Curative medicine, preventive medicine and health status: The influence of politics on health status in a rural Mexican village

Soc. Sci. Med. Vol. 23, No. 2, pp. 139-148, 1986

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CURATIVE MEDICINE, PREVENTIVE MEDICINE A N D H E A L T H STATUS: THE I N F L U E N C E OF POLITICS O N H E A L T H S T A T U S IN A R U R A L M E X I C A N VILLAGE KENYON RAINIER STEBBINS Department of Behavioral Science, University of Kentucky, Lexington, KY 40536, U.S.A. Abstract--This paper examines a recent program which purports to address the health concerns of millions of poor rural Mexicans whose constitutional guarantees of health have been largely ignored. This new program asserts the importance of preventive medicine, but makes little effort to implement preventive measures. The curative medicine it does emphasize in practice may alleviate pain and suffering for a time, but ignores critical factors that contribute to the persistence of disease. This paper examines why underdeveloped countries are more likely to implement curative than preventive services for poor people, even while proclaiming the importance of preventive measures. In dependent capitalist economies, the rural penetration of state-directed health services perpetuates the privileged position of the political and economic elite. Based on research conducted in a highland Chinantec village in Oaxaca, this paper concludes that the recent health services program addresses symptoms rather than causes of disease and is not likely to significantly improve the health status of the people who are most in need of such assistance.

critical factors that contribute to the persistence of disease. Especially important factors which are ignored are such preventive health services as environmental sanitation, nutrition and education. By ignoring these factors, curative medical interventions leave intact the very conditions which contribute so heavily to the onset of many of the illnesses and diseases they are treating. People in the village where I conducted fieldwork frequently complained to me about how the treatment that they had received at the village clinic only helped them for a short while, and they wanted to be free of their recurring ailments on a more permanent basis. This paper examines why underdeveloped countries are more likely to implement curative than preventive services for poor people, even while proclaiming the importance of preventive measures. To consider this question of the penetration of statedirected health services into the rural hinterlands, I use a political economy perspective, because such health systems are better understood by placing them in their broader political and economic contexts. F r o m this perspective, the scarcity of preventive or public health measures in rural areas may be seen as related to the dominance of curative medicine within the medical establishment, as well as related to the social, political, and economic formations of those countries. In dependent capitalist societies such as Mexico [5], the political and economic elites act to preserve their own privileged position vis-?t-vis the lower classes, and rely heavily on showy programs (such as health clinics), powerful rhetoric and outright physical force to control the rural masses [6].

INTRODUCTION

The delivery of health services and the improvement of health status for the underclasses in underdeveloped countries around the world is a topic of great interest for government officials, health planners, scholars and the disadvantaged population themselves. M u c h of the interest focuses on how to best provide health services in order to most effectively reduce morbidity and mortality a m o n g the poor. This paper examines a recent program which purports to address the health concerns of millions of poor rural Mexicans whose constitutional guarantees of health have been largely ignored for decades. One outcome of the 1910-1917 Mexican revolution was the writing of what was then the world's most progressive national constitution. A m o n g the numerous social reforms it contains is the guaranteed right to health care for all Mexicans [1]. Mexico has failed to meet this constitutional promise. In 1976, only 35% of the Mexican population was covered by the health services of the several social security institutions, yet they received 85% of the total public sector health budget [2]. The remaining two-thirds of the Mexican population (including most of the rural sector) are theoretically attended to by the Secretaria de Salubridad y Asistencia (the Department of Health and Welfare), which receives only about 15% of the public sector health resources [2, pp. 181-182] and has only 20% of Mexico's physicians and nurses [3]. This paper reports on how lower class rural people in Mexico are affected when they are the recipients of health services which are mainly curative in nature, rather than preventive [4]. Mexico's new health services program which I examine here asserts the importance of preventive medicine, but makes little effort to implement preventive measures. The curative medicine it does emphasize in practice may alleviate pain and suffering for a time, but ignores

THE C O P L A M A R P R O G R A M

In 1977 the Mexican federal government established a national-level umbrella agency, COP L A M A R [7], to coordinate all of Mexico's programs concerning 'depressed zones and marginal peoples'. Between 1978 and 1980 the government 139

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built, supplied, staffed and supervised more than 2100 new C O P L A M A R rural health clinics, each of which is designed to 'cover' approx. 5000 rural Mexicans. The southern state of Oaxaca, one of Mexico's poorest states by most standards [8], has 321 of these new clinics. This paper is based on data gathered during anthropological fieldwork between October 1980 and May 1982 while residing in a Chinantec community where one of these clinics was opened in September 1979 [9]. The village of Amotepec (a pseudonym), at an elevation of roughly 6000 ft, is about 50 air miles due north of the state capital of Oaxaca. What used to be a demanding 3-day walk for the the villagers from their homes to the state capital is now a relatively easy seven hour ride on the twice-weekly bus, weather permitting [10]. The village has a semi-permanent populaton of about 1600 people whose livelihood derives mainly from below-subsistence plow agriculture in and around the village and from income earned outside the village in a variety of jobs. While nearly all villagers have some land which they work, very few families can subsist without cash incomes earned outside the village. Accordingly, Amotepec men commonly work as self-employed travelling salesmen (especially selling herbs and spices) in the nearby state of Veracruz, or work in factories or businesses in Mexico City, and many Amotepec women work for a few years as domestic servants in Mexico City. As a result, most males and many females can converse in Spanish, although nearly all village conversations are in Chinantec. Although Amotepecans are not an undifferentiated mass of people (having divided into two opposing factions some 70 years ago, and having fought over almost every change proposed for the village [11]), they are in considerable agreement about the benefits and shortcomings of the clinic discussed here. Accordingly, the factionalism and social and economic differentiation which exists in Amotepec has no discernible impact on the villagers' receptivity to health care services. As will be seen below, however, Amotepecans' familiarity with urban health facilities contributes to the widespread frustration and disappointment experienced by villagers utilizing their new clinic. Each C O P L A M A R clinic is staffed by a pasante (a fifth-year medical student serving his required year of social service) and a local female bilingual auxiliary who serves not only as a medical auxiliary, but also as a translator. All clinic supplies and salaries are provided by the federal government, and all consultations and medicines are provided free of charge. Although there is no out-of-pocket charge for clinic services and pharmaceuticals, C O P L A M A R legislation requires each head of household to annually 'donate' up to 10 days of labor toward the clinic's operations [12]. These donated days are not supposed to interfere with a person's 'normal productive activities', a stipulation which erroneously presupposes that all heads of households have ten days of their labor which they can afford to donate. The clinic services are indeed 'free of charge' in Amotepec insofar as the pasantes there never charged for their services, and in fact turned down occasional offers of payment.

