NEWSLETTER FROM THE SIERRA MADRE #13
FEBRUARY 1979

About Project Piaxtla, a villager-run health care network in the mountains of Western
Mexico, and the Hesperian Foundation, a small group committed to health education and informed self care.


Project Piaxtla is alive and kicking. The Hesperian Foundation is up to its ears with work--some of it old hat, much of it new and exciting. If a long time has gone by since the last newsletter came out, it is not because little has been happening, but rather too much.

The villager-run health program in the mountains of Mexico (Project Piaxtla) has become increasingly independent from the Hesperian Foundation and other outside support. Today the entire program is organized and run by a team of campesino health workers based at the training and referral center in Ajoya, a small village at the foot of the Sierra Madre Occidental. No longer are any Gringos--or Mexicans who are not campesinos from the immediate mountain area--continually active in the project. Yet the village team continues to welcome, on its own terms, short visits by outsiders with special skills - medical, dental, veterinary, and appropriate technologies. Such visitors are usually requested not to practice but only to teach their respective skills, thereby upgrading the capabilities of the local workers who provide the continuity of care.

The village health team has learned the hard way that visiting professionals have a tendency to try to take charge. This not only obstructs the growing responsibility of the local team, but also undermines the campesinos' increasing confidence in their own health workers (and therefore in themselves). For this reason, the village team has learned to carefully select the professionals it permits to visit. To avoid the growth of dependency, it also limits the length of their visits and requests that they stay as much in the background as possible. Thus, the visiting doctor becomes an auxiliary to the village health workers, helping out with advice and specialized knowledge when asked. He is also encouraged to pitch in with the agricultural and janitorial work, as do all the members of the village health team. In this way, the village workers help the doctor to demystify his role; education becomes a two-way process.

The team of young campesinos--some of whom, like Martin Reyes and Miguel Angel Manjarrez, have been closely involved with the project for twelve to thirteen years, since they were children--now takes assertive pride in planning and running the program itself. Not only has the group become self-reliant in terms of local personnel, but it is also determined to become financially self-sufficient. To do this, the team has had to look for ways to produce subsistence income. This includes modest fees for service. Except in exceptional circumstances, there are no hand-outs or giveaways. People are asked to pay for services, either with money or with work. However, to keep the cost of services low, all the members of the health team spend a part of their time working at various "self-sufficiency projects," which include hog and chicken raising, vegetable farming, and a cooperative corn bank. By loaning corn at planting time to poor campesinos at low interest rates, the corn bank actively opposes the usurious interest (250-300% in six months) charged by the local land barons. Thus, the corn bank helps the poor of the village in their struggle for self-reliance--and social justice.

The Hesperian Foundation now provides only about 50% of the village health program's ongoing costs. At times it also responds to infrequent requests by the village team for "seed money" to initiate or expand its self-sufficiency projects.


The village health team has found that economic self-sufficiency does not come easily. Their biggest hurdles have been the mastering of management skills and learning to work together democratically as a group. Nevertheless, in both these areas they have made astounding progress, through a process that might be called "continual productive crisis." The obstacles and dilemmas they have had to overcome, especially at the human, intragroup level, have been formidable, but the team has somehow struggled through them. Gradually, the group has learned to work together more cooperatively, more realistically, and mare unselfishly. They have discovered that the building of constructive, more truly human relationships between people is what most influences health--be it of individuals, programs, or communities. Preventive and curative medicine are secondary.

As for myself--as the initiator of the program and as an outsider (though I feel more at home in the Sierra Madre than anywhere else)--Project Piaxtla has evolved to the point where the most positive thing I can now do for it is to keep out of the way. The village health program has grown up, or at least has reached its adolescence. It is fourteen years old. The community team feels its budding strength, its youthful hard-won integrity, and is determined to make it on its own or bust. With personal sorrow yet vicarious pride, I have accepted that my ongoing presence in the village program is no longer wanted or needed. So I have undertaken to phase myself out.

