Modernization and rural health in Mexico: the case ofthe Tepalcatepec Commission

Stephanie Baker Opperman

Rowan University, Department of History, 201 Mullica Hill Road, Robinson Hall, 2nd Floor, Glassboro, NJ 08028, United States

Feature Endeavour Vol. 37 No. 1 Full text provided by www.sciencedirect.com

Mexican policymakers instituted community-basedhealth programs in the 1940s and 1950s to encouragerural participation in state-sponsored health and eco-nomic development initiatives. The Tepalcatepec Com-mission (1947–1961) united previously independentgovernment programs into a multi-tiered collaborationthat addressed regional development through national,state, and local networks. While national policymakersand state officials designed plans to improve agricultur-al production, promote industrialization, utilize thearea’s natural resources, and expand communicationchannels, health workers established unprecedentedrelationships with indigenous community membersby introducing the Commission’s projects in culturallyrelevant ways. They used their on-the-ground experi-ences to learn local languages, customs, and beliefs, andincorporated these factors into their health educationand disease treatment campaigns. The result serves asan example of short-term cooperative relationshipsbetween healthcare workers and indigenous groupsthat not only reduced the major health risks in thearea, but also paved the way for collective economicdevelopment.

The creation of the United Nations (UN) in 1945 led toincreased debate among national leaders regarding theprotection of the rights, welfare, and health of all individ-uals. As historians have noted, ‘individual and collectivehealth was now considered by representatives of the Unit-ed Nations to be ‘‘fundamental to the attainment of peaceand security’’’.1 By linking health to larger political andeconomic motivations, UN officials helped instigate a the-oretical shift from the individual to the collective needs of asociety. In other words, healthy communities became thenew model for national and international economic re-building. Consequently, policymakers in Mexico andaround the world looked for ways to incorporate many ofthe prevailing world concepts of health community, medi-cine, hygiene, government assistance, and collective well-being into their modernizing agendas. According to the1940 census, nearly 65% of Mexicans lived in rural areasand 15% of Mexico’s population was indigenous.2 Althoughrural populations constituted the majority of Mexican

Corresponding author: Opperman, S.B. (opperman@rowan.edu)1 Alexandra Minna Stern and Howard Markel, ‘International Efforts to Control

Infectious Diseases, 1851 to the Present’, The Journal of the American MedicalAssociation 292:12 (September 22/29, 2004), 1474–1479.

2 Emilio Alanis Patino, ‘La Poblacion Indıgena de Mexico’, in Miguel Othon deMendizabal (ed.), Obras Completas, tomo uno (Mexico City: Cooperativa de los Tal-leres Graficos de la Nacion, 1946).

Available online 14 December 2012

www.sciencedirect.com 0160-9327/$ – see front matter � 2012 Elsevier Ltd. All rights reserve

society, these groups were significantly underserved bymedical professionals and state assistance programs.3 Asa result, beginning in the late 1940s, health officials uti-lized advancements in science and technology, as well asanthropological studies of indigenous communities, to re-formulate rural public health programs from uniform na-tional campaigns of the 1920s and 1930s into moreculturally relevant projects at the local level.

In order to adequately serve indigenous communities,Mexican health workers focused on establishing new col-laborations with native populations. There were severalreasons for this. First, they hoped to improve relations withgroups of people who had grown to mistrust governmentofficials. Medical care had previously been utilized as aform of social control, but healthcare workers in this periodstrove to move beyond this top-down method to offerservices they hoped would be useful to their targetedpopulations. Second, health officials wanted to understandlocal languages and customs in order to communicate moreeffectively with community members. While critics justifi-ably argue that some officials focused on learning indige-nous languages as a stepping stone toward incorporation,improved communication was nevertheless a crucial short-term requirement for developing culturally appropriateapproaches to healthcare.4 Third, given the lack of avail-able state resources for health initiatives, healthcare work-ers needed collaborations with local groups to offset theirlimited personnel and budget. Rural volunteers, commu-nity participation, and local financial contributions there-fore became crucial aspects to carrying out new publichealth programs.

The work of former president Lazaro Cardenas and theestablishment of the Tepalcatepec Commission shows howhealthcare workers attempted to foster collaborative rela-tionships with indigenous groups in rural Michoacan.Their work showcases the delicate mediation required toserve both the national development agenda and localhealth needs. As health workers visited communities inremote mountainous regions of the state, they worked withlocal leaders to reformulate state-sponsored health cam-paigns into culturally meaningful programs. As the case ofthe Tepalcatepec Commission exemplifies, indigenousgroups gradually accepted the new health initiatives andcooperated in economic development activities as a way toelevate their standard of living.

3 Miguel Othon de Mendizabal, ‘Por el mejoramiento de la salubridad en Mexico’, inin Miguel Othon de Mendizabal, Obras Completas, tomo sexto (Mexico City: Coopera-tiva de los Talleres Graficos de la Nacion, 1946).

4 Guillermo Bonfil Batalla, Mexico Profundo: Reclaiming a Civilization (Austin:University of Texas Press, 1996), 115.

d. http://dx.doi.org/10.1016/j.endeavour.2012.10.005

Map 1. A Map of the Cuenca del Tepalcatepec. Imagen tomada de: Aguirre,

Beltra n, Gonzalo. Problemas de la Poblacio n Indıgena de la Cuenca del

Tepalcatepec. Memorias del Instituto Nacional Indigenista, Vol. III. Me xico: INI,

1952, p. 31.