Each clinic consists of a reception room and public bathroom; an office, living quarters, and private bathroom for the pasante; a consulting and examining room, and a room for overnight patients. (There had been only two overnight patients in the clinic's first 2½ years of operation, due partly to the fact that patients who were able to get to the clinic were able to get home, where they preferred to spend the night.) THE PASANTES 1N T H E COPLAMAII CLINIC IN A M O T E P E C

By the time I left the village in May 1982, two different pasantes had worked at the clinic for at least a year. Nearly all of my fieldwork was conducted during the time of the second long-term pasante, who eventually decided to stay on in Amotepec for a second year of service. Both pasantes were very poorly prepared for what they encountered in Amotepec. Raised in upper-middle class Mexican families, they received their medical training at institutions located in large metropolitan centers very distant (both geographically and culturally) from the highland Chinantec region of Oaxaca. Neither pasante felt he was anywhere near sufficiently prepared for living in and practising medicine in such a relatively isolated rural Indian community. Both pasantes were largely unaware of living conditions in Indian communities in Mexico, and neither had any idea of the social, cultural, economic, and geographical isolation which they would feel while living in Amotepec (which is much less 'isolated' than many other C O P L A M A R clinic locations). Both pasantes also experienced a great deal of personal and professional frustration in their rural post. Personally, the adjustment from an urban Mexican environment to a rural Chinantec setting was enormous. Communicating with villagers was often difficult for the pasantes (who spoke no Chinantec) because many Amotepecans (especially women) were not proficient in Spanish. Both pasantes viewed the villagers as superstitious and stupid, and they felt that the average Amotepecan was quite unhygienic. In a written report about his observation, the first pasante wrote (erroneously) that the people in Amotepec "bathe once a month at most, and don't change their clothes or brush their teeth or wash their hands", observations which were repeated by the second pasante in his written annual report. Professionally, the pasantes felt frustrated in several ways. Regarding the practice of medicine in the C O P L A M A R clinic, both pasantes reported that their medical training was oriented around highly technical equipment and laboratory apparatus, in marked contrast to the 'simplified' facilities which they were expected to use in Amotepec. Accordingly, both pasantes were also frustrated by their inabilities to practice the medical techniques they had learned during the course of their medical education. In addition to the absence of sophisticated equipment, local beliefs also occasionally interfered with the provision of treatment as learned in medical school. The first pasante illustrated this by noting that he eventually learned why his patients reacted so strongly to his tongue depressors: In Amotepec the

Curative medicine, preventive medicine and health status long-standing treatment for tonsilitis is to vigorously rub the mouth cavity and throat with herbs, involving great discomfort for the patient. Whenever the pasante would attempt to explore a patient's mouth with a tongue depressor, patients feared that it would be similarly painful. The widespread use of, and confidence in, medicinal herbs in Amotepec also frustrated both pasantes. Having been trained in clinical medicine, neither pasante had any confidence in the efficacy of medicinal plants. "Herbs can't cure anything. People here are just superstitious". And yet the villagers of Amotepec have not only utilized herbs for centuries, but also more recently have begun to rely on the sale of medicinal herbs for an important part of their cash income. According to the C O P L A M A R report on the first year's functioning of their 2105 rural clinics [12], each pasante's training included instruction in medical and social anthropology, preventive medicine and family planning, among other things. However, judging from observations and conversations with the pasantes in Amotepec (and with clinic supervisors), the 'instruction' in medical and social anthropology is slighted, if mentioned at all. Instead, the training course is almost entirely devoted to administrative priorities, making certain that the pasantes are familiar with the great volumes of documents and forms which they are required to fill out daily, weekly, monthly, quarterly or annually, depending on the form. The emphasis on documentation further frustrated the pasantes. They felt inundated with paperwork, most of which appeared irrelevant to them. In addition, they felt that the urban-based program planners were completely unaware of the reality of their rural setting. "The people who make up our requirements have probably never been to the Sierra. If we ask them a question about how to provide better services for the villagers, they don't have the slightest idea what we are talking about". The pasante program in Mexico was initiated with the hope that those who worked and lived in a rural setting for a year would want to stay there longer, but this has rarely happened [13]. The villagers of Amotepec do not appreciate the transient nature of their 'doctor' (as they call him). However, far more frustrating for the villagers is the pasante's inability to permanently cure them of recurring ailments. Examples of villagers' dissatisfaction in this regard include the following. "I was treated at the clinic for rheumatism, but a month later it was bad again. I think the doctor doesn't know what he's doing". "The doctor couldn't cure my diarrhea, but herbs quickly did. He is very ignorant of herbs". "He [the pasante] couldn't even do an injection properly. He put the needle right in the middle of my sore, and made it ten times worse". "The doctor doesn't know anything about medicine. He just went to secondary school and a few more years after that. The only thing he knows how to do is drink, and he doesn't do that very well". H E A L T H IN T H E LARGER C O N T E X T