At the request of the village team I have, during the past two years, been spending about one quarter of my time with the project as a friend and advisor. When I am there, I play a minor role and leave the running of the program completely to the village team. It has been easy for me not to make decisions directly. But it has been much harder to avoid manipulating decisions indirectly. Because I had played a leading role in the project for so long, at first the local team tended to take my ideas and suggestions too seriously. Now they are learning to take them more for what they're worth--weighing them against their own experiences and views. (A few really stupid suggestions on my part have helped this learning process no end.)

To become an effective leader is difficult, but to cease being an effective leader is far more difficult--and in the long run far more important. I'm just beginning to learn.

Although both the Hesperian Foundation and Project Piaxtla are now far less dependent on each other, they often work together on exploring alternative approaches within the field of community-based health care and health education. Both have a growing commitment to encourage a productive interchange of experience and methods with other persons and community groups who share the goal of helping people gain more control over their health and their lives. We have approached this process of sharing experience and information in several ways.

For example, during the annual two-month training program for village health promoters the Ajoya team makes a point of inviting participants from other community health programs in Mexico and Central America. Last year, two young men came from a radical, very exciting program training "medicos campesinos" in Nuevo León, two nuns working with the Cora and Huichol Indians came from the mountains of Nayarít, and two very active leaders came from a spirited campesino women's health promoter program in Olancho, Honduras. All these persons contributed a great deal to the Ajoya training program and also learned a great deal from it.

All the teaching and organization of the health promoter training program was done by the village team. My co-worker, Bill Bower, and I attended the training program, but did not give classes ourselves. We remained in the background and helped the local health workers prepare their classes when they asked.

Last year was the first year that the teaching and organization of the training program was done completely by the campesino team. Everyone felt fairly much on equal footing, and shared in both learning and teaching. Through constructive criticism and group self-evaluation, the trainees helped the teachers learn to teach. It is significant that those who had attended the previous year's course, which in large part had been taught by Gringos, all agreed that the campesino-taught program was superior. I thought so, too. One of the most important things that persons from other programs learned was how rich an educational experience can be when a group of unassuming people teaches and learns from each other.

 
 
 
TALK WITH PEOPLE.........................NOT AT THEM
 

 

The Hesperian Foundation, as well, has been involved in activities that have taken us far beyond our original focus on rural Mexico. The new English edition of Where There Is No Doctor is already being used as a training manual for village health workers in at least 100 countries. As a result, we are establishing communications with community-based health care programs all over the world (including some Native American, farmworker, Appalachian, and inner city groups in the U.S.A.). Our two papers, "Health Care and Human Dignity" and "The Village Health Worker--Lackey or Liberator?" have been reprinted and widely distributed in countries as distant as the Philippines, Kenya, and India, and have helped us move toward a world allegiance of humanitarian persons and groups dedicated to what might be called the "health care of liberation."

Last November I was invited to give the opening address at a workshop to be held in India on rural health, development, and technology, called "Let the Village Hear." Since the workshop was supposed to be at the village level, I thought it far more appropriate that Martin Reyes, the coordinator of Project Piaxtla, attend in my place. The coordinators of the workshop agreed to the suggestion, so Martin went to Calcutta to, as he put it, "let the village be heard." Martin got a great deal out of the workshop and, according to letters we have received, he in turn contributed much. He was also able to visit and exchange experiences with several exciting, community-based programs in other parts of India and in Bangladesh.

One of the main focuses of the Hesperian Foundation has increasingly become the development of simple, clearly written handbooks and teaching materials for people-based health care in poor countries and communities. Apart from Where There Is No Doctor, of which we are now winding up a completely revised Spanish edition, we are in the process of preparing a number of publications that will probably appear in the following sequence in the next two to four years:

Just
begun
1. Methods, Aids and Ideas for TEACHING HEALTH CARE IN
A COMMUNITY--especially for use with Where There Is
No Doctor, a village health care handbook.
Half-
done
2. SELF-EVALUATION OF A COMMUNITY-BASED HEALTH
PROGRAM (evaluation as if people mattered).
Begun two
years ago
3. The Role and Training of VILLAGE HEALTH WORKERS IN
LATIN AMERICA--a sourcebook for planners, educators, and
half-done agents of change.
Begun 4. WHERE THERE IS NO PHYSICAL THERAPIST--Home care and
exercise of the physically handicapped child. (To be co-authored with Sophie Levitt, a South African physiotherapist.)
Research
in process
5. THE POLITICS OF HEALTH AND HEALTH CARE IN LATIN
AMERICA from the village to the international level.

