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Even though I've lived in Lima my entire life, it's hard to believe that this much poverty exists in some of its supposedly most "stable" districts. MEDLIFE usually works in the poorest districts of Lima. But we responded last Friday to a request from the municipality of Santiago de Surco, considered a model district of Lima, to hold educational workshops in two of its poorest neighborhoods.
Nobody would have imagined that so close to Surco's main plaza there exists a community, almost hidden, where though the houses are built with brick, the poverty was visible in people's faces. The second community was the same, though much farther away and more isolated. We received a warm welcome in both places; community members were interested and never stopped participating and asking questions during the afternoon.
The MEDLIFE summer interns prepared a presentation about nutrition, demonstrating how to measure body mass index (BMI) and giving advice about eating healthy. Our medical director, Dr. Jose Rodriguez, continued with information about diabetes and the importance of a balanced diet. Dr. Evelyn, the OB-GYN who has been working at MEDLIFE's Mobile Clinics, gave an excellent talk about breast cancer and cervical cancer screening, which were some of the most talked-about topics in the workshop. Finally, Maria, a health promoter who helps with the education station at our clinics, talked about domestic violence and encouraged those present to report abuse if they witness it.
These talks are the result of collaboration with the local government and a critical step in getting to know new communities prior to conducting Mobile Clinics. When we first arrive in new communities, the families there are unaware of what MEDLIFE does and why, and may be reluctant to visit the clinic, which is why educational workshops are an important part of our year-round work.
The visit was a first look at this process for our new summer interns, who will soon be helping to run a special Mobile Clinic just for children in Surco. "It was great to see the response from the community," said MEDLIFE Intern Hailey Bossio. "I was really nervous at first, but everyone listened attentively and really respected our efforts."
In the battle for basic healthcare for poor communities in Peru, the most dedicated fighters are local volunteers known as promotores de salud, or community health promoters. For MEDLIFE, these promoters are indispensable; they help us provide patient follow-up, communicate with the communities where we hold Mobile Clinics, and facilitate health education workshops.
The first modern health promoters in Peru began in the 1920s with a program started by Dr. Manuel Nuñez Butron, a Peruvian physician who had studied medicine in Spain and Lima. When he decided to return to Peru and serve the population in his native Puno, a rural province in the Andes mountain range, he realized that the scattered geography of the agricultural communities made it physically impossible to treat everyone who needed medical care. He also saw that ingrained attitudes and practices regarding medicine and sanitation left rural populations more vulnerable to disease. Though he traveled extensively on horseback through the area in an attempt to implement new health standards and vaccinate the population against the growing smallpox epidemic, the local population was suspicious and resistant to change. So Dr. Nuñez Butron formed partnerships with traditional healers, training them to provide basic medical care and education on sanitation methods in their native language of Quechua. The program expanded to include local schools, mobile libraries and theaters, and medical brigades aimed at spreading the word. Back then, there was no Peruvian ministry of health; these healers are considered the first health promoters. They were known as "rijcharis," from the Quechua word for "awake." This community-based model of healthcare has proved effective around the world, and informs the work of organizations like MEDLIFE.
Health promoters were officially incorporated as a government program only about thirty years ago, and despite facing a low budget and lack of organization, they have been an important force in public health in the region. They are credited with successful vaccination campaigns, reducing infant and maternal mortality, and helping to stem the spread of diseases like tuberculosis, cholera and dengue. Thousands of community agents receive training from the Ministry of Health to work year-round on a voluntary basis. They may work as representatives in local health clinics, government offices, churches, or NGOs like MEDLIFE, though their primary responsibility is always in their own community. Though anyone can be elected by their community to receive training, they are primarily women, who tend to spend the most time with families and communities.
MEDLIFE's field nurse Meri, who was trained as a promotora, says that the program is empowering for women and their communities whose voices might not be heard otherwise. "We can teach that we are all equal, and that we all have rights and responsibilities to our health when we visit with families and hold community meetings," she says. "As community agents, our role is very important to ensure that the entire community works on health promotion and illness prevention." Most importantly, she says, health promoters can relate to patients in a way that others may not. "We are in direct contact with families, we live and share the same situations," she says.
