Week 3: Becoming more mexicana...

On Saturday after the Independence Day festivities had finished, Rahul and I woke up early and went to San Juan Chamula and Zinacantán, two indigenous villages about 6 miles outside of San Cristóbal. Both communities speak tzotzil, which is very different from Spanish (for example, ‘thank you’ in tzotzil’ is kolaval – very different from ‘gracias’). Our first stop in San Juan Chamula was the cemetery, where we saw graves marked with black, green, and white crosses. Our guide (César) explained that the black crosses were for adults, the green crosses were for young people, and the white crosses were for babies. While the majority of the crosses were black, there were definitely a fair number of white and green crosses in the cemetery. We walked through the small town of Chamula and our guide brought us to the town jail, where there was a man behind bars. César explained that when someone commits a wrongdoing (such as being violet after drinking), they are brought to the jail. If they are male, they are put in a cell that is open to the public and everyone can see them in the cell (the women are not publicly shamed like the men). However, the maximum sentence is only three days. If they commit another offense, they have to do a year of community service. And if they commit a third offense, they are banished from the village. Pretty good judicial system, I think :-)

San Juan Chamula

César also brought us to the church in the center of town. While it looks like a western church on the outside, it is a completely different world on the inside. Before entering the church, we were told to put our cameras away because the people there believe that taking pictures inside the church may take the sacredness away (kinda makes sense, doesn’t it?). We walked in and stepped on pine needles, which covered the church floor. There were no pews, no altar, and no confession stand. Instead, there were hundreds of people kneeling on the floor, with dozens of different colored candles in front of them. Apparently, the candles (and their color combinations), different colored soft drinks, and even a chicken (yes, there was a man with a chicken in the church) are all part of the religious experience in San Juan Chamula [it amazes me how CocaCola has found a way to infiltrate an indigenous religion]. In Zinacantán, there was also a church, but inside there were pews, an altar, and a confession stand. However, our guide explained that the cross outside was not meant to represent the crucifixion, but rather, a tree.

Inside the church at San Juan Chamula (stole this from Google images)

On Sunday, I spent most of the day reading about Seguro Popular, a new health insurance scheme in Mexico that provides health insurance coverage for poor, rural, and indigenous people in Mexico. Unfortunately, I wasn’t feeling well on Sunday or Monday, so I just relaxed and worked on my health systems paper. On Tuesday at ECOSUR, Rahul and I had class with Roberto Solís, who does data analysis. He explained that ECOSUR uses SPSS for quantitative data analysis, so unfortunately I will have to learn how to use a new software system to analyze my data. We did a brief exercise using SPSS with Roberto, and fortunately it was not that complicated (there are buttons to click instead of codes to enter). Roberto Solís reviewed the different types of variables, including continuous (akaescala in Spanish), nominal, and ordinal. During the practice exercise, we also learned how to use SPSS to create contingency tables and do T-tests.

Wednesday was our last day of the research methodology class at ECOSUR. Dr. Enrique Eroza came to talk with Rahul and I about our initial thoughts for our research project. I have learned that maternal mortality is a huge problem among the rural indigenous populations in Chiapas, and so I am interested in doing a research project related to maternal health. I told Dr. Eroza that I was thinking about doing a project to find out the level of knowledge in the population with regards to maternal health and signs and symptoms of complications during pregnancy, birth, and post-partum. On Thursday, I met with Dr. Ochoa to talk more about my research project. He suggested that I do a KAP (knowledge, attitudes, and practices) study among pregnant women in the area of Los Altos, where maternal mortality is very high. Next week, he said he would help me set up a meeting with people from the Secretaría de Salud to talk more about the project. Next Wednesday, Rahul and I will present our research proposals to the people at ECOSUR, and then we will hopefully go to the field with Esmerelda next Thursday.

Institute of Health in San Cristóbal

On Friday, I worked more on my health systems paper and did some more research KAP studies at ECOSUR. Now that the class has ended, I have moved into an office at ECOSUR with Milton and Ronnie, the two guys doing research and getting their nutrition license. I’m on my own this weekend because Rahul left on Thursday to go to a family wedding in Texas, but I think I’ll be able to survive. I’ve been making some Mexican friends at my salsa class and at ECOSUR. I’m happy because I no longer have to dance in the gringo group or with the instructors at salsa class – I’ve advanced to the next level! Slowly but surely I am becoming more mexicana. The fireworks that go off during the day (just sound – no light), the random parades in the street, and the marimba music playing outside my apartment as I fall asleep are starting to feel normal :-)

Week 2: Viva México! Viva la Independencia!

