Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.) Chapter 2: Solving Health Problems (introduction...) Juanita’s Story (introduction...) What is the problem? Some illnesses are hard to tell apart What is causing the problem? What Is the Best Treatment? Is a treatment helpful or harmful? Risks and benefits Working for Change (introduction...) Looking for the root causes of health problems Organizing to solve community health problems To the Health Worker Helping women help themselves

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.)

Chapter 2: Solving Health Problems

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Whenever a woman has signs of a health problem, she needs information in order to solve it. She needs to know what the problem is, its cause, what can be done to treat it, and how to prevent it from happening again.

¨ Some problems must be treated with skilled medical care. But most health problems can be treated at home or can be prevented by healthy living.

In this chapter we tell the story of one woman, Juanita, and how she solved her health problem. Although the details apply only to Juanita, the way she thinks about her problem and works to solve it can apply to all health problems. You can use this method to solve a health problem yourself or to make decisions about getting good medical care.

Juanita discovered that a lasting solution to her health problem involved looking beyond her own situation. She also had to identify the root causes of the problem in her community and country, and work to change them. Like Juanita, you and your community can use this method to identify all the causes of women’s poor health - and to plan ways to make your community a healthier place for women.

Juanita’s Story

Juanita lives in a small village in the mountains of western Honduras where she and her husband grow corn on a small plot of land. Their land does not produce enough to feed their 3 children, so several times each year Juanita’s husband, Raul, goes off to the coast with other men from the village to work on the banana plantations.

About 3 weeks after the last time her husband returned home from the coast, Juanita began to notice more discharge than usual from her vagina. Then she started having pain when passing urine. Juanita knew that something was wrong, but she had no idea what it was.

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Juanita decided to ask her friend Suyapa for help. Suyapa suggested drinking teas made from corn silk, because this had helped her when she had had pain passing urine. So Juanita tried the teas - but the pain and discharge did not go away. Suyapa then recommended the remedy her friend Marķa del Carmen had used for pains after childbirth. The local midwife had given Marķa a cotton cloth filled with plant medicines to wrap around her belly. When Juanita tried the remedy and it didn’t work, she thought putting the medicines inside her vagina might be better But nothing helped, and her signs kept on bothering her.

Finally Juanita decided to go to see the health worker, Don Pedro. She felt shy about having a man examine her, but by this time she was scared that something serious was wrong.

What is the problem?

Step I: Start with doubt. This means admitting you do not know the answer yet

Don Pedro told Juanita that in order to help hen he needed to learn as much about the illness as possible. So he asked Juanita these questions

Step 2: Find out as much as possible about the problem. Ask questions like these:

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Some illnesses are hard to tell apart

Step 3: Think about all the different illnesses that could be causing the signs.

After listening carefully to Juanita describe her pain and discharge, Don Pedro explained that signs often tell us the general kind of health problem someone has. But sometimes several different illnesses can cause the same signs. For example, a change in the amount, color, or smell of a woman’s vaginal discharge could be caused by:

· a sexually transmitted disease (STD).

· an infection of the vagina that is not an STD.

· pelvic inflammatory disease (PID), which is an infection of the womb and tubes, often caused by an STD.

· cancer of the cervix.

Step 4: Look for clues that can tell you which answer is most likely.

To get a better idea about which of these problems was causing Juanita’s signs, Don Pedro needed to know whether Juanita and her husband used condoms, and whether either of them had had other sex partners. Juanita admitted that she suspects her husband has sex with other women, since he is gone for months at a time to work. But they had never discussed it, so she did not know for sure. The last time her husband came home, however, he had complained of some pain when passing urine. He blamed it on the foods he ate at the coast.

Step 5: Decide which answer is probably the right one.

With this added information, Don Pedro said he suspected Juanita had an STD, probably gonorrhea or chlamydia. Because it is difficult to tell these diseases apart, it is better to treat both of them.

What is causing the problem?

