Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.) WORDS TO THE VILLAGE HEALTH WORKER (Brown Pages) (introduction...) Health Needs and Human Needs Many Things Relate to Health Care Take a Good Look at Your Community Using Local Resources to Meet Needs Deciding What to Do and Where to Begin Trying a New Idea Working Toward a Balance Between People and Land Working Toward a Balance Between Prevention and Treatment Sensible and Limited Use of Medicines Finding Out What Progress Has Been Made (Evaluation) Teaching and Learning Together - The Health Worker as an Educator Tools for Teaching Making the Best Use of This Book

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.)

WORDS TO THE VILLAGE HEALTH WORKER (Brown Pages)

Who is the village health worker?

A village health worker is a person who helps lead family and neighbors toward better health. Often he or she has been selected by the other villagers as someone who is especially able and kind.

Some village health workers receive training and help from an organized program, perhaps the Ministry of Health. Others have no official position, but are simply members of the community whom people respect as healers or leaders in matters of health. Often they learn by watching, helping, and studying on their own.

In the larger sense, a village health worker is anyone who takes part in making his or her village a healthier place to live.

This means almost everyone can and should be a health worker:

· Mothers and fathers can show their children how to keep clean;

· Farm people can work together to help their land produce more food;

· Teachers can teach schoolchildren how to prevent and treat many common sicknesses and injuries;

· Schoolchildren can share what they learn with their parents;

· Shopkeepers can find out about the correct use of medicines they sell and give sensible advice and warning to buyers;

· Midwives can counsel parents about the importance of eating well during pregnancy, breast feeding, and family planning.

This book was written for the health worker in the larger sense. It is for anyone who wants to know and do more for his own, his family's or his people's well-being.

If you are a community health worker, an auxiliary nurse, or even a doctor, remember: this book is not just for you. It is for all the people. Share it!

Use this book to help explain what you know to others. Perhaps you can get small groups together to read a chapter at a time and discuss it.

THE VILLAGE HEALTH WORKER LIVES AND WORKS AT THE LEVEL OF HIS PEOPLE. HIS FIRST JOB IS TO SHARE HIS KNOWLEDGE.

Health Needs and Human Needs

Dear Village Health Worker,

This book is mostly about people's health needs. But to help your village be a healthy place to live, you must also be in touch with their human needs. Your understanding and concern for people are just as important as your knowledge of medicine and sanitation.

Here are some suggestions that may help you serve your people's human needs as well as health needs:

1. BE KIND. A friendly word, a smile, a hand on the shoulder, or some other sign of caring often means more than anything else you can do. Treat others as your equals. Even when you are hurried or worried, try to remember the feelings and needs of others. Often it helps to ask yourself, “What would I do if this were a member of my own family?”

Treat the sick as people. Be especially kind to those who are very sick or dying. And be kind to their families. Let them see that you care.

HAVE COMPASSION.

Kindness often helps more than medicine. Never be afraid to show you care.

2. SHARE YOUR KNOWLEDGE. As a health worker, your first job is to teach. This means helping people learn more about how to keep from getting sick. It also means helping people learn how to recognize and manage their illnesses - including the sensible use of home remedies and common medicines.

LOOK FOR WAYS TO SHARE YOUR KNOWLEDGE.

There is nothing you have learned that, if carefully explained, should be of danger to anyone. Some doctors talk about self-care as if it were dangerous, perhaps because they like people to depend on their costly services. But in truth, most common health problems could be handled earlier and better by people in their own homes.

3. RESPECT YOUR PEOPLE'S TRADITIONS AND IDEAS.

Because you learn something about modern medicine does not mean you should no longer appreciate the customs and ways of healing of your people. Too often the human touch in the art of healing is lost when medical science moves in. This is too bad, because...

If you can use what is best in modern medicine, together with what is best in traditional healing, the combination may be better than either one alone.

In this way, you will be adding to your people's culture, not taking away.

Of course, if you see that some of the home cures or customs are harmful (for example, putting excrement on the freshly cut cord of a newborn baby), you will want to do something to change this. But do so carefully, with respect for those who believe in such things. Never just tell people they are wrong. Try to help them understand WHY they should do something differently.

People are slow to change their attitudes and traditions, and with good reason. They are true to what they feel is right. And this we must respect.

Modern medicine does not have all the answers either. It has helped solve some problems, yet has led to other, sometimes even bigger ones. People quickly come to depend too much on modern medicine and its experts, to overuse medicines, and to forget how to care for themselves and each other.

So go slow - and always keep a deep respect for your people, their traditions, and their human dignity. Help them build on the knowledge and skills they already have.

WORK WITH TRADITIONAL HEALERS AND MIDWIVES - NOT AGAINST THEM.

Learn from them and encourage them to learn from you.

4. KNOW YOUR OWN LIMITS.

KNOW YOUR LIMITS

No matter how great or small your knowledge and skills, you can do a good job as long as you know and work within your limits. This means: Do what you know how to do. Do not try things you have not learned about or have not had enough experience doing, if they might harm or endanger someone.

