CHIAPAS: No options but substandard healthcare for poor women

Juana de Jesús Pérez Mendez – Women News Network – WNN MDG Stories

San Cristóbal de las Casas, Chiapas, Mexico public health clinic
CEDEM health clinic in San Cristóbal de las Casas, Chiapas, Mexico. Image: Juana de Jesús Pérez Mendez / GPI

This searing October 2009 story covers the needs for adequate health facilities for women suffering under extreme poverty in Chiapas, Mexico.

SAN CRISTÓBAL DE LAS CASAS — Amidst broken windows and makeshift walls, sewer rats play among boxes of nutritional supplements for malnourished babies and nursing mothers.

This is the clinic at the Municipal Recreational Center (CEDEM) in San Cristóbal de las Casas, Chiapas, where more than 33,000 of the city’s poorest residents obtain medical services each year.

The bulk of the CEDEM clinic’s patients participate in Oportunidades, a government program with the stated mission of “promoting human development among the population living in extreme poverty.” The program offers a range of services to marginalized families including scholarships and cash to defray food and electricity costs. Oportunidades participants receive free health services including prenatal care, nutritional assessment and prevention and detection of cervical cancer.

The health services provided are obligatory for families enrolled in the program. If someone misses scheduled doctor’s appointments, their monetary aid is docked or eliminated.

But many of the families who receive help from Oportunidades complain that they receive substandard treatment at the CEDEM clinic, and that the clinic’s offices and examining rooms are dirty and unhygienic. Complaints about pap smears are particularly common, with many women saying that the tests, essential in the detection of cervical cancer, provoke pain and bleeding, and many say they have never seen their test results.

In light of the clinic’s conditions, these families find themselves in a tough situation. If they stop going to their appointments at the CEDEM clinic, they will lose the much-needed monetary support. But some say the care that they receive there causes more harm than good.

Last year, Maria Estela Constantino Zuñiga, 44, had a pap smear at the CEDEM clinic that she said provoked discomfort and bleeding for more than two weeks after her appointment. “I was in pain. My uterus was very sore. I was like this for at least 15 days,” she says. Clinic staff, she said, gave her no explanation for the pain and never gave her the test results.

In April, Zuñiga went back to the CEDEM clinic for another pap smear. This time, there was no pain or bleeding, but she says the test was performed on a bed with no stirrups. Zuñiga is a large woman and when the nurse asked her to hold her legs up so she could give her the test, she could not physically do it.

“How do you expect me to hold the position if there are no foot supports? You’ll have to lend me your shoulders because I can’t do it alone,” she told the nurse who treated her.

Another CEDEM Clinic patient, Maria Vasquez Martínez, 23, also experienced a painful pap smear. Vasquez Martínez went to her scheduled test in the fall of 2006. She says she felt pain as the nurse removed the instruments from her body. Vasquez Martínez left the clinic bleeding with a sharp pain in her lower abdomen.

Vasquez Martínez said the clinic facilities are subpar, “The health center is always dirty. There’s no one who cleans it. There are rats. How is it possible that doctors allow their workspace to be so dirty?”

Though her next pap smear is months away, Vasquez Martínez is already worrying, “My next pap smear is in October, and I’m scared because of what happened to me the last time,” she says.

But pap smears shouldn’t be scary or painful, says Dr. Belinda Calvillo, a gynecologist at the Marie Stopes Clinic in San Cristóbal, one of three reproductive health centers in the state operated by the British non-profit organization Marie Stopes International.

Calvillo says she regularly sees women who decide to go to Marie Stopes for their pap smears because they don’t trust the CEDEM clinic. But pap smears can cost up to 300 pesos, about $30, in private clinics, so this option falls out of reach of many women who are guaranteed free health care at the CEDEM clinic.

Still, about 15 percent of the pap smears performed at the Marie Stopes clinic are for women who come from the CEDEM clinic. So far this year, about 90 women have come from CEDEM, Calvillo says.

Some Oportunidades patients at the CEDEM clinic have received permission to have their pap smears done in private clinics with the condition that they turn their results in to CEDEM.

But CEDEM’s clinic director, Dr. Georgina Domínguez Gordillo, is against this practice. She says women who have pap smears done elsewhere should lose their benefits and make room in the program for women who can’t afford health care in private clinics.

“We offer women a quality service. That’s why we don’t allow them to go to private doctors,” she said. Domínguez Gordillo added that her clinic, which is publicly funded, is able to link needy patients with public hospitals that can provide more extensive medical care than that offered by the CEDEM clinic, in cases of serious health problems.