48 Feature Endeavour Vol. 37 No. 1

Lazaro Cardenas and the Tepalcatepec River BasinThe Tepalcatepec basin encompasses twenty-seven munic-ipalities in the Mexican states of Michoacan and Jalisco.The region is surrounded by mountains to the north, south,and east, and borders the Pacific Ocean to the west. Thesenatural barriers have been a large factor in the area’sisolation. At the same time, the basin also comprisesconsiderable ecological diversity from the high altitudeforests of the Tierra Frıa, through the warmer valleys ofthe Tierra Templada, to the hotlands of the Tierra Calienteand the coast. In 1950, around 300,000 indigenous, Euro-pean, and mixed-race people lived in the region.5 Twoindigenous groups, the Nahua and the Tarascans (or Pure-pecha), inhabited the region prior to the arrival of theSpanish. But, during the colonial period, famine, enslave-ment and new diseases such as smallpox all but wiped outNahua groups. At the same time, European and mestizoimmigration into the fertile valleys of the Tierra Templadapushed the remaining Tarascans toward the mountainoushighlands of the Tierra Fria, where they survived throughsubsistence agriculture and the production of artisanalhandicrafts. Even here, non-indigenous migration in-creased and by the 1940s only twenty per cent of highlandsspoke the Tarascan language (Map 1).6

Despite ecological and cultural differences, both theindigenous and mestizo populations suffered similarhealth risks and environmental dangers. In general, ‘rapiddevelopment of the area. . .was held back by the lack ofadequate communications and by the generally unhealthyconditions’.7 Gonzalo Aguirre Beltran, a well-known Mexi-can anthropologist conducting a study of the Tepalcatepecbasin in the 1950s, referred to the area as a:

Deadly land where botany and zoology exercised astranglehold, where pestilence and vermin were reg-ular guests of man, where deaths exceeded births andsocial disorganization could not be more apparent. . .8

The tropical climate of the region was favorable foragricultural production but heavy rains could leave stag-nant pools of unsanitary water.9 Drainage and irrigation,available near the regional center of Uruapan, barelysufficed to meet the needs of inhabitants in outlying areas.Lava from high volcanic activity infected the soil andcontributed to the population’s poor health. Farmlandswere also constantly invaded by vermin, which dominatedliving spaces and helped spread disease.

Although President Miguel Aleman (1946–1952) estab-lished the Tepalcatepec Commission, the project was thebrainchild of one of his predecessors, ex-president, LazaroCardenas (1934–1940). Originally from Michoacan, Carde-nas first became aware of the poor health and livingconditions along the basin of the Tepalcatepec River while

5 David Barkin and Timothy King, Regional Economic Development: The RiverBasin Approach in Mexico (London: Cambridge University Press, 1970), 120–124.

6 Gonzalo Aguirre Beltran, Problemas de la Poblacion Indıgena de la Cuenca DelTepalcatepec, Vol. I (Mexico City: Fondo de Cultura Economica, 1995), 25.

7 Barkin and King, Regional Economic Development, 126–129.8 Gonzalo Aguirre Beltran, Problemas de la Poblacion Indıgena de la Cuenca Del

Tepalcatepec, Vol. II (Mexico City: Fondo de Cultura Economica, 1995), 130.9 Comision Nacional para el Desarrollo de los Pueblos Indıgenas, Centro de Doc-

umentacion ‘Juan Rulfo’ (hereafter CDICDJR), Secretarıa de Recursos Hidraulicos,‘Comision de Tepalcatepec’, FD 39/0033.

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working on his uncle’s farm on the outskirts of Apatzingan.Much of his military service during the Revolution was alsospent in the region’s flatlands.10

After being elected Governor of Michoacan in 1928,Cardenas introduced railroad construction to the regionas a first step to connect the state’s rural and urban areas.As President, he oversaw planning for interstate road-ways, irrigation, market development, agricultural pro-duction, electrical plants, communications, and medicalcare. All of these initiatives, according to Cardenas, weredesigned to strengthen the role of indigenous groups with-in the modern nation. Under Cardenas’ leadership, socialreforms and public works programs filtered into severalremote areas through newly devised ejidal units, or villagecollectives.11 The success of ejidal clinics in servicingMichoacan’s remote populations encouraged nationalhealth officials to expand the program in other states.By 1936, thirty-six units were established in the nationand by 1940 the total number rose to 141. Several more

10 Luis Gonzalez y Gonzalez, ‘Introduccion: La Tierra Caliente’, in Jose EduardoZarate Hernandez, (ed.), La Tierra Caliente de Michoacan, (Morelia: El Colegio deMichoacan, 2001), 22–23, 43–44.11 Raul Noriega, ‘Mexico pospone cualquier plan de colonizacion’, in Lazaro Carde-

nas, El Problema Indıgena de Mexico (Mexico City: Departamento de Asuntos Indı-genas, 1937).

Figure 1. La zaro Ca rdenas and Alfonso Caso, Director of the Instituto Nacional

Indigenista D.R. � Autor no identificado/Comisio n Nacional para el Desarrollo de

los Pueblos Indıgenas/Fototeca Nacho Lo pez.

Feature Endeavour Vol. 37 No. 1 49

peasant communities petitioned for their own unit, whichprovided immediate access to care based on combined stateand community resources.12

Even though Cardenas had a humanitarian interest inimproving the lives of the indigenous population, he alsohad political and economic motives for integrating thesesocieties into the larger nation. He hoped that establishingan administrative presence in rural areas would reinforcepolitical stability and national authority. By participatingin the bureaucratic processes of the government, such aspetitions, voting, and utilizing public services, he wantedindigenous groups to develop a sense of being an active partof the nation. The ‘desire for social balance’ felt by Carde-nas and his successors aimed at preventing discord byreducing the social inequality of indigenous groups.13 Car-denas also intended to exploit the natural resources ofrural areas while expanding industrial development andcreating a larger cache of healthy workers. Finally, hehoped to gain access to rural markets in order to increaseexchanges of goods with urban centers and expand eco-nomic exportation.14