Infectious diseases are those that are spread from one person to another. They can be spread through touching infected people or objects, or through the air or water. The germs Don Pedro thinks are causing Juanita’s illness are spread through sexual contact. Non-infectious diseases (not spread between people), may be caused by: · something that goes wrong in the body, such as weak bones from aging. · something that harms the body from the outside, such as back problems from carrying heavy loads. · something the body lacks, such as nutrition. By eating too little food or the wrong kinds of food, a person can become malnourished. But illnesses rarely have just one cause. Often people’s beliefs and cultural practices contribute to disease, as do conditions in their surroundings, and the way that land, wealth, and power are distributed.

What Is the Best Treatment?

Is a treatment helpful or harmful?

Although Don Pedro was certain that medicines would solve the problem, Juanita wanted more information before deciding on a treatment. She knew, for example, that home remedies had often helped her mother and grandmother when they were ill. Why, then, did the remedies she had tried fail to work? Here is Don Pedro’s explanation:

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In Juanita’s case, she had used all 3 kinds of remedies:

Corn silk tea would have been very helpful if Juanita had an infection of the urine system. This is because corn silk tea makes a person pass urine more and so flushes germs out of the body. But these teas probably did not help Juanita because her infection was not in the urine system.

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Wrapping plant medicines around the belly is a harmless remedy. It will not make a health problem worse, because the medicines stay outside the body, but it will not help, either.

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Putting plant medicines into the vagina is harmful and should never be done. Plant medicines can irritate the vagina and cause dangerous infections.

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Don Pedro told Juanita that she could learn about a particular treatment and how well it works by talking to many different people who have used it. Here are some questions to ask:

· Why do you use this method?
· When do you use it?
· How do you use it?
· What happens when you use it?
· How often does it help the problem?
· Do things ever go wrong?

Think carefully about what different people say about treatments they have used. Then, when you try a remedy yourself, pay attention to what happens to your signs to see if the remedy helps you. Be careful about trying too many remedies at once.

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To decide if a treatment will be helpful, harmless, or harmful, learn all you can about it first. If you are still unsure whether a treatment is harmless or harmful, consider these things: 1. The more remedies there are for any one illness, the less likely it is that any of them works. 2. Foul or disgusting remedies are not likely to help - and are often harmful. 3. Remedies that use animal or human waste rarely do any good, and often cause dangerous infections. Never use them. 4. The more a remedy resembles the sickness it is said to cure, the more likely that its benefits come only from the power of belief. For example, a red plant will not necessarily stop bleeding. 5. Methods that deny people food, exercise, or rest usually make them weaker, not stronger. 6. Methods that blame people for their problems usually add to their suffering and pain.

Step 6: Decide on the best treatment Always remember to think about possible risks and benefits (see below).

When Juanita felt satisfied that modern medicines were the best treatment for her health problem, Don Pedro gave Juanita some pills called doxycycline and co-trimoxazole and told her to come back in a week, after she had taken them all. He also explained that her husband, who was away again, must be treated with the medicines when he comes back, and that they must begin to practice safer sex.

Step 7: See if there is some improvement. If there are no results, start over again.

When Juanita returned to see Don Pedro the next week, she told him that she had taken all the pills he gave her but her signs had not gone away. She also said her discharge was getting worse and becoming yellow in color. So Don Pedro asked Valeria, a health worker with more training, for help.

Valeria agreed that Juanita had an STD. But because the medicines had not helped, Valeria suspected that Juanita may have a form of gonorrhea that is resistant to co-trimoxazole. Valeria explained that many resistant forms of gonorrhea had come from foreign soldiers at the military base on the coast, who have been infecting the local women when they had sex. Valeria recommended that Juanita go to the city where she could get a more complete exam and be tested for gonorrhea, syphilis (another STD), and cancer. She could also get newer; more effective medicines, if needed.

