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To The Basics
By
Curt Wands
"¡Se va a caer!
"She´s going to fall!" laughed Rosmira. Precariously
balanced on a long two-by-four board, Ana Felicia, a heavy-set Health
Promoter is one of the Health Promoters being held, grasped and
supported as she is passed from arm to arm to the front of the line.
Suggestions and encouragement are conveyed in the languages of Emberá,
Spanish, and Wauunan. Short-statured elderly Indigenous men support
the deeply Afro-Colombian Ana Felica, as she is passed next to mestiza[1]
young women along to middle-aged Afro-Colombian men. All sweating
in the tropical morning sun, all with the common goal of not letting
Ana Felcia fall into the surrounding "water" and find
her rightful place in the line being formed. Ana Felicia does not
fall, and arrives safely to the end of the boards without falling.
However, it takes the opinion of all involved to decide whether
she is in the right order in the line. Does Ana Felicia belong before
Ana Elizabeth? And what about Anival or Albenico?
The objective of this
game is to place everyone in alphabetical order without letting
anyone fall; both tasks equally difficult in this first workshop
of Health Promoters in the Lower Atrato River of Colombia. Though
some have graduated from the equivalent of 6th grade, most have
not. At this point the deficiencies of their formal education becomes
all too apparent. The lack of government programs for education,
health or social development becomes glaringly obvious in one small
game. Yet, this game has a very serious purpose. The inability to
implement such a basic concept as placing one another in alphabetical
order makes it obvious that there it is impossible to look up a
word in the index of their manual "Where There Is No Doctor[2]
." After the game, we head inside to continue applying our
studies.
The walls and floor of
this three-room schoolhouse are made of rough boards, each board
hand-hewn by chain saw. The roof is made of laminated sheet metal
that resound with a deafening roar when the afternoon tropical rains
pass through. There is neither electricity nor running water in
the school. We are fortunate to have the use of this building, one
of the better locations around for gathering a number of people
in an area removed from the active combat of Colombia's civil war.
The afternoon heat, magnified by the corrugated metal roof, makes
it mandatory for afternoon courses to be extremely active. Sweat
drips in sheets from ones entire body while trying to pay attention
to either giving or receiving the course. It is crucial to make
these studies engaging and active.
Anatomy review is begun
with a magic marker and Heberto, a volunteer from among the student
Health Promoters. With his shirt removed, I ask another Health Promoter
to draw her perception of the lungs over the chest of the male volunteer.
The lungs are drawn in a small circle over what might encompass
the right breast. Asking the other promoters if they have a different
perception of the size of the lungs, another draws the lungs a bit
larger, with others providing their commentaries and input until
finally, after many tries, the lungs, approximating their real size,
are drawn over Heberto's chest.
Laboratory
and Diagnostic Work
With the arrival of two
other Concern America volunteers, we are able to provide more attention
to the 32 health and lab workers who arrive from the villages. "Lab
workers" is a relative term in the context of the lower Atrato
River basin. A dozen villages were provided with microscopes by
a project ten years ago, but there has been no follow-up for almost
half of that decade. There were no reagents for doing the stains
necessary to detect malaria, tuberculosis, or bacteria.
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All of the microscopes
are outfitted with reflective mirrors for illuminating the slides,
as there is no electricity in the majority of the communities. During
this course, for the first time many of the promoters saw the difference
between gram-positive and gram-negative bacteria. Most had never
seen the cysts in stool samples that demonstrate the worm (helminth)
infections that are almost ubiquitous in the children of this region.
Promoters learned to detect basic anemias by measuring the quantity
of hemoglobin in the blood. At the end of the course 10 communities
had enough stains and training to do basic lab work to detect urinary
tract infections, pregnancy, intestinal parasites, basic bacteria
and malaria.
We were also able to provide
deeper clinical diagnostic techniques and treatment modalities to
the promoters. There had never been a course on the use of penicillins,
although almost all promoters had experience injecting them in the
communities. One can, after all buy almost any medication over the
counter, without prescription, largely due to free market economics
here. By the time we finished this course there was a new appreciation
and understanding of the basics of this important, though at times
risky, antibiotic.
Among the various techniques
used in this course were the use of a board game where the promoters
took on the role of different parasites; there was practice of medical
exam techniques; listening to tapes of different respiratory sounds;
and a raucously competitive knowledge-challenge game at the end
of the course.
Displaced
Displaced… a word that is an everyday term here, used all-too-casually
to describe the tragedy of almost one in every ten Colombians. It
is a word that should evoke rage, sorrow, and grief for those who
no longer have a place to be; for those have been forcibly removed
from their home and their land. Entire communities of people are
in exodus during these years of war and violence. To not leave is
tantamount to suicide while the factions at war continue their agonizing
process of eliminating those who live in these communities but do
not participate in the divisions of the civil war.
