Sanitation, Open Defecation and Children's Health

I never thought that I'd be interested in sanitation, but the importance quickly became obvious after only a few months in Ecuador. Basic sanitation, clean water consumption, and hand washing are among the most basic and essential hygiene practices necessary to prevent diseases and infections. It's a link that I learned about through working at the clinic in Tixan and in the more rural communities like Chalaguan, where open defecation was the norm. In Chalaguan, four babies died in my first year from various causes, but all were malnourished to some extent. Malnutrition and sanitation will always be issues close to my heart and I'm going to continue using this blog to talk about them.

I came across an article at the Guardian the other day, Will data linking open defecation to undernutrition force change?, that talks about the lack of interest in sanitation issues worldwide despite the fact that it's clearly a big problem:

The UN says countries where open defecation is most widely practised have the highest numbers of deaths of under-fives, high levels of undernutrition and poverty, and large wealth disparities.

The article mostly talks about the situation in India, a country in which 48% of children under 5 are stunted despite substantial economic growth. India recently passed an enormous bill creating a $20 billion a year food program, but experts say that unless the widespread sanitation problems are addressed, increased nutrition won't make that big a dent in the percentage of malnourished children.

Also at the Guardian, UN calls for greater focus on sanitation and an end to open defecation.

Similarly, journalist Rose George talks about worldwide sanitation problems in this TED talk:

Very interesting. If you have a few minutes, check it out!

It would appear that I'm not done posting on this ole' blog yet because I'm not sure what to do with these ideas rolling around in my mind. Not sure if anyone is still reading, but enjoy if you are!

Marzooo

Hello family and friends! You'll be happy to hear that the 24/7 season of fog is ending, which is a major blessing for me here in Tixan. Waking up to fog and not seeing the sun for many days (let alone the end of the street) is depressing. In Oregon, we get lots and lots of rain and darkness during these months, which is also difficult to deal with sometimes, but the fog is a different demon. I'm not saying its better or worse, but there is something inherently menacing about fog that is deeply creepy. It really feels like someone could always be watching or following you.

Things are busy busy busy around here! Officially, I've got about 5 months left of service so I'm trying to cram in as much stuff as possible here before the end. There is just so much work to be done that its hard to say no! Here's a quick run-down:

1. Elementary health classes! They're going really well. So far we've covered nutrition, handwashing, general hygiene, cold/flu prevention, diarrhea prevention, clean water, and we've done a little lesson in story writing with a health emphasis. Some of the lessons have been more successful than others, but overall, it's been good. Next up we'll be discussing the environment, trash, and recycling, and hopefully do some sort of Earth Day celebration (April 22). I also have plans to do an art or essay writing competition in May/June before the end of school. Let me know if you'd like to send/donate any materials for prizes!

2. High school sex ed classes! These are also going really well. I like hanging out with the little kids, but I also really appreciate the fact that I can have a real conversation with the 8th-10th graders. Next week we'll be getting into anatomy, menstruation, pregnancy, and do a condom demonstration. The rural doctor who works at the clinic in Tixan will be helping me with these classes, because I thought it'd be best to split up the boys and girls. Dr. Juan will take the boys and I'll teach the girls, which will be great since there are so few of them! Hopefully this will allow us to have a more honest and productive discussion.

3. Girls Club/Grupo de Jovencitas! I just formed a girl's club with the high schoolers a couple weeks ago. We're going to meet once a week during recess for 30-40 minutes, and do crafts and chat and hang out. At the first meeting, 14 girls showed up! I think that as we continue more girls will want to participate as well. I don't really want to turn people away, but we'll see what happens. Forming this group feels like kind of a last ditch effort to work with girls, and I'm really kicking myself for not doing this a year ago, but OH WELL. I'm trying to squeeze out something positive from every last moment here. My bright idea with the girls is to do some journaling activities. We'll see how things go, but I'd like to make journals with them, and then do a short writing activity every week or two. At the very least, they'll have their journals to take home with them and use. I've thought about making paper and doing a big project, but I think thats going to be too difficult if we're making 15-20. Anyway, if anyone has any ideas about journal/book making, send them my way! Something simple but attractive is obviously what we're going for.

4. Craft classes with the women of Chalaguan! Cecilia, the adult educator, and I have been trying to work with the women of Chalaguan to form a jewelry business, but after many months of discussion, its just not going to happen. The idea is just too big and the women are hesistant to commit. So in place of that, we're applying for a small grant through Peace Corps to get materials to do some craft classes, like knitting, sewing, jewelry making, bead making, etc. This way we can more ladies involved in the classes too, maybe some who are interested in learning a new skill, but who weren't interested in forming a business. Along the way, we can chat about small businesses or health or whatever topics come up during the classes and spread the knowledge in a more informal way. Hopefully it works out!

