Sponsored by Instituto Nacional Indigenista
A. DESCRIPTION OF PROJECT
High in the rugged Sierra Oriental Mountains between Mexico City and Vera Cruz lies the small town of Cuetzalan, the major centre for market activities and the source of health services for the largest group of Nahuatl and Totonac speaking peoples in Mexico. These people, descendants of the ancient Aztecs, Huastecos, Mayas, Oimecas, Teotihuacans, Toltecs, and Zapotecs, practice the traditions of indigenous medicine which are widely known even today for the powers of medicinal herbs and spiritual practices.
Health practitioners - midwives, herbalists, bone-setters, and prayers, passed their knowledge down from generation to generation, and these traditional beliefs and practices of healing are still rooted within the many indigenous cultures that have settled mainly in the southern and eastern parts of the country. These indigenous peoples believe disease exists not only in man’s body but also in his spirit, which unites him to the earth and sky, to the wind and waters, and to the animals and minerals.
Since the conquering of Mexico by the Spaniards, the majority of the population has became a mixture of Indian-Spanish-other blood. This blending has created a tradition which leads people to use various diagnostic and treatment modalities and people do not hesitate to turn to whatever cure or medicine they feel will be effective. As of 1993, 57 Traditional Practitioner Organizations had been officially established in 20 of the 31 states in Mexico. These associations represent a very large portion of the indigenous populations throughout the country.
These people are the most vulnerable segments of the Mexican population with the least access to modern health services. They have one of the highest maternal mortality rates in the country and 70% of children under 13 years of age are malnourished. People also have high rates of fertility, tuberculosis, respiratory, and gastrointestinal illnesses. Because of increasingly difficult living conditions they are rapidly emigrating from their communities to cities and migrant labour camps in search of a better life.
In 1989 the Mexican Government, through their Instituto Nacional Indigenista (National Institute for Indigenous People), launched a demonstration project in a rural government hospital in Cuetzalan. The Cuetzalan Traditional Practitioner
Project serves 46 indigenous communities - a total population of 28 000 - and its purpose is to offer, through a decentralized health system, a combination of scientific/modern medicine, traditional healing, and folk medicine to the local village people.
The objectives of the project included the following:
1. Provide specific Primary Health Care (PHC) services to the region;
2. Coordinate the activities of local institutions and resources to provide health services;
3. Develop traditional medicine and an Herbolarium as a resource for the traditional practitioner;
4. Provide medical and PHC services to treat the major health conditions, reduce the levels of malnutrition, improve sanitation, and increase immunization.
5. Promote the rural health system to local institutions and groups, international agencies and government groups.
The project is based on a primary health care strategy that was adapted to the needs of indigenous communities, promotes full community participation in decision making, recognizes the importance of traditional practitioners in serving the local communities, and involves a close working relationship with Mexico’s national council of traditional practitioners.
C. RECRUITMENT AND SELECTION OF TRADITIONAL PRACTITIONERS
The project began by enlisting the use of Health Promoters (a category of paid community health worker trained and employed by the Government Health Service), who were asked to take a census of all the traditional practitioners in their areas. The practitioners who were identified included traditional midwives (parteras), herbalists (herbalistos), bone setters (hueseros), and spiritual healers (curanderos or prayers). These traditional practitioners (approximately 120) were then all invited to a two day workshop held at the Cuetzalan Rural Hospital where the staff explained the purpose of the project, the training programme, and the plans for utilizing TP services in the communities and in hospitals.
A second workshop was held a month later with only 49 traditional practitioners attending - 24 parteras and 25 other traditional practitioners. This group continued to attend further training sessions held at the hospital. The first two workshops were intended to orient the traditional practitioners to the general nature of the training programme and how they could carry out services within their communities and the hospital.
D. TRAINING CONTENT
After the first two orientation workshops, a monthly training schedule was established. This schedule was developed around the local needs of traditional practitioners and community members who came to town during Saturday and Sunday, market days in Cuetzalan. The training staff therefore established the following schedule to hold training sessions for traditional practitioners at the Government Hospital in Cuetzalan:
• first and third Saturday of every month for TBAs (parteras);
• first Sunday of the month for training herbalists and spiritual practitioners (curanderos and prayers);
• second Sunday of month for training bone setters (hueseros);
• third Sunday of month - open;
• fourth Sunday of month for all traditional practitioners to meet together and plan joint activities.