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Risks and benefits

Juanita went home to think about what to do. She would have to spend most of her family’s savings to pay for a trip to the city and the medicine. Since she would be gone at least two days (the trip is almost 6 hours each way by bus and walking), and her husband was still away at the coast, she would also have to find someone to watch her children while she was gone.

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Juanita was afraid that her husband would be angry if he came back and found out that she had spent so much money to see a doctor But she was also scared that if she did not go she would get worse. Valeria told her that without treatment she could pass the infection on to a new baby if she became pregnant. With time she would probably become unable to have more children, would develop severe pain in her lower belly, and would have problems with her urine system and monthly bleeding. Her husband could also develop many serious health problems.

Juanita felt so uncertain about what to do that she went to see Valeria again. When Juanita explained her fears, Valeria suggested thinking about the problem this way:

Every treatment has risks and benefits. A risk is the chance that something may cause harm. A benefit is the good that something may bring. The best choice is to do something that will cause the greatest benefit and the smallest risk. Figure It may help to think about scales you use to weigh food in the market. When one side weighs more than the other, that side of the scale tilts downward. If the benefits weigh more than the risks, that means the action is worth doing. If the risks weigh more, then the action is not worth doing.

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Juanita decided that the benefits of going for treatment weighed more than the risks.

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So Juanita went to the city for treatment, where the doctors said it was true that she had gonorrhea and probably chlamydia, but no signs of other STDs or problems. They explained that the medicine she took no longer works in her country. They gave Juanita a newer medicine for both her and her husband.

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Working for Change

When Juanita had taken the medicine and was feeling better, it was tempting to think that her health problem had been solved. But she knew this was not true. When her husband returned from the coast, she would get infected again if he did not take the medicine and use condoms. She discussed the problem with Suyapa and other women whose husbands work at the coast, and together they decided to ask Valeria for advice.

Looking for the root causes of health problems

Step 8: Look for the root causes of the problem.

Valeria agreed that Juanita’s health problem was not yet solved, because many of the conditions that created the problem still existed. She suggested playing a game called “But why....?” to help everyone identify all the conditions that created the problem.

Valeria gathered the women in a circle, and asked them to try and answer her questions:

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And so on.

Step 9: It may help to group the causes together to think about what can be done to address them.

When the women had named a long list of causes, Valeria suggested putting the causes in groups. This way it is easier to see the different kinds of conditions that cause health problems:

Physical causes: germs or parasites, or something that goes wrong in the body or that the body lacks

Environmental causes: conditions in the physical surroundings that harm the body, such as cooking smoke, lack of clean water or crowded living conditions

Social causes: the way people relate to or treat each other, including their attitudes, customs, and beliefs

Political and economic causes: causes having to do with power - who has control and how - and money, land, and resources - who has them and who does not

When the women put the causes of Juanita’s problem into these groups, they came up with the following list:

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Organizing to solve community health problems

Step 10: Decide which causes you and your community can change.

The next step, Valeria told the women, is to look at the different causes and decide which ones you and others in the community can change. Then think about what actions must be done to make the changes happen.

Step 11: Decide what actions can make those changes happen.

Juanita and Suyapa thought they could get their husbands to use condoms if their husbands understood more about STDs, and if the condoms were not so costly. The actions they decided to take were:

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Other members of the group suggested these actions:

· Organize a community group to talk about health problems, and include STDs in the topics discussed.

· While women are washing clothes at the river, talk to them about STDs and how to prevent them.

· Talk to their sons about STDs before they leave the village to go to the coast.

Step 12: Make a plan for carrying out the actions.

The last step, said Valeria, is to make a plan to carry out each of these ideas for action. The plan, she said, should answer each of these questions:

· What are we going to do? What steps will we take?
· When are we going to do these things?
· Who are we going to do them with?
· What materials will we need?
· Who is responsible for making sure that the plan is carried out?
· How will we evaluate whether the plan is working?

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To help you use this method of solving health problems yourself, here is a chart with a list of all of the steps. On the left are the steps and on the right are the parts of Juanita’s story that go with each step. Any time you have a health problem you can use this chart to help you remember this method for thinking about and taking action to solve the problem.