The frustrations experienced by the pasante should

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be viewed in the context of rural Mexico. Health indices reveal the impoverished conditions under which most rural people live. For example, children under the age of 5 are approximately twice as likely to be malnourished as their urban counterparts [14]. Significantly, no evidence suggests that their nutritional status has improved in recent years, and in fact it may have worsened [15]. Oaxaca has long been among Mexico's poorest states [16], and it has the highest general mortality rate in the nation [17]. The health of the rural population reflects its disadvantaged position compared with the urban sector [18], despite the fact that vast numbers of urban residents are equally as poor and unhealthy as the rural populace [19]. Data concerning pre-school malnutrition and clinic diagnoses in Amotepec show that this village resembles other Oaxaca villages in its health indices. The C O P L A M A R program promises to address and improve the injustices long experienced by the 'marginal and depressed' rural sector, and also promises to deliver the long overdue constitutional guarantee of health to the rural population. These promises are at best only partially fulfilled, while at the same time certain benefits are accruing to the urban political and economic elites. THE COPLAMAR CLINIC IN AMOTEPEC

Federal legislation states that the new COP L A M A R health clinics are to provide the following services 'free of charge': general outpatient consultations, pharmaceuticals, mother-infant care and family planning, health education, nutritional information, sanitation promotion, immunizations and control of communicable diseases [12]. The curative and preventive [20] services were differentially pursued in the Amotepec clinic. As for curative medicine, 2889 patient visits were recorded during the clinic's first 32 months, and pharmaceuticals were dispensed to nearly all patients [21]. The most common ailments presented to the clinic pasantes were the classic 'diseases of poverty', the gastro-intestinal and diarrheal ailments and upper respiratory diseases, which were 58.3% of the 2889 patient visits (see Table 1). The remaining 41.7% of all patient visits involved a wide variety of diagnoses, of which the most common were (listed in descending frequency): rheumatoid arthritis, diabetes, scabies, back pain, dental caries, skin ailments (various), epilepsy and many other miscellaneous injuries and afflictions [22]. Table 1 also reflects the persistence of gastrointestinal and upper respiratory diseases in Amotepec, accounting for between 50 and 63.6% of all the diagnoses made at the Amotepec clinic during the periods analyzed for 1979, 1980 and 1981. Furthermore, despite the efforts of the pasantes, these ailments do not appear to be decreasing, but rather account for a slightly increasing percentage of patient diagnoses over this 3-year period. With the important exception of occasional vaccination campaigns for immunizing children, most aspects of C O P L A M A R ' s preventive programs were virtually ignored by the pasantes in Amotepec [23].

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KENYON RAINIER STEBBINS Table 1. Gastro-intestinal and upper respiratory ailments as a percentage of all diagnoses made at the Amotepec C O P L A M A R clinic during portions of 1979, 1980 and 1981"

Sept.-Dec. 1979 % of total Sept. Oct. 1980 % of total Sept. Oct. 1981 % of total Combined totals for all three periods above % of total

Total diagnoses

Gastro-intestinal diagnoses

Upper respiratory diagnoses

Gastro-intestinal and upper respiratory diagnoses combined

158 100.0 179 100.0 184 100.0

42 26.6 62 34.6 73 39.7

37 23.4 46 25.7 44 23.9

79 50.0 108 60.3 117 63.6

521 100.0

177 34.0

127 24.3

304 58.3

*Figures reported here are based on author's analysis of pasante's diagnoses at the Amotepec C O P L A M A R clinic.

The other preventive health measures were dealt with as follows. (1) Health education was intended to involve frequent community-wide talks and campaigns. The pasantes in Amotepec ignored these activities, but did occasionally speak to classrooms of school children, despite skepticism about their abilities to understand Spanish. (2) Nutritional information also was rarely provided by the pasantes, even though undernutrition was widespread in the village, according to the pasantes. Between September 1981 and April 1982, the clinic personnel in Amotepec weighed 149 children who came to the clinic for whatever reason (even if only to accompany a family member). Their weight was plotted against their age, and their degree of malnutrition was recorded. Of the 149 children weighed, 42.3% (n =63) were found to be first-degree undernourished, 21.5% (n = 32) were second-degree undernourished, and 4.3% (n = 6 ) were third-degree undernourished. 31.5% (n =47) were found to be adequately nourished. Despite the finding that 68.5% of Amotepec's children under the age of 5 were undernourished (a figure not greatly different from those reported for rural Mexico in general--see Table 2), almost nothing was being done about it through the C O P L A M A R clinic. Inasmuch as most Amotepec residents own inadequate parcels of poor quality land, and have limited cash resources, it is unclear what they would do if they w e r e informed of what their diet lacks. They were certainly well aware of the shortage of corn (which along with beans comprises the bulk of their

diet), and conveyed great resentment toward the federal government for not supplying them with more corn through the local CONASUPO outlet [25]. In Amotepec, repeated attempts by the municipal authorities to increase their weekly shipment of CONASUPO (government subsidized) corn were unsuccessful. So scarce was the corn in Amotepec during the last several months of my fieldwork that weekly rations had to be instituted to ensure that all families were guaranteed s o m e CONASUPO corn. (This period does not represent an unusually poor harvest in Amotepec.) The situation dramatically worsened a few months after I left Amotepec, when the federal government's 'austerity program' resulted in the Amotepec weekly ration being cut from 25 kilos per family to 15 kilos per family. (3) Sanitation promotion was similarly neglected by the C O P L A M A R clinic in Amotepec. The pasante rarely went beyond an occasional reprimand of a patient whose hands or feet were dirty. One enlightening illustration of the pasante's lack of interest in sanitation promotion occurred in late March 1982, when the clinic supervisors began to seriously pressure the pasante to conduct a village-wide census (which was to include information on how to promote sanitation in Amotepe'c). The pasante had successfully stalled his supervisors for months, until a time when the village authorities were conducting their own census. When the supervisors learned that the pasante could complete his own census obligations by merely adding a few items regarding sanitation promotion [26] to the authorities' census,

