Fiedler, 96MPH, was uncomfortable from the start with the
traditional model of improving health in the developing world. She
wanted a different approach from just bringing in outside resources
and telling a community what to do with those resources. Too many
times, she had seen the results of well-intentioned projects that
proved unsustainable when the project ended—latrines used
as storage sheds, preventive techniques forgotten, abandoned stores
of expired medicines.
“The development model reinforces
unequal relationships,” Fiedler says. “While it may
result in actual health gains—latrines, increased rates of
immunization, potable water––it often falls apart when
agencies pull out, and it often disempowers communities. That’s
a useless investment of materials.”
Fiedler is passionate about fostering
relationships between organizations and the developing world based
on solidarity and mutual respect. She is revolutionary in wanting
to transform society from the grass roots rather than simply reforming
it, and she found just such a revolution in the Zapatista movement
in southeastern Mexico.
For four years, Fiedler worked as
part of a team of health promoters, supported by Concern America,
with disenfranchised indigenous communities in Chiapas. She was
inspired by the indigenous movement, which is creating alternative
and autonomous communities from the ground up.
Chiapas borders Guatemala, with a
population of 3.9 million people who live in largely rural areas
in a state roughly the size of Wyoming. With one of the highest
indigenous population in Mexico, Chiapas has an illiteracy rate
of up to 59% in some areas. Half of the population does not complete
primary school. Living conditions are poor: 45% of homes lack electricity,
74% lack running water, and 90% are without sewage services. Typical
housing is a hut with dirt floor, and cooking is done over an open
According to Fiedler, many factors
have contributed to poverty here, including repression and colonization,
discrimination and racism, failure to enact land reform, and NAFTA.
After the passage of NAFTA, the gap between the rich and the poor
has increased, the minimum wage has decreased, and the number of
Mexicans living in poverty has risen from 32 million to 43 million.
On January 1, 1994, the Zapatista
Army of National Liberation (EZLN) staged an uprising, demanding
democracy, liberty, and justice for all Mexicans. Following two
weeks of heavy fighting, the Mexican government declared a cease-fire,
which the EZLN honored. In December of that year, the EZLN launched
a new nonviolent offensive in Chiapas, and without a single shot,
seized 38 county seats, declaring them rebel territory. By 2003,
the Zapatistas had created committees of good governance to further
establish their work toward political freedom, human rights, education,
and health care.
As a health promoter in two areas
of Chiapas—the Highlands and the Canyons—Fiedler worked
under the direction of a health commission, a committee of health
promoters charged with the task of coordinating the development
of a regional health system, preserving traditional healing practices
and integrating Western medicine. In the Highlands, health promoters
staffed the Guadalupana clinic, the biggest and best-equipped clinic
in the territory, with 100-150 patients daily and an operating theater,
a pharmacy, and optometry and gynecology services. The region also
had another 300 small community health centers.
clinic charged no fees for consultation or medicine. Workers gardened
to provide food for clinic patients and staff, and the clinic embraced
income generation projects such as sewing and handicraft cooperatives.
The health promoters prescribed natural medicines along with pharmaceuticals
and built medical plant nurseries as well.
By contrast, the Canyons, with seven
municipal clinics and 100 small community health centers, had fewer
resources and less outside support for health. In the Canyons, collaboration
with organizations was carried out with careful analysis of how
relationships supported or undermined the autonomy of the communities.
The local governments of both the
Highlands and the Canyons identified their health needs, chose the
programs and projects they wanted, and directed manpower and energy.
To be an outsider and work effectively within the community, Fiedler
had to give up control of the project and to respect the communities’
decisions, needs, and processes. For example, the communities’
health commission identified health training priorities and directed
when and where health promoter workshops would be held.
Women’s health education was
one area identified by the health commission as important to its
communities. Fiedler’s health education team wanted to offer
classes and workshops on women’s health that were segregated
by gender since they would be covering sensitive topics. However,
the health commission insisted that instead they teach co-ed classes.
The health educators followed that directive for a year before the
commission decided to reverse its decision and allow them to offer
separate workshops for women and men.
With the segregated classes, the work
began in earnest, and suddenly, topics that were impossible to discuss
in a mixed group were approachable. Fiedler’s team even trained
the community health promoters to do a pap smear, a “huge
undertaking,” she says, particularly because most of these
women had never had one.
The work on the project took patience and years to accomplish. In
a land where the pace of work is slow, where there are no phone
lines, where meetings have to be arranged across a widespread region
with little transportation, Fiedler had to learn a new way of teaching
health prevention skills. Yet by 2004, her project team had accomplished
what they set out to do. With many new health promoters trained
in women’s health and a continuing apprenticeship established
between the health promoters and a community health center in San
Cristobal, the team felt it had set up a sustainable program.
Fiedler returned to the United States
in 2004 with a different vision of what it means to work in health
care and what she has to contribute. In Mexico, she learned to fully
respect the communities in which she works. She learned to leave
decision-making to the communities themselves and to act in a role
of teacher and learner rather than expert. Finally, she learned
that the process is as important as the content.
Currently, Fiedler coordinates a community
outreach project for a nonprofit hospital in Chicago that serves
a predominantly Mexican immigrant neighborhood. She is working to
increase the population’s access to health care, but she finds
herself in a very different context. “I obviously can’t
turn the reins of the health care system over to the community itself,”
she says. “But I am thinking about how can we start to make
shifts in the way we’re working with and providing services
for the community.”
She is committed to changing systems
that exist for the better. How? “I don’t have all the
answers yet,” Fiedler says, “but I have lots of questions.”