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Improving the health of rural communities in Peru

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Jul 04 2012

Village Visit 1 – Team Blair, Beth P, and Jess B

Our brief trip to a community of about 250 people an hour´s peque pèque ride from Mazan was a whirlwind of lessons for my group of 3 CU Peru members. The challenges faced by some of the communities we work with can seem impossibly daunting at times, and our intervention – training volunteer health promoters – can seem like a drop in the bucket. It feels silly teaching hand washing when the school doesn´t always have water near the bathroom (because people living nearby use the school´s water to bathe with instead of walking down to the river), there´s no soap (because it”s one of the many essential school supplies overlooked by the government) and there are no lights in the school at night (because someone stole the school´s solar panel installed by a NGO several years ago). There are innumerable problems that we´ll probably never be able to even touch as a group of foreign students with limited Spanish coming for 1-2 months a year, but every once in a while we stumble into a situation that makes it feel like we´ve made significant inroads into very real problems.

I was reviewing and revising the community health survey we´re hoping to use in future years with the community´s health promoter when Jess interrupted us – there was a sick child whose mother was looking for some guidance. We could not have asked for a more perfect test of the material we had taught one week before in our promoter training, which focused on vital signs and diarrhea. The 2 year old had been ill with diarrhea for 2 days, and she´d been eating and drinking less in the last day than normal. Her mother was concerned that she was getting lethargic as well.

The promoter got a history of the current illness that any medical student could be proud of frequency of stools, color, presence of blood, energy level, oral intake, subjective fevers, and remedies given were all covered online casino before he started his exam. He started with vital signs, which he was successfully able to check on his own, and while he initially misjudged the pulse as being high, a review of the information in the educational materials given out in the training showed that the child´s pulse, respirations and temperature were normal. He checked for skin tenting, sunken eyes and abdominal discomfort, which were also negative. Finally, he reviewed his assessment: non-bloody stools, normal vitals and a reassuring exam, but poor oral intake – oral rehydration therapy would probably be sufficient for the time being, with re-evaluation in the morning and plans made for a trip to the health center (in Mazan, an
hour boat ride away).

It was incredibly gratifying to see our brief training on diarrheal illness triage, treatment and prevention implemented so effectively. We were fortunate enough to work with a highly adept promoter who had worked to become a respected educator in his community, and in conversations with other members of the community, it sounded like our visit boosted his credibility. While I consistently felt like we were only making a dent in the community”s problems, it did feel as though we had done something positive, however modest, during our brief stay.

Written by designer · Categorized: In The Field · Tagged: community, CU Peru

Jul 04 2012

Village Visit 1 & 2 – Team Sonja, Natalia and Tin

After a 6 day adventure in two very different villages, Tin, Natalia and I (Sonja) are back in Iquitos for a few days of recovery before we venture out again for our next and last village visit. We are sad to have Natalia leave our team to go back to the U.S. after her 6 weeks of hard work in Peru, but look forward to our next community visit where we are joined by Shelby Kemper. Our time in these communities flew by, and it was full of new learning experiences of all of us.

We departed Iquitos early last Wednesday morning on a Rapido to Mazan, where the Health Promoter from Nuevo Tiwinza, Rene, met us. We were very thankful to have had him as a guide to our desitination, because getting to Nuevo Tiwinza entailed not only taking an hour-long Peke Peke (small wooden boat) ride on the Mazan River, but also more than an hour hike deep into the jungle with all of our gear, food, and water. We spent three days in the village of Nativo Tiwinza with Rene and his wife Sonia, conducting surveys and home visits within homes in this unusually rural and spread out community of 13 families (70 people). The days were tiring as we had to walk up to 6 km to get to the various houses in the blistering heat and humidity of the jungle. However, it was worth the trip to see this unique village because the households were very friendly and we were able to learn a great deal abou the major concerns within the community. These include: the lack of access to health care because the community is so far away from not only health posts and clinics, but also from any transport to these facilities by boat; snake bites and other injuries; lack of law enforcement; and lack of organization in the community for services like emergency preparedness. Almost none of the houses had latrines, and their water came from wells and was treated by Sonia with bleach, when she visits each house personally every 3 days (very impressive). We were also invited to an Education Committee meeting because Rene, along with being the Health Promoter, is also the Head of Education in the community. At this meeting, we got an inside glimpse into the education system in this community. We spent the evenings talking with Rene and Sonia about their experiences as Health Promoters and learning more about the history of the community, as well as doing some online casino teaching out of the book “Where There is No Doctor” (Sonia and Rene have a voracious appetite for learning), reviewing vital signs with Rene and Sonia, and playing with their sweet children.

