Direct Democracy and Health Care in Zapatista Land:
 A Doctor’s Experience on the Day of Political Transition


by Michael Kozart

It is October 8, 2007. From my perch in the health infirmary (casa de salud) of the Zapatista village of Emiliano Zapata, I can see straight across the open plaza to where the day's festivities are just beginning. People are assembling next to the building where the Autonomous Council meets, and it is the transition of this council, an event that occurs once every three years, that accounts for the fiesta, which began yesterday and ends tomorrow. Today is the official sign-off day, where the outgoing Council members hand their responsibilities to the incoming members, and the ceremony is a somber one, preceded by a Catholic mass and the singing of the Zapatista hymn, as well as the hoisting of two flags: one of Mexico and one of the EZLN, the Zapatista Army of National Liberation.

The village of Emliano Zapata is the seat of local government for the surrounding Zapatista municipality of San Manuel.  Zapatista land is basically organized into five different regions called caracoles, each of which consists of a number of municipalities. Each caracol is governed by a board (the Junta of the Good Government), which consists of representatives from the autonomous councils of all the municipalities that make up a given caracol. The Spanish word caracol has multiple meanings. Literally it translates as a snail or conch shell which evokes the image of a home or, alternatively, in the case of the conch, the horn blast that calls Zapatistas together for events and encuentros. The spiral image of the shell is also symbolic of the human heart in Mayan belief, which implies that the caracol is the central organ of Zapatista life.  The political bodies of the caracol, the junta and the autonomous councils, mediate disputes, establish development projects, manage economic cooperatives, oversee education and health care, etc. It is little wonder that the three-year transition of the Autonomous Council is a very important event and that San Manuel has pulled out all the stops for this fiesta. Later today there will be a basketball tournament featuring teams from villages all over the municipality, and then, at night, music and cumbia dancing until the wee hours of the morning.

My role today is to be stationed in the casa de salud, for I have come to Emiliano Zapata as a medical doctor interested in the Zapatista health care system. I am also part of a group called the Chiapas Support Committee (CSC), which has been invited by San Manuel's autonomous council to participate in the festivities. The CSC is a non-profit organization that has worked for years to support key development projects in San Manuel, the most recent of which has been the construction of a pharmacy warehouse (farmacia bodega), which now proudly sits beside the house of the Autonomous Council. Within months this sturdy concrete and cinderblock building will be stocked with medications and medical supplies that will be made available at affordable prices to the people of San Manuel, and indeed to everyone in the neighboring region whether or not they are Zapatista, because the Zapatistas hope projects like the bodega will benefit the entire region. As the famous Zapatista slogan states, everything for everybody, nothing for ourselves  (para todos todo, para nosotros nada).

Since my current visit to Emiliano Zapata coincides with the fiesta of political transition, there are health promoters from all over San Manuel present in the village today, and I am able to talk with them about the kinds of public health problems they are seeing, how they provide care with so few resources, and their vision for a future health system in Zapatista land. Their main constraints are the lack of money to purchase medical supplies and limited access to hospitals. The closest hospital to San Manuel lies in Ocosingo, a city of about 35,000 inhabitants about a three- hour drive from Emiliano Zapata, assuming the dirt roads are passable and reasonably dry. There is also another hospital in Altamirano, about a six-hour drive from the village, run by the Sisters of Saint Vincent de Paul. Getting to either hospital is difficult under the best of conditions, and a veritable nightmare in the midst of a medical emergency. The promoters talk about their dream of an ambulance, fully stocked with emergency equipment, as well as the enhancement of a central clinic located in La Garrucha, the village where the Junta meets. They also speak about their legacy of traditional Mayan medicine, and their hope to cultivate and spread knowledge of medicinal herbs, both as a means to maintain aspects of indigenous culture and to achieve health care sustainability.

The need for a self-sufficient health system is not just a function of the geographic and financial inaccessibility of vital medical services. There is also the harsh political reality that confronted the Zapatistas when they first rose up in 1994 and which persists today. The Mayans who formed the EZLN faced imminent displacement by large-scale ranchers and industrialists who were (and have been) intent on using ancestral Mayan lands for private gains. The North American Free Trade Agreement, which went into effect on New Year's day 1994, would have paved the way for the appropriation of resource-rich regions of Chiapas by outside investors, forcing villagers off their land and into the swelling class of landless low-wage earners crowding Mexico's maquiladora sector. In 1992, in an act of naked aggression against the indigenous people of Mexico, then president Carlos Salinas modified one of the key provisions of the Mexican constitution that had been enacted after the Mexican revolution of 1917 to forestall the displacement of native communities from their land.  The famous Article 27 expressly prohibited the sale or transfer of land that was held in common. Salinas made it possible for these land tracts, or ejidos, to be sold (or, more properly, seized) to enable the industrialization of the countryside and to spurn Mexico's integration in the global economy under NAFTA.

In 1994 the Zapatistas finally said enough, moving to reclaim land that had been taken away from them or that they were in danger of losing. The struggle continues today in the form of military checkpoints, harassment, discrimination, and in some cases outright hostility perpetuated by paramilitary organizations that are backed by wealthy ranchers. The ranchers in turn exert enormous influence over the state government of Chiapas, which the Zapatistas simply refer to as the "bad government." Not surprisingly, many Zapatistas feel uncomfortable about traveling outside the safety of their communities to seek health care in government-sponsored clinics and hospitals in neighboring cities like Ocosingo, which happens to be the seat of local power for the bad government. In fact, during my present visit to Chiapas, elections were held in municipalities throughout state, and in the municipality of Ocosingo, the reigning PAN party president was reelected, all but insuring the legacy of bad government for the region.