But use your judgment.

Often, what you decide to do or not do will depend on how far you have to go to get more expert help.

KNOW YOUR LIMITS.

For example, a mother has just given birth and is bleeding more than you think is normal. If you are only half an hour away from a medical center, it may be wise to take her there right away. But if the mother is bleeding very heavily and you are a long way from the health center, you may decide to massage her womb or inject an oxytocic even if you were not taught this.

Do not take unnecessary chances. But when the danger is clearly greater if you do nothing, do not be afraid to try something you feel reasonably sure will help.

Know your limits - but also use your head. Always do your best to protect the sick person rather than yourself.

5. KEEP LEARNING. Use every chance you have to learn more. Study whatever books or information you can lay your hands on that will help you be a better worker, teacher, or person.

Always be ready to ask questions of doctors, sanitation officers, agriculture experts, or anyone else you can learn from.

Never pass up the chance to take refresher courses or get additional training.

Your first job is to teach, and unless you keep learning more, soon you will not have anything new to teach others.

KEEP LEARNING - Do not let anyone tell you there are things you should not learn or know.

6. PRACTICE WHAT YOU TEACH.

People are more likely to pay attention to what you do than what you say. As a health worker, you want to take special care in your personal life and habits, so as to set a good example for your neighbors.

Before you ask people to make latrines, be sure your own family has one.

Also, if you help organize a work group - for example, to dig a common garbage hole - be sure you work and sweat as hard as everyone else.

PRACTICE WHAT YOU TEACH (or who will listen to you?)

Good leaders do not tell people what to do. They set the example.

7. WORK FOR THE JOY OF IT.

If you want other people to take part in improving their village and caring for their health, you must enjoy such activity yourself. If not, who will want to follow your example?

Try to make community work projects fun. For example, fencing off the public water hole to keep animals away from where people take water can be hard work. But if the whole village helps do it as a 'work festival' - perhaps with refreshments and music - the job will be done quickly and can be fun. Children will work hard and enjoy it, if they can turn work into play.

You may or may not be paid for your work. But never refuse to care, or care less, for someone who is poor or cannot pay.

This way you will win your people's love and respect. These are worth far more than money.

WORK FIRST FOR THE PEOPLE-NOT THE MONEY. (People are worth more.)

8. LOOK AHEAD - AND HELP OTHERS TO LOOK AHEAD.

A responsible health worker does not wait for people to get sick. She tries to stop sickness before it starts. She encourages people to take action now to protect their health and well-being in the future.

Many sicknesses can be prevented. Your job, then, is to help your people understand the causes of their health problems and do something about them.

Most health problems have many causes, one leading to another. To correct the problem in a lasting way, you must look for and deal with the underlying causes. You must get to the root of the problem.

For example, in many villages diarrhea is the most common cause of death in small children. The spread of diarrhea is caused in part by lack of cleanliness (poor sanitation and hygiene). You can do something to correct this by digging latrines and teaching basic guidelines of cleanliness.

But the children who suffer and die most often from diarrhea are those who are poorly nourished. Their bodies do not have strength to fight the infections. So to prevent death from diarrhea we must also prevent poor nutrition.

And why do so many children suffer from poor nutrition?

· Is it because mothers do not realize what foods are most important (for example, breast milk)?

· Is it because the family does not have enough money or land to produce the food it needs?

· Is it because a few rich persons control most of the land and the wealth?

· Is it because the poor do not make the best use of land they have?

· Is it because parents have more children than they or their land can provide for, and keep having more?

· Is it because fathers lose hope and spend the little money they have on drink?

· Is it because people do not look or plan ahead? Because they do not realize that by working together and sharing they can change the conditions under which they live and die?

HELP OTHERS TO LOOK AHEAD.

You may find that many, if not all, of these things lie behind infant deaths in your area. You will, no doubt, find other causes as well. As a health worker it is your job to help people understand and do something about as many of these causes as you can.

But remember: to prevent frequent deaths from diarrhea will take far more than latrines, pure water, and 'special drink' (oral rehydration). You may find that child spacing, better land use, and fairer distribution of wealth, land, and power are more important in the long run.

The causes that lie behind much sickness and human suffering are short-sightedness and greed. If your interest is your people's well-being, you must help them learn to share, to work together, and to look ahead.

Many Things Relate to Health Care

We have looked at some of the causes that underlie diarrhea and poor nutrition. Likewise, you will find that such things as food production, land distribution, education, and the way people treat or mistreat each other lie behind many different health problems.

The chain of causes leading to death from diarrhea.

If you are interested in the long-term welfare of your whole community, you must help your people look for answers to these larger questions.

Health is more than not being sick. It is well-being: in body, mind, and community. People live best in healthy surroundings, in a place where they can trust each other, work together to meet daily needs, share in times of difficulty and plenty, and help each other learn and grow and live, each as fully as he or she can.

