The Medicine of Making Community, Even in Death
(Translated from the original chronicle in Spanish)
The sun was beginning its westward migration, a steep path was leading us towards the homes of some of the families of the community of Mathayúwàa/Zilacayota. It was the beginning of May in the Montaña alta region (high mountains) of Guerrero. The rains that would convert the dust into mud were yet to fall, still I stepped cautiously given my little experience in walking in the mountains. I was carrying only a portable ultrasound machine in its pack and a few other pieces of medical equipment. The heavier box of medications gathered through the solidarity of friends and acquaintances was being carried by one of the compañeros of the Community Police. We walked up single file, they went ahead and behind us, with an ease formed by a lifetime of navigating much more difficult roads. Upon arriving, the afternoon breeze cooled our sweat. I laid eyes upon a beautiful adobe house and a well kept garden within which, amongst others, the Amapola flowers colored the scene, silent and crystalized by the nostalgic light of the early evening.
Photo: Piaget Solano
We came upon a woman sitting on the terrace, her gaze apparently lost in the distance. Drawing closer, the compañeros greeted her in Mè'phàà, they let her know that we’d arrived for her consult and we followed her and her daughter into one of the rooms. Once again, the ritual of the physical exam which had been repeated about 20 times that day. The demeanor of the young woman didn’t give away the fever of 38.4 degrees that was burning against the infection in her body or the oxygen saturation of 86% which marked the irruption of the infection into her lungs. I buried the malaise that had been knotting itself into the pit of my stomach since the morning after having seen so many people with the undeniable symptoms of a respiratory infection, many of them severe ones.
Sadness throbbed in the room. Without tears or many words, the woman told us that her husband had died the week before with an illness very similar to hers. She recounted how she had taken care of him in his last moments, he never received medical care. We listened. The compañero who was translating relayed our suggestions, a combination of basic medications, nutrition, recommended postures while resting and teas made of medicinal plants. We left her a few medications, a written list of the recommendations and we walked on towards the next family.
I felt the frustration between my ribs, the anticipation of the void that comes from not knowing how to stop the catastrophe of imposed death, the impotence of not knowing which institution to direct the scream towards. In Mexico, the official norms dictate intensive care for people at the brink of death due to severe respiratory problems. However, in the Montaña, one has to travel 5 hours only to be rejected from a hospital, the closest source of supplemental oxygen which is considered to be a fundamental part of the treatment necessary to, perhaps, survive.
Two weeks had gone by since the beginning of the first cases in the community and prior to our visit, four people had passed away, including one of the xi'ña (spiritual guide). In the day and a half of home visits, we got to know about twenty-four affected families. We didn’t know if there were others who hadn’t requested a consult. I met at least five people who had an oxygen level so low that according to my experience working in an emergency room, I didn’t think that they would make it to the next week without oxygen tanks and a medical team to look after them.
During the hours of the journey back home and the days that came afterwards, I waited for the news with fear and a degree of resignation. A week went by, then another, I was told that no one else had died. I was incredulous. I asked again, specifically about the most severely ill, those who had had an oxygen saturation below eighty. The same answer, there were no more deaths. On par with my joy and relief, a question began gnawing at me. How did they do it?
My training as a physician at university and in hospitals prepared me for many things: making a heart beat again, sewing wounds, treating infections, draining blood that is collapsing a lung, seeing the approaching inevitable death of others and warning of its arrival. And all of this, I do with responsibility, commitment, compassionate and critical consciousness. However, the medicine that I was trained in, now hegemonic, never brought me close to the other forms that exist in the world of naming illnesses, explaining their origin and transmission and how to heal them. It left me without a lot of other knowledge that is necessary to heal.
In my books and clinical rotations, institutional practice guidelines, the most celebrated congresses and conferences in the country, I didn’t get the training necessary in order to sit in front of a woman of the Montaña recently bereaved of her life partner, with a body marked by the social, political and economic injustices of a globalized illness. Before her, the community, the Montaña, far from the monitors, the oxygen tanks, a laboratory, the security of the paradigms that gave me degrees as a doctor and a specialist in emergency medicine, I once again felt the weight of everything I had yet to learn, and unlearn.
The visit to the community wasn’t my first experience in doing healthcare work in an environment very different from the hospitals in which I was trained. Since 2014, I had participated in the Brigada de Salud Comunitaria 43 (Community Health Brigade 43) in Tixtla, Guerrero, a group formed in collaboration with a part of the Community Police of the CRAC-PC in order to provide care to the local population by training health promoters.
At the side of the compañeras and compañeros of the Brigada 43, I witnessed the destructive reach of the severe limitations of the healthcare system and learned to confront them collectively. I met elderly men and women with mobility problems who had to walk over half an hour in the hills to get to the health center where, if they didn’t arrive by a certain time, they were denied the care that they had needed during weeks. In other cases, we gave consults to people who had been charged for a blood pressure check, a supposedly free service. The inhabitants of Tixtla told us that they frequently couldn’t access adequate care because the doctors at their health center refused to refer them to the regional hospital, that they often had to buy medication that was supposed to be covered by their health insurance and that they were mistreated during their medical visits.