Last weekend, Rahul and I went to go visit Rancho Nuevo, a cave system with a path winding more than ½ a mile underground. After we emerged from the cave, we walked around the coniferous forest surrounding the cave and passed lots of families picnicking. There was a small stable with a few horses and we decided to go for a horseback ride with a guide around the park (it was Rahul’s first time horseback riding!). Before leaving, we couldn’t pass up the irresistible smell of the food stands and decided to get some quesadillas. We took a combi (minibus) back to San Cristóbal and then walked up a street where the Institute of Health is located. It was a small building, but had signs on the walls reading “eat fruits and vegetables”, “exercise”, etc. We followed the same street until we arrived at the outdoor food market where we bought a few things for dinner. I also decided to add “Los Pinguinos Papa” (Mr. Popper’s Penguins) and “Los Pitufos” (The Smurfs) to my pirated DVD collection (shhh, don’t tell anyone) J

Rahul rode the black horse, I rode the blonde one :-)

On Sunday, I went for a long walk up Calle Real de Guadalupe towards the Iglesia (Church) de Guadalupe. The walk up the steps of the church was tiring, but it was worth it when I saw the view of the city. On my way down the hill, I stopped for lunch and got ‘chile relleno’ (stuffed pepper) and rice, which was incredible. My next stop was “Museo de la Medicina Maya”, a museum introducing the system of traditional medicine used by many indigenous people in the highlands of Chiapas. I watched a very interesting movie about midwives (untrained) in indigenous Mayan communities of Chiapas. The movie quoted a midwife saying, “sometimes babies don’t want to come out…then I have to talk to God and light candles so that the baby will be born quickly.” The midwife may try to speed up the birthing process by giving the pregnant women herbal tea or a raw egg. Once the baby is born, the midwife cleans the baby with an egg “to counteract the jealously of others” and cuts the umbilical cord. If the baby is a boy, the midwife cuts the cord at a length of around 20 to 25 cm so that when the boy grows up he won’t be afraid of heights and will have the strength to work. If the baby is a girl, the midwife cuts the umbilical cord at 15 cm, so that when she grows up and has a family of her own, she won’t be tired or suffer difficult births. The husband buries the placenta in the house: if the next child the family desires is a boy, the husband buries the placenta face down. Outside of the museum there was a medicinal plant garden with placards explaining the name of the plant, the medical use, and the part of the plant used. For example, the leaves and the stem of the “Sitit Vomol” (Vernomia patens) tree are used for treating diarrhea and post-partum bleeding. Very interesting indeed. I’m excited to learn more about traditional medicine in the communities I may work in.

'El Parto'

Medicinal Plant Garden

On Monday, we talked about designing health surveys during our research methodology class at ECOSUR. Surveys can be self-administered (where the person independently fills out the survey) or through an interview. Usually at ECOSUR, surveys are done through interview. The interviewer should speak the same language and come from the same region as the person being interviewed and should ideally be of a similar socio-economic status. Esmerelda showed us an example of an ECOSUR household survey. The survey consisted of questions about demographics, how many years of schooling each person in the family had completed, as well as their occupation. Other close-ended questions included, “do you have health insurance?” and “what do you do when you get sick?”. There was also a section in which the interviewer was supposed to ask whether any persons in the household had experienced any symptoms in a list provided (the list included folkloric conditions, such as “pérdida de alma” = loss of soul). The survey also included a section for the interviewer to fill out that could give an indication about the family’s socioeconomic status, such as the type of floor/walls in the house, the types of animals belonging to the family, how often the family ate meat, whether the family had electricity, water, a refrigerator, a radio, a TV, and/or a latrine in the house.

This week I decided to try out a salsa class that was recommended to me by Katy and Linda who went last year. The class is held every day from 6 p.m. – 8 p.m. I was a little nervous the first time I went to the class, but it turned out to be super fun and I have learned a lot in the 3 classes I went to this week!