Do your best to solve day-to-day problems. But remember that your greatest job is to help your community become a more healthy and more human place to live.

You as a health worker have a big responsibility.

Where should you begin?

Take a Good Look at Your Community

Because you have grown up in your community and know your people well, you are already familiar with many of their health problems. You have an inside view. But in order to see the whole picture, you will need to look carefully at your community from many points of view.

As a village health worker, your concern is for the well-being of all the people - not just those you know well or who come to you. Go to your people. Visit their homes, fields, gathering places, and schools. Understand their joys and concerns. Examine with them their habits, the things in their daily lives that bring about good health, and those that may lead to sickness or injury.

Before you and your community attempt any project or activity, carefully think about what it will require and how likely it is to work. To do this, you must consider all the following:

1. Felt needs - what people feel are their biggest problems.

2. Real needs - steps people can take to correct these problems in a lasting way.

3. Willingness - or readiness of people to plan and take the needed steps.

4. Resources - the persons, skills, materials, and/or money needed to carry out the activities decided upon.

As a simple example of how each of these things can be important, let us suppose that a man who smokes a lot comes to you complaining of a cough that has steadily been getting worse.

1. His felt need is to get rid of his cough.

2. His real need (to correct the problem) is to give up smoking.

3. To get rid of his cough will require his willingness to give up smoking. For this he must understand how much it really matters.

4. One resource that may help him give up smoking is information about the harm it can do him and his family. Another is the support and encouragement of his family, his friends, and you.

Finding Out the Needs

As a health worker, you will first want to find out your people's most important health problems and their biggest concerns. To gather the information necessary to decide what the greatest needs and concerns really are, it may help to make up a list of questions.

On the next 2 pages are samples of the kinds of things you may want to ask. But think of questions that are important in your area. Ask questions that not only help you get information, but that get others asking important questions themselves.

Do not make your list of questions too long or complicated - especially a list you take from house to house. Remember, people are not numbers and do not like to be looked at as numbers. As you gather information, be sure your first interest is always in what individuals want and feel. It may be better not even to carry a list of questions. But in considering the needs of your community, you should keep certain basic questions in mind.

Figure

Figure

Sample Lists of Questions To Help Determine Community Health Needs And at the Same Time Get People Thinking FELT NEEDS

Figure

What things in your people's daily lives (living conditions, ways of doing things, beliefs, etc.) do they feel help them to be healthy?

What do people feel to be their major problems, concerns, and needs - not only those related to health, but in general?

Figure

HOUSING AND SANITATION

Figure

What are different houses made of? Walls? Floors? Are the houses kept clean? Is cooking done on the floor or where? How does smoke get out? On what do people sleep?

Are flies, fleas, bedbugs, rats, or other pests a problem? In what way? What do people do to control them? What else could be done?

Is food protected? How could it be better protected?

What animals (dogs, chickens, pigs, etc.), if any, are allowed in the house? What problems do they cause?

What are the common diseases of animals? How do they affect people's health? What is being done about these diseases?

Where do families get their water? Is it safe to drink? What precautions are taken?

How many families have latrines? How many use them properly?

Is the village clean? Where do people put garbage? Why?

Figure

POPULATION

Figure

How many people live in the community? How many are under 15 years old?

How many can read and write? What good is schooling? Does it teach children what they need to know? How else do children learn?

How many babies were born this year? How many people died? Of what? At what ages? Could their deaths have been prevented? How?

Is the population (number of people) getting larger or smaller? Does this cause any problems?

How often were different persons sick in the past year? How many days was each sick? What sickness or injuries did each have? Why?

How many people have chronic (long-term) illnesses? What are they?

How many children do most parents have? How many children died? Of what? At what ages? What were some of the underlying causes?

How many parents are interested in not having any more children or in not having them so often? For what reasons? (See Family Planning)

NUTRITION

Figure

How many mothers breast feed their babies? For how long? Are these babies healthier than those who are not breast fed? Why?

What are the main foods people eat? Where do they come from?

Do people make good use of all foods available?

How many children are underweight or show signs of poor nutrition?

How much do parents and schoolchildren know about nutritional needs?

How many people smoke a lot? How many drink alcoholic or soft drinks very often? What effect does this have on their own and their families' health?

LAND AND FOOD

Figure

Does the land provide enough food for each family? How long will it continue to produce enough food if families keep growing?

How is farm land distributed? How many people own their land?

What efforts are being made to help the land produce more?

How are crops and food stored? Is there much damage or loss? Why?

HEALING, HEALTH

Figure

What role do local midwives and healers play in health care?

What traditional ways of healing and medicines are used? Which are of greatest value? Are any harmful or dangerous?

What health services are nearby? How good are they? What do they cost? How much are they used?

How many children have been vaccinated? Against what sicknesses?

What other preventive measures are being taken? What others might be taken? How important are they?