The inaugural Interamerican Indigenist Congress in1940 placed additional pressure on Cardenas by callingfor significant improvement to living conditions and accessto care among the indigenous populations. The socialscientists who participated in the Congress, which tookplace in Patzcuaro, Michoacan, concluded that variationsin cultures, languages, literacy levels and ability to pay formedical treatments were all barriers to introducing healthcare to rural areas. Rather than focus on incorporatingindigenous groups into the national system, participantsagreed that cultural plurality and indigenous self-deter-mination were the best ways to protect traditional customswhile bringing native populations into the national fold.They argued that indigenous culture could no longer beignored or replaced, but must find its place within a rapidlyevolving Mexican identity (Figure 1).15

Implementing new health programs, however, provedto be a challenge for national officials. Many communitieshesitated to accept government intervention because theyfeared losing their autonomy. In Michoacan, for example,Tarascans had an established tradition of resisting stateand federal intrusion. To address this ‘indigenous prob-lem’ Cardenas supported the development of large-scalerural programs that would ‘Mexicanize the Indian’.16

Throughout the first half of the twentieth century, Mexi-can government officials used the principles of equalityestablished in the Constitution of 1917 as a platform forintegrating rural areas with their urban counterparts.They focused on a nationalist project to assimilate ruralindigenous groups with relative autonomy into what

12 Anne-Emanuelle Birn, Marriage of Convenience: Rockefeller International Healthand Revolutionary Mexico (Rochester: University of Rochester Press, 2006), 216–218.13 Barkin and King, Regional Economic Development, 87.14 Archivo Historico de la Secretarıa de Salubridad y Asistencia (hereafter AHSSA)

SSA-SubSyA, box 33, file 9.15 Cuauhtemoc Pineda, ‘Los programas de salud rural en Mexico’, in Hector Her-

nandez Llamas (ed.), La Atencion Medica Rural en Mexico, 1930–1980 (Mexico City:Instituto Mexicano del Seguro Social, 1984).16 Lazaro Cardenas, ‘Discurso del Presidente de la Republica en el Primer Congreso

Indigenista Interamericano, Patzcuaro, Mich., 14 de abril de 1940’, in Palabras yDocumentos Publicos: Mensajes, Discursos, Declaraciones, Entrevistas, y Otros Doc-umentos, 1928–1940 (Mexico City: Siglo XXI, 1978).

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historian Alexander Dawson describes as a national com-munity based on a ‘new secular and modern set of culturalbeliefs, a new property regime, new political institutions,and new infrastructures’. In the 1930s, the group of socialscientists, anthropologists, and intellectuals known asindigenistas advocated maintaining the cultural tradi-tions and uniqueness of indigenous communities whilealso introducing modern advances in agriculture, con-struction, communication, and hygiene. They hoped totransform communal laborers into productive citizenswith improved social and economic conditions.17

Miguel Othon de Mendizabal, a prominent anthropolo-gist in the 1940s, maintained that the central problem forindigenous communities was their isolation. These popu-lations did not lack the ability to adopt modern economicand social practices, he wrote, but simply did not haveequal access to the tools they needed for improving theirstandard of living.18

Lack of access to potable water and sanitation servicescertainly contributed to the prolonged poor health condi-tions in the Tepalcatepec river basin. During the 1940s, theleading causes of death per 100,000 inhabitants in thebasin were diarrhea/enteritis, pneumonia, homicide, ma-laria, measles, dysentery, whooping cough, scorpion bites,typhoid, and pulmonary tuberculosis.19 These rates notonly indicate the high levels of malnutrition and unsani-tary living conditions in the region, but also show thatimplementing public works projects to address these issuescould prevent the majority of deaths.

Establishing the Tepalcatepec Commission in aconservative political climateAlthough Cardenas attempted to introduce rural healthservices to the Tepalcatepec river basin during his presi-dency, he devoted significantly more time to carrying out

17 Alexander S. Dawson, Indian and Nation in Revolutionary Mexico (Tucson:University of Arizona Press, 2004), xvii.18 Miguel Othon de Medizabal, (ed.), Obras completas, tomo quinto (Mexico City:

Cooperativa de los Talleres Graficos de la Nacion, 1946).19 Aguirre Beltran, Problemas, Vol. I, 259.

23 Marco A. Calderon Molgora, ‘Lazaro Cardenas del Rıo en la Cuenca Tepalcatepec-

50 Feature Endeavour Vol. 37 No. 1

these aims after his term in office. Not only would he havehad more freedom to promote his own regional develop-ment agenda without losing his carefully balanced nation-al alliances, but he also gained from the World HealthOrganization’s 1940s push for healthy community devel-opment.20 Cardenas’ successors, Manual Avila Camacho(1940–1946) and Miguel Aleman Valdes (1946–1952), alsostruggled to balance the tensions between radical socialprograms and economic development. Collectively, thispolitical climate produced an unprecedented opportunityfor public figures like Cardenas to call for improving ruralliving and working conditions.

By the time of Avila Camacho’s term, health conditionsin the Tepalcatepec river basin were so dire that commu-nity members signed petitions seeking assistance. OnSeptember 5, 1942, one local leader, Pedro Blanco Vega,wrote to the president requesting a resolution to his two-year campaign for improved living conditions in Uruapan.He argued that the city lacked basic health care facilitiesand suffered from unsanitary housing. According toBlanco, the houses rented to workers in Uruapan wereplagued with spiders, bedbugs, cockroaches, and disgust-ing, poisonous vermin. Leaky roofs and flooded floors kepteach unit cold, damp, and uncomfortable. Toilets, sinks,and a clean water supply were minimal. Sleeping quarterswere ‘small dungeons’ that would not even hold the mentrying to rest inside.21 Given these series of humiliations,and the constant discomfort and illness that resulted,Blanco appealed to Avila Camacho to push the state gov-ernment to provide fit living conditions. He evoked Article73 of the 1917 Constitution, mandating that ‘all individu-als had the right to physical and mental health, and thatthe local or municipal government could not endanger thehealth of the community’ as justification for governmentinvolvement.22 In order for the workers to be healthy,happy beneficiaries of a post-revolutionary governmentthat promised to help them, Blanco maintained that theinstitutions established since the 1920s should stop abus-ing the citizens they were designed to protect and insteadrestore the culture and progress of the Mexican people.