5. Nutrition/hygiene/cooking talks at the clinic! In these last few months, I'm trying to step up the number of short talks, or "charlas", that we do in the clinic and involve the community health workers to a greater extent. There is a big recent push to work on lowering malnutrition in our county, which is great, but no one is really coming up with new or creative ideas to solve this huge problem. I've really cut back on the individual nutrition counseling that I do, because it just doesn't seem that effective (and also because my "office" is now being used as storage). I think that its probably more effective to give lots of charlas on general nutrition to everyone thats waiting to be seen at the clinic, in an effort to raise the awareness and knowledge of the whole community. I want to make more educational materials to put up on the walls, and get everyone to talk about nutrition in the same way in order to give more coherent advice. This problem is waaaaaay bigger than me... but hopefully now that I have a better idea of how the system works and how people think, I can make a more focused effort to get the information out there and encourage behavior change. I also want to teach the health workers and my other co-workers how to make cookies and carrot cake and some other things, which they are all very excited about.

There are some other little things happening here and there, but those are the major projects going on in the last few months! My tentative plan is actually to end my PC service at the end of July and then travel/bum around for a month and get back to Portland at the beginning of September. People are getting married and I've got a life to re-start! I love Ecuador, and I've had a great time here (lots of ups and downs, but overall, very fulfilling)... but its just about time to head home. I miss you guys!

I spent this last week in the jungle around Tena and Misahualli, helping out with a health brigade organized by Timmy Global Health. It was the first time I'd ever participated in anything like that, and it was a great learning experience. More than anything, it gave me a lot to think about in terms of development work. A week-long health brigade is obviously vastly different from Peace Corps service, but each has its strengths and weaknesses. Most people are not able to commit to two years of service in a developing country (let alone a month), so they're forced to resort to a week. Is it possible to get to know another culture/country/people in a week? Absolutely not. But they do provide semi-regular health attention to remote communities that have a difficult time getting to see a doctor normally. I think that organizations that do brigades have great intentions, but I also think that they need to understand the Ecuadorian health system better and encourage Ecuadorians to utilize it as best they can... because primary care is free here! So is birth control! And care for kids under 5! And people with special needs! Ecuador has got some inspired programs runnning, and while they still lack efficiency and consistency, progress is being made. Ideally, NGOs should make an effort to recognize the progress that the host country is making and work with the system to help it run better, and just be around to fill in the gaps. Surely there are still gaps in the health system here, like there are anywhere, but my impression is that Ecuador is doing a good job helping more people get better care. Poco a poco.

Anyway, apart from all the theoretical discussions going on in my head, it was great to meet everyone involved in the brigade... and also get a little vacation from Tixan. It wasn't a true vacation, because I was working most of the time, but a change of scenery was good enough. Plus, I love the jungle! Its amazing. So many bugs, so many animals, so much beautiful, inspiring nature. It was humid and sweaty and I loved it. It was a much needed break from the fog and all of its cold creepiness.

Lastly, my sister is coming down to visit next month! She's getting back from Thailand and immediately flying to Ecuador to spend 10 days. It'll be a rushed trip, but I'm really looking forward to it. It'll be nice to see a familiar face and visit a few places I haven't been to yet and be a tourist.

Well I hope you're all doing well! Just in case you've forgotten, I enjoy getting updates from you all as well... don't be a stranger! Five months isn't forever, but its long enough to need some encouragement :)

February Update

Hello! It's been a little while since the last update. Things are going well here in Tixan and at the moment, everyone is gearing up for Carnival, which kicks off tomorrow with the crowning of the King. Ecuadorians take their parties very, very seriously, so it should be a good time!

We're also in the middle of 2 weeks of school vacations, so I've mostly been hanging out at the clinic. It seems strange now that I used to go there all day every day, because while theres stuff to do... theres not THAT much to do. I'm also becoming very conscious of the fact that I'm leaving in 6 months, so I'm trying to back off a bit in terms of the free labor. There are some things I do at the clinic that are mostly outside of their work area (nutrition counseling, organizing/reorganizing the files), things that wouldn't otherwise get done if I wasn't there. However, there are other things that I sometimes do because theres nothing else to do... but I probably shouldn't. Sometimes I help take vitals, do some filing and help clean, because I'm bored. The problem is that these are things that are explicitly in the job description of other people, so to some extent, I'm enabling their inefficient work habits by doing part of their job.

