Equitable Mental Health Care – From Rural Nepal to Rural Mexico

by Pragya Rimal

In July 2017, on my first day as a HEAL Fellow I found myself in the back of a van traveling to the redwoods in the mountains of Santa Cruz, California for the HEAL Global Health Training. I was traveling with other fellows and members of the HEAL team. These were people from different walks of life, who I’d be spending the first 2 weeks of my global health journey alongside. I experienced some nervousness masked with excitement to meet inspiring health care workers from around the globe. I was eager to learn about their stories and to make connections.

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Pragya Rimal (second from right) visits communities in rural Chiapas alongside colleagues from Compañeros en Salud

The first fellow I had a heart-to-heart conversation with happened to be Fátima Rodriguez – who oversees the mental health programming at Compañeros en Salud (CES) in Chiapas, Mexico. After only 10 minutes of conversation about our different sites and how we work, I knew I wanted to visit CES to learn about their approach to mental health care. During the Global Health Training, I had the opportunity to learn about CES and their interventions for chronic conditions, including mental health. These approaches have some similarities and are complementary to our work with Possible in Nepal on community health programs, where community health workers (CHWs) visit patients at the community to follow up on their chronic conditions and encourage medical adherence and hospital visits. The community-based intervention for mental health at CES involves screening, counseling, as well as providing psycho-education at the community level. Mental health care at Possible is mainly hospital-centered but at CES, even treatments (e.g., psychotherapy) are delivered by CHWs.

As we are aiming to scale up community integration at Possible, an opportunity to do a Site Exchange to CES through HEAL gave me the opportunity to learn from CES and to share our experiences in task sharing at the facility-level while learning from CES about the work in the community. CES has a robust community-based intervention and at Possible we are hoping to do the same. The ideal intervention would have strong components that are facility-based (which Possible has) and community-based (which CES has), so there were plenty of opportunities to share our experiences and learn from

one another. In the HEAL network, all of our fellows and partner sites do incredible work and there is so much knowledge, expertise and stories to learn from.

Site Exchange to Chiapas, Mexico

Before my visit to CES, I was expecting to see a lot of similarities between our rural working areas in Mexico and Nepal: lack of specialists, stigma attached to mental health, and a remote, under-resourced community. I wanted to learn about training and deploying CHW

Pragya Rimal and Fátima Rodriguez walk to visit patients in Chiapas.

s to address mental health despite these challenges.. Once I was in Chiapas, I was awestruck with several other similarities between our work sites. On our drive to the CES districts, the weather (hot!) and landscape (beautiful) felt strikingly similar.

Activities in Jaltenango

At the CES office in Jaltenango, I was stunned to see to see the sense of community among CES team members. At our site in Possible, despite a great sense of communal belonging among all staff, we live with the people we work with and often find it challenging to create a meaningful work life balance, while constantly being surrounded by your colleagues. It was encouraging to see other professionals in similar situations akin to the way we worked and lived.

I was fortunate to be present for the monthly ‘courso’, where all of the pasantes (young physicians completing a social service year) return from the communities in which they work for a multi-day global health course with members of the CES team. Despite the coursework being in Spanish, team members were generous enough to spend time with me before, during and after the training to answer my questions and include me in their discussions. I cannot fathom the volume of hard work and meticulous planning that goes into planning and executing this monthly coursework. On the last day of the training, we’d scheduled a 1-hour session to discuss our work at Possible, with a focus on mental health. In spite of the odd hour and after the long day of training, the energy from the audience was uplifting and contagious. We actually spent about 2 hours discussing our work at Possible!

Visit to the Communities

I had the opportunity to join Fátima, my HEAL co-fellow, on home visits in the community of Soledad during her supervision of pasantes. Community visits, be it in Mexico or rural Nepal, are always a very humbling experience. The first patient we visited was an adult man with Schizophrenia. The man, like many in resource poor settings without a strong mental health care system, had been chained for about 20 years. It was astounding to learn that, through CES’s interventions and mental health care, the man was recently unchained. This is the exact kind of impact that we are all working toward – to see our interventions work, to be respectful, and to offer opportunities for patients to live more dignified lives. At another home we visited, we encountered another man still chained by his feet. While this was not a joyful story, speaking with the team, I learned that this was the most stable and oriented the man had been in years. The next step is to have him unchained. I was struck by how the CES team was extremely compassionate and patient with both of these patients and showed mutual respect and fondness for them. I wish that all health care providers were adept with such humility!

Change is a gradual process but sometimes we tend to forget that. Those visits to the communities in Chiapas were a gentle reminder that if we were able to have one patient unchained, we can have similar impact on others too. Much has been done and there’s a lot more to do. These patients live thousands of miles away from my community, but seeing them get better gave me a sense of accomplishment. It made me realize that we are all fighting for the same things, in different ways and on different fronts: equitable access to health. So a win – whether in rural Mexico or rural Nepal – is a win for our whole community working toward health equity.

HEAL Fellows (left to right) Marwa Saleh, Pragya Rimal, and Fátima Rodriguez in Jaltenango, Chiapas.

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