Preparing for Independence Day

Tuesday during class we talked about indicators for the evaluation of health services (such as the number of hospital beds per 100,000 people). Dr. Ochoa also gave a brief presentation outlining the health system in Mexico. In the public sector, there are various health insurance schemes. IMSS covers roughly 50% of the population and is financed by the employer, the employee, and the government. ISSTE is like IMSS, but only for government workers (such as Dr. Ochoa – he automatically gets money deducted from his paycheck for ISSTE, even though he also chooses to pay for private health insurance). There is also SEDENA (for the military) and PEMEX (for workers in the Mexican Petroleum Company). For the “poblacion abierta” (the poor, rural, and indigenous populations), there is the Secretaría de Salud (SSA) that exists in every state and gives health services to the population without health insurance, as well as IMSS-Oportunidades (*not the same as the federal Oportunidades program) that offers services to rural, indigenous populations. Each health insurance scheme has its own facilities and health personnel. Seguro Popular is a relatively new insurance scheme that was created for the poor populations without health insurance and offers a packet of interventions through the Secretaria de Salud and IMSS-Oportunidades. There are also private health insurance schemes for those who can afford it. So, as you can see, the Mexican health system seems to be almost as complicated as the US health system!

The view from my walk up to Iglesida de Guadalupe

Wednesday and Thursday we reviewed qualitative research methods with Dr. Enrique Eroza, a medical anthropologist. He reviewed how to conduct in-depth interviews and focus groups. We also watched a very well-made and captivating movie titled “The Constant Gardener” (I recommend it to everyone reading this) about medical experimentation in Africa. On Wednesday after class, we passed people in the main square celebrating the acquisition of Chiapas into Mexico (187 years ago J). The square in front of the cathedral was filled with food stands selling churros, pizza, cotton candy and people sitting in the plastic chairs eating with their friends and family. That night, we had dinner with two other people in our class and went to a surprise birthday celebration for Esmerelda’s husband, Uriel. At midnight, we all waited outside Esmerelda and Uriel’s house and when the clock struck 12:00, a band started playing in the patio until Uriel emerged from his house. The band continued playing and the party ensued J It was a lot of fun, but we were all very tired during our class on Thursday!

Rahul and the piñata

On Thursday after class, Dr. Ochoa and Rosario invited us to their house for an Independence Day celebration. Their 3-year-old daughter, Ceci, greeted us wearing a pink dress that made her look like a Disney princess and we also met the family’s parrot, cats, and dog. We ate a very yummy late lunch/early dinner and then went outside for the piñata! Ceci and the other two children were very excited and did a much better job of hitting the piñata than Rahul and I J The party ended with a birthday cake for Uriel, Dr. Ochoa (his birthday is coming up), and, of course, Mexico! We stayed at Dr. Ochoa’s house for a while chatting and then at 9:00, we walked to the main square for “El Grito” (the shout). The streets were packed with people whose faces were painted with red, green, and white (the flag’s colors) and there were two giant stages set up in the main square. At 10:45, ‘El Grito’ commenced and everyone was shouting “Viva Mexico! Viva la Independencia!” Fireworks exploded in the sky and the Mariachi band began to play on the stage. Rahul and I met up with Paco, another person who works at ECOSUR, and we celebrated 201 years of Mexican Independence with Paco and his friends J

Rosario and her daughter, Ceci

It’s amazing how easily Rahul and I are accepted here. Despite the somewhat strained US-Mexico relations, I never feel judged here and everyone we have met has been kind and welcoming to us. There is a wonderful sense of community and constant celebration of life among friends, family, and even strangers. It’s something that I think the US could learn from J

Dr. Ochoa (right), Ceci, and Uriel

Week 1: Welcome to San Cristóbal and ECOSUR

Looking out the plane window minutes before landing in Chiapas, I was impressed by the vast expanse of mountains, rivers, and green landscape. The images I saw out the window contrasted from the dry dessert that I remembered from Sinaloa and Jalisco, other Mexican states on the western coast of Mexico where I traveled before my freshman year. When I arrived at the Tuxtla Gutierréz airport, I was greeted by palm trees, heat, and Raul, a man who works at ECOSUR. We drove from Tuxtla Gutiérrez (the capital of the state of Chiapas) to San Cristobal de las Casas, which was about an hour drive through fog and rain into the mountains.

