Hot Coffee

Patrick Elliot, MD, MPH, of BWH’s Division of Global Health Equity, contributes this post about his work with Compañeros en Salud México.

Patrick Elliott
Dr. Patrick Elliott, left, and Dr. Enrique Valdespino perform a prenatal ultrasound for a patient in Valdespino's clinic in Reforma. Photo by Balam-ha' Carrillo, Shoot4Change Mexico

A hot cup of coffee is an almost universal invitation to friendship and conversation, and it’s never truer than in the Sierra Madre de Chiapas.  On Mexico’s southern border, Compañeros en Salud México (CES), a sister project of Partners In Health, has been working in several rural, coffee-growing communities to strengthen the healthcare system alongside the state government of Chiapas.  In six rural pueblos in the mountains of Chiapas, the physicians of CES live and work alongside the people of the community.  The lived reality of the community is shared by both patients and our doctors and opens new paths to discoveries, conversations and quite a few hot cups of coffee.

I began work with CES in February 2012, shortly after it officially began operations.  At first, my work largely consisted of assisting in public sector community clinics that CES helps administer, seeing patients alongside the social service physicians who operate the clinics and are the heart of the organization.  The social service physicians (pasantes) are recently-graduated medical students who must complete a year of required service before gaining eligibility for independent practice or entrance into residency.  The pasantes and I would see patients together in the clinic, discuss cases and management options and in the evenings make house calls to patients who were too sick, infirm or who had simply failed to come to clinic during the day.  As night fell across the town, we’d sometimes sit on the clinic roof and watch the stars.  Our patients came from small, poor communities that had not had a doctor or functioning health clinic in years, if ever; and our clinics offered a bit of hope, a dose of novelty and quality medicine.

CES began with the belief that in Mexico, what was lacking was not necessarily economic resources, but rather human ones and the political will to align the existing resources to serve those most in need.  CES founders Hugo Flores, Daniel Palazuelos, and Lindsay Palazuelos saw the opportunity to use the institution of the social service year to do just that.  And for the past year and a half, the physicians and team members of CES have been working to deliver quality, reliable care to poor families in rural communities in Chiapas.  As word of the pasantes’ care has spread rapidly across the region, CES now finds itself providing care to patients from more than 100 communities, including patients who pass over metropolitan hubs to arrive at our small clinics in rural villages.

We now see patients with rare diseases who have spent years seeking care without solution and present to our clinics in the hope that we might be able to offer something more.  I have had the privilege to be involved in a small number of these cases and see firsthand the distances CES goes to in order to advocate for our patients and ensure they are cared for, spending nights alongside expectant mothers in the hospital; traveling hours to wait in line with young children that need corrective surgery for syndactyly (a condition where two or more digits are fused together); and visiting a patient with a severe rheumatologic conditions every day in her home to ensure she took essential medications during a critical phase of her illness.

Now, having dramatically expanded access to care in the area where CES works, we find ourselves with new goals and new challenges.  CES seeks to create high-quality healthcare delivery systems in coordination with the state ministry of health, and to provide our patients the tools to manage illnesses in their own communities.  Over the coming years, we hope to become a center of healthcare delivery excellence for the rural poor and marginalized in Latin America.  A core component is addressing the rising tide of chronic disease.  To this end, we are currently rolling out an accompañante program guided by Alejandra Almeida that utilizes community health workers to assist in the management of chronic diseases.

In one community where the program was piloted, we found significant improvements in medication adherence. We’re now refining it to build upon its strengths and improve its weaknesses so that it can be rolled out to all six communities in a coordinated effort. To ensure the program is yielding better care, Patrick Newman, another BWH resident, has designed a randomized trial to measure the improvements achieved in adherence and possible improvements in disease-specific measures, such as hemoglobin A1c. Our hope is to create a model of high quality chronic disease care in low-income settings working with community health workers that is replicable and may one day affect the care of patients throughout Chiapas, throughout Mexico and ultimately throughout all of Latin America.  Though we are a young organization, we believe that the mix of passion and rigorous analysis that our team brings to these problems will be a key part of the solution to reaching millions of underserved patients with chronic diseases.

For my part, as a Howard Hiatt Global Health Equity resident in Internal Medicine, Compañeros en Salud has provided me with the opportunity of a lifetime to grow and help guide this amazing project towards the potential that we all see it has.  CES has allowed me to work alongside the people of the Sierra Madre to ensure they have access to high-quality healthcare and, in doing so, to demonstrate its place as a fundamental human right, and moreover to show that it is possible to achieve great results for patients across the region.

This potential is what has me so excited about my work here and so thankful for the opportunity to work alongside some of the most talented physicians and staff that I have ever known.  And for this reason, this month I took over as the new clinical director.  In this role, I hope to support a dedicated group of people who day in and day out do the hard work of treating patients in conditions that inherently predispose them to poor outcomes, but who refuse to accept the logic that what has always been is what always will be.