 

We have been working on #3 (the sourcebook), for over two years, and have had to put it off several times already to complete work on the English and then the revised Spanish editions of Where There Is No Doctor. Nevertheless, Bill Bower and I have decided to put it off once again and first try to complete a simple teaching guide for the use of Where There Is No Doctor (#1). From this January to March, Bill and I will once again be attending the annual training program for village health promoters. We hope to observe and write up--for others to use- many of the educational approaches and techniques developed and used during the course. As this training program will include some health education with mothers and school children, as well as community involvement and "teatro campesino," we hope the coverage of the teaching guide will be both ample and entertaining.

One of the most delightful activities that both the Hesperian Foundation and Project Piaxtla have become involved with during this past year is the so-called CHILD-to-Child Program.

The idea of the program, in brief, is to interest and involve school age children in helping meet the basic health needs of their younger brothers and sisters. This is especially important in poor countries and communities where the families tend to be large and where older children do much of the caring for the younger ones.

At the invitation of David Morley of the Institute of Child Health in London, I joined an international group of educators and community health people in England last April in order to plan the CHILD-to-Child Program, which will be a part of the International Year of the Child (1979). Together we drafted a dozen or so possible "activities" based on our diverse ideas and experiences from working with village children in many corners of the earth. The activities looked good on paper--but they still needed to be tried out.

Back in Mexico, the health workers of Project Piaxtla, the primary school teachers, and the school children of Ajoya helped in the pilot testing of several of these activities. The response of the children, teachers, and health workers was enormous. I have included with this newsletter an English translation of an article on the Ajoya school children's involvement in the CHILD-to-Child Program. (I recently prepared this article for inclusion in El Informador, a periodical publication of the Guatemala-based "Comité Regional de Promoción de Salud Rural," of which Martín and I are members.)

The most exciting outcome of the CHILD-to-Child trials in Ajoya is that these Mexican village school children have taken tangible action to help school children in other parts of the world. They are doing this by making special measuring spoons out of bottle caps and old juice or beer cans. These spoons are used to measure and mix the right amounts of sugar, salt, and water to give to a baby (or anyone) with diarrhea in order to help prevent or correct dehydration. Because the dehydration that results from diarrhea is one of the major causes of death in infants in the world today, it is extremely important that the children and their mothers know how to prevent and correct it. It is safe to say that if the school children (and their mothers) of the world learned how to make and use these "rehydration spoons" correctly, these simple spoons made out of old bottle caps and beer cans could do more to reduce infant mortality today than all the hospitals and doctors on earth!

But first, there was one big stumbling block. Although the school children, teachers, and health workers had been given instruction sheets showing how to make these spoons, no one had taken the initiative to make them. Not until I made one myself and gave it to them. With the sample in their hands, the children began to make more spoons for themselves and had a great time doing it. They demonstrated to their mothers how to use them, and later put on a public demonstration.

The children of Ajoya, recognizing the importance of having an actual sample spoon and not just instructions, determined to make sample spoons to be sent with the CHILD-to- Child activity sheets to school groups around the world. Already they have made several hundred spoons. These have been sent to the CHILD-to-Child headquarters in London, whence they will be mailed to Ministries of Health and Education throughout the developing world, to health program leaders, and to anyone who will put them to good use. With each spoon will be sent a cover letter from the children of Ajoya asking that the spoons be given to classes or groups of children, encouraging them to in turn produce yet more spoons, and so on, until through a pyramid of children to children, a great many schools and villages are reached.

School children from the Peninsula School in Menlo Park, California and from a few other schools in the U.S.A. have also become involved in making and dispatching these spoons.

Whether or not this pyramid of children helping children across international boundaries will succeed remains to be seen. If it doesn't, it will not be for lack of good will or hard work on the part of the children...