Blanco’s petition, signed by seventy-six communitymembers, addressed several themes circulating in Mexi-co’s political circles during the 1940s. Modernization pro-jects were revitalized to position Mexico within the globaleconomic market, and domestic programs endeavored tosolidify the nation through education, sanitation, and gov-ernment participation. Blanco’s knowledge of constitution-al rights and petitioning power spoke to the expansion ofan active citizenry. His appeal to the ideas of progress andmodernization, in contrast to the continued humiliations ofpoor sanitary conditions, laid the blame for lack of devel-opment squarely on the federal government’s shoulders.He argued that for Mexican culture to truly progress, thebasic rights of individuals must be upheld. Finally, Blancoutilized official state rhetoric to acknowledge the growing

20 Frank P. Grad, ‘The Preamble of the Constitution of the World Health Organiza-tion’, Bulletin of the World Health Organization 80, no. 12 (2002): 981–982.21 ‘Concretandonos a exponer causas que exigen el aumento de poblacion dentro de la

higienizacion’, AGN-MAC 503/444.7-66.22 Claudia Agostoni, ‘Popular Health Education and Propaganda in Times of Peace

and War in Mexico City, 1890s–1920s’, American Journal of Public Health 96, no. 1(2006), 58.

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relationship between economic progress and public healthby arguing that without healthy living conditions, workerswould be unable to fulfill their economic potential.

There is no evidence that Avila Camacho resolvedUruapan’s specific problems but high mortality ratesand disease epidemics in Mexico throughout the 1940sdid spark an increased national interest in the publichealth of workers. The pursuit of national economic goalsclosed the gap between urban centers and rural outposts.This became increasingly important with the outbreak ofWorld War II, compelling Camacho to support water worksand agricultural production programs in rural areas inorder to provide food for Mexico’s rapidly industrializingcities. When Miguel Aleman succeeded Avila Camacho in1946, he sought to integrate economic development andstate building with extended public works programs inrural areas. His administration developed large-scale com-missions based on agency collaborations for improvingliving and working environments in previously isolatedregions. These commissions, which included representa-tives from the Ministries of Public Health, WaterResources, and Public Education, worked to provide healthcare, sanitation, education, and irrigation programs as thefirst steps to resolving urgent health problems in areasthat were otherwise economically attractive. From thisbase, policymakers hoped to generate community supportfor regional economic development led by the nationalgovernment.23

Cardenas utilized this opportunity to write Alemanasking to develop a commission that would prioritize publichealth campaigns and provide potable water to the Tepal-catepec region. He maintained that he wanted to work withAleman’s administration to build healthy environments forindigenous communities and to continue the process ofintegration by helping residents in the Tepalcatepec basinrealize that they were part of the nation.24 He also intro-duced a larger plan to improve agricultural development,forest use, and education in the area. Cardenas vowed topersonally oversee the program, using his post-presidencypopularity to gain federal and local support.25

Aleman reviewed Cardenas’ plans with members of hiscabinet. Like Cardenas, Aleman recognized the vast natu-ral resources and economic opportunities available in theregion. Mineral deposits, abundant forests, and large hy-droelectric capabilities could easily contribute to industri-alization and paper manufacturing. Road construction,part of a larger national roadway plan, would link thePacific Coast to Central Mexico and provide access to newdomestic markets in rural areas. With improvements insanitation and disease vaccination, a large pool of newindustrial workers would also be accessible.26 Many of theregion’s healthiest workers had traveled north to theUnited States in search of better working and living

Balsas, in Jose Eduardo Zarate Hernandez (ed.), La Tierra Caliente de Michoacan,(Morelia: El Colegio de Michoacan, 2001), 243.24 Lazaro Cardenas, ‘Comunicado sobre la creacion de la Comision del Tepalcatepec

y las obras a ejecutar: Uruapan, Mich., 1 de agosto de 1947’, in Palabras y DocumentosPublicos: Mensajes, Discursos, Declaraciones, Entrevistas, y Otros Documentos, 1941–1970 (Mexico City: Siglo XXI, 1979).25 Calderon Molgora, ‘Lazaro Cardenas’, 245.26 AHSSA-SSA-SubSyA, box 33, file 9, Mexico City, Mexico.

Figure 2. Water Distribution D.R. � Autor no identificado, Distribuyendo Agua en

San Felipe, ca. 1952. Image taken de: Aguirre Beltra n, Gonzalo. Problemas de la

Poblacio n Indıgena de la Cuenca del Tepalcatepec. Memorias del Instituto

Nacional Indigenista, Vol. III. Me xico: INI, 1952, p. 288 (reverso).

30

Feature Endeavour Vol. 37 No. 1 51

environments as part of the bracero program, leaving avoid of available employees to expand industry and agri-culture. In February 1945, over four thousand healthyyoung men traveled from Michoacan to the United Statesas part of the program. Thousands more would make thetrip each year throughout the late 1940s and 1950s.27

On July 17, 1947, Aleman signed the TepalcatepecCommission into the federal books. The Minister of WaterResources, Adolfo Orive Alba, served as president of thecommission and reported directly to Aleman. His rolesymbolized the importance of water to the developmentof the river basin. But, in reality, Cardenas’ role as directorwas the most prominent. He devoted significant time tocoordinating the Commission’s major programs in collabo-ration with the appropriate agencies. The Ministry ofWater Resources developed programs to redirect waterroutes into communities and establish hydroelectric capa-bilities. The Ministry of Communications expanded trans-portation paths into the river basin, including roads,railways, bridges, and airfields. They also extended radiocoverage into the remote areas of the region. The Ministryof Agriculture and Livestock conducted agricultural creditprograms and irrigation operations. They also instructedlocals on soil and livestock conservation.

