PROJECT PIAXTLA Objectives: To help the campesinos in the remote parts of the Sierra Madre of western Mexico cope more effectively with their health needs; to hele promote a humane, balanced and low-cost health care program operated and sustained by the local people. Area Covered and People Served: Over the past ten years, the project has gradually built up a network of primary health care stations which now cover an area of about 5000 sq. km. of rough mountain terrain, and serve approximately 10,000 campesinos living in more than 100 small ranchos and villages linked by narrow burro trails. The project*s central clinic and training center is located in Ajoya, five additional health “outpasts" are located in smaller, more remote communities, the farthest more than 100 km. over mule trails back into the barrancas (steep ravine country of the Sierra). Primary health care is anoroached at different levels: 1) At the most basic (and most important) level, an effort is made to help the entire community learn to deal with its health needs more effectively. Effort is made to involve mothers, school children, traditional healers + (curanderos) and midwives. Sasic information is imoarted through the schools, through village meetings, and through low-cost distribution and instruction in the use of a villagers’ medical manual written specifically for the area.* Primarily, however, health education comes about when health workers take the time to explain to patients and their families the causes of their illnesses, and what they themselves can do to prevent or treat them. 2) Campesinos from remote villages are trained as promotores de salud in a two-month training program at the Ajoya Clinic. Selected for training by their fellow villagers, most are men and women already serving as traditional healers, “medicos practicantes" or midwives. Training, in which classwork is integrated with clinical apprenticeship and community health work, covers basic aspects of primary diagnosis and treatment, health education, promotion of improved hygiene and diet, vaccination, midwifery, maternal and child health care, family planning, and tooth extraction. Emphasis is placed on the preventive and promotive aspects of health care. After training, the oromotores return to their villages to serve their people's health needs as best they can, usually on a part- time basis.. Effort is made to give them continued support, intermittant supervision, and periodic refresher training. 3) The main Ajoya Clinic is run by village health workers with substantially more training and experience than those mentioned above, partly because the clinic serves as a referral center for the outposts. The Ajoya Clinic is directed by an outstanding local medic, Martin Reyes, who has apprenticed and worked with the project for nine years {since age 14 years). Although the Ajoya Clinic is the hub of many preventive and oromotianal activities, an extensive (excessive?) amount of time and energy are still devoted to diagnosis and treatment. The clinic has a basic laboratory run by village girls, X-ray equipment powered by a gasoline generator and operated by the village health workers, and a fairly complete dental department. *Joande No Hay Doctor, una guia para los campesinos que viven lejos de los centros medicos. Available from Editorial Pax Mexico, Libreria Carlos Cesarman, S.A., Rep. Argentina, 9, ifexico 1, O.F. Referrals: Villagers with health problems they cannot manage themselves Bre encouraged to seek assistance from promotores; promotores refer difficult cases to the central Clinic of Ajoya. Patients requiring procedures or surgery beyond the capacity of the Ajoya Clinic are referred with cover letters--or taken to hospitals in the coastal cities. Health Related Activities: Health in any community is more dependent upon socioeconomic factors, food sugoly and specific patterns of behavior than upon specific health care. As our awareness of this has grown, we have taken increasing interest in a number of health-related fields. These include the promotion of water systems, the fostering of cooperative corn banks, a small credit union in the high country, and conservation activities. In agriculture, we have involved villagers in experimental plantings of Opaque 2 (high protein) corn and other crops, and are presently experimenting with Sudan grass for pasture.. We are becoming more involved in veterinary medicine and in the training of village para-veterinarians, with emphasis on vaccination, preventive care, and improvement of stock. Methodology: 1} Adapting methods to local customs and beliefs. In the training of village health workers, it is imperative that the instructor gain insight into the trainee’s cultural beliefs and customs, and modify training methods and emphasis accordingly. 2) Learning through doing. In our program, training at all levels is based on practical experience and apprenticeship. Some classes are also held, especially for promotores, and on an intermittant basis for all other health workers. 3) Emphasis on teachina. Every health worker, from doctor to mother, should first and foremost be a good teacher. Our golden rule has become: Never do for others what you could be helping athers do for themselves. 4) Rational learning: In teaching health workers, emphasis is placed not on memorization, but on how to look things up and use their own resourcefulness. An important part of the training program for promotores has been teaching them to use effectively the villagers® medical handbook, Donde No Hay Doctor. Economics: The project operates on a cash outlay “mostly from private donations in the USA) of approximately $12,000 a year (approx. $1.20 per person served), plus an equivalent amount in donated materials and supplies. Every attempt is made ta keep the cost of the health-care services as low as possible and to find ways in which this cost can be covered by the community itself. Village health workers ‘medics, dentics, and lab techs) receive modest salaries equivalent to those of the local semi-skilled artisans. All outside workers are strictly volunteers. At the Ajoya Clinic villagers pay for services ‘including medication, when required) with either two hours work or 30 pesos. Realizations: In the 10 years since the health program's modest Beginnings, some apparent improvement is evident in the overall health level of the community served. Most of the "successes" have been achieved through measures which depend more on medical technology e.g. vaccination) than on change in attitudes. Measures which depend partly on shift in attitudes have had more limited success. Slowest headway has been with measures requiring radical shifts in traditional attitudes or customs. Nevertheless, some shift in attitudes is becoming evident.