        As we sit and talk in the casa de salud, the current Zapatista plan for health care in San Manuel is described to me. It involves the construction of a number of clinicas, which are much more substantial than the casas de salud. The one that I'm in is a rough wood hut with a cement floor, several shelves for medical supplies, and of course no electricity. In fact, there is no electricity in the village, and this is ironic given the presence of newly erected electric power lines alongside the main road through the village. I was told that this is merely one example of the corrupt nature of the bad government. Electric power is granted as a political favor, not as a right.
There is also a clinica being built in Emiliano Zapata supported by another NGO from the Basque country of Spain called Paz y Solidaridad. This clinic, when complete, will complement the farmacia bodega, transforming the village into a hub for health care in the entire municipality.  However, everything that happens in the near future, as I am told, will depend upon the ongoing collaboration between the Zapatistas and outside organizations because buildings, medications and medical supplies cost money, of which the Zapatistas have very little. In fact, when we arrived in Emiliano Zapata two days ago and I toured the casa de salud, there were hardly any medications to be had. The local health promoter of the village informed me that they were desperately in need of antibiotics, especially ones to treat infectious diarrhea.

Yesterday I traveled with the health promoter all the way to Ocosingo to purchase medications with money that the CSC had raised. By Zapatista standards, this was a vast sum, about 600 U.S. dollars.  Although I was a bit disappointed about missing the first day of the fiesta in the village, the long drive gave me a chance to ask a lot of questions.  I was especially curious about the importance of the fiesta and how much that reflected the importance of the Zapatista political process. He told me that elections for the incoming autonomous council had taken place three months ago and that they were the result of an elaborate process involving many meetings and discussions about the future of San Manuel, and indeed of the entire Zapatista movement. I was told that everyone voted. There was never a question of not voting.  Nor was the voting a question of money and fundraisers, expensive ads and flashy stump speeches. It was the product of simple town hall meetings and serious discussions. And the more we talked, the more it occurred to me that what seemed to be of importance for this fiesta was the political process itself, the fact that people had come together to directly shape their own future. The autonomous councils and juntas are the Zapatista government, and it is truly a government built from below, or  "below and to the left" as the Zapatistas say. All this was in stark contrast to the flashy, money and political machine-dominated elections that recently took place in the parallel bad government system of Chiapas, which resulted in yet another cycle of corrupt leadership for the municipality of Ocosingo.

We returned to Emiliano Zapata with boxes loaded with medications, and today I will be doing health consultations. In fact, although most of the people in the village are assembled at the political transition ceremony, a rather long line has also begun to form outside the casa de salud.  We have arranged that I will see cases throughout the morning and early afternoon, and that I'll work with two health promoters at a time. I am quite excited about helping, and learning, for already in my discussions with the promoters I've been impressed with their level of medical knowledge and their practical solutions to common health matters. As necessity is the mother of invention, they have evolved many creative clinical techniques.  I am currently trying to grasp the mathematical formula they use to figure out pediatric antibiotic dosing. It is like nothing I've ever seen before. I compare their values to the ones I usually get from reference books, and I see that they are all consistent. I'm impressed! I'm hoping to use this formula when I return home to the clinic I run in California.

With the medications we bought in Ocosingo, we begin our consultations. The first patient is a middle-aged woman with very high blood pressure. She explained that she had received a prescription from a doctor in Ocosingo but did not have the money to buy the medication from the pharmacy. Fortunately, we had purchased some anti-hypertensives and were able to write a prescription for her. She immediately asked how much it would cost. It is at this point that my first real lesson in Zapatista health care occurred. I had assumed that medications we purchased would be passed onto the compas free of charge. However, the promoters explained that it is customary to pay for medications because this is what keeps the clinics going. It is what enables them to purchase more supplies.  Zapatistas generally have very limited means to acquire real money, and the economy (at least in San Manuel) is based around subsistence farming. Nonetheless, it is possible to earn some cash from the sale of surplus beans or corn, or farm animals like pigs, chickens and cows, or from small manufactured goods like hand-woven garments or hand-stitched shoes.  The point of all this, as it was explained to me, is sustainability. Each individual is expected to earn what they can to survive, and by paying for their own needs, they help to subsidize a system of care that can provide for everyone. Collectively, through projects like the farmacia bodega, the Zapatistas are doing whatever they can to lower the cost of essential goods, but the entire system rests upon each individual effort to obtain these goods for oneself, so as to enable the system to purchase goods for everyone else who can't afford them. In the end, perhaps because it was the day of the fiesta or perhaps because the village had such an abundance of new medications, we ended up giving most of what we had out for free, but not without this important lesson drummed into me by each of the promoters: the goal was for everyone to do the best they can to provide for themselves and, in so doing, to provide for everyone.

We left Emiliano Zapata the next day, just as the basketball tournament was in its final few rounds. The cash prize for the winning team would be 400 pesos (about forty dollars), and by the looks on the faces of the players, it was obvious that this was a very serious purse. As we made our way out of the village along a steep dirt road, it occurred to me that there was something organic about the entire experience. The fiesta of political transition was essentially a celebration of autonomous political empowerment, of direct democracy, and the health care system too was predicated on the effort of individuals to contribute to the collective system. The Zapatistas do not govern from above, and the people do not expect handouts or, for that matter, to be lifted from their suffering by any outside force. Rather, the government arises from villages, just as the health care rests on what each individual can contribute to the system. All this makes sense in terms of the spirit of communalism, of indigenous solidarity. In the end, I keep coming back to the image of the heart, the symbol of the caracol. The logic of the system seems to be that each individual makes a difference. No one is obscure, and no one is superfluous. Everyone works hard because they are all part of one very actively beating heart, and this heart is beating, I believe, for everyone.