by José Carlos Gutierrez:
Four years have passed since Diego Sántiz’s children last attended class at their community school in Oniltic, an indigenous Tzeltal community in the highlands of Chiapas, Mexico. The Sántizes and nine other families were expelled from their community for their activities with an organization of traditional doctors and midwives in resistance to a government-funded health clinic. Many members of their organization landed in jail and some were severely beaten by the community police. An 84-year-old traditional doctor was tied to a post in the blazing sun for 18 hours.
These incidents had nothing to do with the drug trafficking, religious conflicts, or territorial disputes that underlie violence in rural Chiapas. Instead, their roots lie in patterns of patronage and abuse within the Oportunidades Human Development Program.
Oportunidades is Mexico’s flagship social program. Targeting the country’s poorest, it distributes cash stipends to families based on their attendance at doctors’ appointments and health lectures and children’s school attendance. The program provides nutritional supplements to mothers, babies, and undernourished children.
Since the program’s founding in 1997, academics have praised it and foreign governments have imitated it. According to Laura Rawlings of the World Bank’s Human Development Department, Oportunidades is so innovative because it addresses “both future poverty by fostering human capital accumulation among the young… and current poverty by providing income support for smoothing consumption in the short run.”
The monetary support is designed to encourage a more diverse family diet and cover the opportunity cost of a child staying in school instead of working in the fields.
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Although on paper Oportunidades seems like a cure for poverty, its implementation has been far from smooth. Doctors have abused their privileges in some clinics. The government clinic in Oniltic claimed that pregnant women would lose their Oportunidades benefit money if they did not submit to extra blood testing. Sántiz explained, “They refused to tell us why they wanted the blood samples; they never even returned results to the women who did comply. Of course we were going to object.”
A cultural divide exists between doctors and their indigenous patients. Sántiz’s organization opposed both the clinic’s use of papsmears by male doctors and its emphasis on family planning. Dr. Miguel Maza, who administered a rural -clinic in Guanajuato and then left Oportunidades for an NGO, said the program is overbearing in its encouragement of birth control or sterilization right after or even during birth. “They would say things like ‘you see, do you really want another one?’… or ‘Oh! It didn’t hurt while you were doing it now, did it?’”
“Starting with your education as a doctor,” Maza continued, “you are taught that poor people lead better lives if they have less children.” But in an agrarian society like rural Chiapas, having more kids means more hands to work the fields, additional income, and better care for parents in old age. “you’re not going to eradicate poverty by preventing poor people from having babies,” concluded Maza.
Family planning programs, though, are useful in rural communities where gender inequality often restricts a woman’s right to choose how many children to have. Access to contraception is vital. But there is doubt that a push for gender equality really drives the program’s focus on family planning: The program essentially takes control away from husbands only to give it to doctors, not women.
Traditional medicine in Mexico has been haunted by state persecution, not to mention disdain from modern physicians. But the conflict in Oniltic alludes not only to the clash between two medical paradigms, but also between two civilizations: one modern, urban and western, and the other rural and indigenous. Throughout history, the Mexican state has attempted to “integrate” the country’s various indigenous groups into modern Mexican society, which has often meant the loss of indigenous languages, traditions and ultimately culture. For indigenous beneficiaries like Diego Sántiz, Oportunidades can be a double-edged sword, tearing the social fabric that underpins the community’s way of life.
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Doctors also complain that the Oportunidades clinics are poorly staffed and maintained. Maza said that “in practice, [the doctors] are residency students, youth who go into a community for a year and don’t want any problems. They don’t try hard and the workload is heavy. They don’t even give the health lectures.” Maza’s own year with Oportunidades fulfilled his post-medical school requirement for social service.
Many facilities have dirt floors and generally poor infrastructure, says Dr. Aurora Hernández: “you should see where I see patients.” Doña Eufemia of the Marqués de Comilla municipality in Chiapas is one of many Oportunidades beneficiaries who has to walk hours to reach a clinic. She cannot afford to miss a day of work spending hours in the waiting room before an appointment. Nor can she afford to return home empty-handed when the inhouse pharmacy does not have medication.
Almost all healthcare programs would benefit from additional resources. But the most surprising criticism of Oportunidades is that its programs are designed more for international acclaim than for poverty reduction. According to Hernández, the program’s focus on pregnant women is due to the current global emphasis on reducing maternal mortality. She continued, “There are people who Oportunidades really does help, but I see it more as a political strategy… it helps make the numbers look better.” She paused and smiled nervously: “But we’re not supposed to say that now, are we?”
Dr. Gerardo Juarez, who also works with Oportunidades, commented that “the objective isn’t health,” but rather keeping households dependent on the government. Oportunidades can comprise more than half of a family’s income, creating an enormous incentive to comply with the program’s requirements and endowing nurses and doctors who record attendance with considerable power within communities. Oportunidades beneficiaries are not always well-informed on which medical procedures are obligatory and which are not, and if they are, the simple threat of losing Oportunidades benefits can often persuade them to comply with any extra-official demands made by clinic personnel. The conflict in Oniltic provides an example of this scenario. According to Sántiz, “There are people who say, ‘the government is our father. We have to obey…’ It’s a way of dividing us and winning us over. To me, that isn’t aid.’”
In April, the government recalled all government doctors—essentially terminating Oportunidades benefits—from the Montes Azules Reserve, a stronghold of the indigenous political movement Zapatismo. “They left without ever saying why,” remarked José Alfredo Esqueda. “The only explanation I can see is that they’re being punished for being Zapatistas,” arguing that the government may be using denial of care as a weapon against political dissidents.
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Oportunidades has helped many of Mexico’s poorest, and its focus on women and girls is intended to help close the gender gap in Mexico: Stipends are higher for girls and are usually channeled through women to help overcome roadblocks to female education. But when a program affects social behavior so strongly, it is important to question whose rights are being respected—and whose are not—in the process.
Perhaps surprisingly, Mexican law offers a solution to the conflicts involved in the implementation of Oportunidades. According to Esqueda, the program currently violates Article Two of the Constitution, which requires programs affecting indigenous populations to “be designed and operated jointly with [the indigenous communities].” This coordination is certainly not practiced with Oportunidades, and the failure is no exception to the rule: In Mexico, the letter of the law hardly determines the practice.
With Oportunidades, at least, the root of the problem points to a potential solution: respecting indigenous culture and autonomy. This is surely easier said than done, but only within a framework of equality can rural healthcase improve and a truly pluralistic society become possible. “If the law was followed,” explained Esqueda, “and indigenous people had a real say in how the program was applied in their communities, perhaps Oportunidades could work.”
*Some names have been changed to protect the identities of the sources.
José Carlos Gutiérrez ’11 is a History major in Silliman College. Contact him at jose.gutierrez@yale.edu.