and understanding of your goals, so young people can’t experiment as much as they do here. We have to decide early.

What was medical school like?

I went to the Technological Institute of Monterrey, one of the top medical schools in the country. The school’s overt mission is to train doctors to go abroad. It even says that on the website. It’s the only school in the entire country to offer international clinical rotations, so you can study medicine in hospitals around the world. One of my friends even went to Hong Kong. The majority of graduates go to the United States, and others to Europe.

I couldn’t afford to do a clinical rotation abroad, so I went to Mexico City to work in the specialized hospitals there.

How did you go from a medical school that exports doctors to work in one of the most under-served areas of your own country?

I had seen the different levels of care in private clinics versus public facilities. People who were born in Monterrey have access to great medical care through the hospital where we studied. It’s for the elite of the elite, and that’s where I trained. But during my clinical rotations I was also exposed to dozens of health centers and hospitals, both public and private. I realized that it’s what you have or where you were born that determines your access to services. These inequalities made me feel angry at the system. I didn’t want to be part of it; I didn’t want to feed into it.

I met Dr. Daniel Palazuelos, one of the founders of CES, at a student conference in Monterrey. For the first time, I heard about global health and CES’s work in Chiapas. It opened my eyes, because it was the first moment I saw I wasn’t alone. There are others thinking the way I think. There are others who have seen what I’ve seen, and although it seems impossible, they’re trying to do something unprecedented in the face of great need and great frustrations. In this moment I decided to do my social service year in Chiapas.

And how was it?

It was a hard year. I went in with a lot of energy, almost euphoria, but by the third month I was in tough shape. What you have to understand about the work of a CES doctor is that you have many jobs: you act as a manager, responsible for all the operations of the clinic; you act as a doctor, diagnosing and treating patients; you act as an administrator, making sure you order supplies and do all the paperwork. A lot of times you’re alone, because the nurse couldn’t come because of the long distances they have to travel. And there are always a lot of patients, because word gets out that there is a good doctor with good medicine.

People often say to me, 'Stop being idealistic, and start being realistic.'

As a general doctor who’s in charge of the health of the entire community, you are in charge of all these public health programs you’ve never heard of—tuberculosis, hypertension, malnutrition, and vaccines. They don’t teach it in school, and now you’re in charge of implementing it. And now you have two bosses, the Ministry of Health and CES. You need to be totally dedicated to do this.

How did the community react to you being there as their doctor?

The people of Chiapas call us from CES gringos. I’m as much a foreigner in Chiapas as an American would be. But after a year, I was very involved in the community. Living there was an entirely different experience for me. The community gave me a house, they gave me food, and I had a river to swim in every day. There were mountains to visit, and caves, and families invited me into their houses to eat. I found myself encountering nature for what felt like the first time.

I realized something remarkable: if you showed me the logos of 100 brands, I could name them by the image alone in a few seconds, but I couldn’t name five species of trees or five flowers. All the people there knew the names of the trees. It was difficult to adapt to the absence of pavement, of services, of infrastructure. It was a shock, the transition to a natural life, from the big elite hospitals of Mexico to the country. Now when I come to the city, it’s the opposite. Everything is artificial. Everything is made by human hands. It didn’t grow on its own.

Dr. Enrique Valdespino accompanies Adelaida Lopez, left, a community health worker, and Ophelia Dahl, right, PIH executive director, on the way to a patient's home in Chiapas, Mexico. Photo: Rebecca E. Rollins / Partners In Health

How did your friends and family respond to you making this choice?

I often receive negative feedback about what I am doing. Friends, family, colleagues, and others say, “What are you doing there? Are you trying to save the world? You are going to fail, you’ll be better off if you come back. Stop being idealistic, and start being realistic.”

I always respond to this by explaining that I am being realistic, which is why I’m participating in this huge, novel social science of global health. We’re creating a better reality based on equity and justice and constructing new ways to cure ourselves.