Table 2. Undernutrition among pre-school children in Amotepec as compared to rural pre-school children nationally

Nutritional status First-degree undernourished (10-25% below desirable weight) Second-degree undernourished (25-40% below desirable weight) Third-degree undernourished (over 40% below desirable weight) Total undernourished Total adequately nourished

Amotepec pre-school children (ages 0-5)

Rural Mexican pre-school children (ages 0-5) [24]

42.3%

42%

21.5

II

4.0 67.8% 32.2%

2 55% 45%

Curative medicine, preventive medicine and health status they agreed to allow him to do so, under the condition that the pasante was not to accompany the census team, because his responsibilities were with the clinic and its potential patients. However, as soon as the supervisors left Amotepec, the pasante left the clinic and joined the census team on which he had a trusted confidant. It soon became apparent that the pasante's interests had very little to do with the well-being of the villagers of Amotepec. Rather than concerning himself with promoting sanitation improvements, the pasante was attempting to build community support for his tenuous position vis-?t-vis his supervisors, who had earlier walked through the village asking people about complaints they had received. Accordingly, at each house (except those where the occupants were known to be unsympathetic to him), the pasante would have his confidant tell the family (in Chinantec) to speak favorably of the pasante if ever questioned by any supervisors. The pasante did this in an attempt to cover up numerous instances of insensitive and unprofessional conduct (primarly drunkenness and absenteeism). Amotepec residents complained especially about the pasante's absenteeism. During his first year at the Amotepec clinic he was out of the village more than he was in it, despite regulations requiring him to be working in the clinic at least 23 days out of each month. His public drunkenness was also widely disliked [27]. There were numerous occasions when he was in the village, but not at the clinic, because he was drinking, or hung over. It is not uncommon to hear similar reports about other pasantes in Mexico. On the other hand, I have heard glowing reports about sincere and dedicated pasantes [28], and believe that the first full-time pasante in Amotepec (who finished his year of service shortly after I began my fieldwork, but returned to the village for visits) was very conscientious about his duties and obligations to the people he was there to serve [29]. FACTORS AFFECTINGHEALTH STATUS Analysis of illness and disease involves much more than evaluating the performance of a health clinic and its personnel. Health status has long been associated with environmental conditions and nutrition. Declines in morbidity and mortality in 18th and 19th century England and Wales, for example, have been shown to be best attributed to two important changes in the environment: improved nutrition and hygienic advancements (especially improved water supplies and sewage disposal) [30]. Medical measures were found to have little, if any, association with the improved health conditions of the population. Environmental conditions such as nutritional status and sanitation mechanisms, so important in influencing illness and disease, are best understood by examining the political and economic contexts in which they are found. Laurell, a Mexican anthropologist who has studied disease and underdevelopment, reports that "the economic structure and the social relations of production and exchange present in a society, and not the biological phenomena by themselves, d e t e r m i n e . . , the type of pathol-

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o g y . . , afflicting people" in underdeveloped nations such as Mexico [31]. The C O P L A M A R program recognizes the importance of public health measures such as improved nutrition and environmental sanitation, at least in theory [32], and even attempts to provide its pasantes with (albeit brief) specialized training in preventive medicine. In practice, however, preventive health and public health services in Amotepec are largely ignored. Clinic pasantes did almost nothing along these lines, as reflected in the examples (above) of the pasante's disinterest in providing nutrition information and promoting sanitation measures during the village census. The clinic supervisors did not encourage (or demand of) them to pursue these matters, most likely because their superiors (the C O P L A M A R bureaucrats) were not emphasizing these aspects of health delivery. Accordingly, the various nationallydetermined C O P L A M A R health services were differentially implemented at the local level, with the end result being that certain of them were all but non-existent. Certainly, the C O P L A M A R clinic cannot be charged with all the blame for Amotepec's conditions. Most of rural Mexico's unhealthy conditions existed long before C O P L A M A R was created. For example, Amotepec's piped water system (of questionable purity) was installed in 1973. And Amotepec's requests for sewage drainage systems have gone across bureaucrats' desks for years, and remain unmet. With each new presidential regime in Mexico there is considerable reshuffling of administrative personnel within the bureaucracy. There is also great competition among bureaucrats for power, prestige and resources [33]. However, while the acronyms and agencies may change, conditions of inequality often remain unaffected. Meanwhile, the kinds of illnesses and diseases most prevalent in Amotepec are predisposed to persist, given the conditions of poverty (especially the poor food intake and inadequate sanitation services). In addition, Amotepecans are in many respects ignorant of the role which microbes play in disease causation, and thus have unreasonable expectations of physicians' abilities to cure their ailments. The inadequate education provided for Amotepecans is yet another example of the national elites' lack of commitment to improving the lot of the rural poor [34]. NATIONAL LEVEL INFLUENCES Given the widespread recognition of the importance of preventive medical measures among health planners, especially for the poor sectors in underdeveloped countries, it is instructive to ask why such programs are de-emphasized in favor of curative medicine. The answers to this question all relate to the society's more powerful sector wishing to preserve its privileged position vis-a-vis less powerful sectors. Several vested interests within the Mexican bureaucracy stand to benefit from C O P L A M A R ' s curative health emphasis, including the medical establishment, pharmaceutical interests and the nation's political and economic elites. The medical establishment in Mexico, like most in the world, has a predominantly curative orientation. Mexico's medical schools em-