The role of the Ministry of Public Health and Welfare(SSA) included improving environmental sanitation, hy-giene education, and disease prevention; developing medi-cal clinics, hospitals, and laboratories; and conductingexperiments in entomology and epidemiology. In turn, theSSA coordinated with local health brigades and the Direc-torate of Interamerican Cooperation on Public Health(DCISP) to ensure widespread application of their pro-grams.28 In 1943, the Institute of Inter-American Affairs,a U.S. government organization designed to control andprotect public health in the Western Hemisphere, estab-lished the DCISP to develop cooperative agreements withother nations.29 The Institute originally sought to protectthe health of U.S. troops stationed in strategic tropical areasduring World War II and of workers manufacturing vitalmaterials for the war effort. After the war, its purpose wasextended to include improvement of sanitary conditions inthese targeted areas as a way to increase productivity,standards of living, and economic expansion. DCISP agentsworked with government officials in each of the eighteennations participating in the program to assess health prior-ities and develop funding agreements in their nation. Mexi-can health officials viewed the DCISP as an integralcollaborator for their ability to organize, promote, and fi-nancially support fundamental health development pro-jects. The Cooperative Health and Hygiene program,established by a joint resolution between Mexico and theDCISP in 1943, included programs to provide salaries forhealth officials who acquired advanced education and certi-fication (Project MEX-MED 1), establish a public healthdemonstration and training program in Xochimilco (ProjectMEX-MED 2), and improve sanitation along the northern

27 Gabriela Cardoso Morayla, ‘El Programa Bracero en el municipio de Uruapan y suimpacto socioeconomico,1942, 1964’, Unpubl. BA thesis, Facultad de Historia de laUniversidad Michoacana de San Nicolas de Hidalgo, Morelia, Michoacan, 2011.28 AHSSA-SSA-SubSyA, box 25, file 16.29 AHSSA-SSA-SubSyA, box 11, file 4.

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border of Mexico (Project MEX-MED 3). The success of theseinitiatives prompted SSA officials to seek cooperation andconsiderable financial support from the DCISP when estab-lishing its public health program for the Tepalcatepec Com-mission (Project MEX-MED 4).

Project MEX-MED 4: the health component of theTepalcatepec CommissionThe stated objective of Project MEX-MED 4 was ‘to makethe Cuenca a healthy region’.30 The majority of healthproblems in the Cuenca revolved around the issue of water.The region’s vast supply of mineral deposits and lavacreated areas with soil too thick to absorb water. As lateas the 1940s, no drainage systems existed to filter thestagnant water created by heavy rain seasons. The stag-nant water was also an excellent breeding ground formosquitoes, resulting in high malaria rates. Additionally,sewage runoff contaminated drinking water and producedhigh levels of water-borne diseases. Between 1940 and1949, the coefficients of mortality per 100,000 inhabitantsof the region were 257.6 for diarrhea and enteritis, 174.0for pneumonia, 51.1 for malaria, and 37.4 for dysentery.31

These numbers show that deaths in Mexico were largelypreventable. While other health risks existed in the region,sanitation and education about the proper use and disposalof water and sewage became the key priority of healthworkers.32 To reduce endemic diseases, sanitary engineersneeded to develop a fresh water supply and a sewagesystem, and provide drainage for the wetlands (Figure 2).33

Preventive medicine was the second essential compo-nent of the project. Commission officials hoped epidemio-logical studies of the area, including health data collection

AHSSA-SA-SubSyA, box 33, file 9.31 Aguirre Beltran, Problemas, Vol. I, 259.32 Nathan L. Whetten, ‘Salud y Mortalidad en el Mexico Rural’, in Hector Hernandez

Llamas (ed.), La Atencion Medica Rural en Mexico, 1930–1980, (Mexico City: InstitutoMexicano del Seguro Social, 1984), 147–180.33 CDICDJR, Secretarıa de Recursos Hidraulicos, ‘Comision de Tepalcatepec’, FD

39/0033.

52 Feature Endeavour Vol. 37 No. 1

on both individuals and the environment, would providecritical information on current living conditions and dis-ease contraction. They established sanitary districts in LosReyes, Uruapan, Apatzingan, and Ario de Rosales to allowspecialized sanitation engineering and treatment at thelocal level. So-called investigation and emergency brigadesalso promised nearby support in times of health crises.Finally, expanding medical center development from ur-ban centers to more rural locations would ensure thathealth care was accessible to more populations.

Alongside the sanitation efforts, the preventive medi-cine component worked to control transmittable diseasesthrough antiviral immunizations and anti-malarial publichealth campaigns. Health officials expanded existing med-ical clinics and established new clinics to treat tropicaldiseases, parasites, malaria, tuberculosis, mal de pinto (atropical skin disease endemic to the area) and venerealdiseases. They also built maternal–infant care centers andnursing stations. The Apatzingan hospital, originallyestablished by Cardenas in 1928, was refurbished to pro-vide up-to-date medical care, and plans for hospital con-struction in the other sanitary districts soon followed.34

Finally, twelve aid stations were established throughoutthe region to provide local accessible care. With these goalsfirmly established, health officials began their work in1948 in the centrally located city of Apatzingan. Commis-sion delegates used epidemiological and anthropologicalstudies to determine that this site was the basin’s primearea for the worst health conditions and the most economicpotential. Therefore, Apatzingan became both a testingground for implementing new health programs and adevelopment model that would hopefully be replicated inother regions.