SELF-HELP

Figure

What are the most important things that affect your people's health and well-being - now and in the future?

How many of their common health problems can people care for themselves? How much must they rely on outside help and medication?

Are people interested in finding ways of making self-care safer, more effective, and more complete? Why? How can they learn more? What stands in the way?

What are the rights of rich people? Of poor people? Of men? Of women? Of children? How is each of these groups treated? Why? Is this fair? What needs to be changed? By whom? How?

Do people work together to meet common needs? Do they share or help each other when needs are great?

What can be done to make your village a better, healthier place to live? Where might you and your people begin?

Using Local Resources to Meet Needs

How you deal with a problem will depend upon what resources are available.

Some activities require outside resources (materials, money, or people from somewhere else). For example, a vaccination program is possible only if vaccines are brought in - often from another country.

Other activities can be carried out completely with local resources. A family or a group of neighbors can fence off a water hole or build simple latrines using materials close at hand.

Some outside resources, such as vaccines and a few important medicines, can make a big difference in people's health. You should do your best to get them. But as a general rule, it is in the best interest of your people to

Use local resources whenever possible.

The more you and your people can do for yourselves, and the less you have to depend on outside assistance and supplies, the healthier and stronger your community will become.

Not only can you count on local resources to be on hand when you need them, but often they do the best job at the lowest cost. For example, if you can encourage mothers to breast feed rather than bottle feed their babies, this will build self-reliance through a top quality local resource - breast milk! It will also prevent needless sickness and death of many babies.

Encourage people to make the most of local resources.

BREAST MILK - A TOP QUALITY LOCAL RESOURCE - BETTER THAN ANYTHING MONEY CAN BUY!

In your health work always remember:

The most valuable resource for the health of the people is the people themselves.

Deciding What to Do and Where to Begin

After taking a careful look at needs and resources, you and your people must decide which things are more important and which to do first. You can do many different things to help people be healthy. Some are important immediately. Others will help determine the future well-being of individuals or the whole community.

In a lot of villages, poor nutrition plays a part in other health problems. People cannot be healthy unless there is enough to eat. Whatever other problems you decide to work with, if people are hungry or children are poorly nourished, better nutrition must be your first concern.

There are many different ways to approach the problem of poor nutrition, for many different things join to cause it. You and your community must consider the possible actions you might take and decide which are most likely to work.

Here are a few examples of ways some people have helped meet their needs for better nutrition. Some actions bring quick results. Others work over a longer time. You and your people must decide what is most likely to work in your area.

POSSIBLE WAYS TO WORK TOWARD BETTER NUTRITION

FAMILY GARDENS

CONTOUR DITCHES to prevent soil from washing away

ROTATION OF CROPS

Every other planting season plant a crop that returns strength to the soil - like beans, peas, lentils, alfalfa, peanuts or some other plant with seed in pods (legumes).

This year maize

Next year beans

MORE WAYS TO WORK TOWARD BETTER NUTRITION

IRRIGATION OF LAND

FISH BREEDING

BEEKEEPING

NATURAL FERTILIZERS - Compost pile

BETTER FOOD STORAGE

SMALLER FAMILIES - THROUGH FAMILY PLANNING

Trying a New Idea

Not all the suggestions on the last pages are likely to work in your area. Perhaps some will work if changed for your particular situation and resources at hand. Often you can only know whether something will work or not by trying it. That is, by experiment.

START SMALL

When you try out a new idea, always start small. If you start small and the experiment fails, or something has to be done differently, you will not lose much. If it works, people will see that it works and can begin to apply it in a bigger way.

Do not be discouraged if an experiment does not work. Perhaps you can try again with certain changes. You can learn as much from your failures as your successes. But start small.

Here is an example of experimenting with a new idea.

You learn that a certain kind of bean, such as soya, is an excellent body-building food. But will it grow in your area? And if it grows, will people eat it?

Start by planting a small patch - or 2 or 3 small patches in different conditions of soil or water. If the beans do well, try preparing them in different ways, and see if people will eat them. If so, try planting more beans in the conditions where you found they grew best. But try out still other conditions in more small patches to see if you can get an even better crop.

There may be several conditions you want to try changing. For example, type of soil, addition of fertilizer, amount of water, or different varieties of seed. To best understand what helps and what does not, be sure to change only one condition at a time and keep all the rest the same.

For example, to find out if animal fertilizer (manure) helps the beans grow, and how much to use, plant several small bean patches side by side, under the same conditions of water and sunlight, and using the same seed. But before you plant, mix each patch with a different amount of manure, something like this:

1 shovel manure

2 shovels manure

3 shovels manure

4 shovels manure

5 shovels manure

This experiment shows that a certain amount of manure helps, but that too much can harm the plants. This is only an example. Your experiments may give different results. Try for yourself!

Working Toward a Balance Between People and Land

Health depends on many things, but above all it depends on whether people have enough to eat.