When I arrived in San Cristobal on Sunday night, I met Rahul at our apartment. We each have our own room and there is a small kitchen with a gas stove that you have to light with a match (I went to go buy one of those long barbeque lighters because I’m very afraid of fire). On Monday I spent most of the day walking around the city, going to the bank, doing some grocery shopping, and buying a big bottle of water for the apartment. The city of San Cristobal is really beautiful with windy cobblestone streets and brightly painted buildings. It is just small enough so that you can walk pretty much everywhere in the main part of the city. Our apartment is very centrally located next to the main square (Zócalo) and the Cathedral. There are beautiful mountains in the background and the backdrop of the city is picturesque from every angle. There is definitely an eclectic mix of cultures here – Rahul said that he had been to an Indian restaurant and I passed a Lebanese restaurant up the street from our apartment. There are indigenous women and their children speaking Tsotsil (an indigenous language), American/European backpackers walking around the streets, and, of course, the local Mexicans. Everyone seems to coexist beautifully and I love how nobody stares at us when we walk by J

The view from a café in San Cristóbal

Despite the different climate (chilly and rainy), the images in San Cristobal remind me of images from Jalisco and Sinaloa - most restaurants and cafe’s are open to the street, indigenous women with their small children sell crafts to tourists in front of the Cathedral and despite the continuous rain, there is live marimba music every night in the main square. I love the simplicity of life in Mexico - the stores are named ‘papelería’ (paper store) and ‘zapatería’ (shoe store) instead of big names like ‘Staples’ and ‘Aldo’. There are little shops everywhere selling everything from phone cards to piñatas and the names of the stores are hand-painted on the walls of the colorful buildings.

One of the main streets in San Cristóbal

On Tuesday we traveled via taxi to ECOSUR (located on the outskirts of San Cristobal) for our first meeting with Dr. Hector Ochoa (our preceptor). Before our meeting, we had lunch in the ECOSUR cafeteria (the food is amazing and really cheap). While at ECOSUR, I met Rosario (the woman who helped us find an apartment) and other people who work in the health department at ECOSUR, including an indigenous translator. Dr. Ochoa introduced himself and explained that for the next two weeks, we will have class at ECOSUR (in Spanish) to review research methodologies and learn about the ongoing health research projects at ECOSUR.

ECOSUR

Wednesday was our first day of the research methodology class. Dr. Ochoa introduced us to Enrique Eroza (a medical anthropologist) and we met other Mexican students who would be joining our class. Two of the students (Ronni and Milton) are getting their license in nutrition, another student (David) is completing his master’s degree, and another woman (Esmerelda) is completing her PhD. Dr. Ochoa reviewed the different types of research (health systems research, health services research, social health research, etc.) and the different stages of research (selection of theme, literature review, development of a research proposal, definition of variables, selection of research methodologies and instruments, etc.). He presented the schedule for the course and a calendar outlining the approximate schedule of our internship: during September we will complete the research methodology course and select a research topic. The first week in October is ‘planificación’ where we will complete a research proposal. The second week of October we will prepare instruments for data collection, and in the second half of October we will collect data and conduct field work. In November, we will finish our data collection, process the data and interpret the results of our findings. In December, we will draft our final report before presenting our research to ECOSUR. Sounds like we have a lot of work ahead of us!

On Thursday we had our second day of class. We discussed the homework from the night before, which was to find and compare health indicators for Mexico, another country in Latin America, a country in North America, and a European country. The other students in the class shared some of the graphs they had found illustrating various health indicators over time. I presented a few graphs that I had made this summer while interning at PAHO that illustrated trends in health research in Latin America. Here is the link:http://new.paho.org/hq/index.php?option=com_content&task=view&id=5709&Itemid=4099&lang=en. We also learned how to find health data from the State of Chiapas using government websites (not always an easy task!).

On Friday we talked more about how to choose research topics and develop objectives and methodologies for a research project. Dr. Ochoa reviewed the different kinds of epidemiological studies, such as observational studies (including transverse cross-sectional studies) and experimental studies (including controlled clinical trials). We got side-tracked a little bit and started talking about the Zapatistas in Chiapas. We learned that there are Zapatista municipalities in Chiapas that have their own government, educational services, and health services. This system seems to work well for those who live in Zapatista municipalities, but many Zapatista families who live in other municipalities are rejected from their communities and may even be prohibited from accessing the water source L Next week we will talk more about developing surveys and hear more about the ongoing health research projects at ECOSUR.

After class, me and Rahul took the ECOSUR bus back to the center of San Cristobal. Since it was a beautiful day and it wasn’t raining (yay!), we decided to go for a walk. After passing a fish store and debating whether we should buy a pet goldfish for our apartment (we decided against it), we kept walking and followed two men pushing a giant cart of tomatoes towards a food market. I have never seen fruits and vegetables so beautifully arranged in my life. I think tomorrow I might go grocery shopping at the market and then go explore my surroundings … thank goodness I have 14 more weeks to see all that San Cristobal and Chiapas has to offer J