On paper at least, Apatzingan quickly became a hotbedfor scientific studies. Institutional expansion helped tobuild a strong presence of professional medical care inthe region. Additionally, medical researchers establishedlaboratories to study, diagnose, and treat local diseases.Entomologists cataloged insect species to determine envi-ronmental conditions and disease transmission. Biostatis-ticians collected demographic data on the health and well-being of local inhabitants. Hygiene educators establishedprograms in schools through the use of film and radio. Inreality, though, project workers faced many of the finan-cial, personnel, and local acceptance problems of previoushealth officials. For instance, in his February 1948 report,Sanitary Brigade leader Carlos Hernandez Aguirre notedthat his team could not adequately complete their goalsdue to lack of technically-prepared personnel. He ques-tioned, ‘What can one doctor do, where there are multiplehealth care problems, with little hygiene education for thepeople, and a township of more than 7000 people?’ Fur-thermore, many of the recruited health workers seemedreluctant to travel within the region and made it clear theyhad no long-term plans to stay. Aguirre petitioned theproject’s main office to establish training for local staffto assist his team and to provide an additional nurse andsanitary engineer in the interim. This would not only

34 Ana Maria Kapelusz-Poppi, ‘Physician Activists and the Development of RuralHealth in Postrevolutionary Mexico’, Radical History Review 80 (2001): 35–50.

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ensure that future health workers had adequate skillsand preparation, but also that they would be more likelyto remain in their villages for longer periods of time.35

Even with these initial setbacks, it did not take long forhealth workers to reach beyond Apatzingan into the othersanitary districts. The recent completion of the Carapan-Uruapan highway, along with additional project fundingallocated for transportation, allowed health brigades toreach a larger percentage of the population than previousmedical services. The brigades quickly became the mainoutlet for the project at the local level. They worked withepidemiologists to collect spleen samples and study localenvironments to learn about determinants of malaria.They collaborated with local hygiene centers to providesmallpox vaccinations and weekly anti-pinto clinics. Theyalso trained local health workers and rural teachers toproperly detect and treat intestinal parasites. Althoughtheir efforts were slightly delayed due to personnel train-ing, the program set up a new medical team that includedan executor of the eradication campaign, a sanitary official,three brigade leaders, six group leaders, and thirty-twovaccinators.36

During the first few months of program implementation,health workers in the Tepalcatepec region ascertained thatlocal populations responded differently to state-designedhealth projects. They realized that while mestizos living inthe area quickly adopted new health initiatives, indige-nous groups struggled with language barriers, culturaldifferences, misconceptions of healthcare, and distrust oflocal officials.37 Workers also recognized the mountingresistance of community leaders against assimilationiststate health policies. Their on-the-ground experiencestaught them that community leaders did want to receivemodern health services but were reluctant to accept carethat jeopardized their native cultures. Furthermore, work-ers discovered that different peoples understood health indifferent ways.

Consequently, rather than encouraging state-designedassimilationist health projects, healthcare workers metwith community members to introduce modern medicalpractices in culturally relevant ways. They concentrated onlearning local languages to correct previous false impres-sions of national healthcare initiatives and encourage localparticipation. Most importantly, they mediated official andlocal dissension to provide short-term health campaignsthat satisfied the needs of SSA officials and communityleaders. As a result, just as the Western definition of healthshifted from individual to collective care in internationalcircles during this period, local definitions also transi-tioned from supernatural beliefs into a medical pluralismthat incorporated helpful practices from many differentcultures.

The 1949 smallpox outbreakThe 1949 smallpox outbreak was an early test of thisapproach. First visible in late 1948, the disease reachedepidemic proportions before word could get to health au-thorities. Loaded down with bags of supplies, the men and

35 AHSSA-SSA-SubSyA, box 25, file 16.36 Aguirre Beltran, Problemas, Vol. II, 150.37 Aguirre Beltran, Problemas, Vol. I, 36–37.

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women of the sanitary brigades traveled by cars, horses, oron foot to administer the vaccine to communities. Femaleworkers typically treated individuals in urban areas whilemales traveled out to ranches and communities. Word oftheir work soon spread between villages, helping somegroups to more readily accept treatment while othersdeveloped an even greater fear of outsiders. Additionally,some communities had heard about an earlier outbreak ina nearby region and were terrified of the high mortalityrates that followed. Gonzalo Aguirre Beltran recounts thatduring the 1949 epidemic, mestizos triggered alarmistrumors in local communities to discourage cooperationwith health officials and to protect their own local power.Stories that the vaccine made women unable to havechildren, reduced men’s strength, and killed childrenand the elderly quickly spread throughout indigenousvillages and increased the challenges for health workersto gain acceptance.38

As a result of this initial resistance brigades soonlearned to work with local guides, who they employed tolocate remote villages and to comply with local customsbefore administering medical treatment. Often a smallgroup approached a village ahead of the medical team toexplain the purpose of their visit and to garner supportfrom local officials. One brigade leader recounted that histeam successfully worked with a local priest in the rebel-lious region of Quitupan, Jalisco, to help carry out vaccina-tions. The priest used his pulpit to explain why the medicalteam was in the area and to encourage community mem-bers to participate in their programs. The brigade leaderalso commented on the mixed results of these collaborativeintroductions:

I must add to all these precedents that the coopera-tion requested with the Municipal Authorities andEjidales has been effective in only a few cases; inothers, the indifference, the bad faith, the suspicion,and the absence of authority have been motives fornot providing us with assistance, including the prac-tice we have of approaching locals for free use of theirhorses. For everything previously exhibited, if thisBrigade is not provided with cyclical funding and theconfidence of this Superiority to Ministry, our workswill be obstructed.39

In other words, part of the difficulty brigades had indeveloping relationships within the communities stemmedfrom the lack of funds and supplies provided by theirsupervisors. The fact that they often needed to borrowhorses and rely heavily on the largesse of communityleaders to successfully complete their mission made manylocals skeptical about the nature of their work and of theirauthority.

