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 plaintains..  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 conducted 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 acqiured 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" aslo 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 incompotent 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.  

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 delecious 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 occurance 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 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 illneses 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.
- Igor Shumskiy, MS2

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 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 recieved 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 unnanounced. Because the homes were much closer together in this community than in Nativo 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 cirriculum will continue to grow and adapt with every community we are allowed to visit.

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 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.

Amazon Illness vs. Modern Medicine

Hola fellow would-be-travelers!  Thank you for vicariously tagging along with our groups activities through our blog posts!  I write this post in response to the age old question (or at least the one my mother asked me the most before I left) “what happens if you get sick in the jungle?”

All was well when we embarked for our first village visit on Wednesday, July 13th.  The team I was with was traveling to Tamanco (a one-hour rapido ride to Mazan followed by a 1.5 hour peke-ride).  Once we arrived, we spent the day administering surveys to randomly chosen houses, setting up meetings for Thursday, and engaging in Shelby’s favorite pastime; getting our butts kicked in volleyball by the local youth.  That we had a crowd of teenagers who gathered in our gazebo around 6:30pm (remember, it is pitch dark then) to talk to us, and eventually encourage us to throw an impromptu dance party complete with American top 40 music.  The kids were floored, and we all found out that Igor has horrible taste in music.

Thursday morning we had a meeting with the higher-ups in the community to talk about working together in the future.  During the meeting, I started to feel COLD.  This was shocking to me, as I have been sweating through every piece of clothing since I arrived in Peru.  After the meeting, Jess Miller and I went to talk with the healthcare promoter and review what he had learned from our training.  His vital signs skills were put to good use on me.  He dubbed my 38.0° C (100.4° F) temperature as “muy peligroso!”, but decided I was not significantly dehydrated since my pulse was not elevated and my blood pressure was normal (114/78).  Finally, we could see our curriculum in action, and it was working!

The rest of the afternoon was a blur of Shelby insisting I eat Pringles because they are salty, Igor feeding me Advil, and Jess forcing me to drink Oral Rehydrating Solution (ORS).  A side note on ORS: we instructed our healthcare promoters at the trainings on how to make this solution from scratch, since the packets are expensive and not readily available.  I was drinking the packets, which were supposed to taste better.  In reality, they do not.  They are incredibly salty, with an acidic aftertaste.

Since I couldn’t drink the ORS and was in a semi-somnolent state I became very dehydrated overnight.  Coupled with the fact that I started vomiting and having diarrhea I was ready to “go home” Friday morning.  Our healthcare promoter insisted on driving me and Jessica M. back to Mazan on his peke, since he was so worried about me.  Upon returning to Nativa Apartments in Iquitos (or Monica’s, as we all fondly call it), Dr. Dick Anstett took one look at me and said, “you should probably go to the hospital.”  Fortunately, we still had people in Iquitos, so Jessica B. and Blair accompanied me to Clinica Ana Stahl, which is the sister hospital in Iquitos run by Centura Health Care out of Littleton, Colorado.

Once we got to Clinica Ana Stahl, things started to look up.  We had made some friends at the beginning of the trip when we did Saturday clinics with members from Ana Stahl, and we ran into Carmen, one of the doctors from the clinics.  She set me up with my favorite nurse’s husband, who performed a physical exam (temp 38.4° C = 101.1° F; BP 90/60) and had me get a urine, stool, and blood sample.  While I was messing with that in the bathroom, he got on the phone with his wife, Cynthia, and said, “guess who I have here?!”  Cynthia came and took me to the Emergency Department and started me on a liter of electrolytes.  Once my tests came back they decided I had a GI infection and administered an IV dose of Cipro as well.  After the fluids, I was feeling much, MUCH better.

After that ordeal, I returned to Monica’s to drink fluids and rest up.  Saturday morning I received my second dose of IV Cipro, and from that point on I have been spending the weekend solo at Monica’s while my team is out tromping through the jungle and saving lives.  Monica and her mom have been feeding me chicken soup (it cures all your ailments both in the USA and abroad), tea, and my new favorite drink, a “hot banana milkshake,” or HBM for short.

I’m feeling nearly back to 100% and I’m excited for our last village visit coming up at the end of this week, followed by the health fair in Mangua.  Before coming down, I wasn’t sure what would happen if I got sick in the jungle.  However, I am more at ease because I know that I am traveling with knowledgeable team members.  Furthermore, we as a group have made valuable contacts who have turned out to be compassionate friends and healthcare providers in Peru.  So for the future, mom and dad, that is how you get sick, and recover, in the jungle.

