With a photo showing the ejido (public land) of San Jacinto, community of Linares, Nuevo León, Mexico, Melissa Luna, MD, said goodbye to her social service. Even though she made friends and considered herself “privileged” to “come out alive” from this experience, the medical intern lamented all the times she was unable to attend to a patient because of a lack of supplies, as well as the occasions when she was afraid of being alone in a strange place.
For the young doctor, the biggest challenge was being so far away from other health jurisdictions and being in charge of the first-level clinic, which did not have basic drugs, such as loratadine or metformin, and did not have supplies to treat wounds.
She acknowledged that at the beginning of her social service, what she feared the most was being raped like Dr Mariana Sánchez, who was first sexually abused while doing her social service in a community in Chiapas and, after filing a complaint, was murdered in January 2021. For this reason, Luna traveled to San Jacinto with pepper spray and a taser, but in her year of service, she discovered that violence was not the only thing she needed to face.
“The community took great care of me. They told me not to walk alone, not to go to other ejidos, but the heads of the jurisdictions disregarded it. However, that was not the worst part. It was the helplessness of not being able to attend to a patient with diabetes or a minor cut, let alone deliver a baby. The best thing I could do that year was send people to Linares. It was my only way of not risking their life, because sometimes we didn’t have [any drugs, let alone antidotes] to treat snake bites, nothing,” she told Medscape Spanish Edition.
She also mentioned the occasion when a family brought in a 90-year-old woman who had fallen over, and Luna could only take her vital signs and send her to Linares, because, in her clinic, pain-relief drugs “were just a dream.” Luna pointed out that to get from San Jacinto to the center of Linares, you have to travel by car for about 60-90 minutes.
The biggest frustration for Luna came on the day that her immediate bosses asked her to give condoms to each of the patients, in addition to testing them for tuberculosis and malaria, even if it was not necessary. She also pointed out that a large part of the community was made up of older adults, so it would be better to request drugs to control chronic diseases. The answer left her cold.
“They told me that it didn’t matter, that the expense had already been made, that they would know if they gave them away, used them, or burned them. It was very frustrating to see what was spent on supplies that were not necessary and that, in my year of service, I could not treat a single person properly because there were no basic drugs. It is very sad to see that they only want to meet goals and that, if the statistics are good, reality does not matter. It’s unbelievable that patients don’t come first,” she said.
Not Cheap Labor
Lack of social security; payment that does not correspond to the activities carried out; sexual and labor harassment; psychological abuse; theft; and lack of bedrooms and a dining room are the main complaints that medical interns have about their social service, according to Andrés Castañeda Prado, MD, coordinator of the Causa de Salud y Bienestar de Nosotrxs (Nosotrxs Cause for Health and Welfare).
In an interview with Medscape, the doctor highlighted that in 2019, the Mexican Assembly of Medical Interns in Social Service was created to file claims on the precarious conditions in which they provide their services and demand changes. Change has so far not occurred, and the complaints continue to pile up.
“Violence is what is reported most, not only in rural areas, but that violence that has been normalized for years and has to do with hierarchies, as well as the lack of security and of qualified doctors in clinics, the lack of sufficient supplies to provide medical care, and salaries that do not correspond to the workload. Some doctors earn 1750 pesos a fortnight [US $87 every 2 weeks]. All of this generates anger, as does the lack of bedrooms and dining rooms.”
Official Mexican Standard (NOM) 009-SSA3-2013 establishes that medical interns must have a financial remuneration corresponding to their work. In addition, it requires that if an intern’s position is in a remote area and they must stay in the clinic, they should have a suitable bedroom and a dining room where they can eat healthily. For the interns, this is a utopia. They consider that they are used as cheap labor.
“What is expected is that each health center have a hired, qualified doctor, but now we know that there are more than 5000 health centers in Mexico that do not have a qualified doctor; 60% of them have a social service intern and, not only must they attend to patients, but they also take charge of the hospital in administrative matters,” said Castañeda. “It seems that instead of training doctors, the social service works as cheap labor, and we must put an end to that.”
Angélica González, MD, tried to do her social service in the city of Puebla, but she got a position in Acatlán de Osorio, Puebla. In addition to the precariousness in terms of medical equipment and supplies, to get through her social service, she endured sexual and labor harassment from superiors. When she filed a complaint, she received no response.
“They made comments to me about my body, that someone had finally arrived to warm them up, with a good body and face, and that if I weren’t effective in my work it didn’t matter as I could be efficient in another way. I filed a complaint at my university, and it was as if they left me on hold. I filed a complaint with the health jurisdiction and received more violence. They began to steal my gowns, handbags, shoes, even money. I miraculously finished my social service and after a long time I entered a legal process, because I must not allow these people to get away with it,” she said.
Dr Jesús Moreno did his service in the ejido of Los Gatos Güeros, in Linares, Nuevo León, very close to Tamaulipas. In his first week, he witnessed an attempted robbery in the medical unit. At night, the perpetrators tried to enter, broke windows and destroyed furniture in the waiting room, and although the young doctor filed a complaint, he received no response.