Most food comes from the land. Land that is used well can produce more food. A health worker needs to know ways to help the land better feed the people - now and in the future. But even the best used piece of land can only feed a certain number of people. And today, many of the people who farm do not have enough land to meet their needs or to stay healthy.

In many parts of the world, the situation is getting worse, not better. Parents often have many children, so year by year there are more mouths to feed on the limited land that the poor are permitted to use.

Many health programs try to work toward a balance between people and land through 'family planning', or helping people have only the number of children they want. Smaller families, they reason, will mean more land and food to go around. But family planning by itself has little effect. As long as people are very poor, they often want many children. Children help with work without having to be paid, and as they get bigger may even bring home a little money. When the parents grow old, some of their children - or grandchildren - will perhaps be able to help care for them.

For a poor country to have many children may be an economic disaster. But for a poor family to have many children is often an economic necessity - especially when many die young. In the world today, for most people, having many children is the surest form of social security they can hope for.

Some groups and programs take a different approach. They recognize that hunger exists not because there is too little land to feed everyone, but because most of the land is in the hands of a few selfish persons. The balance they seek is a fairer distribution of land and wealth. They work to help people gain greater control over their health, land, and lives.

It has been shown that, where land and wealth are shared more fairly and people gain greater economic security, they usually choose to have smaller families. Family planning helps when it is truly the people's choice. A balance between people and land can more likely be gained through helping people work toward fairer distribution and social justice than through family planning alone.

It has been said that the social meaning of love is justice. The health worker who loves her people should help them work toward a balance based on a more just distribution of land and wealth.

Figure

Working Toward a Balance Between Prevention and Treatment

Figure

A balance between treatment and prevention often comes down to a balance between immediate needs and long-term needs.

As a health worker you must go to your people, work with them on their terms, and help them find answers to the needs they feel most. People's first concern is often to find relief for the sick and suffering. Therefore, one of your first concerns must be to help with healing.

But also look ahead. While caring for people's immediate felt needs, also help them look to the future. Help them realize that much sickness and suffering can be prevented and that they themselves can take preventive actions.

But be careful! Sometimes health planners and workers go too far. In their eagerness to prevent future ills, they may show too little concern for the sickness and suffering that already exist. By failing to respond to people's present needs, they may fail to gain their cooperation. And so they fail in much of their preventive work as well.

Treatment and prevention go hand in hand. Early treatment often prevents mild illness from becoming serious. If you help people to recognize many of their common health problems and to treat them early, in their own homes, much needless suffering can be prevented.

Early treatment is a form of preventive medicine.

If you want their cooperation, start where your people are. Work toward a balance between prevention and treatment that is acceptable to them. Such a balance will be largely determined by people's present attitudes toward sickness, healing, and health. As you help them look farther ahead, as their attitudes change, and as more diseases are controlled, you may find that the balance shifts naturally in favor of prevention.

You cannot tell the mother whose child is ill that prevention is more important than cure. Not if you want her to listen. But you can tell her, while you help her care for her child, that prevention is equally important.

Work toward prevention - do not force it.

Use treatment as a doorway to prevention. One of the best times to talk to people about prevention is when they come for treatment. For example, if a mother brings a child with worms, carefully explain to her how to treat him. But also take time to explain to both the mother and child how the worms are spread and the different things they can do to prevent this from happening (see Chapter 12). Visit their home from time to time, not to find fault, but to help the family toward more effective self-care.

Use treatment as a chance to teach prevention.

Sensible and Limited Use of Medicines

One of the most difficult and important parts of preventive care is to educate your people in the sensible and limited use of medicines. A few modern medicines are very important and can save lives. But for most sicknesses no medicine is needed. The body itself can usually fight off sickness with rest, good food, drinking lots of liquid, and perhaps some simple home remedies.

People may come to you asking for medicine when they do not need any. You may be tempted to give them some medicine just to please. But if you do, when they get well, they will think that you and the medicine cured them. Really their bodies cured themselves.

Instead of teaching people to depend on medicines they do not need, take time to explain why they should not be used. Also tell people what they can do themselves to get well.

This way you are helping people to rely on local resources (themselves), rather than on an outside resource (medicine). Also, you are protecting their health, for there is no medicine that does not have some risk in its use.

REMEMBER: MEDICINES CAN KILL

Three common health problems for which people too often request medicines they do not need are (1) the common cold, (2) minor cough, and (3) diarrhea.

The common cold is best treated by resting, drinking lots of liquids, and at the most taking aspirin. Penicillin, tetracycline, and other antibiotics do not help at all.

For minor coughs, or even more severe coughs with thick mucus or phlegm, drinking a lot of water will loosen mucus and ease the cough faster and better than cough syrup. Breathing warm water vapor brings even greater relief. Do not make people dependent on cough syrup or other medicines they do not need.

