June 19, 2007

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Poor Health Care for the Poor

By Juana de Jesús Pérez Mendez, senior reporter

SAN CRISTÓBAL DE LAS CASAS -- Broken windows. 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 also receive free health services including prenatal care, nutritional assessment, and the prevention and detection of cervical cancer.

These health services are obligatory for families in the program. If they miss 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. Women complain that the tests, essential in the detection of cervical cancer, provoke pain and bleeding, and many say they never see their test results.

In light of the clinic's conditions, these families find themselves in a tough situation. If they quit going to their appointments at the CEDEM clinic, they will lose 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 said. Clinic staff, she said, gave her no explanation for the pain and never gave her the test results.

Poor Health Care for the PoorMaria Estela Constantino Zuñiga, 44.

In April, Zuñiga went back to the CEDEM clinic for another pap smear. This time, there was no pain or bleeding, but she said 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. "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 recalled saying to the nurse who treated her.

Another CEDEM Clinic patient, Maria Vasquez Martínez, 23, also believes that staff performs pap smears badly. Vasquez Martínez went to her scheduled test in the autumn of 2006. She said she felt pain as the nurse removied the instruments from her body. Vasquez Martínez left the clinic bleeding with a sharp pain in her lower abdomen.

Vasquez Martínez also complained about the clinic's facilities. "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?" said Vasquez Martínez.

Poor Health Care for the PoorMaria Vasquez Martínez, 23.

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 said.

But pap smears shouldn't be scary or painful, said 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 said that 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 USD) 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," said Calvillo.

Some Oportunidades patients at the CEDEM clinic get 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.

Poor Health Care for the PoorThe CEDEM Clinic in San Cristóbal.

"We offer women a quality service. That's why we don't allow them to go to private doctors," she said and 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 said 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 said. She said that complaints about the clinic's hygiene and the lack of equipment and privacy in examining rooms are also common.

Poor Health Care for the PoorAna Maria Jiménez Martínez, a volunteer community liaison at the clinic hears complaints from many women.

Calvillo of Marie Stopes 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," said Calvillo.

But despite the clinic director's claim that it is against program regulations Oportunidades 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," said 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 Opoturnidades-affiliated public clinics, said Alcoser. It isn't important where women go for pap smears, said Alcoser, "What's important is that they do it."

But Domínguez Gordillo of the CEDEM clinic stands by her decision, and said 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 said.

Domínguez Gordillo denied 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 said 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 said.

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

Poor Health Care for the PoorThe facility does not have tables with stirrups for women to receive pap smear tests.

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

When asked about the reports 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 once 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 said there are no resources to resolve these problems. Until seven months ago, the clinic had no running water, she said. And until recently, there was no cleaning staff, but 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 said.

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

Poor Health Care for the PoorThe CEDEM clinic is run down inside and out.

For now, patients like Vasquez Martínez have little choice but to continue going to their appointments at the CEDEM clinic. "I have to go. If not, they mark it as a missed appointment, and they can take away the money they give us," she said.

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