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phasize hospital-based training, and graduate far more physicians than nurses or any other nonphysician personnel [35]. Medical education in Mexico pays very little attention to community orientation or preventive medical measures, and "rarely takes into account the promotion and preservation of health" [35, p. 91]. The C O P L A M A R program's attempt to provide training in preventive medicine for its pasantes is recognition of this fact. Mexico does have schools of public health. However, their numbers of graduates are infinitesimal when compared to the thousands of physicians graduated from Mexico's medical schools annually, and they are therefore unable to significantly benefit the nation's population in need of their services. For example, between 1967 and 1974, Mexico's School of Public Health had graduated only 438 people [36]. Mexico's medical schools, by contrast, currently graduate approx. 7000 physicians annually [37]. Moreover, Mexico's health care orientation is "highly dominated by the influence of the drug and medical supplies industries" [38]. In fact, a 1973 survey on health research in Mexico showed that only 4.3% of the research projects were in the field of public health, while most research was clinically based and mostly sponsored by drug companies [39]. While the kind of curative medical intervention which has occurred in rural Mexico recently largely ignores the problems of unsanitary living conditions and inadequate diet, it may be viewed as serving to preserve the priviliged position of Mexico's elite ruling class [1]. The PRI government* utilizes powerful rhetoric in pointing to C O P L A M A R ' s 2105 new clinics as evidence of having at long last brought to 10 million rural Mexicans their inherent right to health. Such rhetoric not only serves to inform the rural sector that their government has not forgotten them; it also serves to suggest to the nation as a whole that the government is correcting the injustices which the rural poor have too long suffered, and that they now have physicians and even hospitals 'readily available' to them, 'free of charge'. Such powerful rhetoric which proclaims the benevolence of the State could conceivably be influential in terms of public support for any repressive actions which the State might deem necessary to quell any rural 'unrest' [40]. Thus, the 2105 C O P L A M A R clinics, while highly 'visible' to the public (unlike many preventive health measures), have the advantage of being able to appear to be providing health benefits while not necessarily actually doing so [41]. The favorable appearance of health care portrayed by the government may be quite different from the actual practice of the health care services. The example of 'readily available' physicians and hospitals is instructive. C O P L A M A R plans call for each health clinic to be within a 1 hour walk of the 'covered' population, yet nearly half of the Amotepec clinic's 'coverage' lives farther away, up to 2½ hours' walk from the clinic over very rugged mountain trails. Similarly, the C O P L A M A R plans call for the cov-

*The Partido Revolucionario Institucional (or Party of Institutionalized Revolution) has ruled Mexico for decades.

ered population to not be more than 3 hours' travel time from the referral hospital. However, residents of Amotepec are 8 hours' bus ride away from their referral hospital in Tlacolula (involving changing buses in Oaxaca City). Despite leaving Amotepec at 7 a.m., the bus arrives in Oaxaca too late in the afternoon to be able to transfer to a Tlacolula bus and reach the hospital before it closes for the day. Further complicating referrals to the hospital is the requirement that all patients must first be seen by their rural clinic's pasante. Thus, if a resident of Amotepec needs medical attention while in Tlacolula or Oaxaca, he or she is required to go back to Amotepec to obtain permission to be admitted into the Tlacolula hospital. In the not uncommon event that the pasante is not in the village, the bilingual auxiliary is not able to authorize a referral [42]. Also of interest is the requirement that all persons covered by the C O P L A M A R clinics [which are largely run by IMSS (the Mexican Social Security Institute, by far the highest quality public health provider in Mexico)] may not utilize the IMSS hospitals (such as the large one "in Oaxaca City), but may only go to I M S S 4 2 O P L A M A R hospitals. This requirement is consonant with Kreisler's analysis of the politics of health care policy in Mexico [1, p. 161], inasmuch as the politically powerful constituency served by the IMSS health resources would likely deeply resent sharing their facilities with lower-class peasants. SECOND-CLASS MEXICANS

The villagers of Amotepec are frustrated and feel like second-class Mexicans in many respects. Like great numbers of 'rural' Mexicans, they are very familiar with many aspects of urban life [43], including the provision of health services. Many of them travel frequently to urban areas where they see a wealthier lifestyle than their own, and some have even spent weeks in Acapulco as maids for wealthy Mexico City families. They also hear their government proclaim that the rural sector is now much better off than ever before. Despite numerous governmentsponsored changes in the village in the past decade (including the arrival of the vehicular road, a new school, electricity, piped water, a CONASUPO store and the C O P L A M A R clinic), they feel that their situation has not sufficiently improved. Their perceptions are not unfounded. Despite Mexico's phenomenal economic growth during the 1970s, government figures show that economic conditions in the rural sector improved at a very slow rate, if at all. During the same period, however, the upper and middle classes enjoyed marked economic improvement. Thus, even if the rural sector during the 1970s did experience some absolute gains, their condition became relatively more deeply impoverished vis-a-vis the urban upper and middle classes [15, p. 33). The health clinic under study here (one of 2105 such new clinics in rural Mexico) is the latest in a long series of efforts on the part of the Mexican government to assimilate (or 'Mexicanize') the ethnic populations throughout the republic. In the case of the health clinic, the goal of assimilation is quite subtle

Curative medicine, preventive medicine and health status and almost coincidental to the stated goals of the health program. However, the clinic reflects the national culture, the national worldview, and biomedical understandings of health and disease, and shows virtually no knowledge of, interest in, or sensitivity to the Chinantec culture and worldview. With a long history of being in a disadvantaged position when interacting with more powerful outsiders [44], the Chinantec Indians of Amotepec feel powerless to effectively challenge the system which frustrates them. The pasante in Amotepec is a convenient, immediately visible representative of the very system which they dislike, and they are quick to fault him for "not doing what doctors are supposed to do--cure people!" But the pasante, while a convenient scapegoat, is merely the most obvious representative of a much larger social system in which the rural poor have little power. As one health planner put it, "Is it reasonable to expect individuals [such as pasantes] to fulfill socially useful roles when there exists no context of social responsibility and community service within which to do so, but rather one of ever-increasing potential material reward for the upwardly mobile?" [45]. UNREALISTIC EXPECTATIONS