Last week Meri attended an event held by the Ministry of Health to recognize these tireless volunteers for the official Dia de Promotor de Salud (Health Promoter Day). They shared stories and talked about the importance of strengthening health promoters in their communities by providing training that goes beyond just medicine, focusing on new programs to prevent malnutrition and infant mortality. "Now with MEDLIFE I try to link these elements that could help our patients receive a little more help, to be heard, and to see the social and human side of their cases," Meri said.
This week, MEDLIFE student volunteers are helping out with the construction of an auditorium at an orphanage in Cusco, Peru. Learn more about the girls benefiting from this project in the blog post below, written by Rosali Vela and translated by Rachel Goldberg.
Jessica has a shy smile, but when she starts talking no one can stop her. Living in the San Judas girls' home wasn't easy at first, especially when her mother left her there at the age of 9 in the care of the nuns that governed the institution at the time. It was hard to find a moment alone there, even in the bathroom, which is shared with more than 20 other girls. But in spite of it all, she says now she's never been happier.
Jessica looks at me doubtfully when I ask her if she is able or willing to tell me the reason why she lives in the orphanage. "My mom left me here because she couldn't take care of me, and her partner- her partner didn't want me," she tells me, her eyes misting. "I'm fine here, the mamis take care of us, they teach us to take care of ourselves, and especially to protect ourselves." The "mamis" are what the girls call the women who run the orphanage.
When I asked her what the girls needed protection from, she looked at me like the answer was obvious. "To protect us from people who want to hurt us," she says.
At 15 years old, Jessica is one of the oldest girls in the home. Her dream is to finish high school. Now she studies cosmetology in a government-subsidized institute and takes high school classes at night. "I want to be a lawyer," she tells me when I ask about her plans, and then she seems lost in thought for a moment, as if reflecting on what she wants to tell me. Finally, she adds, "I have two younger sisters who live with my mom and with him." She doesn't need to say more.
Like Jessica, almost all of the girls in the home were rescued from violent homes, where relatives abused them or abandoned them to seek a better future elsewhere. But not all of the cases are the same.
"Take my photo," says one small girl in the accent that is particular to the Cusco region of Peru. "I'm going to be famous," she says confidently. "I already have a band, and I'm the singer." Johana, 9, has lived in the San Judas home since 2012 with her younger sister. Their mother couldn't afford to take care of them after her husband left her for another woman, and couldn't find help in her small community. Now she is working in a market in Puno. She visits her daughters every other Sunday without fail.
The orphanage is currently administered by the government of Cusco, with Señora Maruja in charge of running the day-to-day operations. "We're always looking for support for the girls," she tells me. "Our dream has always been to have a big auditorium where the girls could exercise, visit with their parents on the weekends, or have classes and performances." Maruja is a strong woman who seems full of energy, and disposed to do everything she can for her girls. "We may be poor," she says, "but if I've learned anything, it's that the most valuable thing isn't money, but education and love."
One curious thing that caught my eye was the Barbie doll carefully placed in a glass case in a living room. With her long hair and pink dress, she seems to watch over the place from her perch high up on the top of a dresser. Rosacarmen finally gave me the answer to what I had been wondering. "The mamis put her there to remind us that we are all ladies," she told me. It seemed to me an apt analogy; these girls are all princesses.
Our latest educational workshop was located in a small community in the Nueva Esperanza area of Via Maria del Triunfo. MEDLIFE will bring a Mobile Clinic to this same community in March of 2013.
During the workshop, MEDLIFE staff members presented on a number of health topics, including the importance of psychological health and sleep, preventative tests for breast and cervical cancers, and nutrition. Along with our usual preventative health topics, we also touched on – for the first time – the important issue of property rights.
As many of our supporters know, MEDLIFE Peru works primarily with low-income, informal settlements established just outside of the city of Lima. Poverty, terrorism, and a lack of opportunities in rural Peru have prompted thousands of residents to migrate to these urban slums. As these communities become bigger, more established, and better organized, residents begin to move toward legal formalization of their homes and communal spaces.
