Nourish and the Health and Sanitation Campaign

Check out the new video – Peru Review: Pictures from the Nourish International Summer 2009 Peru Project

Kat Burns—Director of Public Health Programs, micromanager, general, den mother—is fondly dubbed La Jefa, the boss.

Up at dawn with the rest of us, La Jefa stops in the courtyard to check on the month-old puppies between bites of breakfast, making a mental note to take them to the vet in Trujillo next week. As we hurriedly cobble together avocado-and-cheese sandwiches, Kat collects tape measures from the archaeology students staying in the lab house for the day, so that we can borrow them for our health assessments. She leaps upstairs to tell us that the bus is here, to grab scales, surveys and go! We yank our toothbrushes out of our mouths, scooping up bags of rice to give to survey participants. Shovels and daypacks in tow, we scramble into the van.

An hour later, we’re in the valley, having picked up the nurses in the city on the way and dropped off the latrine team in Ciudad de Dios. Indiana Jones hat perched on her curly hair, Kat deftly navigates the roads through the cane fields with a cell phone to her ear. First it’s Kevin: “Who has the key to the schoolhouse where the PVC pipes are kept?” Next its an Engineers Without Borders volunteer: “Can we help the Water Committee set up a payment plan so a family can afford to get on the water line?”

Followed by the van, she drives deeper into the sugar cane, parking her clunky gray sedan in the middle of the dirt road to ask some laborers how to get to Las Cocas. We have a map, but the map has no roads—only houses in the sugar cane, and, occasionally, the names of the families who live there. After fifteen minutes, we’ve finally oriented ourselves. As the health assessment team heads off on foot, Kat hops back in the car.

La Jefa and members of the health assessment team meet at Ciudad de Dios for lunch.

The rest of the morning is spent dropping the visiting nurse practitioner off at Trujillo’s public hospital, finagling permission for her to observe the emergency care unit and talk to a doctor or two. Stuck in traffic, she recognizes the face of a passing pedestrian from Moche and stops to arrange a meeting later in the week. Next, we go to the carpenter’s to check on the doors and discuss the design of a small seat for the latrines.

On the way back to the valley, La Jefa lists the day’s schedule. She has a meeting with the Water Committee at one, then a community meeting in Santa Rosa to ask if we can conduct the surveys there. Then it’s off to Bello Horizonte to remind the pregnant ladies about the prenatal classes next week. She’ll take the EWB volunteers to the airport while we head home.

Back at the house, we organize the completed surveys of the day and use a random number generator to choose houses on tomorrow’s map. The latrine team discusses relocating the third latrine: they’ve hit a boulder halfway down the first hole. We don’t see Kat again until after dinner, when we meet in Spanglish to go over finances, data entry, and prenatal classes. Finally—dusty, exhausted, and tense from the day’s hard work—we goof off for a while and head to bed early.

La Jefa calls every kid in Ciudad by name and breaks up dog fights sin temor. She knows all the right people and draws maps with a rock in the dirt. She coordinates rides, supplies and schedules, and is quick with a joke or smile. Things rarely run smoothly around here, but La Jefa helps us juggle the details and keep the chaos in check.

Kat talks with Andres, the latrine team's go-to guy.

A peek into a day of health assessments in the Moche Valley.

Dusty air. The kind that settles in your lungs and under your fingernails.

The caw of a rooster, loud and hungry. KIKIRIKI it screams, over and over.

A litter strewn street, where a combi rumbles by, kicking up dust from the unpaved road.

A door made of tin roofing, latched to its ‘hinges’ with twine. It bangs back and forth with the morning wind.

Past the door lies the yard, though lacking that lush shade of green we know so well. In its place is a struggling garden of maize and other plants, sprouting defiantly out of the brown earth.

A clothing line, mended with various strings, droops with the weight of faded, worn items, drying in the spotty sun.

Swat the flies away as you step inside. The uneven dirt floor of the house is worn down with repeated shuffles of dirty flip flops to and fro.

The meagerly decorated adobe walls glow as the lone light bulb sways from its perch near the tarp that serves as a ceiling.

A kindly woman offers you her own seat, a sullied lawn chair—the best seat in the house. As you sit down, the crouched morsel of a woman hands you a cup of jugo, complete with blessings and welcomes to her humble dwelling.

Settling in for the hour-long ‘encuesta de salud’, you take mental notes of all you just experienced and prepare to travel through the jumbled and often sad history of this woman’s life.

Such is the day we’ve come to expect each morning as we set out to implement health assessments for all the communities of the Moche Valley.

