No doors, no drawers
An essay by Kate Venable MD,
CTropMed
It
was some time after I left Peru in March when I realized that the indigenous
people group with whom I had the privilege to work had existed successfully for
hundreds of years with no doors and no drawers… no keys or locks, no towels or
sinks. They live with their environment, for better or
worse, not excluded from it. They are completely dependent on the Chambira
River in the Amazon Basin for water and fish, for bathing and washing, for the
plants and animals of the jungle, for practically every aspect of life. And have been for hundreds of years.
To
put this in context, I was part of a community development team that has been
meeting yearly in March with this people group in the Amazon Basin of
Peru. Though it was my first year as
part of the team, these “Annual Meetings” – focused on health, literacy (the
initial connection which spurred the Annual Meetings), agriculture and
spirituality—were initiated several years ago by the community itself, with
support of Peruvian and foreign volunteers. The indigenous community had been working with a literacy
project, and through that connection and growth, became hungry for input in
other areas of life.
Prior
to the Annual Meetings this jungle community had encountered the “outside
world” through various avenues: the
literacy outreach project, oil-seeking businessmen, anthropologists eager to
study their cultural practices, jungle eco-tourists, service-oriented medical teams
offering miniature floating clinics, and the Peruvian government—trying to
figure out how to bring the indigenous under its authority while still allowing
them a degree of autonomy (clearly a polemic topic, unfortunately not to be
addressed here).
Some
in this community have sought medical attention from physicians in the cities, though
they are the exception, and some of them have been exposed to basic health education.
Community Health Workers (CHWs) from each community had been appointed by the
Peruvian government, but typically received little training along the way. In hopes to augment their training, the
indigenous community leaders requested that the Annual Meetings include some
training for the CHWs on potable water, basic health concepts, and common
conditions encountered in their villages. This had been done in the few years
prior, using a community assessment tool called the “Ten Seed Technique.”[i]
All involved recounted tales of how gratifying and helpful it was to learn the
indigenous CHW’s perspective on their health needs, causation of disease, and
the health priorities held by the community leaders.
When
the CHWs came together at this year’s Annual Meeting, discussion continued on
some familiar topics. While
discussing issues associated with non-potable water consumption, the question arose
about how many among them regularly implement methods for purifying their own
family’s water. One of the 20 CHWs volunteered that he uses a small amount of
bleach in his water. No one else spoke. Many eyes were averted. The volunteers listening sat in silence
as well. This was profound. It did
not take long to calculate that this one man represented 5% of the CHW’s in
this community (of the ones attending the Annual Meeting, but likely a
reasonable sample)… and that only a very few were implementing what they had
been taught regarding water safety and disease.
The
silence was soon broken, and the CHWs were asked why they were not treating or
boiling their water when they had been taught that it makes them sick. Their candid
responses were as follows:
“We
have been drinking from the River for hundreds of years – why should we cook
the water now?”
“What
do you [read: gringos] know about our river? We live in communion with the river
for every part of our life. You do not know the river like we do.”
“My
children don’t like how the water tastes when we boil it – it tastes like smoky
fish.”
This
one CHW who treats his family’s water supply voiced, “My children used to dislike
the taste [of the bleach-treated water], but now they drink it and we are not
often sick.”
This
is the change – 5% of the community - that has come after over several years of
teaching, being given the opportunity to see with a microscope that more exists in water than what we see with
our eyes, after receiving education about cause of illness, hygiene and the
basic concepts we may even accept as common sense.
The
scene closed shortly thereafter, as the sounds of lunch time offered a natural
escape. The CHWs dispersed, the
volunteers packed up their teaching materials, and we made our way to the
dining area for lunch. And no more conversation over potable water would be had
for the remainder of our time with these CHWs. Enough had been said.
The
humility and courage of this lone CHW continues to captivate me. The objections
and honesty of the others likewise speak a clear message. Even today, I am
still trying to listen.
I
return again to the phrases with which I started: No doors … no drawers. It was
certainly not my first encounter with indigenous people and their way of living.
I have had the privilege of meeting various people groups on several
continents, including this same region in the Amazon Basin, who also live
without the confines of keys, locks or doors, doing what their people have done
for centuries, in these same lands and rivers.
And
so why did these scenes strike me with such weight, lingering for days? I think because I was expecting
that they were living out the hygiene lessons I had been told “were already
taught” to this people group. And perhaps
their realities faced off with my comfortable, “established” (Western), North
American approach to health care, staring with an unwavering gaze, demanding
that I more deeply examine the weighty matters of culture, power, education,
medical care, and expectations surrounding the results of my (our) “service” in
their community.
My
reflections have stirred many questions regarding my own personal approach to
the health needs of people living like my jungle friends. Here are a few:
- Is it really appropriate to give albendazole, explaining that it kills the “bichos” (regional term for parasites/worms) when they are drinking the river water to wash it down?
- What if they feel better after the one dose of albendazole (for a few weeks anyway) and think, “that pill from the foreign doctor made me feel better…I need to get another pill”? And find their way to a pharmacy or health post to consume albendazole too frequently, thinking that more is better?
- What will they do with the little plastic bag of amoxicillin I give them to treat (maybe) pneumonia? Since there are no drawers, no doors - where will it stay? How will it not become wet like everything else during the two day canoe journey back home when the inevitable, daily rains come?
