At the beginning of the twentieth century, Mexico’s flagship national university was criticized by the Mexican government for being removed and detached from the rural pueblos, where scientific advances rarely caused improvements in living standards. During the populist Lázaro Cárdenas’ administration of 1934-1940, the very existence of public universities, autonomously operated since 1929, was threatened for their elitism and lack of utility in improving the lives of the general population. Perhaps in part as a measure of self-preservation, Dr. Gustavo Baz, Director of the National Autonomous University of Mexico’s School of Medicine, made a momentous announcement to the sixth-year medical students in 1936. They were told that instead of graduating that year as expected, they would be required to serve the most rural parts of their nation as medical pasantes, intern physicians.
This program, what would later be called the social service year in medicine, was subsequently mandated for all Mexican medical students by federal law. Though well-intentioned, it was seemingly filled with contradictions from the start. The program was born out of pressures to provide services to the pueblos but initially coincided with repressive Hispanicization campaigns to ‘modernize’ indigenous peoples by suppressing everything from indigenous languages to customary clothing, particularly in southern Mexico. Moreover, while Baz Prada created the program to preserve the maintenance of public but autonomous universities, the pasantes have very much functioned as instruments of the state. After the students are first placed in their communities, the universities essentially transfer responsibility to the Ministry of Health or other state-led so cial institutions, which have at times been criticized for emphasizing data collection over patient care. Despite the program’s initial purpose to appease Cárdenas’ socialist administration, the social service program shifted the blame for urban-rural health disparities from the state to the pasantes. The social service program’s failure to emphasize fundamental problems, such as inadequate social, medical, and economic resources, could then lead the rural public to blame poor health outcomes on their local community pasantes’ poor performance. This shift in focus has caused a misframing of possible solutions to the health disparities and to the challenges of the social service program.
The contradictions of the program have never been fully resolved. In response to continuing social disparities and inequalities, though certainly not a direct result of the social service program, the indigenous Zapatista movement began in the 1990s for effective democracy, and continues to call for liberation from harmful hegemonic actions of the Mexican federal government as well as the US government and business interests. The annual arrival of medical students, who come without significant prior experience in primary care and often lack sufficient medicines and medical technologies to work with, has represented ineffective government intervention in the state of health care in rural communities. Many pasantes, for their part, have reported that their patients live in desolate conditions due to their own inability to help themselves. While the social service year was created to bridge the discrepancy in the quality of medical care between the elite and the residents of the pueblos, few physicians remain in rural areas after their social service year, causing a severe maldistribution of doctors.
Yet the negatives should not be over stated. The revolving door of pasantes does bring medical care to marginalized areas, usually free of charge. Consequently, Mexico has been making strides in health outcomes. According to the Global Burden of Disease Study, life expectancy in Mexico increased by three to four years from 1990 to 2013 alone, and states with the most severe marginalization outperformed the national average. In addition, many pasantes are truly welcomed in indigenous communities and report being valued for their time and efforts. Modest changes have been made to the program to give pasantes more choices of station sites and more support once they arrive. For example, some re search and hospital based positions are now available for the students who feel they would not be effective or comfort able practicing in rural areas. However, these positions are highly competitive and do not directly address the poor access to primary care in rural areas. Though there are occasional educational seminars and supervisions to strengthen pasantes’ skills, financial and logistical limitations have kept these attempted improvements modest and infrequent. More broadly, the program has been considered a pioneer in Latin America, inspiring similar medical social service programs in Colombia, Chile, and other countries.
Still, the program now sits on unstable ground. The stipend that pasantes receive is hardly enough to cover basic expenses. The placement process, in which students with the highest grade point averages are given the first choice in where they will serve, often results in the most talented students choosing positions in the least marginalized areas. Ministry of Health evaluations, focused on properly collecting statistical data and filling out extensive paperwork, shift the focus away from patient care. Moreover, after multiple cases of murder and several cases of sexual assault inflicted on pasantes, some argue that the social service year should be scrapped altogether. What that would mean for hundreds of thousands of Mexicans living outside the range of a graduate physician is uncertain and worrisome.
Now, 81 years after Baz Prada gave his announcement to the first generation of future pasantes, it is time for changes in the social service year in medicine. What those changes will look like is yet unknown; in particular, the urgent question of personal safety yields no easy solution. Yet one thing is clear: the success of the social service year is inextricably linked to the quality of the overall health care system. If clinics can be supplied with sufficient medication and tools, and if pasantes can receive better professional support, the pasantes’ work will prove to be more effective. These results will cul tivate a greater sense of trust and admiration among patients, yielding a better experience for the pasantes. Lastly, more extensive improvements to the problems in Mexico’s health system, including the limited socialized medical insurance program Seguro Popular, maldistribution of medical facilities, insufficient educational focus on primary health care, and general scarcity of resources, should be realized. When these health disparities diminish, the contradictions in the social service year in medicine will be resolved more quickly.