The disparity between ourselves and the people we’ve come to help hangs in the air, along with the common ‘gringos’ slang used to describe us. Each day I meet someone new, my eyes open a bit wider to the situation these people live in and how better we can serve them. Although living in substandard housing with no bathrooms, scraping to feed their families, the kindness and openness these individuals have shown our organization is overwhelming. The women invite us into their homes; the men greet us as we pass them on our search; and the children are endless sources of energy and questions.

Today we completed our field work for the health assessments, and while we are glad to have reached our goal, the process itself has been very rewarding. To be welcomed so intimately into a community and treated with the utmost hospitality, while we ask our hosts to divulge their most personal information has made an enormous impression on all of us.

Generally the mention of an older man being six feet under ground would elicit feelings of sorrow and sympathy. When our team heard the news, we were pumped.

The site of our third latrine is in the backyard of an elderly couple’s property. They have a daughter that spends much of her time in their house, a son who works construction in Trujillo, and at least two grandchildren. The older man was ecstatic about the prospect of the new latrine, and he delightedly showed us around his property in search of the perfect location. As we marked out the 2 x 2 meter square, he offered his services and those of his son to help dig the hole.

We were excited about having his son onboard, picturing an experienced, strapping young construction worker. But we exchanged some skeptical smiles at the thought of this hobbled old gentleman with a pick-axe and a shovel. We weren’t expecting his contribution to be much beyond his enthusiasm and some words of wisdom. This couldn’t have been more incorrect.

We were greeted yesterday with the sight of the elderly man, shirtless, in the bottom of an almost entirely completed hole. The son was working along-side, but the alacrity with which his father was beating the ground with the pick, and the rippling muscles barely contained by his aged Peruvian skin, identified the real power-house of this operation. We self-consciously hopped into the hole to give them a breather, knowing that progress was actually going to slow with inexperienced young gringos manning the shovels. The grandfather chuckled to himself as he watched us dig.

This was hardly the first time that the incredible Peruvian vitality took us by surprise. Two Peruvian brothers dug the first latrine’s hole in only three hours—a feat that our team of six struggled to accomplish in three days. We were assisted in digging the second hole by a nursing mother. She would remove the baby from her teat, work her shift with the shovel, and replace the baby during her break. On the work-day to repair the water-system, we passed her seventy year-old mother walking to the dig site armed with not one, but two shovels.

The individuals in Ciudad de Dios lack many basic resources, from health-care to education. But at least among the families we have had the pleasure of knowing from the latrine project, one resource they do not lack is resilience. Many of our projects are made possible by their incredible work ethic and fortitude. As privileged, educated volunteers and donors it is easy to look upon beneficiaries of development projects as needy, helpless or inferior. But it is important to remember that having need does not make you needy, requiring help does not make you helpless, and being a member of a low socio-economic stratum does not make you inferior.

Needless to say, as I attempted to shovel dirt out of the hole even half as fast as my elderly Peruvian counterpart, my shirt stayed on.

Video: Six Feet Down and Still Digging

The disturbing sight of two dogs viciously biting, snarling, and clawing at each other was not part of the plan.

Before setting foot in Peru we had multiple pre-departure meetings to solidify the project’s main objectives. While discussing the prospect of health assessments and sustainable latrines for the villages of the Moche valley, a secondary goal emerged: to provide a health fair with basic education to the community members with whom we would be working.

Last week was exhausting. While digging holes in hard clay during the day, we also made posters, pamphlets, and curricula. We learned how to take blood pressure and blood sugar during our downtime. Although many community members had heard about the fair by word-of-mouth (which travels fast here), last Friday, the day before the fair, we placed flyers all around Ciudad de Dios:

Even though we were all exhausted that night, every person in the group actively worked to help finish the last tasks to make the health fair a success. We hustled to finish the posters, rushing to internet cafes and copy shops before they closed for the night.

Robby and Abe taught kids how to clean their teeth the fun way.

The next morning, 5:45 a.m. felt earlier than usual, but I was still excited. I added extra coffee concentrate to my cup and extra jam to my rolls.

Once in Ciudad de Dios, we started to set up our stations in two dusty rooms of the four-room schoolhouse. When we met the first family from a nearby village making their way up stone steps, they smiled and asked us quietly if this was the health fair.
Thus, our stations began rolling and people started arriving in droves.

This was one of the kids games that taught them nutritious eating skills, behind which is line for the doctor's free consultation.

When a Peruvian doctor and a visiting American nurse practitioner arrived mid-morning, a line was formed out the door for free health consultations. After making their rounds through the health stations and receiving a consult, each visitor got a bag of lentil beans and a hot chicken empanada.

The children were a handful, but luckily there were many of us to deal with them.

This was a puppet show scripted by Melissa and Britney that was put on as part of the children's games.

