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  Leslie 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 fire.
     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.
       The 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.”


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