On Saturday morning we hiked back to the river and returned to Mazan on a Peke Peke. Our second community, Arturo Rios Arana, was actually a part of the town of Mazan. We met the Health Promoter, Cesar, and got to work immediately, conducting surveys in five different households that day. Arturo Rios Arana has access to a clinic just on the edge of the village in Mazan, so the health concerns and Health Promoter´s role was very different from what we had seen in Nuevo Tiwinza. On Saturday night, we had a meeting with members of the community (about 20 people turned up) where Tin, Natalia, and I taught a lesson on diarrheal illness and how important basic hygiene and healthy practices in the home are in preventing these illnesses. Cesar had asked us to present on this topic to use it as an introduction to conducting home visits in the community the next day. Although we received less feedback from community members during that meeting than we had hoped for, the homes we visited with Cesar the next day were much more receptive to our visits and the suggestions Cesar gave them, than the response we had gotten the day before while conducting the surveys unanounced. Because the homes were much closer together in this community than in Nuevo Tiwinza, we were able to help Cesar with 10 home visits on Sunday, during which he gained confidence and skill, and we were able to learn a lot about the community as we visited with these households.

One of the major major we learned during our village visits this week is that it is important to be flexible and adapt our approach to surveys and home visits depending on the community, because these communities that we visit are far from uniform. We are gaining so much knowledge as a group from these amazing Health Promoters and the community members we talk with during the village visits. I have no doubt that our project and curriculum will continue to grow and adapt with every community we are allowed to visit.

Written by designer · Categorized: In The Field · Tagged: CU Peru, Mazan River

Jul 04 2012

Thoughts from Lima

Sitting in a hostel in Miraflores, Lima, with a shower, kitchen, and city life around me, it”s easy to forget the wonders of the jungle. No more cans of Deet, no more satisfying the need to itch, and no more bathing in the river. No matter whether you consider the former or the latter as perks of life, I”m sure my fellow CU Peru members can agree we lose something important when we step out of the jungle. I for one miss the unmatched hospitality of the people – we were constantly invited into people´s homes to break bread with them, enjoy some delicious coffee, or just to chat about differences between our hometowns and theirs. It´s magical to have a whole classroom of young children come to us just to sing the songs they recently learned in school. But what I will miss most is every community´s burning desire to improve, build, mobilize, and live symbiotically with one another and their land.

Although we have returned to “normal” life, our friends in the Napo River communities continue to live with the day-to-day struggle of inadequate health care. But, this is not a problem that is unique to the Loreto region of Peru, rather it´s a problem we face in our own backyards, then why should they receive special attention? I discovered the answer to this question while visiting Centro Unido, a community along the Napo River of around 70 people. Centro Unido has a treated water source (thanks to the NGO CONAPAC), a central square with two soccer fields, and a schoolhouse. There are two health promoters and the community residents are only a 15 minute walk away from a health post. On the surface the community is quite advanced in comparison to some others. However, peeling away the layers, we found more than meets the eye. During our visit, one of the promoters was away for 4 days on a work trip (a normal occurrence since the promoters are only volunteers and must work to provide for their family) The other promoter had difficulty taking a pulse, not because he didn”t understand the technique, but because he couldn”t read the small numbers on the digital watch we provided him during the training. Although the residents are just a walk away from the health post, many had resorted to using best online casino plant medicine when the medicine they received in the health post did not treat their children”s illness sufficiently. This could be due to the fact that the community and the health post are about 6 hours by boat away from the health clinic in Mazan. Such isolation leaves the tecnico to treat illnesses better suited for the clinic, and the residents to travel to the clinic only under grave circumstances. Just imagine if your pharmacy around the corner was out of Tylenol (often occurs in the health posts) and you had to drive 6 hours, or even one hour! I know this would cause me to second guess whether I was really sick enough.

For these reasons and so many more that we have yet to uncover, the communities of the Napo River are starving for improved health care. This change must begin with the local health promoter. A man or woman that is knowledgable, respected, and available. Only such a person can decide whether a child is really sick and needs to travel to the health post and then convince the family that they must take the time to do so as well (often a more difficult task than triaging). Only such a person can petition for a change of the health habits of their community. Without the right training and continued support, these promoters are under utilized, but most importantly the people of their community don”t get what they deserve; adequate health care.