There are only two countries
in the world reputed to have more displaced people than Colombia;
these are Somalia and the Democratic Republic of the Congo. Here
in Colombia, with over 40 years of civil war, the scars of this
conflict have touched almost every family in the country. Many families
have sons, husbands or fathers in both the guerrillas and the army
or paramilitary. When one of the armed factions takes over a community
there are almost always reprisals and vengeance against those who
have either supported another side or merely not joined up with
the newly dominating faction. The intertwining of personal and political
affairs in these reprisals has lead to an extremely complex web
of ties, betrayals, and subterfuge that break down the tenuous sense
of community that would exist in any war situation. These divisions
are antagonized by those with money and power from the narcotics
trade or the neo-liberal "free trade" that dominate people's
lives here. To counteract these tendencies, our works of Health
Promoter training and organizing are among the primary objectives
of this project. The formation of a Health Promoter association
is building bridges among these communities that have not been felt
for years.
The
Risks of Providing Decent Health Care
Dedicated to Mario Flores, M.D., Medical Director
of the Murindó Hospital.
Colleague, companion in service to those in need, and friend for
all too short of a time.
In June,
"Oliverio[3]" the Parish priest at a local Catholic Church
was getting into his boat to 8-hour trip upriver. We hadn't had
a chance to talk about much except the most urgent of details; the
guerrillas pressuring in this river valley, the army attacking and
killing a young man in that one. Where are there more malnourished
people right now? Which community hasn't had a medical visit for
months, if ever? The cord on the boat's motor is pulled, the putting
sound of the 25 hp engine is warming, and last messages and greetings
to others are exchanged. I asked of Oliverio, "Please send
my warmest greetings to Mario, the director of the hospital in Murindó."
From the
very first time I met Mario I was impressed. He was one of the only
Colombian medical doctors I met who was willing to work in the remote
and conflictive zone of the Jiguamiandó River basin. As director
of the Murindó Hospital he certainly had more than enough
work to keep him busy without leaving that small town where he lived.
But Mario was all too aware of the very real needs of those who
could not make the nine to fourteen-hour hike to the hospital. So,
several times a year, he would enlist the aid of one of the other
two M.D.s at the hospital to accompany him on visits to these communities
at risk. He lived life in these difficult areas like everyone else;
bathing in the river, sleeping on the hard wooden floors with barely
a mat to cushion him, and enduring the stifling heat and clouds
of mosquitoes during extremely long days of medical exams. We often
met on these long, difficult excursions and immensely enjoyed our
mutual commitment to heal in these zones and we often conversed
about professional cases as well as about our personal lives.
Oliverio's
quizzical look had me concerned immediately. "Mario Flores?"
he inquired. "Yes." I replied, "I haven't seen him
since I returned. He doesn't even know I'm in the country yet."
As he softly started his response I felt I could no longer hear,
my ears and face became hot as the blood rushed to my head, I found
it hard to breathe without sobs welling up as I fought tears that
would pour out later when I could hear and register… "So,
you haven't heard…." At the moment I could hear only
selective words to confirm the worst, "terribly tortured, mutilated",
"almost a year ago", "paramilitary", "accompanying
Maria's deaf-mute nephew", "tragedy", "I'm sorry,
I know…"
Later, when
Maria confirmed the gruesome details of Mario's death I was able
to grieve more fully. What Mario's primary "crime" was,
why the paramilitary decided to kill him, I still do not know. Possibly
it was due to his visits to the communities, perhaps he cured the
"wrong" person who was seen as an enemy of the para-military
or army, or perhaps he had pushed the government too far in his
fervent efforts to end corruption and to appropriately fund the
hospital and public health programs he was associated with.
Taparal
Deep, obscure water flows slowly from the mouth of the narrow Domingodó
River, with a depth belying the appearance of tranquility. Life
giving vegetation, normally above the shoreline in the all-too-short
dry season, now slowly decays under the river surface. The almost
impenetrable sheen on the oily dark surface allows one to see the
world reflected as inversely as society itself functions here.
Waves from
our four wooden longboats break the placid reflection of trees and
surrounding brush as over two dozen members of the Chicao community
head upriver, accompanied by several members of a Peace and Reconciliation
team, religious members of the Catholic Church, and myself. Our
boats are all flying white flags to demonstrate the civilian nature
of our mission. These flags are in dramatic contrast to the official
army and marine boats we have just passed. They uniformly fly the
skull-and-crossbones flag, reminiscent of the pirate age they all
too aptly symbolize. The flags skull eyes are painted in deep red.
We haven't
gone more than a couple of kilometers[4] before we have our first
of many encounters with the paramilitary on this trip. The "Para"
military are Colombia's version of the death squads made famous
in Central America in the 1980s. Working hand-in-hand with the government
and army they are the judge, jury and executioner of the local populace.