The TBAs were trained by a team of three experienced Health Promoters (auxiliary nurses) and assisted by the other staff members of the hospital. The training content for TBAs included:
• Signs and symptoms of pregnancy;
• Proper care of pregnant woman, ie personal hygiene, rest, nutrition, sanitation;
• How to identify position of fetus and what to do in difficult cases;
• How to hygienically prepare for and deliver a baby;
• How to properly cut and care for the umbilical cord;
• History taking and record keeping;
• How to identify high risks of pregnancy and refer to hospital;
• Referring women for tetanus immunizations and children for other immunizations;
• Breast feeding and weaning practices.
Three staff members trained the herbalists, hueseros and spiritual traditional practitioners. Two were trained in agronomy, specifically in the identification and growth of herbal plants and the third was an experienced herbalist practitioner who volunteered as a trainer.
The herbalist group was trained in identifying and using herbal plants in their region; collecting, drying, and preserving these herbs in a hygienic way; in growing herbal gardens to provide a ready supply of herbal medicines for their own use; and in selling herbs in the market for income. The bone setters were taught basic anatomy, hygiene, and how to collaborate with physicians in setting broken bones.
E. TRAINING METHODS
The training techniques used for all groups of traditional practitioners were generally the same. The staff used a combination of adult education methods including the presentation of information in a didactic form, using question and answer formats, demonstrating techniques and methods, illustrating points with diagrams and posters, and breaking the participants into small groups for discussion.
An important part of training sessions was having the participants share with each other their own techniques and methods of healing. This enabled the traditional practitioners to better understand what others were doing and gave the staff a chance to point out the positive or unsafe methods in their practices. The traditional practitioners were appreciative of these sharing sessions.
A review was made of the training materials which staff members used in the workshops. A manual for training indigenous doctors had been prepared jointly by UNICEF, the National Institute of Indigenous People, and the Government of the State of Oaxaca, and this was used for the training of herbalists, bonesetters, and spiritual traditional practitioners. Some visual aids were available in Spanish for training Health Promoters but contained few pictures and these were not completely appropriate for the low literacy level of the TBAs. Since few posters, flip charts and models were available, the staff improvised by creating their own visual materials. One outstanding production of the herbalist training group was the development by the traditional practitioners of a book on indigenous medicinal plants. The training staff acknowledged that the lack of suitable training materials was a serious problem for them to conduct effective training.
F. FOLLOW-UP SUPPORT
The follow up and support for the traditional practitioners was built into the continuing monthly training sessions as described in “D” above. The TBAs met twice a month to learn new information and skills and to exchange experiences with each other. The same procedure was followed with the other traditional practitioners who met once a month. At that time the training staff identified any difficulties encountered by TPs and helped resolve them.
In addition to these opportunities to provide follow up, all traditional practitioners met together once a month in a general assembly to discuss problems and plan their activities. Hospital staff provided guidance to traditional practitioners coming into the hospital on a rotating basis to offer traditional health services according to their own specialty areas.
All eight of the health agency staff members interviewed indicated they felt it was necessary to provide this type of support in order to reinforce what the traditional practitioners had learned and to insure that proper methods of treatment were used. Staff felt this type of supportive environment facilitated a positive interchange of ideas between traditional practitioners and health agency staff.
G. CHARACTERISTICS OF PERSONS INTERVIEWED
1. Health Agency Staff - Eight official health agency staff representatives were interviewed regarding their relationship with and views on traditional practitioners. There were seven females and one male, and the average age was 30.5 with a range of 24 to 38. Their occupations included: Chief of the Department of Traditional Medicine, hospital director, nutritionist, social worker, general practitioner, and nurse. The average amount of time worked in their current position was 3.8 years, with a range of 1.5 to 12.
2. Traditional Practitioners - Seventeen traditional practitioners who received training through the Cuetzalan Project were interviewed, thirteen females and four males. Of the thirteen females, twelve were TBAs (parteras) and one was a Health Promoter, while male representation consisted of two spiritual healers and two bone setters. The ages of the traditional practitioners ranged from 31 to 68 with an average age of 53.6. Eight of the seventeen interviewed were literate, although the highest level of schooling reported was six years. The average number of years in practice was 18.5, with a range of 0 to 38 years. An interesting note is that the two priest healers spoke Nahuatl, and were provided with interpreters for the training, which was conducted in Spanish.
3. Community Members - Five representatives from two communities were interviewed about their satisfaction with the traditional practitioners serving their communities and with the hospital staff services. Three men and two women aged 22 to 60 years in the occupations of farmer, mother and President of the Cooperative were asked about the health problems of their families and the services that the trained healers provided. All but one of those interviewed had at least one child under the age of six. When asked about their family’s health problems over the past year, the community members listed: diarrhoea, high fever, vomiting, and coughing. Three of the five reported that they had not visited traditional practitioners but only went to the hospital for their health problems.