The villagers of Amotepec want to be free of their medical ailments, and they blame the pasante for the persistence of their illnesses. However, it is unrealistic to expect any pasante to significantly improve the health status of rural Mexicans, because the proximate causes of their chronic ailments are rooted in an unsanitary environment, inadequate nutrition and insufficient education, conditions which go hand in hand with poverty. Rather than fault the pasantes for unsatisfactory performance, this paper suggests that the greater responsibility lies within the structural aspects of the Mexican political economy, in which is embedded the health planners and institutions which train pasantes to work primarily in highly technical urban settings, with almost no preparation in preventive health measures or low-technology health care delivery in cross-cultural rural situations. Unfortunately for the poor sector, it appears that the political, economic and social interests of the elites combine to interfere with meeting the basic health needs of the many [46]. "The Mexican health care system is built to serve the needs of the population in reverse: the greater the need, the less is the care" [47]. Stated another way, "The major obstacles to more just and efficient health delivery systems are not the usually cited ones of limited resources, poor communications, or lack of technical knowledge and data, but rather social systems that fail to place high value on the health care needs of rural peasants" [42, p. 411]. As a result of increased petroleum revenues in the 1970s, the Mexican government has invested enormous sums of money in its 2105 new C O P L A M A R clinics. Rural Mexicans such as those in Amotepec derive some benefits from their C O P L A M A R clinic (especially in the form of emergency first-aid and vaccinations). However, C O P L A M A R ' s investment in rural Mexico also benefits Mexico's urban-based elites. For example, the 1978-1982 C O P L A M A R

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budget for the state of Oaxaca clearly demonstrates the fact that the C O P L A M A R agency is primarily concerned with resource extraction (rather than health services). While only 7.4% of the budget was targeted for 'health', 79.2% was stipulated for the following sectors: agriculture and timber (33.8%), industry (27.1%) and communications and transportation (18.3%) [12]. CONCLUSIONS

Improving the health status of rural Mexicans requires significant redistribution of resources (especially food-related) and improved sanitary conditions (especially pure water, and adequate sewage and refuse disposal). These kinds of structural changes involve concerns outside of the existing medical establishment, including education, land redistribution programs, water agencies, roads, agricultural extension services and financial assistance, all of which are slighted by the C O P L A M A R program. Curative medical services such as those provided by the C O P L A M A R clinic in Amotepec treat the symptoms of many recurring ailments, but do almost nothing about the unsanitary environmental conditions and undernutrition which contribute so heavily to the onset of such ailments. Accordingly, patients treated at the Amotepec clinic for chronic ailments are often only temporarily relieved of their symptoms. By treating symptoms, rather than causes, the C O P L A M A R clinic in Amotepec is leaving intact the very conditions which need to be addressed if the villagers' health status is to be significantly improved. Amotepecans' desires for a more competent doctor and more effective pharmaceuticals should not be taken as a preference for curative medical services over preventive services. Instead, these sentiments reflect the villagers' particular understandings of the potential healing powers of physicians and pharmaceuticals, as well as their lack of awareness of the importance of preventive measures. From the perspective of the villagers, the distinction between curative and preventive services is unimportant. What is important to them is to be permanently cured of their ailments, rather than temporarily relieved of the symptoms. In dependent capitalist economies such as Mexico's, the conflicts between class interests prevent the lower class from enjoying a representative share of the country's health-related resources. While the 1917 constitution declares that the Mexican state is obligated to provide for the well-being (including health services) of its entire population, the implementation of these responsibilities has always been left to the political leadership [1, p. 87]. Many political scientists who have studied the distribution of health resources in Mexico conclude that the State often distributes medical care services when they are necessary to serve as political mediators between the state and various interest groups [48]. The more politically powerful (or threatening) groups get the most attention [49]. Until such time as the rural sector in Mexico organizes to bring significant pressure to bear on their government (which has a history of co-opting or repressing potentially threatening sectors), it is unlikely that their

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genuine health needs will be effectively addressed. Despite recent gestures on the part o f the de la M a d r i d government which suggest an increasing democratization o f the P R I government (such as allowing more opposition political parties to participate in elections), there remains in Mexico powerful forces which will likely maintain the status quo for years to come [50].