“I filed the report, and they didn’t even come to change the lock,” said Moreno. “Since the place borders Tamaulipas, it was common to see well-lined trucks at full speed. They told us to keep quiet, to pretend we hadn’t seen anything. They carried weapons and went by shooting. I had to treat patients with gunshot wounds. I reported it, and there was no solution. It made me very angry that sometimes the funeral services arrived before an ambulance. I reported it and nothing ever happened. There was nothing more to do other than put up with it.”
After 1 year of social service, Moreno said that he did not leave with anything positive. He pointed out, with irony, that it is said that this obligation is about repaying society for the education received, but he said that if the authorities really thought about patients, the latter would not be left in the hands of medical interns, and at the very least each hospital unit should have a qualified doctor and administrative staff.
“[Society] did not give me anything, nor is it that you can give something to society because there are no conditions to do so,” said Moreno. “They ask a lot when they do not give anything. You cannot work, there are no opportunities to do more for the patients or for us. I do not believe that social service should be canceled, but it should be modified so that the Health System does not depend on interns. Because I think if my biggest reward is referring people with appendicitis, women about to go into labor, people with gunshot wounds, to a hospital with the tools to care for them, that’s very disappointing.”
Although the reports he issued elicited no response, and his service was characterized by precariousness, Moreno concluded that what he developed was character and the courage to speak up. “I didn’t want to be another intern who was murdered, violated. We discovered that we can organize ourselves and demand things. Maybe we don’t have immediate results, but we can put in a grain of sand so that the new generations have better conditions. We have to do it, it’s our duty, it’s what we can contribute.”
Research and Outreach
In 2021, Eva Pizzolato, MD, representative of the National Assembly of Medical Interns, had to find a place to do her social service. Although she always dreamed of doing it in a rural community, the murder of medical interns Mariana Sánchez and Fernando Montes de Oca in 2021 forced her to opt for research and involvement.
“I didn’t want to be part of the statistics. I am from Durango, so I saw that I could do it in research and therefore traveled to Mexico City. I learned and did not live in fear that something would happen to me. It is something we can do, look for other options. We all want a complete overview of health in the country, we dream of going to rural communities and supporting, putting into practice what we have learned, but we can also find another path, one that makes us feel safer,” she said.
Bruno Vargas García, MD, also aspired to do his service in a remote community, but he wanted to have support and accompaniment, so he sought out the organization Compañeros en Salud (Companions in Health), where he now works professionally.
“Personally, the year of service changed me,” he said. “It was the best experience. Although I worked in a clinic in a health jurisdiction in the Sierra Madre de Chiapas, I was accompanied all the time, they trained me, and I did not feel vulnerable. I think I would never have dared to do my social service in this community if it had not been for the support of the organization.”
He explained that this organization has an agreement with the National Autonomous University of Mexico (UNAM) and other universities. Each year, it offers a number of places for students who wish to do their social service in rural areas. What made the difference was having a team that supported him at all times. Although he was in charge of giving primary care consultations and went to marginalized areas of between 1500 and 2000 inhabitants, he never did it alone.
“They not only trained me to care for and check patients with chronic diseases, such as diabetes or hypertension, but also to provide emotional support,” said García. “It was not only medical management, but also the incorporation of motivational therapies, breathing exercises, meditation and seeing how you help patients. It is very rewarding. That is why it is very unfortunate that colleagues from the health system are seen as vulnerable and as a number that goes to areas where they do not want to go, not for lack of vocation, but because the conditions that guarantee safety and integrity do not exist.”
Much to Change
Castañeda questions whether there really is academic training, retribution to Mexicans, or whether it is normal for medical interns to be murdered, sexually abused, or assaulted by communities that are dissatisfied with the health service, pointing out that these situations are obviously not normal.
He reiterated that the social service model cannot be based on the needs that Mexico had in 1936, so it should be reconsidered how it will contribute not only to the training of medical interns, but also to the health benefit of all Mexicans.
“From the outset, its duration must be evaluated,” said Castañeda. “Why a year? Because that only fosters this idea that interns are cheap labor to serve marginalized communities where no one wants to go, because the authority would have to take care of that. Secondly, it should be considered whether the scholarship they receive really allows them to have a decent life. And protocols should definitely be put in place with regard to gender, otherwise we will continue to contribute to these bad practices and put the trade and society in danger.”
Meanwhile, Pizzolato emphasized that it is essential that there be punishments for those who assault interns, and sanctions for those who violate others physically, emotionally, or sexually.
“We are thirsty for justice. We do not want more black ribbons, we do not want more violations of medical interns without consequences, we do not want more attacks because the clinics do not have the minimum to offer a decent health service. We do not want more fear of spending nights in abandoned clinics without security. All this must change. It is time for the authorities to listen to us and take action,” she said.
Luna, Castañeda, González, Moreno, Pizzolato, and Vargas report no relevant financial relationships.
This article was translated from the Medscape Spanish edition.