Room for a view
Chiapas: a state of health in a state of siege

CMAJ 1999;160:538-9

© 1999 Canadian Medical Association

Mexico's southernmost state is undergoing a "low-intensity war." This armed conflict between the government forces of the PRI (Institutional Revolutionary Party) and the indigenous rebels (named "Zapatistas" after Mexico's famed father of the revolution, Emilio Zapata) erupted officially Jan. 1, 1994 -- as it happens, the same day that the North American Free Trade Agreement came into effect. The peace accords of San Andres, signed by both the government and the Zapatista Army of National Liberation (EZLN) in 1996, ostensibly granted the indigenous people the right to self-determination. This has not been respected; already, three of the newly declared autonomous regions have been dismantled by the government, with disastrous consequences for the local population. The death toll mounts, as does the number of displaced people, in parallel with increases in government troops and state security personnel.

As a student of the medical sciences, I have always felt passionately about international health, an interest I pursued through campus groups and graduate-level research in tropical medicine. I studied in Cuba at the Universidad de la Havana in 1995, and the following summer I worked in São Paulo, Brazil. I became fascinated by the role of international economics and fiscal modelling in determining who on this planet has access to health care and who does not. Mexico seemed to present another model to explore in the summer of 1998.

Jarred by the three-and-a-half hour ride on the back of a flatbed truck, we arrived at the Tzeltal municipality of Francisco Gomez, one of the 5 aguascalientes or autonomous zone capitals that serve as a base for meetings, debates and festivities for the 100 or so communities nearby. A multitude of foreign observers come to the region as anti-assassination devices, reminding the military that their every move is being documented by international eyes and telephoto lenses. This seems to deter the blatant violence that has been inflicted on communities sympathetic to or allied with the EZLN, but seems to have little effect on the inevitable migration roadblocks and checkpoints, the incursions of camouflage trucks transporting armed soldiers or the daily intrusions by air from military and police forces. Pro-government paramilitary groups with names like "Peace and Justice" recruit mostly indigenous young men with incentives of money or "a good job in the city" to do the actual killing — as in the pro-Zapatista community of Acteal on Dec. 22, 1997, where 45 people were gunned down while attending mass. Despite our ignorance of the local dialect, it became clear to us after we had settled in to our observation post that tensions were running high and that the people were frightened.

"The women are afraid to collect wood for burning," explained one of 60 health promotors responsible for the well-being of the local inhabitants. "They are afraid of going alone and they no longer bathe or wash clothes in the river." This in reference to the recent surge of assault and rape against the women in the community by on-duty soldiers whose goal it is to intimidate the populace. The town of Francisco Gomez is not unique in being surrounded by newly erected military installations whose presence is continually felt. "Many people suffer from gastritis and ulcers. They suffer from insomnia and have trouble working on the harvest. When there are no observers here, no one sleeps at night." In the local clinic, beside the rapidly depleting stores of cimetidine, was a review article from the British Medical Journal on the effects of torture on civilians.

Unlike other medical posts in the lush mountains of southern Mexico, the clinic in Francisco Gomez is completely under the command of the local people. Before declaring autonomy, indigenous campesinos had no access to health care: even in the state hospitals, physicians' fees surpassed what anyone could afford. Paying for a four-hour truck ride over the unpaved, potholed and sinewy path through the mountains to the nearest hospital in Altamirano is impossible for most, whose sole source of income is selling their corn or coffee harvests at artificially low prices in the local market, competing in vain with the output of local corporations. Rumours abound that it is best to avoid the state hospitals: "You are guaranteed to come out in a body bag if your political alliances are not viewed favourably by the PRI," one community member told me.

Now, in the declared Zapatista territories, the indigenous people exercise more control over their present lives and their future, not least by taking charge of their health. "For generations the government has kept us poor to keep us unhealthy. This way they know that we are helpless. But no longer," explained a young Tzeltal woman waiting to be seen by a health promotor. The modest clinic at Francisco Gomez is one of the few buildings in the area constructed of cement. It includes a pharmacy, where sparse stocks of donated drugs await distribution, and a medical examination room and a dental examination room, both with posters of Che Guevara and Fidel Castro adorning the unpainted walls.

After our second day we were approached by a young man whose index finger had been lacerated by a swing of a machete. It soon became evident that his main concern was whether he would be able to wrap his fingers around his machete once more and return to the field. For the people of Francisco Gomez the most urgent costs of illness and injury are days lost from the harvest and, hence, food from the table. For health promotors, whose responsibilities include accompanying patients to the nearest hospital, the cost is the same. And they have even more to lose: as trusted community leaders, they are the preferred targets of the military.

When the next batch of observers arrived from the city, our sojourn at Francisco Gomez came to a close. Our departure was similar to the arrival. Travelling by night, again we shared a local truck with livestock and with silent men, women and children who were apparent in the darkness only by the shine of their eyes. As our journey out of "the region" progressed, the light of dawn gradually appeared over the gorges and mountains of Chiapas. So did the red bandanas that hid the faces of our travelling companions. I found myself following suit by drawing my baseball cap further down, ostensibly to conceal myself from military personnel. Part of me felt that I did this in solidarity with a strong-willed people asserting their rights. But perhaps another part of me did so out of shame, a feeling that somehow I was an accomplice to injustice by virtue of nationality, trade agreements, politics and ignorance. What was now clear to me, however, was that the most powerful tool that any population requires in bringing about fundamental change to the status quo is sovereign control over their status of health.

Ms. Zakrison is completing studies in paramedicine and in infectious disease.

Tanya Zakrison, BSc(Hon), MHSc

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