For most diarrhea of children, medicines do not make them get well. Many commonly used medicines (neomycin, streptomycin, kaolin-pectin, Lomotil, chloramphenicol) may even be harmful. What is most important is that the child get lots of liquids and enough food. The key to the child's recovery is the mother, not the medicine. If you can help mothers understand this and learn what to do, many children's lives can be saved.

Medicines are often used too much, both by doctors and by ordinary people. This is unfortunate for many reasons:

· It is wasteful. Most money spent on medicine would be better spent on food.

· It makes people depend on something they do not need (and often cannot afford).

· Every medicine has some risk in its use. There is always a chance that an unneeded medicine may actually do the person harm.

· What is more, when some medicines are used too often for minor problems, they lose their power to fight dangerous sicknesses.

An example of a medicine losing its power is chloramphenicol. The extreme overuse of this important but risky antibiotic for minor infections has meant that in some parts of the world chloramphenicol no longer works against typhoid fever, a very dangerous infection. Frequent overuse of chloramphenicol has allowed typhoid to become resistant to it.

For all the above reasons the use of medicines should be limited.

But how? Neither rigid rules and restrictions nor permitting only highly trained persons to decide about the use of medicines has prevented overuse. Only when the people themselves are better informed will the limited and careful use of medicines be common.

To educate people about sensible and limited use of medicines is one of the important jobs of the health worker.

This is especially true in areas where modern medicines are already in great use.

WHEN MEDICINES ARE NOT NEEDED, TAKE TIME TO EXPLAIN WHY.

For more information about the use and misuse of medicines, see Chapter 6. For the use and misuse of injections, see Chapter 9. For sensible use of home remedies, see Chapter 1.

Finding Out What Progress Has Been Made (Evaluation)

From time to time in your health work, it helps to take a careful look at what and how much you and your people have succeeded in doing. What changes, if any, have been made to improve health and well-being in your community?

You may want to record each month or year the health activities that can be measured. For example:

· How many families have put in latrines?

· How many farmers take part in activities to improve their land and crops?

· How many mothers and children take part in an Under-Fives Program (regular check-ups and learning)?

This kind of question will help you measure action taken. But to find out the result or impact of these activities on health, you will need to answer other questions such as:

· How many children had diarrhea or signs of worms in the past month or year - as compared to before there were latrines?

· How much was harvested this season (corn, beans, or other crops) - as compared to before improved methods were used?

· How many children show normal weight and weight-gain on their Child Health Charts - as compared to when the Under-Fives Program was started?

· Do fewer children die now than before?

To be able to judge the success of any activity you need to collect certain information both before and after. For example, if you want to teach mothers how important it is to breast feed their babies, first take a count of how many mothers are doing so. Then begin the teaching program and each year take another count. This way you can get a good idea as to how much effect your teaching has had.

You may want to set goals. For example, you and the health committee may hope that 80% of the families have latrines by the end of one year. Every month you take a count. If, by the end of six months, only one-third of the families have latrines, you know you will have to work harder to meet the goal you set for yourselves.

Setting goals often helps people work harder and get more done.

To evaluate the results of your health activities it helps to count and measure certain things before, during, and after.

But remember: The most important part of your health work cannot be measured. It has to do with the way you and other people relate to each other; with people learning and working together; with the growth of kindness, responsibility, sharing, and hope. It depends on the growing strength and unity of the people to stand up for their basic rights. You cannot measure these things. But weigh them well when you consider what changes have been made.

Teaching and Learning Together - The Health Worker as an Educator

As you come to realize how many things affect health, you may think the health worker has an impossibly large job. And true, you will never get much done if you try to deliver health care by yourself.

Only when the people themselves become actively responsible for their own and their community's health, can important changes take place.

Your community's well-being depends on the involvement not of one person, but of nearly everyone. For this to happen, responsibility and knowledge must be shared.

This is why your first job as a health worker is to teach - to teach children, parents, farmers, schoolteachers, other health workers - everyone you can.

The art of teaching is the most important skill a person can learn. To teach is to help others grow, and to grow with them. A good teacher is not someone who puts ideas into other people's heads; he or she is someone who helps others build on their own ideas, to make new discoveries for themselves.

Teaching and learning should not be limited to the schoolhouse or health post. They should take place in the home and in the fields and on the road. As a health worker one of your best chances to teach will probably be when you treat the sick. But you should look for every opportunity to exchange ideas, to share, to show, and to help your people think and work together.

On the next few pages are some ideas that may help you do this. They are only suggestions. You will have many other ideas yourself.

TWO APPROACHES TO HEALTH CARE

Tools for Teaching

Flannel-graphs are good for talking with groups because you can keep making new pictures. Cover a square board or piece of cardboard with a flannel cloth. You can place different cutout drawings or photos on it. Strips of sandpaper or flannel glued to the backs of cutouts help them stick to the flannelboard.

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Posters and displays. “A picture is worth a thousand words.” Simple drawings, with or without a few words of information, can be hung in the health post or anywhere that people will look at them. You can copy some of the pictures from this book.

