The promotores, some of whom have now been involved for three years, have leapt to a whole new level of confidence and leadership, even since I was here last December. One of my favorite moments in all my years so far occurred in a community meeting in Chacanceo this trip. This is the most remote of the communities (think 3 hour UPHILL mule ride, no road). First, the promotores had taken the initiative to organize a community meeting for the first day we arrived, in the absence of both Lupe, the Ecuadorian Dr. with whom we work, and the local teacher, who is the main c
ommunity leader. They had a written agenda, and took turns leading the community in discussion. (Yay! We taught them those skills!) Wilson (the youngest) excitedly presented his idea of a community project to build wood burning stoves that vent outside the house, rather than the smoky versions that most people now use. He listened to others’ opinions, and then articulately and confidently presented his ideas. He has been a promotor for 2 years, and learned about the design of these wood burning stoves during a trip to an international health conference he attended with us 2 years ago in Cuenca. But the thing that made it so special for me to see him promoting clean stoves for his community was that on my first ever trip to Chacanceo, he was sent down to meet us with his family´s mules. He guided us back to the community. At that time, he was a tiny, shy 12 year old boy who I first guessed was about 8. We engaged in halting conversation for much of the hike up the mountain. He was sweet and curious, but like many people in his rural village, fairly reserved. Now, at age 18, he is truly a community leader, and the transformation is amazing. He also has a playful, goofy teenage boy side, which brightens our workshops and long hikes. But I feel so lucky to have seen him grow up, and to be able to support and encourage his commitment to his community.
This trip I spent a week working with the 3 proms in Manta Real, the biggest community, then another week with the 3 proms in Chacanceo. In daily sessions we talked about the value of various kinds of data collection, implemented a community survey about family planning, discussed the theory and practice of popular education, and designed a small project that ARSE will fund and the proms will implement in each community. Each group also planned and led a popular education style workshop for the community. It was a busy two weeks!! Here are some highlights:
In Chacanceo the community organized so we would eat with a different family each day. (At this point “we” is my fie
nd Alison from Columbia, who joined me after a week of language school, and a nursing student from San Francisco who came along as a volunteer.) Chacanceans are farmers, so the community is widely dispersed and the terrain is MOUNTAINOUS. I know I tease the east coasters about their description of the Berkshire Rolling Hills as “mountains,” but these Ecuadorian mountains involve some SERIOUS incline, even by my Oregon standards. Anyway, we were getting good workouts because each walk to a meal could be a 15-40 minute serious hike. One time a tiny 7 year old was sent to guide us to his uncle´s distant house. At first he was too shy to even speak to us, but it was clear he was there to take us, so we followed him off down the path. Soon he warmed up, and started to be playful, running ahead, hiding, and jumping out from behind trees to startle us. He insisted that we skip, then wanted us to run. He pointed out sights: “7 chicken,” “a pig,” “a butterfly,” “my uncle’s house” (seemingly miles away down the hill). I couldn´t help compare him with Wilson, and hope that 10 years hence he too might be a promotor.
Sebastian, another promotor from Chacanceo, has a daughter who´s 4. She appeared one day carrying a long stick with a rope attached to one end. I asked what it was, and her dad said “It´s a horse.” I was terribly confused, until I realized it was kind of like an old-fashioned hobby horse, only headless. And sure enough, the little girl soon mounted up, and took off galloping across the field, swatting her “horse/mule” with the attached rope and shouting “Cho! Cho!” (which is how you get your Spanish-speaking mule to move forward.) Next she stopped her mule next to the soccer goal post, dismounted, and proceeded to tie the beast up with an elaborate knot, using the same rope. It was such a perfect replication of what she must see adults doing every day, it was precious.
There is a dramatic generational gap in terms of family planning attitudes. People who are around 35 and up tend to have huge families, 5-12 kids. No planning methods other than some of the younger women in that bracket now have their tubes tied. Younger women may have 2 kids by their early twenties, but most of them are currently using some kind of family planning (depo provera injections or the pill, according to my sense from collecting data, not yet analyzed). One family where we went to eat had 9 kids, one a baby, and the mom in her early 40s.I asked about family planning, and the dad replied that he didn´t want his wife to use anything because those things cause cancer. I invited them to come to the workshops we were doing with the proms, because they were curious what was going on and I didn´t want them to feel excluded. They came the day we were practicing the questionnaire, so there was a lot of discussion of family planning, it turns out the oldest prom (early 40s) also felt that modern methods caused cancer, but had successfully combined the rhythm method with condom use with his partner. I decided not to confront the cancer myth in the moment, because I was getting the idea it was widespread and wanted to think about an effective and respectful way to address it.
Anyway, what unfolded was beautiful. The guy with the huge family left soon after we started the questionnaire, I think because he may have been uncomfortable with so much of the proms’ talk of why it´s desirable to limit family size. His wife, however, hung around. When we started practicing the survey, she said, “Call him back, ask him the questions, I want to hear what he says! I want you to ask him! I don’t want any more kids, but he won’t do anything!” So the proms called him in, and administered the questionnaire. Then they started to ask why he was opposed to family planning. The oldest prom, who is a similar age but with only 3 kids told his personal story. He said “I had two kids and didn´t want to have more. But then the third one was born, and I didn´t know what to do. I went to a workshop and learned about the rhythm method. You don´t have to use those things that can hurt your wife, you just have to count the days from when she has her period, and from the 14th day…” And he explained how it works, how it required cooperation and communication between the partners, how you have to use a condom if you want to have sex on the unsafe days, almost textbook perfect. Ok, sure, the rhythm method is not 100%, but the prom has 3 kids, and the other guy has 9, and they´re the same age! It was an ideal illustration of the power of community health workers. We sat back and said nothing, while he non-judgmentally shared his personal experience with his peer - how he had been unaware and frustrated with a situation, had received new information, had changed his behavior and was pleased with the outcome. Now he wanted to offer the same information to the community. Perfect. Later in the week we talked about family planning myths (cancer! infertility! impotence!) with the proms, and it was one of the things they chose to include in their community workshop at the end of the week.
I don’t know how it could be better! I feel like now I’ve been here so many times, have relationships with the proms, and can much better communicate with them. When we discussed “myths” (a word they had a hard time understanding and suggested we change to “false beliefs”) they were completely open to hearing new information. They asked lots of questions, shared the things they’d heard, and puzzled through the story problem I gave to illustrate the ideas of confounding and causality (diagram thanks to Alison): Twenty women take the pill. Five get cancer. Twenty women don´t take the pill. Five get cancer. What’s going on? What is cancer? Why do some people who take the pill get it and some don´t? Why do people get cancer if they don´t take the pill? Why do people associate cancer with the pill? It was an amazing discussion, which they replicated themselves with slight modifications and a slightly confusing description in their own workshop. Seven women – IUDs – 5 deaths…I think they got tired of drawing women, and high death rates make for engaging drama!
Ok, not even halfway through my list of community adventures, but i´m now in the Galapagos and the internet café is about to close. Tomorrow Alison and I take of on an 8-day boat trip so I want to get some sleep while still on a stable surface. More later.
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