Tale of Two Cities
A long-distance field trip to a Mexico hospital sheds light on how the culture shapes its health care system

By Melissa Gaskill
December 30, 2002

In October, six nurses from University Hospital in San Antonio visited Hospital General Regional de Sahuayo in Sahuayo, Mexico, a town of about 20,000 in the state of Michoacan, southeast of Guadalajara. One of the first things they noticed was the Mexican nurses' white uniforms and caps. But that was only one of many differences they observed between the health care systems of the two countries.

The weeklong exchange was arranged by the Secretaria de Relaciones Exteriores of Mexico as part of its program for Mexican communities abroad. Marco Antonio Fraire, press and community affairs officer for the agency, based in San Antonio, explained that the Mexican government is interested in improving the quality of a variety of services, including health care, for Mexicans living in the United States.

"An exchange like this is a chance to understand each other's systems," Fraire said. "Because San Antonio hospitals care for many Mexicans, the people here need to understand the expectations of patients coming from that system. The trip immerses the participants in the culture so they see how people behave in Mexico and return with more understanding."

University Hospital posted flyers about the trip and was able to take all the nurses who signed up. The Mexican government provided room and board for the nurses, and American Airlines donated airfare.

"This program could be done anywhere," Fraire said. "Our interest is to serve the Mexican community that is already here in the U.S. by showing people our way and telling them about our people." [If your hospital or group is interested in an exchange trip to Mexico, contact the nearest Mexican consulate.]

Nancy Ray, MA, RN, associate administrator at University Hospital, participated in the exchange along with 14 other nurses.

"There was a great deal of value in our nurses seeing the cultural component and expectations there," she said. "For example, we saw how family is so important, and we need to accommodate that here. I gained a personal appreciation for being somewhere and you don't speak the language and can't communicate. I see how that must be for people here who are at their most vulnerable, in the hospital.

"If I didn't believe before that we need Spanish in our hospital, I certainly would now."

First look

The hospital in Sahuayo has 42 beds, an infant ICU, emergency room and a surgical suite. The facility employs about 200 people, 51 of them nurses. According to Arnulfo Degollado, a doctor and administrator of the hospital, doctors and nurses at the public hospital are employees of the federal government. They are assigned to their jobs based on need and seldom change. The hospital serves a large geographic area of mostly rural villages that includes 1 million people. All services are provided free of charge or on a sliding scale to workers and their families. A separate, private health care system serves those who can pay.

The bright blue building is clean and spartan, sunshine streaming into open windows, bougainvillea blooming in a courtyard. Pregnant women accompanied by their mothers, women holding tiny babies wrapped in bright blankets with their husbands and older children, and clusters of old men crowd the lobby. Children run around the patio outside.

Most people come in through the front door; doctors decide if someone needs to go to the emergency room, which has four adult and four pediatric beds, two nurses morning and afternoon, one at night. There is no triage, unless you count the security guard outside who directs people to either the lobby or the ER. The hospital has an ambulance to bring people in from the surrounding area or to take critical cases to a 1,500-bed hospital in Guadalajara, two hours away, which is often full.

The San Antonio nurses said they were impressed with what the hospital and the Mexican health care system do well. For example, a program provides free prenatal care for mothers who agree to have five checkups and inoculations for their babies and to attend classes on breast-feeding and baby care. A diabetes support club meets weekly over breakfast, the members checking on each other, learning about nutrition and other issues.

A system is in place for tracking individuals with HIV. Education programs run by the hospital have reduced childhood deaths caused by diarrhea from 100 a year to three or four. In rural villages, laypeople are trained to provide basic services and refer people to the clinics. Such simple things work dramatically.

Limited resources

But not everything works so well. At a rural public clinic toured by the group, medicines are free, but a doctor confessed that it often doesn't have what is prescribed for patients. The medicine may be available at pharmacies in town, if the individual can afford it.

"We don't have the economic and political resources in Mexico that you do in the U.S. There are fine doctors here, but they don't have the infrastructure and resources to fight diseases," said Pedro Garcia Figuaroa, a doctor at the clinic. "The problem is poverty."

Rosa Sanchez, RN, a med/surg nurse at University, noticed a nearly complete lack of universal precautions, which could be explained by limited resources. "They are doing a lot of good things," Sanchez said. "But I was really surprised by the lack of universal precautions. That is so basic."

AIDS is a problem in this area; posters in the clinic and murals on rural buildings encourage condom use.

"If we don't have the resources to treat the AIDS problem, it affects us all," Figuaroa said. "It is a worldwide problem."

For Ernest Prince, RN, who works in the emergency department at University, the most interesting differences were the lack of triage and the approach to emergency treatment. Prince watched an orthopedic doctor set a broken wrist with no nurse support and little pain medication, using screws and a cast. Patients were discharged from the emergency department with no written instructions, little beyond prescriptions for ibuprofen.

Several of the nurses noted differences in perception and treatment of pain, and said they now have a better understanding of the apparent tolerance to pain they see in their Mexican patients.

"If your expectation is that you won't get pain relief, then you just take it," Prince said. "That could explain the culture, why the men are so stoic."

There is no nursing shortage in Mexico, but that statement can be deceiving. About 70 percent of nurses come from three-year technical programs that students finish at about age 16. The other 30 percent complete five years of training and are licensed. Most licensed nurses work in the large cities. In Sahuayo, only Magdalena Sanchez Urbina, the hospital's head of nursing, is licensed.

Before the trip, Ray predicted that nurses in the two countries would have much in common. "We all hold sacred patient safety, wanting to give the best service and competency. I think we'll find that the patient is at the center of what they do, which will emphasize the universality of patient-centered care."

Ray spent the week with a second group that visited hospitals and clinics in Zamora, an hour from Sahuayo. Her prediction, she said, was right on target.

All the nurses who participated expect to have a better understanding of their patients who come from Mexico.

"I think understanding their health care system will really help when we treat someone here," Prince said.

Contact Melissa Gaskill at gaskill@dbcity.com