On several occasions, the brigades had to negotiate withcommunity leaders and rebellious individuals before theycould enter a village. One report noted that a commissionerin Quitupan refused to lend his collaboration to the brigadeand gave them the impression that it was in their bestinterest to leave without attempting to administer vac-

38 Aguirre Beltran, Problemas, Vol. II, 150–152.39 AHSSA-SSA-SubSyA, box 25, file 16, Mexico City, Mexico.

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cines. Given the rocky terrain and long distance traveled,the brigade decided to risk upsetting the commissioner bycompleting their work before leaving. Ultimately, the vac-cinations were well received and laid a positive foundationfor future work in the area. In another case, the brigadeencountered resistance in Los Reyes. Although local lea-ders had refused treatment for their community oncebefore, the brigade hoped to quietly infiltrate the areaand administer vaccines before the illnesses of unhealthyindividuals spread to larger neighboring communities.Upon arriving in the city, they encountered a group ofarmed, rowdy men playing cards and drinking. Once themen realized what the brigade was trying to do, they beganhurling insults at them. Undeterred, the brigade continuedadministering vaccines and using a calm, tactful approacheven persuaded the rowdy men to be inoculated despitetheir shouting.40

Medical negotiationsIf the 1949 smallpox outbreak presented an immediate testfor the brigades’ methods, their further work reflected theirdeveloping skills in negotiating with local communities.The brigades’ larger mission was to break prejudicesagainst modern medicine through hygiene education. Theyworked with translators to develop bilingual pamphletsexplaining the aims of the health programs to local Tar-ascans. In Pampiri, a weekly newsletter distributed byrural teachers, the authors explained the history of small-pox, the national eradication campaign, and the impor-tance of protecting the local community. The pamphletencouraged citizens to help control the disease by receivinga vaccination, maintaining, ‘This entrusted task is nobleand highly beneficial to the people, but for this to take placein all its aspects requires the collaboration of all inhabi-tants’.41 Additionally, educators fluent in Tarascanaddressed audiences unable to read, and screened filmsdeveloped by the Ministries of Public Health and PublicEducation as supplemental learning aids. Topics for thefilms included latrine building, the use of clean water, thelink between flies and diarrhea/enteritis, the danger ofmosquitoes and gnats in spreading malaria, and generalhygiene practices. The films were often followed by infor-mation sessions in community centers. SSA officialsreported that many parents were unaware that smallpoxwas contagious or that their children were at risk. As aresult, they had been hesitant to accept vaccinations.Health workers worked diligently alongside families toeducate parents and children by encouraging them to visitlocal clinics on a regular basis, regardless of their currenthealth, in order to become more comfortable with bothtreatment and prevention practices. They also utilizedlocal volunteers and community promoters to help transi-tion communities into regional hubs of state activities(Figure 3).42

From smallpox vaccinations and health education pro-grams to the installation of water resources and sanitationservices, the Tepalcatepec Commission paved the way for anew collaborative relationship between rural community

40 AHSSA-SSA-SubSyA, box 25, file 16.41 AHSSA-SSA-SubSyA, box 33, file 9.42 AHSSA-SSA-SubSyA, box 25, file 16.

Figure 3. School children D.R. � Autor no identificado, Ninos Escolares. Imagen

tomada de: Aguirre Beltra n, Gonzalo. Problemas de la Poblacio n Indıgena de la

Cuenca del Tepalcatepec. Memorias del Instituto Nacional Indigenista, Vol. III.

Me xico: INI, 1952, p. 328 (anverso).

54 Feature Endeavour Vol. 37 No. 1

leaders and government officials through the mediation ofhealth workers. Healthcare workers recognized the will-ingness of community members to integrate valuable con-tributions of modern medicine into their folk medicalconcepts, and used this opening as a way to discuss broadercooperation in health programs. As Marcos Cueto andSteve Palmer have argued, modern medical campaignsin Latin America often generated a broad medical plural-ism ‘characterized by coexistence, complementarity, anddialogue more than outright rivalry and ideological war-fare’.43 Similarly healthcare workers in the 1940s and1950s worked with community members in Tepalcatepecto establish a fluid definition of health that evolved, like thenational health policies themselves, through trial anderror. Ultimately, workers used their position as middle-men to develop programs that were sensitive to ruralbeliefs, and therefore more attractive to community mem-bers, while also continuing to work toward the long-termassimilationist plans of state officials.

For their part, rural populations largely cooperated withthe new culturally-sensitive health campaigns. They feltthey could directly support their own community’s wellbeing by working with public health officials in promotinghealth programs, building latrines and drainage systems,and contributing financial resources. Indigenous groupsresponded favorably to health initiatives that includedfamiliar cultural aspects, and taking the time to explainand demonstrate new procedures to local families resultedin overwhelming support for health programs. Additional-ly, indigenous groups utilized the new collaborative rela-tionships they forged with health officials to recount theirgrievances with public services, or lack thereof, in theircommunities. This dialogue between national and localrepresentatives improved the way healthcare treatmenttook place in the Tepalcatepec basin’s rural villages.

43 Marcus Cueto, ‘Appropriation and Resistance: Local Responses to Malaria Eradi-cation in Mexico, 1955–1970’, Journal of Latin American Studies 37 (2005): 533–559.Steven Palmer, From Popular Medicine to Medical Populism: Doctors, Healers, andPublic Power in Costa Rica, 1800–1940 (Durham: Duke University Press, 2003), 9.