Yet, the country has struggled in developing a comprehensive plan for urban development. With changes in government administration, treatment of informal settlements has varied widely. The involvement of several different agencies, sometimes with conflicting policies, also makes the process of legalization a murky one to navigate.
Santos Abad, a government lawyer, explained the basics of acquiring land title, highlighting the primary agencies involved in the process: COFOPRI (government agency that deals with property formalization), the municipal government, and – in some cases – the court system.
Abad outlined an important law called the prescripción adquisitiva de dominio. This law states that an individual may gain legal land title simply by possessing the land, peacefully and consistently, for a minimum of 10 years. The government's 10-year rule is a seemingly adequate amount of time for legal owners to reclaim their land or, if they wish, take squatters to court.
Community members listened attentively and immediately began to ask questions. In addition to general information about legalizing their property titles, many wanted to know more about the intricacies of sharing property. What happens when you share a home but are not married? How can parents ensure that their homes get passed on to their children?
Residents have voiced a need for more education, in order to better understand their legal rights. MEDLIFE hopes to begin including this type of training, focusing first on property rights, in our upcoming educational workshops.
Stay tuned for more information on important issues regarding land rights in Peru, coming soon!
Last Friday we visited the community of 8 de Diciembre for a seminar on various topics regarding preventative health care, as well as to hand out the Pap smear results for patients who attended a previous Mobile Clinic. The turnout was a lot bigger than we expected, showing us that this community is eager to learn about preventative measures they can take to help protect themselves and their families. From the moment we arrived we saw a very organized community; they had taken the time to rearrange the room to be able to accomodate all participants.
Biz Shenk, one of our MEDLIFE interns, gave a short presentation about mental health, which the community appreciated enormously. Several residents had questions regarding psychological health, but felt ashamed to ask them publicly; for this reason, MEDLIFE is trying to organize visits so that community members can meet one-on-one with psychologists. Two representatives from Manuela Ramos, an NGO that works to secure women's rights, also helped MEDLIFE Field Nurse Meri Lecaros present information about sexual and women's health. Among the topics addressed were how to recognize and prevent STDs, how to prevent cervical cancer, and how to do a quick breast exam to check for breast cancer.
Although participants listened with interest to all of the topics, the one that seemed to interest them the most was malnutrition. Almost every mother in the room was asking for advice; they all wanted to give the best possible nutrition to their children. At the end of the seminar everyone was satisﬁed with the answers given to their questions, and conﬁdent that the information received was not just for them to keep, but to also be shared with others. This group's interest was so strong that they even asked for more meetings, and MEDLIFE plans to continue returning to the zone to provide information on additional health topics.
Inge is a Communications Intern based out of Lima, Peru
We are slowly but surely making progress on our very first Wawa Wasi daycare center in Lima, Peru, thanks to the help of MEDLIFE chapters and supporters around the world! So far, the project is about 30% complete, but the environmental hazards of the area make this project a complicated one.
Working together, community members have dug 7 meters deep at the project site in order to reach solid ground and give the Wawa Wasi a safe foundation. They've also installed an iron framework in order to keep the ground from sliding and bringing down nearby houses with it. Rainy conditions this time of year can mean delays in construction, when it's not safe to traverse the muddy hills.
As planned in previous meetings between MEDLIFE and community leaders, local residents are doing their part by providing manual labor free of charge. Because they work during the week, these men and women take time each weekend to organize work days devoted to building the Wawa Wasi for their children. A portion of the funds raised for the Wawa Wasi will go to safety gear like helmets, glasses and gloves, so that they can continue to work without fear of injury.
The Wawa Wasi will be fully equipped to serve about 30 preschool-age children, with sanitary bathrooms, a classroom, and a nap area. It will provide a safe place for parents to leave their children while they work during the day, and create jobs for local women. Once construction is complete, the Wawa Wasi will operate in accordance with a program created by UNICEF and the Peruvian government, with a curriculum that includes important basic hygiene and nutrition education for both children and their families.