Nothing is unchangeable. If you think you can´t improve systems, the environment, or people, then you are living in a false realistic world. In this moment, while we’re talking, new doctors under our mentorship are converting idealism and clear-eyed optimism into a better reality.

Occasionally, I get positive feedback that’s also unrealistic. A lot of my friends and colleagues say to me, “You are so brave to go there, to a place where so few people live.” The reality is that millions of people live “there,” and yet no one is offering basic services and satisfying basic needs.

Now you’re working as a supervisor of the new doctors who are now going through this themselves. How is it?

I’m learning. I’ve been a supervisor for four months, and it’s supportive supervision. I’m invested in the emotional state of the doctors. They’re new doctors, just getting into their work. I want to make sure they feel good in their communities. Mental health is an important issue for global health staff, especially at the beginning when you face enormous difficulties for the first time. I make sure they have somewhere to live, something to eat, that they can communicate with us and their families. There is no cell phone signal in these communities, just one or two satellite phones for the entire community to share. And sometimes we use walkie-talkies.

I heard about this. You have code names, right? What’s yours?

I don’t really think many people use code names as I do, for fun. Mine is “bici-burro,” or bike-donkey, because I use a mountain bike to get around. Other people in the community go by names such as “pollero” (chicken guy), “corazón de leon” (heart of a lion), or “pequeña” (little girl).

What else do you do as supervisor?

My responsibilities also include clinical supervision. I visit the new doctors and provide accompaniment, teaching, and supervision. I help make sure they are taking care of patients well, giving them follow up for chronic illnesses, such as depression or malnutrition. I make sure they are there in the clinic, respecting the patients and managing their work so that they do their jobs and also prepare for the next day.

We have to make our own way. We’re the first brick, and we’re trying to build an edifice.

I help make sure they’re forming relationships with the community and with the Ministry of Health. I make sure that the clinic and the community are in harmony. I look after their professional development to make sure they are learning, and I also look after their well-being, to ensure they have free time to exercise, study, relax, and rest. I’m with them, working side by side. I also teach a monthly course on global health for them, which is certified by the Technological Institute of Monterrey.

Tell us about the pathogen that is affecting the coffee harvest this year. What effect will this have on the communities CES serves?

The plague is a fungus called la roya, and it’s the most damaging pest in the world for coffee. It’s not unique to Mexico; it’s all over Latin America. It affects the berries of the tree, which contain the beans. Normally in Chiapas about 10 percent of the crop is affected by la roya. As a rough estimate, the average coffee producer in this region harvests 10 sacks of coffee every year,  yielding about US $1,000 to $1,400, to support a family of four or five people. This year, because of la roya, a family that produced 30 sacks will only produce five.

The main problem is going to be with the people who don’t grow corn and beans as subsistence crops. The coffee harvest is in January, so November and December will be the worst months, because their cash from the last harvest will have run out. We call them the thin months.

One of the issues CES has tried to tackle is to help families avoid catastrophic expenses on health. If you understand how much they make in a year, then you can appreciate the price of 1,500 pesos (about US $115) for a simple medical consultation. Sometimes it’s for a health problem as minor as a cold. If a kid has a cough or a fever, the family is going to take them to see the doctor, and they can easily spend a huge sum on transportation or for the doctor’s fee. We’re trying to provide as much care as possible in our primary care clinics for free so that these families don’t have to travel or pay fees that bankrupt them.

What’s next for you, after this job?

I’ll be here for at least a year more. Then I’d like to do a master’s degree in global health delivery at Harvard Medical School—the course PIH clinicians have helped develop. I want to work in Mexico to help strengthen its health systems and teach. I want to make global health a part of the Mexican medical education system.

We can demonstrate in Mexico and everywhere that global health is a science, it’s a field of study, and it should be taken seriously. We have to make our own way. We’re the first brick, and we’re trying to build an edifice.