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.