While from a far the fair looked like clockwork, every one of us worked hard and dealt with multiple small problems throughout the day. At one critical moment during the fair, two dogs tore at each other ferociously. The people turned silent and everyone exchanged nervous glances. Luckily, Katherine Burns, or la jefa (the chief), arrived a minute later to save the day.  Like a pro, she grabbed one of the growling mutts by the back of its neck and yanked it off of the other. It was no surprise to find that along with being Director of Public Health programs for MOCHE Inc., Kat is also a dog whisperer.

Despite putting out small fires throughout the day, we put on a rowdy and fun family event and provided health advice to over 100 Moche Valley residents.

The group after setting up the health fair. From top left: Michelle, Olivia, Melissa, Linda, Katie, Paula, Britney, Paul, Vera, Abe, Becky, Robby, Kevin

Peru has among the highest rates of infant mortality and maternal mortality during childbirth in Latin America.

In turn, the department of La Libertad, which includes the Moche Valley, has the highest rate of maternal mortality in Peru. Leading causes of death like preeclampsia are largely preventable if diagnosed and treated during routine prenatal checkups.

Dra. Campos, the obstetrician at the clinic in Menocucho, brought up this sobering fact during a meeting for our upcoming prenatal classes. Despite Dra. Campos’ evident devotion to her patients and the proximity of the clinic to many valley communities, a striking number of women do not receive potentially life-saving prenatal care. The most important barriers to care are economic: few families can afford the short combi ride down the valley, let alone the fees for consults, vitamins, and medications.

Our meetings at the clinic and our health assessment surveys have reiterated the local need for better information about prenatal health. Since we cannot hope to address the issue of affordable care during our time here—a symptom of a broader, systemic problem—the classes will focus on how women can take charge of their own health and that of their families, in addition to the vital importance of monthly prenatal checkups.

Healthcare in Peru is subsidized, but not free, so patients must pay out-of-pocket for services at public hospitals and clinics. The government has resisted privatizing the health sector, but austerity measures imposed by international financial institutions like the IMF undercut funding for social services. External financial obligations prevent the state from providing its citizens with basic needs like clean water and primary care.

Our global political economy systematically undermines health, favoring corporate welfare over social justice by leveraging poor countries’ debt for private gain. The struggle for change needs the voices of those most deeply exploited by this system demanding justice for their families and communities. That means healthy moms and healthy babies.

Have you ever seen a guinea pig killed, skinned and gutted mere moments before it was placed before you as lunch? Today I did.

But before I talk about that, I should backtrack and explain how we got there. As part of our group tackles health assessments, the rest of us are getting our hands dirty, designing and constructing pilot latrines. Many of the families in Ciudad de Dios and the surrounding area don’t have any kind of infrastructure set up to use as a bathroom and those who do generally only have a hole in their backyard.  Without getting too explicit, any permeable structure threatens the health of residents in the village, as bacteria can seep into the ground water and even into the water pipes.

We’ve decided to build four latrines and thus far, we have chosen two beneficiary families. The first is a single mother with two young children. They don’t have any bathroom structure, so the erection of this latrine will hopefully mark a significant improvement in their lives. Her two brothers were kind enough to help by digging a hole of 2.5 squared meters in the compact Peruvian soil for three hours.

Although we were impressed, we thought our group of six could complete a similar sized hole in, perhaps, twice the time—until today.

Today, we visited Senora Maria, head of the second family for whom we decided to build a latrine. Senora Maria is a small, spunky 70-year-old woman living in absolute poverty who, despite missing a few teeth, looks at least 20 years younger. She spent the vast majority of her life without electricity, which she acquired only a few months ago, and running water, which she was able to access after last years MOCHE-Nourish International service group’s installation of a clean water system. Unfortunately, the backyard of her house is ridden with trees, rocks, and animals, and we soon realized the difficultly of finding a viable location. Luckily, her daughter lives less than a minute away with her children, and we decided that her daughter’s spacious and cleared backyard would be a safer spot for construction.

Two young neighbors of Senora Maria watch as we dig.

So we dug. And dug. And dug some more. Three hours later, we were about 1/3 of the way through and utterly exhausted. Needless to say, when Senora Maria offered us a hot lunch, we happily accepted.

Covered in dirt, we trekked up the rocky trail leading to the house and salivated with thoughts of steaming rice and spicy soup. As I made my way through the brush, I had expected to see Senora Maria leaning over a pot, stirring our lunches on a stove. Instead, I found her fragile little arms whacking dead guinea pigs with a polished knife. She smiled at our initial horror (which may or may not have been well hid) and informed us that she was cooking all of her adult cuys, or guinea pigs, for us as a token of her gratitude. To be the recipient of such amazing kindness was a real honor.