Written by designer · Categorized: In The Field · Tagged: CU Peru, Lima, Miraflores, Napo River

Jul 04 2012

A Tale of Two Cities…er, Villages

Don’t worry, I’m not going to go into an analysis of the complex social climates of Paris and London during the French Revolution. Because to be honest, I’ve forgotten most of what I learned in my high school world history class and couldn’t do that if I tried. But as I look back on our first round of community visits, for some reason this classic Dickens title comes to my mind.

In many ways, the two communities that Tanya, Jason and I (Beth H.) visited (Puinauhua and Juancho Playa) were very similar. Both communities sat just off the river with the characteristic “maloka” or gazebo near the river bank in the center of the village. The houses in both towns were made of wood with leaves woven together for the roof. Dogs, cats, chickens and pigs roamed freely in both communities and curious children wandered shyly over to get a closer look at what the three random gringos were up to. In both communities, the people were incredibly hospitable, opening up their homes and sharing treats of the tropical caimito fruit and sweet manzana bananas. Both communities had a school, a futbol field and a never-ending supply of plantains.. But despite their many similarities, there were also some fundamental differences between these two communities – fundamental differences that are extremely relevant to our goal of training effective “health promoters”, or community health workers.

The promoter in the first community that we visited, whom we”ll call “A”, was the valedictorian of our training in Llachapa, literally. He came in with 23 years of experience as a health promoter and was excited to share his knowledge and experience with the rest of the promoters. He stood out as a leader during the training and scored a perfect 100% on our post-test.

When we talked with “A” in his community, his questions were prompted by cases that he had seen in Puinauhua. He gave example after example of times when people from his community (and even people from nearby communities) had come to him for help. As we our public health survey in random homes in Puihahua, nearly all of the families reported that they seek advice from “A” before going to a health post or the clinic in Mazan. It was clear that “A” is an established promoter who is trusted and respected by the people in his community. I have no doubt that “A” will be able to put into practice the knew skills and knowledge he acquired at our training in a way that will benefit the people of his community.

After three days in Puinauhua, we travelled about 30 minutes down the river to the second community of Juancho Playa. There were two promoters from Juancho Playa at our training- “L” (the only female promoter at the training) and “N”. “N” was reserved and offered very little feedback or participation when prompted. Throughout the training, it was difficult to gauge how much of what we were teaching was actually registering. “L”, however, was clearly one of the brightest promoters at the training. Although she was quiet in a large group setting, when I talked with her one on one, I could see that she was engaged and processing everything that we were teaching. “L” also did very well on her post test and by the end of the training, she could take a thorough history on a diarrhea case, measure accurate vital signs (pulse, respiratory rate, etc.) and perform a physical exam with very little prompting. As we talked to “L” and “N” in their community, however, it quickly became apparent that they lacked experience because people just didn’t come to them. Our surveys in the homes confirmed this as family after family reported that they go straight to the health post in Tamanco when there is an illness and rarely consult with the promoters of their community first. In further conversation with people in the community, we learned that people were wary of trusting the promoters because a promoter in the past had been incompetent and untrustworthy. Unlike the confidence I felt about “A” in Puinauhua, I doubted whether the information “L” and “N” had learned at our training would ever have the opportunity to affect the people of Juancho Playa. How could it if no one came to the promoters?

One of the reasons we went to the communities after the training was to spend more one on one teaching time with the promoters, and we were certainly able to do this in both Puinauhua and Juancho Playa. But another important reason we went to the communities was to see what areas of our curriculum needed improvement. In these two community visits, we were made aware of a huge gap in our curriculum. It would be naïve of us to think that when a promoter can take a pulse and treat diarrhea with oral rehydration solution, our job is done. “A” and “L” were two promoters who were comparable in skill and knowledge, but I predict that the effect “A” will have on his community will be far greater due to his established position. What good is knowledge if the promoter doesn’t have the credibility to share it with his or her community? In future trainings, I think it will be as important for us to train the promoters to teach their community about their role and the services they can provide, as it is for us to teach the promoters themselves. It would be worthwhile to set aside time in the trainings to brainstorm with the promoters ways in which they can make their presence known in their communities and gain the trust and respect of their neighbors.

Written by designer · Categorized: In The Field · Tagged: Juancho Playa, Puinauhua

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