But Ana Maria Jiménez Martínez, a volunteer community liaison at the CEDEM clinic, says that despite Domínguez Gordillo’s claims about the quality health care offered in the clinic, patients regularly complain to her about their pap smears. “It’s always different women,” she says. She added that complaints about the clinic’s hygiene as well as the lack of equipment and privacy in examining rooms are also common.

Calvillo confirms that many of the women she sees complain about severe pain during and after pap smears at the CEDEM clinic, while others say they never see their test results and are left wondering if they are healthy or if they have a problem that needs attention. Calvillo says women should be able to choose where they seek health care. “This violates women’s rights. This decision should be left up to them. Women’s health should not be conditional, and health services shouldn’t be used to manipulate the population,” says Calvillo.

But despite the clinic director’s claim that it is against program regulations for Oportunidades patients to seek care elsewhere, officials disagree. “Technically speaking, getting a pap smear [in an Oportunidades-affiliated public clinic] isn’t obligatory, but in practice it is,” says Antonio Alcoser, the Chief of Citizen Attention in the Chiapas Oportunidades office. He went on to say that if cases exist in which doctors obligate women to realize their pap smears in public clinics, these are irregularities that should be denounced before the program leadership.

According to Oportunidades’ rules, patients are allowed to have pap smears at private clinics as long as they turn their results into their doctors at Oportunidades-affiliated public clinics, says Alcoser. It isn’t important where women go for pap smears, adds Alcoser, “What’s important is that they do it.”But Domínguez Gordillo of the CEDEM clinic stands by her decision, and says that Oportunidades’ administrators don’t always understand the realities faced by the doctors and nurses of the program. “There are differences between the administration and those of us who work on the ground. We don’t always agree,” she says.

Domínguez Gordillo denies that Oportunidades violates women’s right to choose where they receive medical attention, saying that the program is voluntary. “Both sides have a responsibility, the doctors and the program participants. The doctors [are responsible for] giving medical attention, and the patients have the responsibility to come to their appointments.” She says that part of the problem is that Oportunidades participants didn’t take the time to inform themselves about their responsibilities they assumed upon enrolling in the program, “The women didn’t read the rules. They just signed up because they knew that they were going to get money,” she says.

When asked to respond to patients’ complaints about pap smears, Domínguez Gordillo said she doesn’t believe there is any problem with the tests her staff administers. She added that she has not received any complaints from patients about pap smears.

The root of the problem, says Domínguez Gordillo, is poor communication between clinic staff and patients. A language barrier exists between some patients who speak only indigenous dialects and members of the staff, who speak only Spanish. Other times, doctors don’t thoroughly explain procedures to their patients.

When asked about the articles of post-pap smear pain and bleeding amongst CEDEM clinic patients, Domínguez Gordillo said these women probably had pre-existing conditions such as infections or inflammation, that were aggravated by the test, but not caused by it. She cited poor communication again, saying that doctors don’t explain these situations to patients so women with these problems end up blaming the CEDEM clinic staff and wrongly concluding that the tests were administered incorrectly.

Domínguez Gordillo agreed that the clinic is dirty and poorly equipped, but says there are no resources to resolve these problems. Until seven months ago, the clinic had no running water, she added. And until recently, there was no cleaning staff. Now another local clinic lends them their janitors two or three times a week. “[These problems] make it hard for us to provide quality services,” she admits.

Money is so tight, she says, that clinic staff are forced to pay for things like gasoline to get to emergency house calls, telephone calls and laundry from their own pockets. Pointing to a pile of dirty laundry she says, “Look at the dirty clothes here. I have to pay 30 pesos, about $3, out of my own pocket so that this laundry will be washed.”

For now, patients like Vasquez Martínez have little choice but to continue going to their appointments at the CEDEM clinic or risk losing vital funds provided by the government. “I have to go. If not, they mark it as a missed appointment, and they can take away the money they give us,” she says.

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As a domestic laborer with three daughters and a second grade education, Juana de Jesús Pérez Mendez’s road to journalism was more challenging than most. Her reading and writing skills were unrefined and unpracticed. She had never used a computer, so she spent tireless hours learning to type. While her writing was rough at first, she proved to be a natural reporter. She was the first to tell of a government that forced poor women to receive check-ups in filthy facilities in order to receive their welfare checks. Her reporting on illegal land use changed government policy and put two men behind bars for swindling the poor. Today, Juana remains one of The Global Press Institute’s best reporters covering important issues from Chiapas.  

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