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The collaboration between health workers and commu-nity members dramatically reduced the major health risksin the Tepalcatepec region and strengthened ties betweennational and local organizations. Rather than followingpreviously formulaic efforts for uniform healthcare, work-ers went to great lengths to develop culturally sensitivehealth projects that appealed to community members.Once they gained the trust of indigenous groups, healthworkers served as intermediaries between local leadersand national policymakers on larger questions of develop-ment. They reinforced the need for both groups to worktogether toward the common goal of rural life enhancementand encouraged community members to take an active rolein protecting their health and well-being. When the Min-istry of Public Health and Welfare could no longer afford tocontinue health initiatives in the area, community mem-bers contributed their own financial resources and wroteletters demanding the continuation of healthcare in theirvillages. They recognized the benefits provided by orga-nized health programs and, like the Blanco Vega lettershows, drew on their constitutional right to health in orderto petition for more public service projects. By demandingthe enforcement of their rights, many community membersseemed to accept their role as part of the larger nationalpolitical and economic model.

Just as the health component of the Tepalcatepec Com-mission was starting to make headway, however, theproject received a major setback. In November 1949, theDCISP decided to reduce its financial contribution to thepreventive medicine program from $450,000 to $100,000.Most likely, DCISP officials were satisfied with the successof administering smallpox vaccinations and felt that theMexican government could control other, less internation-ally threatening diseases. In reality, this budget cut sig-nificantly lowered the number of services local sanitarybrigades could offer. Moreover, policymakers continued toshow their vocal support for the programs but did not offerany additional financial resources from the state budget.To help offset the expenses required to carry out its healthobjectives, project leaders increasingly relied on contribu-tions from the local communities themselves. In 1951, forexample, the sanitary district in Apatzingan received$351,748 from the national government, $100,000 fromthe DCISP (all of its contribution to the Project), and$84,200 from local villages. In the districts of Nueva Italiaand Lombardia, the national government and local villagesmade equal contributions of $200,000 and $140,000 respec-tively.44 These numbers highlight two important changestaking place in the Tepalcatepec basin.

First, local communities were clearly seeing the bene-fits of vaccination, hygiene education, and potable waterservices. They not only wanted to ensure the continuationof these programs, but also realized that they could notrely on the state to provide adequate resources and there-fore supplied their own contributions. Second, as theBlanco Vega letter exemplifies, individuals in the regionbecame increasingly aware of their rights to health care inthe 1940s and 1950s. Healthcare workers, schoolteachers,sanitary engineers, industrial employers, agricultural

44 AHSSA-SSA-SubSyA, box 33, file 9.

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specialists, and international aid officials all brought newideas of citizenship to local communities. Cardenas andhis team continually emphasized the importance of feelinglike part of the larger nation. As community membersstarted to understand the benefits that came with beingintegrated into Mexican society, they also began expres-sing their rights as individuals participating in the statesystem. If they were going to become part of the modernnation, they expected the modern benefits that camewith it.

ConclusionAlthough the economic development projects of the Com-mission continued until 1961, the health component offi-cially ended in 1951. The DCISP terminated its fundingcommitments and officials in the SSA felt the health riskreductions achieved in this short period were sufficient toestablishing long-term improvements in the river basin. Ashistorian Luis Gonzalez y Gonzalez argued, the Commis-sion succeeded in ending the isolation of the Tepalcatepecbasin as the region became significantly more accessiblevia roads, airports, and telephones. Furthermore, he con-tended that Cardenas and the Commission convertedMichoacan ‘into an attractive region out of one that wastraditionally repulsive’. Immigrants, investors, capitalists,and developers all made their way to Michoacan in re-sponse to its new economic potential. The national popu-lation almost tripled over two decades from 46 millionpeople in 1940 to 120 million in 1960. Literacy rates alsorose, from 25% in 1940 to 43% in 1960.45 Although nolonger the official leader of the Commission after 1952,Cardenas continued to work on various projects until 1958.He also took steps to fulfill his goal of expanding the work ofthe Commission into new areas. Many of the same govern-ment agencies teamed up with him again to form the

45 Gonzalez y Gonzalez, ‘Introduccion’, 47–53.46 Calderon Molgora, ‘Lazaro Cardenas’, 259.

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Balsas Commission in the 1960s. This new initiative usedthe Tepalcatepec experience to offer similar developmentplans and public services along the Pacific coast in thestates of Oaxaca, Guerrero, Colima, Jalisco, and Michoa-can.46 In February 1965, Cardenas wrote that he encoun-tered a spirit of coordination throughout the country toelevate rural living conditions. He reiterated that schools,industry, potable water, technology, and welfare serviceswere key to the success of the project.47

The health programs of Project MEX-MED 4 estab-lished improved relationships between healthcare workersand indigenous populations. Through the Commission, theProject became a laboratory for addressing the immediatehealth needs of rural indigenous and mestizo communitieswhile determining longer-term solutions in sanitation,environment, and preventive medicine. Project leaderscarefully negotiated a balance between raising the stan-dard of living for individuals in the area while also raisingeconomic possibilities for the nation. They successfullyadministered disease vaccinations, implemented large-scale hygiene education programs, and joined forces withother agencies to oversee water treatment and irrigationprojects in previously remote villages. They assembled anetwork of local and national administrators to continuethe public works started during their tenure. Finally, theyestablished a national presence that helped connect thesecommunities with their urban counterparts.

The Tepalcatepec Commission is one example of thehealthcare workers’ acumen in providing culturally relevantservices to a large disparate rural population in mid-twen-tieth century Mexico. Their experiments in medical plural-ism, improved communication with indigenous groups, andopportunities for community participation changed the na-ture of healthcare and opened the door for revolutionarysocial programs by conservative politicians.

47 Lazaro Cardenas, ‘Palabras de Vocal Ejecutivo de la Comision del Rıo Balsas alPueblo de Ayuquila de Juarez, Oax. 12 de octubre de 1966’, in Palabras y DocumentosPublicos: Mensajes, Discursos, Declaraciones, Entrevistas, y Otros Documentos, 1941–1970 (Mexico City: Siglo XXI, 1979).