I1. Stebbins K. Second-class Mexicans: state penetration and its impact on health status and health services in a highland Chinantec municipio in Oaxaca. Ph.D. dissertation, Michigan State University, 1984. 12. COPLAMAR documents cited in this paper include: Primera reuni6n anual de anhlisis del desarrollo del programa IMSS~COPLAMAR. Unidades M6dicas Rurales. Instituto Mexicano del Seguro Social, Mexico City, 1981;~,and Programas integrados, Vol. 22, Region Mixteca de Oaxaca. Presidencia de la Republica, Acknowledgements--The author is grateful to Arthur J. Mexico City, 1978. Rubel, John H. Johnsen, Hans Baer and Merrill Singer for 13. Collado Ard6n R. M6dicos y estructura social. Fondo helpful comments on an earlier, shorter draft of this paper de Cultura Econ6mica, Mexico City, 1976. which was presented at a session on Medical Anthropology 14. Aylward F. and Jul M. Protein and Nutritional Policy at the annual meetings of the American Anthropological in Low-lncorne Countries, p. 25. Wiley & Sons, New Association, Chicago, November 1983. The author is also York, 1975. grateful to Charles Leslie and several anonymous reviewers 15. Grindle M. S. Official interpretations of rural underfor their helpful comments. Any errors are the author's development: Mexico in the 1970s. University of Caliresponsibility. fornia at San Diego working paper No. 20, San Diego, 1981. 16. Whetten N. L. Rural Mexico. University of Chicago REFERENCES Press, Chicago, 1948; Wilkie [8]. l. Kreisler R. Politics and health care in the republic of -,,17. COPLAMAR [12, 1981, p. 129]. Mexico: a study of the dynamics of public policy. Ph.D. 18. Lopez Acufia D. La salud desigual en Mexico. Siglo XXI Editores, Mexico City, 1980. dissertation, Columbia University, 1981. 2. Musselwhite J. C. Public policy, development, and the 19. Chfi.vez A. NutriciSn: problemas y alternatives. In Mkxico, hoy (Edited by Gonzales Casanova P. and poor: health policy in Mexico. Ph.D. dissertation, Johns Florescano E.), Siglo XXI Editores, Mexico City, 1982. Hopkins University, 1981. 3. Lopez Acufia D. Health services in Mexico. J. publ. Hlth 20. Family planning is not generally considered to be a preventive health measure. Its operations are reported Policy 1, 90, 1980. here for the sake of completeness. Family planning 4. Preventive health services is used here in a broad sense, activities in the Amotepec clinic consisted of 13 women to include not only such things as vaccination camhaving received birth control pills from the pasante paigns but also nutrition assistance, environmental saniduring the clinic's first 212 years. Most of these women tation, and access to adequate productive agricultural did not apply for more pills when their initial months' land. supply ran out. 5. Examination of Mexico's dependent capitalist economy is beyond the scope of this paper. For elaboration of 21. It should be noted that, in addition to the COPLAMAR clinic, Amotepecans seek treatment in an eclectic and analysis of the Mexican political economy, derived from pragmatic way from a variety of other treatment opdependency theory, the reader is referred to Cockcroft tions, many of which rely heavily on herbal medicines, J. Mexico. Monthly Review Press, New York, 1983; and including home remedies, five local traditional healers Hodges D. and Gandy R. Mexico, 1910-1982: Reform (curanderos), and extra-local curanderos and physior Revolution? Zed Press, London, 1983. cians. 6. Kreisler [1]; Musselwhite [2]; Wilson R. The corporatist welfare state: social security and development in 22. People who came to the Amotepec clinic were generally young (54% were under age 16). This is explained by the Mexico. Ph.D. dissertation, Yale University, 1981. youthfulness of the general population in Amotepec 7. COPLAMAR refers to the Coordinacion General del (and in Mexico in general). For example, males under Plan Nacional de Zonas Deprimidas y Grupos Marage 20 comprise 59.4% of the general male population ginados, or the General Coordinating Board for the in Amotepec, and comprise 59.5% of the males who National Plan [to aid] Depressed Zones and Marginal visited the clinic. Similarly, females under age 20 comGroups. The COPLAMAR agency was significantly prise 56.9% of the general female population in Amrestructured during the transition from Lopez Portillo's otepec, and comprise 55.8% of the females to visit the presidency (197(~1982) to de la Madrid's. The health clinic. As for gender, the patients seen at the Amotepec services program remains intact, but with a seriously clinic are almost equally divided between males (50.5%) reduced budget, due to inflation. and females (49.5%). 8. Wilkie J. The Mexican Revolution: Federal Expenditures and Social Change since 1910. University of California 23. Explanation for the pasantes' disinterest in most preventive health measures is two-fold: (l) they were not Press, Berkeley, 1970. personally interested in pursuing these matters, largely 9. The views presented here are based on observations of because they felt the villagers would not be receptive to this particular clinic in Amotepec, and may differ from them. (2) With the exception of the vaccination camother COPLAMAR clinics. However, clinic supervisors paigns, the pasantes were not sufficiently pressured by and COPLAMAR officials in Oaxaca City suggest that their supervisors to carry them out. Villagers did not the circumstances of the Amotepec clinic are generally complain about not being provided with these services representative of other COPLAMAR clinics. because they did not know that the pasante was sup10. The citizens of Amotepec have struggled long and hard posed to be providing them. to obtain most of the services which they now have, including electricity, 'potable' water, a road into the 24. Daschbach C. C. and Green K. E. Medicine in Mexico: nutrition. Ariz. Med. 35, 543, 1978. village, a COPLAMAR store and a school. Based on decades of experiences while pursuing these efforts, 25. The CONASUPO outlets in Mexico provide basic food staples at reduced prices. For a detailed analysis of the villagers widely agree that any improvement in AmCONASUPO, see Grindle M. S. Bureaucrats, Poliotepec which requires government participation is virtuticians, and Peasants in Mexico: A Case Stud)' in Public ally impossible to obtain without repeated pestering, Policy. University of California Press, Berkeley, 1977. cajoling, reminding, and bribing of the proper bureaucrats. 26, The items regarding sanitation promotion which were

Curative medicine, preventive medicine and health status

27.

28.

29.

30.

31.