Obligated by the absence of state services and the distrust born of generations of bad experiences, I saw how many families went into debt to pay for private care and even then couldn’t access the care that they needed.
One of the first decisions taken by our Brigada was to give free care to everyone, irrespective of their political affiliations. And though it was on a small scale, we also put the following changes into practice: a distinct relationship between the knowledge of doctors trained in State institutions and the territorial knowledge of women and men of the community which was forged across generations, a different dynamic between the science of biomedicine and the science of traditional medicine, and the ability to offer a medical consult and instead of accepting the monetary payment that we were offered in exchange, to ask instead for an act of solidarity with the Brigada’s activities or perhaps an article of food.
Another fundamental aspect of our work was the participation of women. They dedicated their training to serve the community, before, during or after their work at home or in the fields, they recognized themselves as health promoters, one of the greatest strengths of the CRAC-PC. After two years of knowing each other, in a workshop about healing our fears, one of the first health promoters of the Brigada told us how her dream as a young girl had been to become a doctor and how, in a way, she was finally accomplishing it.
All of these experiencies of the Brigada 43 knocked over the supposed truths of the education and healthcare systems in which I’d learned to be a doctor and which had led me to the main objective of identifying illness in a single body and eliminating it. During many years, this is what I considered to be the act of curing. For the same reason, a raw frustration grew every time I found myself in a clinical encounter in which the malaise of my patients needed closer accompaniment, a stronger social network and solutions to deeply economic and social problems for which, not only did I not have the resolution skills, but I had also been taught either directly or indirectly that it wasn’t my problem to think about them. It was in the collective practice of health in Tixtla that I began to understand the healing power that lived in making community, in making a medicine of liberation, of health with territory and not imposed upon territory.
Seeing the illness in the Montaña once again led me to confront the successes and errors of the biomedical model. Before the consults of May, during an entire year, I had seen many people get sick of the same infection that had now anchored itself in the heart of the community. When these people got to my hospital, because of the risk of contagion, they were separated from their families, left alone, except for the contact with the health care workers which could be frequent or non-existent depending on the shortage of personnel. Sometimes, they didn’t eat for days for the lack of someone who could assist them. No one rubbed their backs or helped them change positions in their beds, no one gave them encouraging words. They died alone, far away from their homes, their flowers, the smells of the kitchen, the love that sustained a place for them in the world. It was difficult for me to fathom the loneliness and fear that they were going through. To date, I remember the terror that I saw in the eyes of many.
In the majority of cases, the terrible conditions weren’t a result of the cruelty of those of us who worked in the hospitals and clinics but rather the product of decades long wholly inadequate structuring of healthcare services and an ever intensifying privatization which resulted in us having less and less material and human resources to attend the needs of the population.
In that context, many doctors fell into the normalization of suffering, justifying it with a learned impotence. We questioned and criticized our work conditions, but few of us questioned the type of medicine we were practicing, how it is practiced or why. Few of us questioned our participation in a healthcare model that isn’t focused on healing in its true dimension but rather needs to perpetuate itself as the model that holds the absolute truth, even at the cost of those who seek our help. Few of us turned around with curiosity and humility to look at other traditions of healing and accompanying illness, traditions that we could surely complement the useful aspects of our biomedical practice with.
During my time in the Montaña, the absolute truths of the official health care system fell. In the community that we visited, as in many others of the region, the healthcare system is practically non-existent. The doctor assigned to the healthcare center refused to attend those he perceived to be affected by the illness that was killing young and old. I didn't see him once in the two days that we gave consults, nor did I hear a single positive comment about his relationship with the community.
What I did see abound was family unity and collectivized care. I saw how children, brothers and sisters and wives of the sick, mobilized themselves to learn how to take care of them, nourish them, administer their medications, and sustain them with presence. I witnessed how the organizing efforts of the community government and community police allowed for the home visits without leaving any family who requested care, behind. I also heard about how the rituals for the recently deceased had been carried out despite the risks inherent to that accompaniment. In every moment, there existed the imperative of thinking, feeling and healing as a community, and if that was impossible, to make community even in death.
By the time the first rains fell in the Montaña of Guerrero, the wave of the illness that suffocates had pulled back. Along with the weakness it left in the bodies of those who manifested its symptoms, it also provoked deep losses in the community’s fabric, the absence of those who had carried its memory, of those who had defended it. In June came the Festival of the Mouse, a moment to renew time, there was music and dance in the streets, the rituals weren’t forgotten, the circular walk of life was reaffirmed collectively.
While we moved along the innards of the community once again, this time accompanied by jokes and laughter, I thought about the resilience of its people and its world. Nothing could forgive the historical negligence of the healthcare system in their territory and I didn’t want to fall into romanticizing the suffering it had caused. However, they had left me with another important lesson in how to confront illness together, a severe and necessary contrast to the violence normalized by the healthcare system.
The illness that suffocates, as many others, is devastating the world due to the imbalance which exists in the harmony that maintains life. In order to cure it, we will have to, with curiosity, humility and respect, understand what sustains life in each territory. Will we doctors be able to make community in order to achieve that deep listening?
*Born to a Punjabi family in Montreal, Canada, Mandeep is an organizer and emergency medicine trained physician who has lived, worked and participated in social movements in Mexico over the past decade.