And truth be told, guinea pigs don’t taste all that bad.

After a frustrating week of planning, our health assessment surveys are finally underway.

Yesterday we began our surveying in Cerro Blanco, the first village on our list in the middle valley. Equipped with the map we made last week, which after several drafts was incomplete at best, seven of us partnered up with Peruvian nurses and volunteers to conduct the assessments. We had chosen a random sample of households and quickly found that sticking to that sample was harder than we had hoped. We found ourselves traipsing narrow paths through sugar cane fields and up the craggy slopes of the cerro in search of the next house, which was often unoccupied.

A view of the valley from the hills.

Still, having spent the last week going back to the drawing board to redesign the latrines, redraw the maps, and rewrite the health surveys, it was a relief to finally start the assessments. I was surprised and moved at the openness of the participants, who without exception have welcomed us into their homes to share details about their families’ health. The questionnaires, designed for female heads of household and female interviewers, probe on sanitation and hygiene, common illnesses and injuries, pre- and post-natal health, domestic violence, access to care, and other topics.

 Our work over the past few days has given us insight into the difficult process of community-based health research, especially as a team with a diversity of backgrounds and experiences. We are continually learning from each other about how best to conduct these surveys with professionalism as well as with compassion and respect. The interviews themselves provide a window for understanding the communities we serve, their strengths and needs, and the potential for improvement of preventative health services like latrines and education programs.

From left: Kevin, Katie, Vera, Paula and Linda in Bello Horizonte for a community meeting.

Talking to community members outside of the survey context has encouraged and energized us. We had the serendipitous fortune of meeting Sr. Rodrigo in Quirihuac, who offered us maps of most of the villages in the Moche, thus saving us days of mapping. Still dumbfounded by our good luck, we listened to his story about another group of gringos who had come to Ciudad de Dios last year to build a water system. “Do you know that place?” he asked. “It’s like it’s received a touch of light, un toque de luz.” 

Looking over the new-found maps of households in the valley.

Little known fact about Peruvian transport: 12 people can fit (barely) in an 8 person van.

As our 12 person team squished into the van for the first time Monday morning, everyone talked about our schedule for the day. We headed to Ciudad de Dios to begin our 6 week project. After seeing the sites briefly over the weekend, we were excited about getting to work and discussed how our ideas would neatly work within the community. Our plans included building pilot latrines in a least one home in Ciudad de Dios. Before we got to Ciudad, we were convinced our approach was the best… little did we know.

As soon as we began talking to folks around the village, we found out many more homes than we thought already had latrines. We visited the community leader’s home to see how his latrine worked. His family taught us about how the upper class within the community is lucky enough to have their own, functional bathroom facilities. We noticed some major differences. Their design seemed perfect…but it was too close to the waterline to be completely sanitary.

Our previous design was not exactly the same and we wondered how accepted it would be within the community. After much discussion, we decided to go ahead with our VIP design that we are still currently working on perfecting. And so ended the first day of the first week…

This was part of the area where we mapped, which had an amazingly intricate irrigation system.

Tuesday brought our group to another village called Cerro Blanco. Many of the villages are close together but no one knows for sure who lives there. Another element of our project is knowing how many people live in each part and where they live. We will be giving health assessments to the citizens to see where their health needs concentrate so we can later build a clinic serving those needs. The task of the day was to map out the different zones…this proved to be a little more challenging, but with the help of locals, it was done quickly and efficiently.

For the first time, we all were able to interact with local people as we walked around and observed the place they call home. Many people told us how much they appreciated what we would be doing. Simply hearing that what we are doing means something to the citizens gave me a renewed energy for the day and hope for the rest of the project.

Even with all the planning and strategizing, we had time to see the miracle of life. The dog at our hostel gave birth to 5 pups. The dog had been sporting a fashionable yet oversized plaid sweater since we got here. Unbeknownst to us, she had begun having contractions. We finally discovered what the jacket hid as 5 small puppies became new members of the Nourish International family.

Now that we have a clearer idea of what we need to do, we can visualize our final project and who it will benefit.

The Peruvian government and indigenous groups in the north of Peru have been at odds in recent months regarding the government’s licensing of drilling and mining by foreign companies. This unease erupted in the last two days as protests and riots which have rattled the area near Bagua, many miles north and inland from where we are currently.

Today, BBC News reported that the riots have resulted in missing people with witnesses blaming the government, and the government calling for the arrest of indigenous leaders.  

While these events have sparked lively conversation among the people we have been working with– politics are always on the discussion table in Peru– we are not worried about our safety in Huanchaco or the Moche Valley.