Occasionally, I help out because theres just no one else to do it (like the days when all the nurses leave to do vaccines, and the doctors are left without anyone to take vitals), but this is also problematic. The doctors are perfectly capable of pulling files and taking vitals themselves... it's just that it takes so goddam long to do, people will end up waiting for literally 5-6 hours. My conscious always sides with the patients, so when I help out its always to make things more efficient and pleasurable (as much as possible) for the sick people. I think that people appreciate and like me for this, which is great for me... but what happens when I leave? Will things just go back to the way it was before? When everyone yelled and treated the patients (and each other) like crap?

I don't know. It's impossible to know now. I worry about it though, and I wonder if there are any measures I can put in place to help prevent things from reverting back to the inefficient, unhelpful status quo. To some extent, I think that my presence sort of shames people into acting better. I don't yell, I say please and thank you, I don't give people a hard time about stupid, random things. I'm always mystified on the days when the occasionally enforced "rule" is that people can only get one appointment per family. What if 2 kids are sick with fever? What if the family comes with 5 people because they live really far away and can't make it more often? What if the mom needs to get her birth control TODAY and her child is sick? (All of which happened the other day).

I should point out that I don't think its not like this everywhere. Other clinics and hospitals have a better system, more management oversight, and more doctors. The major problem with my clinic can be summarized in one word: burnout. People are jaded and don't even try to have patience anymore. Burnout exists in every field, in every area of the world, but its especially harmful in this sort of first-tier dealing with the public situation. Tixan is a difficult area to work in, FOR SURE, but it doesn't excuse the behavior of some health workers. I've had days where I just have to leave after a few hours because I can't believe how horrible people are being and I feel like continuing to work condones their behavior. Could I say something? Maybe, if the perfect opportunity came up. Otherwise, I keep my mouth shut, because after all I'm just a random, privelleged gringa. There are some moments when I put in my 2 cents, moments that are more suited to my areas of expertise, but when it comes to basic human behavior... nope. I'm no one's mother. The way most Ecuadorians avoid taking the blame for anything (even in situations when it was clearly their fault), it would be suicidal to give a name to the obvious problems.

I've thought about possibly bringing up some of my issues right before I leave, but if I ever want to come back to visit and actually be welcomed, I can't do it. Be smart, Chloe! When has burning bridges ever been beneficial in the long run??? Never ever ever.

Anyway! In terms of other work... the health classes I teach at the two schools have been going really well. The kids are finally calming down, so classroom management hasn't been as big of a headache as at the beginning. I also finally got the 6th and 7th grade teachers at Escuela Luz Elisa Borja to pay attention to me and help me out with behavior issues, so my last classes in January were very pleasant and productive. It took nearly 2 months of complaining, walking out of a couple classes, and finally complaining to the other teachers to get them to change, but better late than never! For the first time, the kids listen, participate appropriately, and are (mostly) respectful for the entire 40 minutes I have with them. Imagine! Its a small miracle.

In my spare time, I'm also working on compiling my lessons into a manual for the teachers to have once I leave. Probably no one will use it, but hey, you never know! I mentioned this project to a woman who works at World Vision (the largest NGO in the world. You know, "for only pennies a day you can sponsor a child...") who is in charge of a national effort called Escuelas Promotores de Salud or Health Promoting Schools or something. Last year, I presented at a conference for the schools in my area, but they haven't asked me to do anything else. Anyway, I mentioned that I'm putting together this manual of lessons for health classes and Veronica seemed interested in possibly using it for this network of healthy schools. I'm going to try and get it done in the next month or two, because it would be awesome to promote it at the participating schools before the year ends in June. The Health Promoting Schools project is a great idea, but its also really vague. At the conference I went to, they didn't exactly teach the teachers how to incorporate health lessons into their curriculum. They mostly just told them stuff they should already know, about hygiene, sexual health and nutrition. To me, taking that information and translating it to the classroom is the real challenge! Luckily, I've got a bunch of tried and true lessons that do just that.

There are a few others projects in the works, such as a women's jewelry cooperative, a girl's club, baking/cooking classes, and English lessons, to name a few, but I'll return to talk about those another day. It's funny that with 6 months left, all these opportunities suddenly fall in my lap. I wish I'd had these bright ideas a year ago, but what can you do?

Lastly, I applied to the Portland State University Master's in Social Work program for entrance this fall, so fingers crossed they let me in and give me lots of money! This means that I'll be heading back to Portland after Peace Corps ends in July or August, which is pretty exciting. It feels really good to have something of a plan and a place to be for the next couple years... which is a big reason I signed up for PC in the first place. I can't seem to settle down in one place on my own, so I have to force myself to do it using other means! Restlessness is really a big problem.

Anyway, I hope you're all doing well! I'd love to get an email update when you get a chance. Seriously! I'll leave you with a picture of me and some of the health workers after our Christmas program at the clinic. The ladies helped me buy my outfit and get all dressed up, which was a lot of fun!