Anyone perceived as not conforming to their brutal tactics, their
social/military project or their promotion of the narcotics trade
is seen as enemy. In fact the flight of the entire village of Taparal
was due to the paramilitary attacks on their village.
The killing
of "Chanana," a Health Promoter in Taparal had been the
last blow for the people there. Chanana was intimately involved
in the lives of the people of his community. When one neighbor was
picked up by the paramilitary and taken to their nearby encampment,
Chanana trusted that he could negotiate for the release of his neighbor.
He was wrong. After paddling downstream in his dugout canoe to the
paramilitary encampment he explained that his neighbor was not involved
in the insurgency and should be released. Instead, Chanana himself
was accused of being involved with the insurgency as well, and was
killed alongside his neighbor. Several days later the entire village
fled into the jungle. For the next half year people struggled to
stay alive under the dense jungle cover, unable to plant, harvest
or fish with any regularity. Their children virtually starving,
they contacted Catholic Church members to help get them out of the
river basin where they had fled. Still, half of the community stayed
behind, preferring a precarious life, with implicit hunger and lack
of even the most basic services, to the life in Río Sucio
with the paramilitary watching their every move. Now, the community
who relocated to Río Sucio has returned to re-clear their
land in the hope of returning there by the end of 2004.
The water
is murkier as we climb further upstream, ever farther even from
the remote town of Río Sucio. The faster current mixes in
mud now, making the water impenetrable and obscuring stinging "toadfish"
and freshwater stingrays lurking below. Community members are all
aware of the dangers of this water and this environment. So, fear
is palpable as we pass each of the checkpoints of the paramilitary
forces, omnipresent in this river basin. The gun holsters on the
hips of these deadly serious soldiers each display the classic "U.S."
lettering of previous U.S. military use. In one way or another,
the $2,000,000 U.S. tax dollars sent daily for military support
is deeply felt, and blatantly obvious in its intent. We continue
to pass paramilitary soldiers as they stand quietly on the shore,
as they look out from their tents and as they dry their uniforms
drying in hot, humid air. We pass them in the village of "La
Madre" their armed presence the only evidence of life in this
previously active town. We stop only when they insist on questioning
our presence and purpose. On the boats, people are uncharacteristically
quiet.
After a five-hour struggle
of cutting through logjams, shoving boats over lowspots in the river,
and answering to paramilitary harassment, we arrive at the shore
of Taparal. Trees have grown up to 30 feet tall and homes now hide
behind the overgrowth of weeds. As the first men disembark onto
the muddy riverbank, their machetes are out, clanging with a metallic
ching, each stroke bringing down a swath of overgrowth. Within the
first hour there is a clearing to the first line of houses on the
bank. Meanwhile two of the houses are organized for cooking and
sleeping. Wasp
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nests are cleared away, floors are swept, and
food is prepared for the evening meal. I look for an appropriate
site to do medical exams from. The health post had been used
by the paramilitary as a latrine. The floor is covered with
feces. I decide to work out of the building we will stay in.
Violent and pornographic graffiti is painted on almost all the
homes. Pseudonyms of paramilitary fighters "The Nazi",
"The Tiger" and |
others sign
the walls, overtly taking credit for previous killings and attacks
in the zone, as well as cleared away, floors are swept, and food
is prepared for the evening meal. I look for an appropriate site
to do medical exams from. The health post had been used by the paramilitary
as a latrine. The floor is covered with feces. I decide to work
out of the building we will stay in. Violent and pornographic graffiti
is painted on almost all the homes. Pseudonyms of paramilitary fighters
"The Nazi", "The Tiger" and others sign the
walls, overtly taking credit for previous killings and attacks in
the zone, as well as threatening for the future. Over the next days,
the entire town is cleared of overgrowth, and the homes are once
again cleared for possible occupation in the future. While
clearing of the land occurs in Taparal, I take the opportunity to
visit surrounding the Indigenous villages of Pichindé, Jagual
and Marcial. The Indigenous villages did not flee either the guerrilla
nor paramilitary incursions, however they suffered even worse in
some ways. The armed forces effectively blockaded this river over
the last years, ensuring a lack of economic participation, guaranteeing
worsening malnutrition and poverty. The Wauunaan and Emberá
people here are in as desperate conditions, or more so, than those
who fled.
The two dozen
families who inhabit the tiny community of Mamey Dipurudú
contend with nightly paramilitary fighters occupying the village.