If you have trouble getting sizes and shapes right, draw light, even squares in pencil over the picture you want to copy.

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Now draw the same number of squares lightly, but larger, on the poster paper or cardboard. Then copy the drawing, square for square.

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If possible, ask village artists to draw or paint posters. Or have children make posters on different subjects.

Models and demonstrations help get ideas across. For example, if you want to talk with mothers and midwives about care in cutting the cord of a newborn child, you can make a doll for the baby. Pin a cloth cord to its belly. Experienced midwives can demonstrate to others.

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Color slides and filmstrips are available on different health subjects for many parts of the world. Some come in sets that tell a story. Simple viewers and battery-operated projectors are also available.

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A list of addresses where you can send for teaching materials to use for health education in your village can be found in chapter Addresses for teaching materials.

Other Ways to Get Ideas Across

Story telling. When you have a hard time explaining something, a story, especially a true one, will help make your point.

For example, if I tell you that sometimes a village worker can make a better diagnosis than a doctor, you may not believe me. But if I tell you about a village health worker called Irene, who runs a small nutrition center in Central America, you may understand.

One day a small sickly child arrived at the nutrition center. He had been sent by the doctor at a nearby health center because he was badly malnourished. The child also had a cough, and the doctor had prescribed a cough medicine. Irene was worried about the child. She knew he came from a very poor family and that an older brother had died a few weeks before. She went to visit the family and learned that the older brother had been very sick for a long time and had coughed blood. Irene went to the health center and told the doctor she was afraid the child had tuberculosis. Tests were made, and it turned out that Irene was right.... So you see, the health worker spotted the real problem before the doctor - because she knew her people and visited their homes.

Stories also make learning more interesting. It helps if health workers are good story tellers.

Play acting. Stories that make important points can reach people with even more force if they are acted out. Perhaps you, the schoolteacher, or someone on the health committee can plan short plays or 'skits' with the schoolchildren.

For example, to make the point that food should be protected from flies to prevent the spread of disease, several small children could dress up as flies and buzz around food. The flies dirty the food that has not been covered. Then children eat this food and get sick. But the flies cannot get at food in a box with a wire screen front. So the children who eat this food stay well.

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The more ways you can find to share ideas, the more people will understand and remember.

Working and Learning Together for the Common Good

There are many ways to interest and involve people in working together to meet their common needs. Here are a few ideas:

1. A village health committee. A group of able, interested persons can be chosen by the village to help plan and lead activities relating to the well-being of the community - for example, digging garbage pits or latrines. The health worker can and should share much of his responsibility with other persons.

2. Group discussions. Mothers, fathers, schoolchildren, young people, folk healers, or other groups can discuss needs and problems that affect health. Their chief purpose can be to help people share ideas and build on what they already know.

3. Work festivals. Community projects such as putting in a water system or cleaning up the village go quickly and can be fun if everybody helps. Games, races, refreshments, and simple prizes help turn work into play. Use imagination.

4. Cooperatives. People can help keep prices down by sharing tools, storage, and perhaps land. Group cooperation can have a big influence on people's well-being.

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5. Classroom visits. Work with the village schoolteacher to encourage health-related activities, through demonstrations and play acting. Also invite small groups of students to come to the health center. Children not only learn quickly, but they can help out in many ways. If you give children a chance, they gladly become a valuable resource.

6. Mother and child health meetings. It is especially important that pregnant women and mothers of small children (under five years old) be well informed about their own and their babies' health needs. Regular visits to the health post are opportunities for both check-ups and learning. Have mothers keep their children's health records and bring them each month to have their children's growth recorded (see the Child Health Chart). Mothers who understand the chart often take pride in making sure their children are eating and growing well. They can learn to understand these charts even if they cannot read. Perhaps you can help train interested mothers to organize and lead these activities.

7. Home visits. Make friendly visits to people's homes, especially homes of families who have special problems, who do not come often to the health post, or who do not take part in group activities. But respect people's privacy. If your visit cannot be friendly, do not make it - unless children or defenseless persons are in danger.

Ways to Share and Exchange Ideas in a Group

As a health worker you will find that the success you have in improving your people's health will depend far more on your skills as a teacher than on your medical or technical knowledge. For only when the whole community is involved and works together can big problems be overcome.

People do not learn much from what they are told. They learn from what they think, feel, discuss, see, and do together.

So the good teacher does not sit behind a desk and talk at people. He talks and works with them. He helps his people to think clearly about their needs and to find suitable ways to meet them. He looks for every opportunity to share ideas in an open and friendly way.

TALK WITH PEOPLE

NOT AT THEM

Perhaps the most important thing you can do as a health worker is to awaken your people to their own possibilities... to help them gain confidence in themselves. Sometimes villagers do not change things they do not like because they do not try. Too often they may think of themselves as ignorant and powerless. But they are not. Most villagers, including those who cannot read or write, have remarkable knowledge and skills. They already make great changes in their surroundings with the tools they use, the land they farm, and the things they build. They can do many important things that people with a lot of schooling cannot.

