Our first day working was incredibly fun and productive. Claudia and I (Akshay) arrived at the main office of Red Accion (one of our NGO partners in Cochabamba) to start the first community health worker (CHW) training session. All 11 women representing 6 different communities or “barrios” arrived on time and were ready to learn. We started by introducing the CHW training program and explaining our main objectives:
To train CHWs in each barrio to serve as health educators and resources for all members of the community
To learn more about the lives, attitudes, habits, and situations of the populations living in these impoverished areas of Cochabamba
The goal of this training program is not just to train CHWs through lectures, but also to become more familiar with the situations of these people through open discussion and productive conversations.
During the planning stages of this program, it was brought to our attention that the majority of women in these communities is illiterate. Maria Eugenia, the leader of Red Accion, said that a few of the women selected as CHWs may have had an education up to the 3rd grade level, but that some may not be able to read or write at all. This posed a significant challenge for me when designing the curriculum. I had to find a way to effectively convey the material without relying heavily on written explanations. This also limited the possible methods of evaluation to oral and practical exams. We were somewhat anxious to gauge the literacy of the CHWs ourselves on the first day of training.
The first order of business was to register the personal information of all the CHWs. We used this opportunity to assess their basic reading and writing skills by having them fill out a registration form. To our great excitement, all the women were able to fill out the form without much difficulty. I asked them questions about their own literacy and about overall literacy levels in their communities, to which they were very receptive. All of the CHW women had anywhere from a 2nd - 4th grade education, which they cite as the reason for their ability to read and write. However, these women are not representative of the overal literacy levels in their communities. They said that most women in the communities cannot read or write. Some, especially the older generations, only speak Quechua, an indigenous language of Bolivia, because they did not have the opportunity to learn Spanish in school.
When asked what problems illiteracy causes in their communities, almost everyone’s initial response was that being illiterate prevents them from teaching their children to read and write. Other problems they identified were not being able to go to the bank to withdraw or deposit money (requires a signature), not being able to go to healthcare facilities (requires paperwork), and other procedures that require a signature or basic information. We need to do more investigation into the literacy levels of these communities and what types of problems illiteracy causes.
One of the CHW women runs a small pharmacy in her community. The pharmacy is stocked with basic medicine (pain killers, cold medicine, etc.) provided by Red Accion. The general consensus among the CHW was that the pharmacy is incredibly useful to members of all surrounding communities. Our discussion about the pharmacy is a prime example of why it is important to have open conversations about the lives and needs of these people. In subsequent training programs, we can revise our curriculum to include a section on how to properly distribute and take basic medications. We can also look into establishing more pharmacies as part of our public health interventions.
Since the main topic of today’s training session was water and sanitation, I covered the content outlined in our training manuals with them and discussed their personal habits regarding water consumption and sanitation. One particularly interesting discussion was about possible sources of water contamination. They accurately identified open defecation and trash disposal in open air as sources of water contamination in their communities. They also cited another source that has extremely dangerous implications: dead animals. According to the CHW, when the dogs, cats, and chickens that live in the community (wild and domestic) die, residents often throw the dead carcasses into the river. This is clearly a HUGE health hazard, and must be addressed through comprehensive community education and other sanitation interventions.
Our conversation about water contamination led to a discussion about trash disposal. Some communities have a garbage service that comes twice per week to collect trash. We still have to look into details such as who provides this garbage service, if it is a government service, and if it is free. One problem that the women cited is that if no one is at home on the days that garbage is collected, those families cannot take advantage of the disposal service. In other countries like the US, trash collection does not depend on anyone being in the house; we just put the trash cans outside and they are collected. We have to learn more about their garbage collection system to see if or why it depends on someone being in the house.
For the communities further from the city that do not have a garbage collections service, there are 2 main methods of waste management: open air disposal and burning. Some families simply throw their trash in the river or on the ground. Others burn their trash on their own property. Neither of these waste disposal methods are safe or healthy. This conversation about trash disposal is yet another example of how discussing the habits of the community help us to better understand their needs and circumstances. In subsequent curricula, we will definitely need to include material on safe waste disposal. Although our current curriculum talks about how burying trash can be a safe alternative to open air disposal, we need to include content that is specific to the communities that we work with (talking about burning, their garbage collection system, and dealing with dead animals).
Although some communities have a central water tank with plumbing going to many of the homes, almost all families pay for water from privatized companies. These companies distribute water in either barrels or large plastic bottles. Water that is sold in barrels is clearly contaminated; the women said that the contaminants are visible (black substances, insects). The water sold in large bottles is usually clear, but unsafe nonetheless. The companies collect the empty plastic bottles from the homes and refills them, which proves that they are not selling Poland Spring-grade packaged water.
The women identified several places where people go to the bathroom. The few households that have their own constructed toilets (that RB built) use and maintain their own bathrooms. Others have homemade wells that serve as toilets. We are still unclear as to the exact appearance of these homemade wells. Some others defecate on their own property, and bury the waste underground. The vast majority, however, practice open defecation. This involves going to the steep slopes on the edges of the communities (the barrios are located on mountainous steeply sloped terrain). These slopes are dangerous for several reasons. Firstly, there is the obvious risk of falling. Secondly, many of the slopes have plants with spined branches, which pose another painful threat. Thirdly, women who go out to the slopes in the middle of the night are at risk for being attacked or raped.
I was happy to have had a positive discussion about rape in the communities. It is difficult to say exactly how big of a problem rape is, because the topic is clearly stigmatized. When asked if they ever discuss rape during their community meetings, the women said that they never do due to fear of being singled out. They mentioned that rape does occasionally happen, usually when women are going to the bathroom alone at night on the slopes. Interestingly, they pointed out that the offenders are never from their own community, but alcoholics and mentally insane people from outside communities. They made it clear that rape is not tolerated within the communities, and that if any man in their communities were identified as a rapist, he would be exiled. This topic requires a lot more discussion and investigation. Although the women are aware of the traditional criminal definition of rape, they may be unaware that domestic violence and sexual abuse may be more subtle and may be inflicted by their own partners. Since it is known that domestic violence is a prevalent issue in the community, these issues need to be discussed and investigated more thoroughly.
After covering the rest of the content in our training manuals, I gave them a pop quiz, on which they scored pretty well! I was happy with how the first day of training went. They learned the content, and we learned a lot about their lives.