We Build Health Systems: Caring for People in Chiapas

Ubaldo Roblero, 34, lived locked inside a shack behind his family home in rural Chiapas, Mexico, a prisoner to his diagnosis of schizophrenia. A square hole in the door served as his portal to the world for nearly a decade. Beyond giving him his medication, his parents didn’t know how else to respond to his violent spells. That is, until Dr. Luz Valderrama visited in February last year.

Valderrama recognized Roblero was reacting poorly to his medication. Twice in four months he got so sick she feared he might die. With the help of her supervisors, she got him admitted to a hospital in Tuxtla-Gutiérrez, eight hours away from his home in Buenos Aires, where he could be under the direct observation of a psychiatrist.

Such an intervention likely never would have happened if Valderrama, and Partners In Health, had not been there.

PIH started working with Mexico’s Ministry of Health in 2011 to place pasantes, or first-year doctors, like Valderrama in remote clinics in Chiapas. Now 10 clinics have doctors, which significantly improves residents’ access to health care. With support from PIH staff, these young physicians provided more than 10,000 patient visits in 2012 and about 28,000 in 2015—a nearly 170 percent increase.

Historically, pasantes have preferred spending their social service year in urban hospitals or research institutions. But public clinics—the ground floor of the nation’s health care system—are exactly where they’re needed most. The clinics are often inactive, because the government doesn’t assign a doctor to the locations or does so temporarily. It’s a pattern rural Chiapanecans have seen often, so they’ve struggled to cope with irregular care.

PIH changed that. Our unique training program attracts pasantes who graduated near the top of their classes. The Ministry of Health assigns them to one of 10 clinics we support. And our supervisors visit them several days each month to provide mentorship and help troubleshoot complex cases. Pasantes also return to our headquarters in Jaltenango for monthly seminars created by instructors from Harvard Medical School and accredited by Tecnológico de Monterrey, a highly regarded medical school in Mexico. 

Mental health is one area in which pasantes receive regular supervision and advice from trained professionals. The first-year doctors are true pioneers in providing community-based mental health care where access was nonexistent, and where stigma prevented patients from seeking care. Theirs is essential work, considering that the World Health Organization estimates depression alone will be the leading cause of disability globally by 2030—outpacing heart disease, cancer, and HIV.

Valderrama stocks a PIH-supported clinic in Soledad, Chiapas.

 

Support doesn’t end at mentorship. Our staff always ensures pasantes have “the stuff” they need to do their jobs. Each clinic pharmacy is fully stocked with medications and supplies. And every clinic has a laptop loaded with an electronic medical record system to track patient visits.

 

A complex case

While following Roblero’s case from afar, Valderrama visited another patient struggling with mental illness in Soledad. She walked the short trek to his house trailed by her dog, a stray she’d named Terry. The doctor with a lip ring and a pink streak in her hair has a warm personality and seems undaunted by any challenge. This patient, though, tested her.

Valderrama was told that Humberto* had begun showing violent behavior nearly two decades ago. He regularly beat his wife and was so abusive toward family and friends that they eventually chained him to a shed adjacent to their home.

There was no other option at the time. Psychiatrists didn’t make house calls in that part of Chiapas. And his family, like Roblero's, had traveled in vain to Tuxtla and Mexico City several times in search of care and could no longer afford further trips. So they kept him locked away, caring for him as best they could.

After talking to his family, Valderrama learned Humberto had also suffered a machete blow to the head around the same time his schizophrenia surfaced. She suspects her patient’s mental illness is aggravated by this brain injury. It’s a complex case. And so far, neither she nor the other pasantes who preceded her has found the perfect combination of medication that “helps him connect with the world,” she says. But through constant communication with PIH’s mental health coordinator based in Jaltenango and support from PIH’s cross-site mental health team, she knows she’s not alone.

And Valderrama hasn’t given up. Her goal is to get her patient to the point where he can live free physically and have an improved quality of life. And she thinks it’s possible considering the support she receives through PIH. “Here we have the opportunity to treat patients with schizophrenia because we are in touch with psychiatrists, with someone more specialized who helps us,” she says. Pasantes working in other remote parts of the country aren’t as lucky.

For now, though, Humberto continues to pace back and forth, a chain linked to his left ankle as he methodically etches a shallow groove in the dirt bordering his home.

A long road ahead

Meanwhile, Roblero fared better. Specialists at the Hospital San Agustín in Tuxtla discovered he is one of extremely few people who suffer adverse reactions to haloperidol and olanzapine.

Two weeks after starting on a new drug, Roblero returned home a changed man. His parents noticed the transformation. His father, Francisco, says that he became more conscious, didn’t talk to himself, or rip at his clothes.

“He didn’t even come and sit and talk to us before,” says his mother, Idolina. “What do you think about that? That’s what bothers me.” Her words trail off as she thinks about the 10 years of life her son lost to mental illness.

Valderrama, center, visits Roblero, right, at his home and checks his medication.

 

But like many people who struggle with mental illness, Roblero is engaged in a lifelong battle. After several weeks on his new medication, he started having violent spells again while working in his father's coffee fields. Afraid his condition might worsen and fearful that he'll have a crisis they can't control, his parents reluctantly decided to chain him again.

 

Now that Valderrama's social service year is over, she has trained a new pasante who continues to visit Humberto and Roblero at home to oversee their treatment twice each month. Meanwhile, PIH has taken this as an opportunity to train staff in psychological strategies to help patients transition from living chained and isolated to being part of the community.

There's a long road ahead for these patients and their familes, but pasantes—and the entire PIH team—will be there every step of the way.

*The patient's name has been shortened.