The armed troops insist on staying in the houses of the Indigenous
inhabitants, violating what is a basic constitutional guarantee
in the U.S. and most civilized countries. One can barely imagine
this amendment being violated even under George Bush's version of
the national security / anti-terrorist state. On this July night,
paramilitary soldiers stormed into the village of only a dozen families,
yelling epithets and making threatening gestures. Only when one
of the priests and I illuminated ourselves with flashlights did
the soldiers stop their aggression. One soldier approached us to
announce they were going to stay in the village due to the inclement
weather on this night. When we challenged their assumption to place
the community at risk by staying in the limits of the village, one
of the soldiers clarified that they usually "only stay in the
school." We pointed out the school is still located within
the village and is still an absurdly inappropriate place to locate
armed troops. They eventually stayed the night in people's homes.
Medical
Challenges
Work and
life are a mix of brief glimpses of the positive working against
the enormous swath of negative, as death tries to overshadow life,
war dominating as much as it can over peace. Still, the light in
the world is ever-present...
I saw it
in the face of Guille (pronounced Ghee-yeh), a 62-year-old Afro-Colombian
man, and a catechist for most of his life, dying of cancer. The
first time I met Don Guille we had wonderful interchanges that brought
an immediate bond between us. His spirit of humor, reverence and
appreciation for life were very apparent in his cachectic face and
alertly deep-set eyes. "So, Don Guille, how old are you?"
I asked. "Ayyyeee...." came his Afro Colombian drawn out
response indicating forever, more or less. "More than 200 years
old?" I asked. "More than 300," he replied. "So,
you knew Christopher Columbus?" I had to ask. "When he
was just a young lad" came the immediate reply. Guille was
given Acetaminophen (Tylenol) at the hospital to relieve the excruciating
pain of his metastatic cancer even as he became unable to walk or
sit. Thankfully, I was donated some morphine and fentanyl patches
so that his last days became gratefully less excruciating.
It is quite
an ordeal to get to where Done Guile's "house" of rough-hewn
boards among the other thousands of displaced in the town of Rio
Sucio. His house is raised on poles above the 3 feet of murky, stagnant
lagoon water. Water rains in through the leaky corrugated aluminum
roof. To get to the house one has to walk from board to board stretched
between the houses extending into this marsh. The boards bounce
up and down as I traverse them, and I've fallen in more than once.
Beautiful purple flowered water lilies bloom along the way.
When I told
Don Guille that I was leaving for these days to Apartadó
he acknowledged this, replying; "Well then, so I'll see you
there. I'll be waiting there for you." We have had a lovely
meeting of spirit and I knew immediately what he meant. He passed
away quietly in his sleep two days later.
So, how to
sum up even a day where Don Guille was one of a dozen people I was
fortunate enough to be touched by and to touch? The medical care
I provide is minimal at times. I have no lab work or diagnostic
methods other than what I can carry in my bag, which is to say it
is woefully inadequate. And that is still more than most people
here have ever had. It is such a privilege to be with people in
these places and conditions!
There is
so much more to recount of the lives and deaths, and near-deaths
of people here. I intensely feel the lack of medications and resources.
Treating a young, violent schizophrenic man with the old option
of Haloperidol; sweating through an acute asthmatic crisis with
a woman with a syringe of adrenaline and a metered dose inhaler
of Albuterol; struggling with an infant whose respiration is three
times as fast as it should be from pneumonia; making clinical calculations
on what type of malaria I should be treating for when the patient
in front of me has a 103° fever.
The day-to-day
life here is inspiring as the Health Promoters in their villages
begin to organize for the right to have vaccines instead of bullets,
medical training instead of military training. They are attempting
to heal in the midst of absent or incapable government services.
They provide a front line of non-violent, constructive presence
for those who sorely lacking in hopeful options. It is a gift to
share a bit of the life and light here with those of you taking
the time to read and hear a bit of the lives of those who touch
mine. Thank you for your efforts to be a healing and positive force
in the world. We will overcome.
En Paz y
Servicio,
Curt Wands
[1]
Mestiza is a person of mixed Spanish and Indigenous descent.
[2] Where There Is No Doctor (Donde No Hay Doctor), Werner, Thuman,
Maxwell; Available from the Hesperian Foundation, 1919 Addison St.,
#304, Berkeley, CA 94704
[3] "Oliverio" is a priest whose real name is not used
because his work in this conflict zone has placed him on a death
list. As his boat pulled away from the shore, and even before he
has passed the first bend in the wide Atrato River, I found myself
praying I never have to dedicate the same type of memorial to him.
[4] 1 km = 1.1508 statute miles
Alan
"Curt" Wands practices spirituality as a Quaker and healing
as a Physician Assistant in northwest Colombia.
Alan (Curt)
Wands
Pastoral Social
Calle 105, 95-20
Colonia La Chinita
Apartadó, Antioquia
Colombia, South America
Tel:
Casa Apartadó: (57)(4) 826-2172 / 826-6090
Casa Río Sucio: (57)(4) 681-0012
Fax: (57)(4) 828-4786
email: cwands@igc.org <mailto:cwands@igc.org>
www: <http://home.igc.org/~cwands/>
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