Ciao for now!
~Alia Broman, MS2

Llachapa training: The Home Stretch

On the final day of the Llachapa training, we had our promoters get started early with their post-test, hoping our boat driver remembered to come get us by noon so we could get back to Mazan in time to catch the last rápido to Iquitos. The promoters performed impressively on their post-test. We even had one perfect score. Every last promoter showed a remarkable improvement from his pretest score, honestly better than I was expecting, and all this after only a few days of training.

As we were getting ready to conclude with the certificate ceremony, during a lengthy monologue from one of the community’s authorities about how useful promoters are and how sorry they were about the mix-up with the high school, something unexpected happened. One of the promoters stood up and, after profusely thanking us for our time and efforts, started a ceremony where each of the promoters presented us with necklaces, each of which had dozens of local seeds for beads and featured a different wild animal part: piranha jaws, one inch paiche (a monstrous local fish) scales, or rhino beetle horns. There were also beaded bracelets and fans intricately laced with local ropes. As I stared down at my rhinobeetle horn I nearly teared up.

These guys put up with a lot, sleeping on concrete for 3-4 nights, being patient with gringo Spanish, having to wait a really long time for food some meals, all of that just to be able to learn what we had to teach them. And as if their endurance was not enough, they must have pulled about $20 dollars (a lot of money down here) together to buy us these little mementos as thank yous. I have done and seen some crazy, remarkable and rewarding things, but as I looked down at my necklace, I knew that this was probably the most rewarding experience of my life.

Of course our motorista never showed up to take us back to Mazan. Luckily, one of the villagers was more than willing to take us for less than the other guy was going to charge anyway. So we embarked in his large canoe with all of our things under the blistering Amazon sun for the painfully slow journey up river. We had planned on meeting the rest of our crew in Mazan and finding a rápido back together, but they had finished around the same time we did and were ready to get back to Iquitos hours before we were to arrive in Mazan. As we rolled up to the port on the Amazon river, it was nearly 4:45. The rápidos do not usually travel after dark because there are too many logs and debris floating in the river to safely travel at high speeds. By the time we arrived at the dock, the last rápido had already left for Iquitos.

Of course that wasn’t going to stop us. One of the guys said he had a rápido motor and a small metal boat he could attach it to in order to bring us back to Iquitos as a group. As soon as Igor took one step on this boat, however, it began to sink. Not willing to give up on the significant amount of money we had offered for the journey back to Iquitos, this man had a plan. Using a chainsaw (in his safety flip flops) he quickly modified the back of one of the larger peque canoes and, after about 15 minutes, was able to successfully transform the boat into a rápido. We may have ridden in the first wooden rápido. And of course the sun set around 6, about halfway back to Iquitos, but Igor and I sat up front with our small flashlight frantically directing the motorista to turn this way and that to avoid the various trees and floating islands we encountered. We safely got into Iquitos a little after seven, ready to take a day of R&R before preparing for our next jungle adventure.

-Jason Murphy, MS4

Llachapa training: talking about diarrhea

Each year, we hope to focus on one disease process that promoters commonly deal with. This year’s focus was diarrheal illnesses, and after teaching vital signs, our lessons were divided between proper triage and treatment of diarrhea and its prevention. Saturday afternoon was spent going over the promoters’ role as educators on clean drinking water, clean houses and healthier communities. The promoters seemed to really get a lot out of this. They especially loved brainstorming in small groups how best to address some of the basic public health goals in their communities. By the end of the second full day of the training, we were all tired but feeling pretty satisfied with the way the trainings had gone.

Our afternoon was briefly interrupted by the Mayor of the district, a man I met two summers ago when he was the area dentist and the person responsible for health education trainings at the time. Dr Edward has been a phenomenal support to us in organizing the trainings, and one of the best politicians I have seen, like a Peruvian Obama when he gives a speech. It really meant a lot to everyone there that he took time out of his busy schedule to visit our training down river and speak to them about the important role they play in their communities.

That night I was invited to talk to the students in Llachapa’s secondary school, and this time I just spoke with the 15 or so students involved in the first aid program. We talked about basic first aid for snake bites, broken bones and heavily bleeding wounds, all of which they seemed really interested in. Then they start asking me which antibiotics they should be using for which diseases.

Apparently they have a mini pharmacy. Apparently they have been ‘prescribing’ antibiotics and other medicines to the other students as needed without any idea what the hell they were doing. Apparently they have been treating everything from minor muscle aches to sever headaches with powerful steroid injections.

I spent 45 minutes explaining the inherent dangers in all of these treatments and pleaded with them to please not give antibiotics to anyone and, for the love of god, stop giving steroid injections. I went over proper use of Tylenol and Advil for pain. I can only hope that some of my message got through. 
-Jason Murphy, MS4