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supposed to be shared with every household in Amlife expectancy at birth among developing countries in otepec were as follows: (1) "Try to dampen your [dirt] the 1970-1975 period show close association with social floors before you sweep, in order to keep the dust down, factors, such as literacy and school enrollment, and also because dust causes throat and stomach problems". (2) with water supply and sanitation. These two groups of "Try to burn or bury your trash" [no explanation was factors explain statistically almost 90 percent of the given]. (3) "Pen up your animals so that the town will change. Levels of health expenditure, investment in look nice for Easter week". health facilities and personnel, and average income per It should be noted that the Chinantec drink a great deal capita add little to the statistical explanation" Grosse themselves, and Amotepecans recognize that they also R. N. and Harkavy O. The role of health in develoccasionally miss work because of hangovers. However, opment. Soc. Sci. Med. 14C, 168, 1980. they want their 'doctor' to be sober during working 32. COPLAMAR [12, 1981, pp. 60, 61, 101, 125]. hours, and are openly frustrated when he is not. While 33. Smith P. H. Labyrinths o f Power: Political Recruitment this may be seen as a double standard, Amotepecans in Twentieth-Century Mexico. Princeton University feel they have a right to expect sobriety from the Press, Princeton, N.J., 1979. pasante, because they feel that they deserve reliable 34. The fact that rural Mexicans like those in Amotepec health services during regular clinic hours. It should also equate physicians with improved health is also a be noted that the first pasante in Amotepec was much reflection of the medical establishment's portrayal of more conscientious than his successor, and was never themselves as such, and their powerful influence over reported to have a drinking problem. the dissemination of such information. See Illich I. Medical Nemisis. Bantam Books, New York, 1976. During the time of my fieldwork I learned that three pasantes and one nurse lost their lives when the vehicle .~5. Lopez Acufia D. Health services in Mexico. J. publ. Hlth in which they were riding to their rural health post was Policy 1, 88-90, 1980. In 1971, Mexico had 102,673 health workers, of which 36% were physicians, 18% swept away in a raging river which they were attempting to cross. nurses, 3% specialized nurses, 32% assistant nurses and 11% other. "This shows the remarkable imbalance of I do not speculate here as to why one pasante was more health workers and the hegemony of physicians in the dedicated than the other. I do know that Amotepec's current pattern of services. The accepted worldwide dedicated pasante was far more respected as a person than the other pasante. However, despite their great ratio of three nurses per one physician is not adhered to in Mexico... Circa 1976, Mexico had 8 physicians, 4.6 differences in terms of dedication and sincerity, the villagers made little distinction between them as profesnurses, and 8.2 assistant nurses per 10,000 inhabitants, sional medical practitioners. Both were seen as young, whereas the United States had 16.3, 44.% and 69.4, inexperienced, second-class doctors who were not good respectively" [3, pp. 89-90]. enough to hold jobs in an urban setting where their 36. Cafiedo L. Rural health care in Mexico? Science 185, patients would be far more sophisticated and insistent 1132, 1974. upon quality care. While these critical observations of 37. Riding A. Mexicans lack health care, but doctors can't individual pasantes are perhaps not essential to the find work. New York Times 9 March, A6, 1979. more general analysis and critique of the policies and 38. Lopez Acufia D. Health services in Mexico. J.publ. Hlth practices of the Mexican health establishment, they are Policy 1, 88, 1980. included here to provide the reader with a view of 39. Lopez Acufia D. Salud y seguridad social: problemas problems that are hardly unique to Amotepec, and to recientes y alternativas. In Mbxico, hoy (Edited by provide the reader with a sense of the ineffectiveness of Gonzales Casanova P. and Florescano E.). Siglo XXI the clinic supervisors. Editores, Mexico City, 1982. McKeown T. R., Brown G. and Record R. G. An 40. Elling R. Political economy, cultural hegemony, and interpretation of the modern rise of population in mixes of traditional and modern medicine. Soc. Sci. Europe. Popul. Stud. 26, 349, 1972. These same authors Med. 15A, 94, 1981. also write (p. 356):"In the case of epidemic infec41. Wilson R. R. The corporatist welfare state: social t i o n s . . , infection rates are largely independent of nutrisecurity and development in Mexico. Ph.D. dissertation, tion; nevertheless, survival rates among those infected Yale University, 1981. are substantially influenced by nutritional state (unless 42. Gish points out that referral systems rarely function the infection is particularly virulent) . . . . In the case of effectively in developing countries. Gish O. Resource chronic endemic infections such as tuberculosis, the allocation, equality of access, and health. Int. J. Hlth disease is much more common among the poor, and Serv. 3, 406, 1973. while this may be partly due to exposure, it is also 43. Uzzell D. Ethnography of migration: breaking out of largely attributable to nutritional state. [Thus,] a subthe bi-polar myth. Rice Univ. Stud. 62, 1976. stantial increase in food supplies would lower mortality, 44. For a fascinating discussion of resettlement programs from both epidemic and endemic infections as well as forced upon the highland Chinantec by representatives from malnutrition and starvation...". Others have of the Spanish Crown in the early 1600s, see Cline made this point. Gish, for example, writes: "The great H. F. Civil congregations of the Indians in New Spain, advances in the state of health to be seen in the now 1598-1606. Hisp. Am. Hist. Rev. 29, 1949, and Cline industrialized countries of the world have stemmed H. F. Civil congregations of the western Chinantla, New largely from other factors than the provision of curative Spain, 1599-1603. The Americas 12, 1955. medical services. Access to clean water, generally im- 45. England R. More myths in international health planproved hygiene, increased incomes for lower social ning. Am. J. publ. Hlth 68, 157, 1978. England concludes classes leading to better nutrition, improved educational that it is a myth to think that "governments are possibilities, better housing, etc., all made an important universally committed to improving the health of their contribution to improved standards of health during the populations and that the health planner operates simply late nineteenth and early twentieth centuries." Gish O. as a technical expert within such a context of commitAlternative approaches to health planning. Carnets ment. In many countries, few things could be farther Enfance 33, 32-33, 1976. from the truth. Technical knowledge is one thing--and Laurell A. C. et al. Disease and rural development: a an essential one--but without political will it is of little sociological analysis of morbidity in two Mexican viluse. Where there is presently no such political will lages. Int. J. Hlth Serv. 7, 402, 1977. Also, Grosse and because governments represent the more powerful and Harkavy note that "analysis of the changes in levels of more healthy rather than the less powerful and less

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healthy, then development will occur only through demands by the latter upon the former" (p. 158). 46. Horn J. The Mexican revolution and health care, or the health of the Mexican revolution. Lat. Am. Persp. 39, No. 4, 1983. 47. Lopez Acufia D. Health services in Mexico. J. publ. Hlth Policy 1, 89, 1980. 48. Kreisler [1]; Musselwhite [2]; Wilson [4~; Spaulding R. J. Medical care, social security, and inequality: the case of Mexico. Paper presented at the Latin American Studies Association Meeting, Pittsburgh, 1979.

49. Mexico's two largest social security institutions, the IMSS and the ISSSTE (the Institute of Social Security and Services for the Workers of the State) were created in response to effectively organized demands on the part of unionized industrial workers (in the case of IMSS, 1943) and government workers (in the case of ISSSTE, 1960). 50. While Mexico's current financial crisis does not bode well for C O P L A M A R ' s rural health program, I have been reliably informed that Amotepec's clinic continues to function as of March 1985.