The Steps	Juanita’s Story
1. Start with doubt.	1. Juanita noticed unusual discharge from her vagina and pain when passing urine. She asked friends and a health worker for help.
2. Find out as much as possible about the problem. Ask questions.	2. Don Pedro asked her questions to find out what could have caused the problem.
3. Think about all the different illnesses that could be causing the signs.	3. Don Pedro thought about all the illnesses with these signs.
4. Look for clues that can tell you which answer is most likely.	4. Don Pedro tried to find out if an STD could have caused Juanita’s illness.
5. Decide which answer is probably the right one.	5. Don Pedro decided Juanita probably had an STD.
6. Decide on the best treatment.	6. Don Pedro chose a treatment that works for several STDs.
7. If there are no results, start over again.	7. Juanita took the pills but did not improve and developed new signs. Valeria thought Juanita had a new form of gonorrhea, and that she should go to the city for an examination, tests, and other medicine.
8. Look for the root causes of the problem.	8. Juanita and her friends thought about the reasons why there was this kind of STD in their community.
9. Put the causes into groups to think about what can be done.	9. The women put the causes into physical, environmental, social, political, and economic groups.
10. Decide which causes you and your community can change.	10. Juanita and Suyapa think they can get their partners to use condoms.
11. Decide what actions can make those changes happen.	11. They decided to practice how to talk to their partners about using condoms, to see if the health center will give out free condoms, and to ask Don Pedro to talk with their partners about STDs.
12. Make a plan for carrying out the actions.	12. They made a plan for each action they decided to take.

To the Health Worker

Helping women help themselves

In this chapter Don Pedro and Valeria played an important role in helping the women in Juanita’s community solve a health problem. The reason that Don Pedro and Valeria were so effective was that they did not tell Juanita and her friends what to do. Rather, Don Pedro and Valeria helped the women learn how to help themselves.

You, too, can help the women in your community by following Don Pedro’s and Valeria’s example. You can:

· Share your knowledge. To help themselves, women need information. Many health problems can be prevented if people know how. But remember that you do not have to have all of the answers to help people. Many times there are no easy answers. It is fine to admit when you do not know something. The people you work with will be glad for your honesty.

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¨ Share your knowledge with other women, other health workers, and with the people who make decisions in the community.

· Treat women with respect. Each person should be treated as someone who is capable of understanding her health problems and of making good decisions about her treatment. Never blame a woman for her problem or for past decisions she has made.

· Keep health problems private. Health problems should not be discussed where others can hear Never tell anyone else about a problem someone has unless the person with the problem says it is OK.

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· Remember that listening is more important than giving advice. A woman often needs someone who will listen to her without judgment. By listening, you let her know you care and that she is important. And as she gets a chance to talk, she may find that she has some of the answers to her problem.

· Solve problems with others, not for them. Even when a woman’s problems are very large and cannot be solved completely, she usually has some choices she can make. As a health worker, you can help her realize she has choices, and help her find the information she needs to make her own decisions.

· Learn from the people you help. Learning how others solve their own problems can help you to help others better (and sometimes yourself, too).

You learn from those you help, and those you help learn from you.

· Respect your people’s traditions and ideas. Modern science does not have all the answers. And many modern medicines come from studying plant medicines and traditional ways of healing. So it is important to respect and use what is good in both methods - and to realize that both methods can cause harm when used in the wrong way.

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· Find out what people really want to learn about. It is easy to fall into the trap of giving information without finding out if it will be helpful. This often happens with health workers who give prepared talks. But if you find out exactly what people want to know, they will get knowledge that is useful to them. This also helps them build on their own knowledge.

· Plan with people, not for people. When you plan your work, be sure to talk first with women and men in your community. Find out how they view the problem you are working to solve. Together, talk about what they think causes the problem and how they would like to solve it. Working together brings the best results!

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