It is hard to evaluate the success of a small, grassroots program like Project Piaxtla--especially when it comes to gauging its contribution to long-term social change, which is the ultimate determinant of health. Piaxtla and the organization of poor farmers that grew out of it have sparked a process of empowerment which has had a limited but significant impact locally. Child mortality has declined to 20% of what it was when the program began. Despite a drop in real wages in Mexico as a whole, extreme poverty in the program's area of coverage is less common than it used to be. The gap between rich and poor in the distribution of land, wealth, and power has narrowed substantially. And the people's election to conserve their ejido status for the time being helps make their gains in land and health more sustainable.

But the Piaxtla team knows it is playing with fire. The government has made several attempts to shut down the villager-run program. Members of the Piaxtla team and of the organization of poor farmers have been jailed and threatened. The government has also tried to put Piaxtla out of business by starting its own rival health services in the area (instead of turning its attention to the many areas of Mexico which are still without health services). Paradoxically, however, while the government clinic has seriously weakened Piaxtla's actual health service (which is currently in disarray) it has also freed the program's most motivated health workers to focus on addressing the more basic social, economic, and political causes of poor health. In the final analysis, the Piaxtla team's work in these areas has done far more to reduce child mortality and improve people's health--and overall quality of life--than a narrow medical approach alone could have accomplished.

Now in the 1990s, the villagers recognize that the future is less certain than ever. They foresee that the improvements in health won through years of community organizing and struggle may be lost tomorrow due to greed-driven global policies. They have seen the constitution that their forefathers fought for violated by foreign powers in conspiracy with their own self-seeking leaders. For them, the "free trade" agreement is not free; it has cost them their land, their health, their most basic human rights, and the dignity of self-determination. The plight of poor farming and working people in Mexico is not an isolated situation. Similar hardships are being wrought on disadvantaged peoples in every corner of today's endangered planet. The global power structure--comprised of big government, big business, and the international financial institutions--has imposed its New World Order worldwide. It has tied most areas of production and development to the global market in a way that benefits powerful interests and weakens the bargaining power of the poor. Today no nation--and, indeed, virtually no village--has the liberty of self-determination.