Popular Education Makes Headway in the Forgotten Hills of Nicaragua
by Sophie Watson
“I agree with reducing public expenses, it’s just where you cut—that’s the problem, the ministers here are earning so much more than what they were 10 years ago. And it is always health and education that they choose to cut,” says Dr. Saul Contreras Martinez. Dr. Saul’s comments on health care in the second poorest country in the Western hemisphere, Nicaragua are strikingly relevant to the current state of health care in Alberta where according to the Canadian Institute for Health Information, provincial government spending on health care per capita has dropped from $1,360 in 1986 to $1,201 in 1996.
In Nicaragua, “social spending has been dropping since 1994. There have been particularly strong cuts in health spending, which appear even more serious when the declining public health budget over this decade is contrasted with the population increase over the same period.” Nicaragua is a country that is literally up for sale, Texaco and Coca Cola line the pot-holed streets. Concessions to IMF and World Bank demands that public spending be dramatically reduced to promote private industry has made health care and education in Nicaragua a privilege, not a right. Living in Klein-country where discussion of private, or for-profit health care has appeared in various disguises and culminated in its current incarnation as Bill 11, it was eye-opening to visit a country with so few resources and see how they deal with the issue in comparison.
The health program involves going out into the rural areas, often in the mountains, recruiting 1-3 promoters and training them in primary and preventative health care, setting them up with a kit of instruments for cleaning and stitching and basic procedures, and a medical manual that is tailored to their region.
When governments cannot afford or choose to give up responsibility for the health and physical well-being of their people, a state of great need and suffering arises that perpetuates through generations. When it is not economically profitable to put a hospital in a region, it does not happen—so what happens to these marginalized people and their health needs? Wanting to help deal with the health needs of the isolated communities of Nicaragua, many of whom live high up in the mountains, Dr. Saul Contreras Martinez put together a health program that he can take on the road. Private enterprise for social good, seems like an oxymoron in the context of the health industry in Canada but in the case of Dr. Saul and the Attencion en Primaire Salud, it has arisen out of third-world necessity—with no government subsidy, and no revenue, Dr. Saul and his colleagues had to create a program that could sustain itself. Their version of private enterprise is geared towards a humanitarian objective, the goal is sustainibility rather than profit. While I was in Nicaragua researching Canadian development workers in October 1999, at a tiny four-room bare-bones clinic painted turquoise green, I had a chance to meet Dr. Saul and learn about his unique program. In Nicaragua, where over one million children have no access to health care or education, Dr. Saul and Atencion Primeria en Salud (APS) is one of the rural people’s only options.
Setting up clinics in poor barrios, Dr. Saul trains groups of women in medical/dental consultation, laboratory work and administration. He has now started four clinics in urban areas of the country and along with his colleagues he has trained health educators in 33 communities in the mountains of Nicaragua, people who would otherwise have no access to health care. In his late thirties, wearing a t-shirt with a logo of Nicaraguan and Canadian hands clasped, Dr. Saul eagerly explains: “We are trying to offer an option for the people, it’ll cost a little but at least they’ll have some care.” He talks passionately while trying to stabilize the blowing papers on his desk; the ceiling fans is going at high speed and we’re still sweating and using books to fan ourselves. Entrepreneuring on several different levels, he is creating an industry of the production and distribution of natural medicine; creating self-sufficient health clinics; publishing accessible educational health manuals; providing health care and knowledge to as much of the marginalized rural population as he can; and running a restaurant whose profits help to offset the costs of medicine enabling him to charge his poor clients only the minimum necessary for him to stay in business. The Pulp, Paper and Woodworkers of Canada, Co-Development Canada, the Canadian International Development Agency and Edmonton’s Change for Children have supported his projects because they recognize the tangible effects his work has.
Having finished his medical studies and exiled from Guatemala in 1983, Dr. Saul moved to Toronto where his brother lived. He found himself working with Canadian organizations that were helping Central American refugees. When he learned more about the plight of Nicaraguans struggling with economic desperation, a strangling US embargo and civil warfare, he decided to head back south. He went by his own means and once there, landed a job with Oxfam Quebec who had many programs in Northern Nicaragua in 1986. Despite the war, the poverty, the country’s tragic inclination for volcanic eruptions, hurricanes and earthquakes, Dr. Saul says though he loves Canada, he actually feels more secure raising his kids in Nicaragua than in Toronto, he says there are less drugs in the schools. With Oxfam Quebec he worked in Nicaragua and El Salvador for six-seven years. Dr. Saul did primary health training in El Salvador and wanted to bring the same thing to Nicaragua and so he had to go into private business to make it happen. He says that because he is operating in free enterprise he is safe—if he was strictly non-profit, he would have problems with the current government. Including Dr. Saul there are five people on the board of directors of APS who all work for salary in the 4 clinics the association runs—the training of the health promoters in the countryside is all done by them voluntarily.