And even if the spoons do not reach far and wide, the making of them has helped give, school children in both a Mexican village and a few U.S. towns a sense of active concern for the well-being of other children in other lands. Also it has been loads of fun!
--David Werner

Help is still needed in the following ways:

1) Volunteer help with typing and secretarial skills, especially in the Palo Alto area.
2) Volunteer help in translating materials into Spanish; also typing and/or proofreading in Spanish--preferably native Spanish speakers in the Palo Alto or Bay Area.
3) Persons driving down the west coast of Mexico who are willing to take down supplies and (depending on timing) bring up or take back children in need of reconstructive or orthopedic surgery at Stanford (Interplant) or Shriner's Hospital for Crippled Children in San Francisco.
4) Although Project Piaxtla is increasingly independent economically, seed money is still needed from time to time for starting or expanding self-sufficiency projects. For example the group has hopes of building rat- and insect-proof storage bins and of expanding the cooperative corn bank. Outside monies are also still needed for the health promoter training program (the village of each health promoter pays half his living expenses during training and the program pays the other half and provides an initial medical kit).
5) Although the Hesperian Foundation still relies primarily on volunteer help, we now find it necessary to compensate some of our workers. Also, the preparation of books, papers, and educational materials runs up our expenses. The sale of Where There Is No Doctor brings in some money, but its low price--especially in poor countries--allows us Little margin for reprinting. Also, an excellent film has been produced on the villager-run health program in Mexico (called Health Care by the People). Although most of the funds for the production of this film were raised by its producer, Elvie McKean, we still need financial help in producing a Spanish version, which could be an important educational tool throughout Latin America.

In short, we still need and appreciate your help.
The Hesperian Foundation is a public, nonprofit foundation. Donations are tax-deductible when made to:

Hesperian Foundation
Box 1692
Palo Alto, California
94302

Project Piaxtla no longer needs or accepts long-term outside volunteers. However, it still welcomes occasional short (one to four week) visits by persons with special skills who speak Spanish and are willing to teach. It also welcomes a limited number of short-term visits by persons who have special reasons for learning from the program or exchanging ideas. Anyone interested in visiting Ajoya should write directly to the village team: Martin Reyes, Coordinador La Clinica de Ajoya, San Ignacio Sinaloa, MEXICO

Write in Spanish and explain who you are and why you would like to visit. Please try to understand that the village team is now determined to make it on its own and is reluctant to have too many outsiders--especially Americans. This does not, however, mean that they do not welcome certain persons willing to teach special skills.

***

The following publications by David Werner are available from the Hesperian Foundation:

Book: Where There Is No Doctor available in Spanish, English & Portuguese ...
$5.00 ($3.30 for orders of five or more)

Papers:
General Statement

CHILD-to-Child activity sheets on:
Understanding Children with Special Problems (Eng. & Sp.)
Luchando Contra La Diarrea
Para Saber Si Ven y Oyen Bien Los Niños

Health Care & Human Dignity...$1.00

The Village Health Worker--Lackey or Liberator?...$1.00

Maria
(describing tragic death of a woman, a turning point in Project Piaxtla toward a more human and appropriate approach to medicine and health care)... $1.00

Film: Health Care by the People (in color -28 minutes) available in Spanish and English ... $350.00 for purchase $ 35.00 for rental

Bird Prints: David Werner's black & white paintings of Mexican birds... $10.00 (set of four $25.00, autographed)

Still in preparation:
"Health Care in Cuba Today: A Model Service or a Form of Social Control--or Both?" Fifty pages. This is based on a visit to Cuba last summer by David Werner and Bill Bower. It is still in preparation, but if you want a copy, let us know and we will send it to you when it is ready ...$2.00

WORK FIRST FOR THE PEOPLE--NOT THE MONEY.
(People are worth more.)
 
KEEP LEARNING-Do not let anyone tell you there are things you should not learn or know.   PRACTICE WHAT YOU TEACH
(or who will listen to you?)
HELP OTHERS TO LOOK AHEAD.

 


KNOW YOUR LIMITS.
WORK WITH TRADITIONAL
HEALERS AND MIDWIVES--
NOT AGAINST THEM.
Learn from them
and encourage them
to learn from you.
   
LOOK FOR WAYS TO SHARE YOUR KNOWLEDGE.
HAVE COMPASSION.
Kindness often helps more than medicine.
Never be afraid to show you care.