- Are amoxicillin and other pharmaceuticals really the best type of treatments for these people?
- What happens when a patient’s cultural values promote sharing equally between all persons in the family, and therefore the patient gives each person a dose of amoxicillin that was intended for one person’s pneumonia?
- Do I honor and serve them, respecting their dignity as human beings by applying my allopathic treatments to them in spite of their unbelief about microbe-based/water-borne disease causation?
- Do I perpetuate dependence on foreign aid and perceived powerlessness by bringing “free” treatments and offering “free” medical care? (Reality is, of course, that both have a cost. What’s more, patients are not, in most cases, utterly destitute and could bring something to the table?[ii]) Would it be better to suggest that each family bring something to contribute to their medical care and medications–for example: a bushel of plantains, a woven mat, some fish?
- What is the effect on the local economy when I bring supplies from the US to give away free to patients, who, without my free offerings might find a way to purchase something from their local clinic or pharmacy? (Again, realizing that some of these people do NOT have access to such resources or that it would cause an insupportable financial burden for some.)
- Are there ways that I (or someone else) could better meet their needs, taking into account environmental concerns, resource-appropriate treatments, geography and culture?
- Might there be many effective plant-based remedies growing at their fingertips that have been abandoned in hopes of the occasional “magic pill” to fix that which ails? (I know for a fact that there is a large institute in Iquitos, Peru which studies the botany and natural resources of the Amazon Basin, aiming to respectfully and appropriately take advantage of the Amazon’s treasures – for health and nutrition, and many other purposes to be sure.)
- Does this specific people group simply need more time for that one CHW to model his water treatment to his village, demonstrating how his children aren’t sick with “bichos” any longer, so that the villagers believe him, while they reject or ignore foreigners’ teachings?
These
are uncomfortable questions. They
touch on the core of our “diagnose-treat-cure-repeat” model. They threaten my
paradigm that I am a well-trained American doctor, and so therefore I “know”
how to be a doctor, anywhere, for anyone.
They also raise difficult questions about our motives, and perhaps the
implications of our efforts to help. I don’t have answers to these difficult questions. But I
believe they need to be asked – if nowhere else, in my own life – as I consider
what kind of involvement I want to have in the Global Health arena.
I believe
there is a role for allopathic
medicine in some cases and settings: for vaccines, basic teaching and modeling
of hygiene, water management, and nutritional concepts. I don’t know who is the best person to share
allopathic medicine with cultures world’s away from our own. I suspect that local,
national efforts are best, and better still ones that are indigenous-led. I have seen some of these efforts at
work throughout the world…but they are not quick, nor especially plan-able.
They cost a lot of time, investment from a community, and a patient, open-handedness
(on the foreigner’s part) to wait until the community is ready to affect its
own changes. I think that knowing to
some degree the Amazon Basin’s people after my three other visits and time
spent there, talking (in Spanish) with local people, and learning about their
beliefs and values, helped create my awareness of the situation above, and it’s
profundity. This also takes time. A
lot of time. And in our hurried,
outcomes-based, results-driven world (and profession), we are often unwilling
to offer to our patients the proverbial ‘tincture of time’ as it might pertain
to health and development.
There
are certainly a number of these conversations going on in the world,
undoubtedly more than I know.
Recently, I encountered an article referred to me by a friend (who is on
the board of directors for Doctors for Global Health, an excellent organization
doing solid work empowering local communities in health and development): “Rules
of Engagement: The Principles of Underserved Global Health Volunteerism” by Dr.
John Wilson and colleagues at Mayo Medical Center in Rochester, MN.[iii]
I commend this article for reading on their experiences and challenges, in
particular as they examine such principles with medical education in view.
Having
opened this can of worms (or bichos, if you prefer) I can only hope it will
stimulate reflections, conversations and dialogue, leading each of us to
examine how we might live and practice with ever-growing cultural sensitivity
to our neighbors—even those right here at home. I know after the scenes I described above, my group of
volunteers (Peruvian and foreign) began some difficult discussions on these sensitive
matters. I don’t at all question the intent of my Peru-based team, or others of
which I have been a part. The
challenges in these situations are many, only one of which is that in my
example, the medical team was invited
by the indigenous community, and there were relationships established and
groundwork laid in years past. As
we witnessed during our week as a whole, expectations, assessments of needs,
balance of costs, division of labor, and projected course all vary widely
depending on our culture and experiences.
And it seems the most lasting, sustainable projects are forged through
committed relationships in a community, with shared resources & local
investment… and a lot of patience
with the process. This is
happening with my jungle friends – but very slowly. One CHW at a time. My hope is that by examining these
matters, we might serve well, share our resources appropriately, and be respectful
of the doors we find before us.
[i] The Ten Seed Technique is a
modified Participatory Learning and Action (PLA) tool. It was introduced by Dr
Ravi Jayakaran as a tool that can enable illiterate community members to
participate in the discussions about their community’s needs. See http://www.csd-i.org/ten-seed-technique-field-note/
[ii] An excellent book called Toxic
Charity by Robert Lupton has recently shaped my thinking on the issue of
free care in settings other than emergency/crisis. It’s more focused on social services than medical, but there
are definitely applicable principles.
[iii] The American Journal of
Medicine, Vol 125, No 6, June 2012