If you can help people realize how much they already know and have done to change their surroundings, they may also realize that they can learn and do even more. By working together it is within their power to bring about even bigger changes for their health and well-being.

Then how do you tell people these things?

Often you cannot! But you can help them find out some of these things for themselves - by bringing them together for discussions. Say little yourself, but start the discussion by asking certain questions. Simple pictures like the drawing on the next page of a farm family in Central America may help. You will want to draw your own picture, with buildings, people, animals, and crops that look as much as possible like those in your area.

USE PICTURES TO GET PEOPLE TALKING AND THINKING TOGETHER

Show a group of people a picture similar to this and ask them to discuss it. Ask questions that get people talking about what they know and can do. Here are some sample questions:

· Who are the people in the picture and how do they live?

· What was this land like before the people came?

· In what ways have they changed their surroundings?

· How do these changes affect their health and well-being?

· What other changes could these people make? What else could they learn to do? What is stopping them? How could they learn more?

· How did they learn to farm? Who taught them?

· If a doctor or a lawyer moved onto this land with no more money or tools than these people, could he farm it as well? Why or why not?

· In what ways are these people like ourselves?

This kind of group discussion helps build people's confidence in themselves and in their ability to change things. It can also make them feel more involved in their community.

At first you may find that people are slow to speak out and say what they think. But after a while they will usually begin to talk more freely and ask important questions themselves. Encourage everyone to say what he or she feels and to speak up without fear. Ask those who talk most to give a chance to those who are slower to speak up.

You can think of many other drawings and questions to start discussions that can help people look more clearly at problems, their causes, and possible solutions.

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What questions can you ask to get people thinking about the different things that lead to the condition of the child in the following picture?

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Try to think of questions that lead to others and get people asking for themselves. How many of the causes underlying death from diarrhea will your people think of when they discuss a picture like this?

Making the Best Use of This Book

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Anyone who knows how to read can use this book in her own home. Even those who do not read can learn from the pictures. But to make the fullest and best use of the book, people often need some instruction. This can be done in several ways.

A health worker or anyone who gives out the book should make sure that people understand how to use the list of Contents, the Index, the Green Pages and the Vocabulary. Take special care to give examples of how to look things up. Urge each person to carefully read the sections of the book that will help her understand what may be helpful to do, what could be harmful or dangerous, and when it is important to get help (see especially Chapters 1, 2, 6, and 8, and also the SIGNS OF DANGEROUS ILLNESS). Point out how important it is to prevent sickness before it starts. Encourage people to pay special attention to Chapters 11 and 12, which deal with eating right (nutrition) and keeping clean (hygiene and sanitation).

Also show and mark the pages that tell about the most common problems in your area. For example, you can mark the pages on diarrhea and be sure mothers with small children understand about 'special drink' (oral rehydration). Many problems and needs can be explained briefly. But the more time you spend with people discussing how to use the book or reading and using it together, the more everyone will get out of it.

You as a health worker might encourage people to get together in small groups to read through the book, discussing one chapter at a time. Look at the biggest problems in your area - what to do about health problems that already exist and how to prevent similar problems in the future. Try to get people looking ahead.

Perhaps interested persons can get together for a short class using this book (or others) as a text. Members of the group could discuss how to recognize, treat, and prevent different problems. They could take turns teaching and explaining things to each other.

To help learning be fun in these classes you can act out situations. For example, someone can act as if he has a particular sickness and can explain what he feels. Others then ask questions and examine him (Chapter 3). Use the book to try to find out what his problem is and what can be done about it. The group should remember to involve the 'sick' person in learning more about his own sickness - and should end up by discussing with him ways of preventing the sickness in the future. All this can be acted out in class.

Exciting and effective ways to teach about health care are in the book Helping Health Workers Learn, also available from the Hesperian Foundation.

As a health worker, one of the best ways you can help people use this book correctly is this: When persons come to you for treatment, have them look up their own or their child's problem in the book and find out how to treat it. This takes more time, but helps much more than doing it for them. Only when someone makes a mistake or misses something important do you need to step in and help him learn how to do it better. In this way, even sickness gives a chance to help people learn.

Dear village health worker - whoever and wherever you are, whether you have a title or official position, or are simply someone, like myself, with an interest in the well-being of others - make good use of this book. It is for you and for everyone.

But remember, the most important part of health care you will not find in this book or any other. The key to good health lies within you and your people, in the care, the concern, and appreciation you have for each other. If you want to see your community be healthy, build on these.

Caring and sharing are the key to health.

Yours truly,

David Werner

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NOTICE

This book is to help people meet most of their common health needs for and by themselves. But it does not have all the answers. In case of serious illness or if you are uncertain about how to handle a health problem, get advice from a health worker or doctor whenever possible.

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