Your donations to the MEDLIFE Project Fund will help us obtain the materials we need to finish the Wawa Wasi! Stay tuned for updates about both the Wawa Wasi and MEDLIFE's potable water project happening now in Unión Santa Fé.
Savannah King, a MEDLIFE Summer 2012 Intern in Lima, Peru, writes about her recent work using preventitive nutrition education to combat some of the root causes of malnutrition:
Nutrition. A commonly used word. A commonly found problem. MEDLIFE has already written about it a few times, with good reason. According to UNICEF, of the twenty five regions of Peru, nine have a chronic malnutrition rate in children aged 0-5 of over 30 percent. Preventative and educational programs seem to be the leading campaigns for addressing the nutrition problems in areas like periurban and rural Peru and other South American countries, and many of these programs have seen measurable success.
Of the programs I have reviewed, education is always at the forefront of the battle against malnutrition, stunting and deficiencies. Rather than handing out bottles of supplements, the programs aim to make changes starting at the base: teaching a new mentality about food and providing lessons on basic health and diet knowledge.
For instance, one program stressed three main messages in the populations where they worked. The first message was that serving babies a thick puree at mealtimes will satisfy and nourish the child. The second suggestion was to add a small portion of liver, egg or fish to babies’ plates. These three food options are all inexpensive but bring large health benefits when added to a diet. It is not unreasonable budget-wise to suggest adding these items regularly into meals, and the extra protein and iron contribute largely to the children’s intake of nutrients. Lastly, the third message was umbrella advice about how to eat. The program urged the population to think about meals as a time to eat slowly, enjoy the food and spend time as a family. This simple change in mentality likely also encourages a more happy and positive household environment. Also utilizing tools like food preparation demonstrations and group educational sessions, this program saw a significant (⅔) decrease in the rate of stunting, increases in knowledge and preventative behavior and improved feeding practices and growth rates.
Another program focused specifically on pre-natal and newborn care by addressing not only nutrition, but hygiene and proper stimulation of newborns as well. After a four year implementation, the program saw measurable decreases in stunting, vitamin A and iron deficiencies and malnutrition.
Pre-natal nutrition education has both been proven effective by studies and specifically mentioned to me by local women as the type of education they see as most important to changing the health of their communities. During an interview with two women in Villa El Salvador about their families’ typical diets, the women informed me that pre-natal and newborn nutrition education in their community was significantly lacking. We discussed the young age of many mothers in their area and the vicious cycle of poor diets that is often the result. When a mother raises her children with poor eating habits, those children grow up lacking the understanding of what it means to eat balanced, healthy meals, thus increasing the likelihood that they will raise their children with poor dietary habits as well. The women were very insistent that nutrition education, especially for young mothers, would be a welcome and much needed help to their communities.
Along with other topics including the importance of cervical cancer screening and the risks factors of hypertension, infant nutrition has its own informational pamphlet that MEDLIFE hands out at sites during our weeks of Mobile Clinics. Recently, we went one step further and held a workshop on obesity, breast and cervical cancer and family nutrition. Carolyn, Maureen and I (three of MEDLIFE's Summer Interns in Lima) presented on the components of a balanced diet, suggested nutritional boosters to the daily diet and explained why each of the food groups is important to one’s body. We finished with a sampling of a fresh, colorful vegetable salad in the hopes of introducing all those present, including mostly mothers and a few children and men, to how tasty and economical a nutritious snack or side dish can be!
Nutrition is an issue not only in Peru, but all over the world. For the most part, though, it is not going unnoticed and, however slowly, non-profits and governments are addressing the problem through various programs and interventions. From the programs I’ve reviewed and the affected people with whom I’ve discussed the topic, it seems education -- starting at the pre-born stage -- is one of the most important battles that we can fight, and I believe that positive results are inevitable.
Villa El Salvador, one of the many districts in Lima, Peru where MEDLIFE operates, is characterized by a long history of diligence and self-sufficiency. The area was awarded the Price of Asturias Award for Concord in 1987 and was nomiated for a Nobel Peace Prize for excellence in social work and community growth in 1986. Even in the face of numerous challenges affecting all aspects of daily life, the people of Villa El Salvador have proven themselves to be stalwart and community minded.