The agenda of Dr. Saul and APS has two main objectives, to set up clinics in urban areas and to run training programs for the rural population. “Until all the communities can have a doctor we will do it this way; until that time this is the only way to reach the people,” Dr. Saul tells me. The health program involves going out into the rural areas, often in the mountains, recruiting 1-3 promoters and training them in primary and preventative health care, setting them up with a kit of instruments for cleaning and stitching and basic procedures, and a medical manual that is tailored to their region. The kit also provides them with some medicine. There is a mango medicine that helps with rheumatism; seven of the medicines in the kit are herbal which has the added benefit of not causing side-effects.
In 1998 the Canadian International Development Agency supported APS’ programs which enabled them to get the truck that they use to go out to the communities. “With their support we went from reaching 3 to reaching 33 communities.” The project works because it is relatively inexpensive; they do not construct a building, the recruited health promoters designate a place in their own homes. The promoters are usually community leaders to begin with, people were already visiting them for advice. Saul says they didn’t focus the program to be gender specific—but they have found that working with women is more effective as they look after the children, are experienced caregivers, and are at home. After a cheer from me, he says, “Claro,” and elaborates, “95% of all the promoters are women and they have developed the project in such way that it is working really well.” In Nicaragua, out of a population of just over 4 million, roughly 50% are under the age of 18—it is the children that need the most help. Saul says that this project is quite revolutionary because it is comprehensive, the newly-trained promoters cover all basic health care to birth control. Dr. Saul advises the promoters to sell the medicine for a cost, no matter how small, because the goal is for them to become self-sufficient. Over the years Saul has found that this is the best way to do it—the promoters end up self-financing themselves after the initial supply he gives them, the medicine is well taken care of and the project sustains itself.
APS follows the World Health Organization initiatives (WHO) to get the basic things for the communities because even the basic supplies are really difficult to get at these altitudes. There are two parts to the rural program, one is curative, one is preventative. “For so many years we have just tried emphasized the preventative, but let me tell you people get tired of hearing how they have to wash their hands—which is good information—but when they are sick they want something to alleviate their pain. We give them the curative medicine so they feel okay, then when they feel okay and they trust us we go into the preventative education area.” The major illnesses are Dengue Fever and Malaria, the most common are respiratory and digestive. There are also a lot of problems with parasites, skin diseases and urinary infections. “It’s not enough to have the water clean, we need someone there teaching the people,” Saul states.
The promoters are taught how to recognize illnesses and to differentiate between a common cold or pneumonia, or bronchitis. The manual that Saul produces and provides the promoters with covers all this information. Many people in the rural areas might only have 3 years of schooling and so the diseases are explained in such way that is understandable. The manual with its large diagrams and simply-explained descriptions of basic ailments allows the promoters to diagnose and solve most common problems. The manual also provides information on local herbs that can help various conditions. “Stitches aren’t in the manual, but people confess they have done stitches without knowledge, they want to learn the proper way, so I teach them.” At the end of their training, Dr. Saul awards them with a certificate. He has found that this has had truly positive results—the women feel very proud. “This was a side-effect we didn’t expect as part of the program but we realized we are giving them the opportunity to gain a skill, and people give them a lot of respect because of the work they are doing especially since even the government was not able to solve their problems.” After the training is completed, Saul and his colleagues go visit the promoters once a month, drop off the medicine and see if they need any help. There are still many more communities that are in desperate need of the knowledge and tools that Dr. Saul’s program offers. “They have seen what some of the other communities have received and they want it too. And so I have to tell them to wait. In the Matagalpa region there are 100 communities; we won’t be able to reach them all.”
Right off a blasting loud highway we sit in the open cafeteria/restaurant that is attached to the Managua clinic and Dr. Saul speaks proudly of his former students. He says that knowing the basic things, they will be able to help the whole community. “Some of the people can’t read, but they can work—the problem is that no one wants to teach them. I like it. I used to go a long distance to this one community almost every two weeks and I would see 60 people, now since the promoter started working, the last time I went I saw only 5 people. She was doing the job. It was incredible! She said, ‘sorry Doctor not many people came to see you today.’ And I said, ‘Hey don’t worry.’ Almost laughing, she said to me, ‘I’m taking your job’ ”That’s the idea!’ I told her.” And this is the ultimate dream of development work—a project that can sustain itself. Dr. Saul and his colleagues have learned to be creative with their minimal resources. With all the resources that we have, perhaps we too could find a more creative approach to enhancing our existing health care without introducing a system whereby profit dictates policy.
For more information on Dr. Saul and APS’ health initiatives please visit http://www.apsnicaragua.org/news/feature01.htm
This article was produced with the support of CIDA. It was published in Briarpatch in May 2000 Volume 29, Number 4.
Envio: The Monthly Magazine of Analysis on Central America, Volume 18, Number 219, October 1999
Clear Answers, by Keven Taft and Gillian Steward, The University of Alberta Press, 2000