Piaxtla's Evolution: from Curative Care to Social Action

In this setting, Project Piaxtla's strategies to improve health evolved through three phases. In its earliest phase it had no political agenda, but focused on curative care, the immediate need of the people. Village health promoters were trained using participatory, learning-by-doing methods, and became relatively competent in the treatment of common illnesses and injuries. But as time went on, the health team and the villagers it served became aware that the same illnesses and injuries kept recurring. In response, they gradually shifted the program's focus to preventive and promotive measures such as immunizations, latrines, and water systems. As a result, during this second phase of the program, certain illnesses became less common and health improved noticeably. Fewer children died of tetanus and whooping cough, and fewer were left disabled by polio and complications from measles. Nevertheless, many children and women were still malnourished and sick, particularly in years when harvests were not good. The Under-Five Mortality Rate remained high, especially among children of the poorest families, who were landless, underpaid, underserved, and in many ways taken advantage of by a small minority with land, wealth, and power. So the program's main focus changed again: this time to organized action to defend people's basic needs and rights. In this way, the village health program evolved from curative care to preventive and promotive measures to sociopolitical action.

The shift in the program's focus from more conventional health measures to organized action was partly the result of a learner-centered, discovery-based, problem solving approach to health education. Workshops led by health promoters with farmers, mothers, or schoolchildren would start off with a "situational analysis" or "community diagnosis" in which participants identify and discuss health-related problems in their community and how these problems interrelate. Rather than looking at the death of a child as having a single cause (such as diarrhea), they would learn to explore the chain of causes that leads to that child's death. The links would be identified as biological, physical, cultural, economic, and political, or (in simpler terms) having to do with worms and germs, things, customs and beliefs, money, and power.

In the early phases of the program when the focus was mainly curative and preventive, the links people identified in the chain of causes tended to be mostly biological, physical, and cultural. The chain traced back from a child's death from diarrhea might have included death, dehydration, diarrhea, gut infection, germs carried from feces to mouth, and lack of latrines, hygiene and sufficient water. But as people began to explore more deeply, the chains of causes they discovered tended to include more economic and political links. For death from diarrhea, the chain might now include: death, frequent bouts of diarrhea, undernutrition, not enough food, no money, father works as a sharecropper, good farmland held by a few rich men, land reform laws not applied, payoffs to government officials, institutionalized corruption, lack of participatory democracy, insufficient organization and action by the people. After common problems and the root causes were defined, the group would explore possible solutions. Sometimes this was done through story-telling or role plays, or--to involve a wider audience--by publicly staged "campesino theater." Finally, when the group agreed that the circumstances and timing were right, a strategy for action might be developed.