MEDLIFE's relationship with the former shantytown over the past year and a half has grown significantly in the form of reoccuring Mobile Clinics, workshops and patient follow-up care.
This past May, MEDLIFE held another successful health workshop in the town's civic center with nearly 180 residents in attendance. MEDLIFE staff handed out pamphlets covering an array of health topics, including breast cancer, cervical cancer, diabetes, malnutrition, hypertension and cholosterol, fungal infections, and sexually transmitted diseases.
After discussing the risks of breast cancer, Dr. Jenifer Soto led an exercise in self breast examination which received enthusiastic participation from everyone -- even a small number of men. Dr. José Luis Rodriguez explained how to detect and treat malnutrition among children and senior citizens.
Workshops like these are a crucial component of our ever-expanding education program as we strive to teach patients about the importance of preventative care.
MEDLIFE Intern Amara Channell writes about a new facet of our educational programs -- health and nutritional workshops for the poor in Latin America:
“What can I do to make my child eat more?”
If you have ever attended one our Mobile Clinics, chances are you have heard at least one mother ask why her child is not eating and what medicine the doctors can give her to fix it. Each time the doctors patiently explain that picky eaters are not sick -- they just have a behavioral or taste issue.
Through our expanding educational programs, we have found that one of the biggest problems is that patients lack or misconstrue basic nutritional knowledge. Very few Peruvian schools offer health education, and even if they did, many of our patients have not completed school. The mothers we work with sincerely believe that the more they can make their children eat, the healthier they will be. Their goal is to have chubby children because to them it is a sign of health. Unfortunately, this means that these children are eating fattening diets, not balanced ones, with large amounts of white rice and potatoes, but not much else. Along the way they are developing greater risk of diabetes.
Although very few of our patients show signs of traditional malnutrition, Kwashiorkor or Marasmus, many of them do suffer from micronutrient deficiencies (or “hidden hunger”) which are harder to spot. Worldwide, over one billion children suffer from micronutrient deficiencies. Even though these children may seem perfectly healthy, they have depressed immune function, smaller attention spans, decreased muscle development, height stunting, and poor teeth. They are less likely to complete school because of increased illnesses and decreased brain development. As adults they continue to have issues because the lack of nutrients causes them to be more susceptible to obesity, illness, and muscle weakness. A recent Economist article states that these adults will end up with lower paying jobs, die sooner, and have poorer partners.
In the past few weeks, MEDLIFE has started trying to counter these problems with nutritional “talleres,” or seminars, for local Peruvian women. The seminars last about an hour and give women the absolute basics about nutrition as well as a chance to ask individual questions.
The presentations start by suggesting affordable changes that the women can make, such as eating eggs instead of bread for breakfast, and emphasizing how important variety is. There is an incredible abundance of affordable fruits and vegetables here, but it is not a cultural norm to include them in most meals. By adapting the new MyPlate program (developed by USDA), we can show them a healthy and balanced way to think about preparing their plates.
Although our staff members, doctors, and student volunteers conduct Mobile Clinics that last one to two weeks, the preparation for these clinics begins well in advance. MEDLIFE Fund Project Director Carlos Benavides visits several different communities, assessing needs and attempting to pinpoint locations that will serve the greatest amount of patients. Carlos also looks for a "compromiso" from the community -- a commitment to collaborate with MEDLIFE by providing community support and local labor. Community leaders also pledge to publicize the dates of the clinics and clinic services to the members of their neighborhoods.
Three to four weeks before the clinic date, another meeting is held with each community to share our plans and to receive questions. This meeting serves as an opportunity to speak about common health problems, to inform the community about our Mobile Clinic process, and to explain the types of services we offer.
In preparation for our most recent Mobile Clinic in Lima, Peru, MEDLIFE staff members held a meeting with the community of Villa El Salvador to present information about our diagnostic screenings (breast and cervical cancer) and dental services. Check out our before and after photos below!
MEDLIFE staff members meet with the community of Villa El Salvador in preparation for an upcoming Mobile Clinic:
Photos from a subsequent January Mobile Clinic in Villa El Salvador: