Working in Global Health: Dr. Mercedes Aguerrebere

Starting a career in global health can be intimidating. It’s a diverse field that evolves quickly and demands collaboration across disciplines, from finance to supply chain and logistics, to computer programming.

That’s why we ask seasoned colleagues to share advice for those interested in forging a career in global health. This month we asked Dr. Mercedes Aguerrebere, mental health coordinator for Compañeros en Salud, PIH’s sister organization in Mexico, to discuss how she became involved in the movement for global health.

When I was in high school, before I had field experience, before I had been trained as a doctor, I thought that education was all we needed to reduce inequity. So I committed myself to the task by attending medical school and vowing to share the knowledge with the most vulnerable people in my country.

During my second year of medical school, I met a group of students with similar concerns and similar goals. So we got together and started organizing activities and events to promote health. But it wasn’t until we visited a marginalized region in the state of Querétaro that I realized the complex challenges to delivering medical care. Due to the lack of access to quality primary care in the region, we, a bunch of medical students with some donated over-the-counter painkillers, were giving medical attention to more than 100 people. These people often could not go to their primary care clinic because the health professionals were almost never there. It was also common for these clinics to be out of medication and supplies, which rendered the clinics ineffective.

Witnessing these challenges firsthand allowed me to understand that the lack of medical attention could not be overcome by mere education and knowledge-sharing. Instead, I realized that we needed committed doctors in the field, along with political, economic, and operational commitment from the Ministry of Health.

As my interest in health equity grew, I had the opportunity to go to a congress organized by one of the elite medical schools in the country. The congress was named “Global Health 2010.” I had never heard that term before, "Global Health." But the curriculum seemed interesting. Lucky for me, Dr. Daniel Palazuelos, chief strategist of Compañeros En Salud, PIH’s Mexican sister organization, was one of the speakers. He discussed what they were doing in the Sierra Madre mountains of Chiapas, and the stories he told us were heartbreaking. I was being pulled toward the movement for global health.

In Mexico, all medical students are required to do a social service year at the end of medical school. These social service year physicians are called pasantes. Sometimes the pasantes work with a team of physicians and nurses, sometimes with a team of just nurses, and sometimes they find themselves working alone in challenging environments with few resources or support.

It is estimated that 82 percent of rural primary care clinics under the purview of the Ministry of Health are operated by pasantes. The pasantes have a fuzzy status; they are not students, nor employees, and they are often forgotten by the medical school and overlooked by the MOH because they are only “passing by.” Pasantes usually do not receive any kind of continuing medical education, training, or support. They are left facing many challenges—medication stock outs, or the expectation to provide care without any functional team for patients who are suffering from complicated illnesses.

I didn’t think twice when presented with the opportunity to do my social service year with Compañeros en Salud, which was launching a model that included supportive supervision and ongoing medical education. I was part of the third generation of pasantes who would spend the year working with Compañeros en Salud. And I am now among the 90 percent of them who have decided to stay working with the team after the end of the social service year.

I learned to see disease as a social illness as well as a biological disturbance.

That year exposed me to a transformative education: I learned to see disease as a social illness as well as a biological disturbance. The lack of access to quality care makes rural farming families, like in many other countries, vulnerable to charlatan doctors. A family can spend more than its monthly income in search of care. Many families encounter catastrophic expenses for illnesses that could be easily treated in their primary care clinics, if their primary clinic were properly staffed and stocked. Mental illnesses like schizophrenia and depression are perfect examples of how patients and families suffer.

In the three years PIH/CES has been working in the region, we have accompanied many patients with schizophrenia or psychosis. Before we were able to link some of these patients with proper medication and care, their families and communities were frequently forced to chain the patients’ ankles or lock them in sheds to protect both the person and themselves from harm. All of these patients had visited several private and public doctors, including specialized mental health facilities. They bought expensive medications and paid for follow-up consultations in the capital city, which is six hours away, but they didn’t find a solution to their illness. PIH/CES has also seen more than 150 patients across six communities who were diagnosed with depression. They, too, faced similar histories in their quest to find health care.

Many pasantes have little to no training in mental health and struggle to meet the needs of these patients. Still, it has been proven by PIH and others that mental health care can be provided in marginalized rural areas when primary care doctors and community health workers are trained and have the tools they need.

To achieve equity, we all have to work from our different fronts, paying special attention to the most vulnerable among us.

And that is my job now: to make it possible for pasantes to deliver care for patients with mental health needs by finding and providing the tools they need, and by arranging ongoing medical education and training in mental health and psycho-education. At the same time, my job is to make sure that those patients receive not only clinical care but the social support they and their familes need, which can be done through a psycho-education strategy and by working with community health workers who visit patients’ homes to encourage them to adhere to their medications. This strategy makes it possible for our patients to receive quality care in their communities, through primary care and low-cost interventions, liberating patients from their physical and mental chains.

Working with the CES team, I have learned that people who make a difference are ordinary people with broad insight into the complexity of social issues and a vast capacity to continue working in spite of constant frustrations and disappointments. I now know that we all have the ability to act in a way that facilitates the integral development of fellow human beings. To achieve equity, we all have to work from our different fronts, paying special attention to the most vulnerable among us.