Training Villagers to Become Healthcare Workers

by Victoria Porter

Published 8/14/01; © Medscape 2001

Providing healthcare to underserved populations is only the first step in curing disease and promoting good health in less developed countries. This goal cannot be achieved without properly educating these populations about illness prevention and disease management. Margaret Nelson, a Registered Nurse from Washington State who has been serving the underprivileged in Uganda, East Africa, for the past 2 years under the leadership of Foursquare Missions International (FMI) Missionary Greg Fisher, first realized the truth of this statement after spending 3 weeks at a mobile clinic in Kenya in February 1998. She quickly realized that “clinics themselves can have little lasting impact upon local health.” Nelson was surprised to discover that patients — especially in rural areas — are not only generally uninformed about disease prevention, but they rely heavily on the teachings and care of traditional healers and herbalists — ie, health workers without training in Western medicine.

Struck by the inadequacy of healthcare in the region, Nelson decided that she wanted to be involved in disseminating knowledge and providing better health management. She returned to Africa in 1999, this time directing her efforts to becoming acquainted with local diseases and modes of treatment at a clinic 50 miles north of Kampala, Uganda’s capitol. This clinic was part of an indigenous program, called Africa Village Outreach, whose goal is to establish churches, schools, and medical clinics in remote areas. Since that time, she has been providing medical help and training to this community; her efforts are supported by the New Life Center in Everett, Washington, which started out as the Everett Foursquare Church in 1940 and is affiliated with the International Church of the Foursquare Gospel.

Current Conditions in Uganda

Uganda is one of the poorest countries in the world and has one of the lowest life expectancies (32.7 years).^[2] Nelson witnessed firsthand the frustrations of delivering effective healthcare to a population with no electricity, no running water, and very little knowledge of or access to proper nutrition or health management. On one occasion, she unexpectedly delivered a baby on a grass mat in a mud hut, relying only on the natural light that was shining through the doorway. All she had to work with was gray swamp water (boiled!), an old pair of gloves, a bar of soap, and her Swiss army knife. Despite the surprise element and the less-than-ideal conditions, Mom and baby did fine, and so did she.

Nelson was encouraged by one statistic: the incidence of AIDS in Uganda had dropped from 14% in the early 1990s to 8% in 2000 because of an aggressive government campaign to promote AIDS education.^[3,4] This statistic fortified her belief that illness — and the ignorance surrounding it — can be fought by arming the people with knowledge.

After a few months at that clinic, Nelson began working at the grassroots level in remote villages that had little or no Western style healthcare. With the guidance of local authorities, and after meeting with individual villagers to gain their approval, she began to implement the program in certain villages, which she selected with the help of a local public health nurse. (Uganda has a decentralized government and healthcare system, largely based on a pre-British Colonial system of hierarchy of authority. Nelson had to obtain permission from the District Medical Officer to implement this program; she then visited with various government leaders, called “local chairmen,” similar to chiefs, starting with the higher-level ones and working her way down to the village-level chairmen.)

Villages Selected for the “Helping Health Workers Learn” Curriculum

Kigombe (chee-GOME-bey)

Approximately 25 students in the class, equally divided between men and women
The class initially assembled under a mango tree, but eventually moved into an unfinished church building.
One pastor’s wife was nearly stoned by other Christians when she recommended inhaling steam to treat a bad cough, because that was a method similar to one that some witch doctors use.

Kyevunze/Kasaala (che-VOON-zee, ka-SAH-lah)

Kyevunze is the village Margaret Nelson has been living in.
There has been a great deal of conflict between Catholics and Protestants in these 2 villages, but much of it was healed when both sides participated in Nelson’s classes.
The priest of the mission at Kasaala threw Nelson and her class of ~25 students out of a church in another village, having heard she was teaching family planning.

Bwaziba (BWA-zee-bah)

The most remote village in this program.
Approximately 50 students in the class.
Classes were held in a large brick building until it got rented out as a school; the remainder of the course was taught under a mango tree.
While teaching dental hygiene, Nelson learned of the village practice of removing the canine teeth from the gums of infants with a knife, intended to cure certain illnesses but actually causing many deaths.
Nelson saw her first case of “kwashiorkor” here.
A young boy with severe burn scars came to Nelson to seek care; she referred him to a mission hospital for surgery, where he died from the anesthetic.

Kabanyi (ka-ban-YEE)

About 14 students, mostly Congolese.
Classes were held in a tiny mud and grass church. (The old people of the village would gather in the hut next door and listen in on the entire class, forgoing their work that day of the week.)
Conflict between the more educated and the less educated graduates.
Villagers often gave Nelson chickens as gifts.

Kyampisi (CHOM-pee-see)

About 18 students
Classes were held in a Catholic church until the priest evicted Nelson and her students after he heard that she was teaching family planning and demonstrating condom use.
The remainder of the classes were taught in a small, mud church.
A “witch doctor” from this village who attended Nelson’s classes voiced much support for the program; he had brought a boy with a severely infected leg home from the government hospital in Kampala (the doctors had wanted to amputate, but the boy’s family refused). He treated the boy’s leg with antibiotics, soaked it in sterile water, and left it open to air. He was cured in 10 days!

After obtaining their consent, she met with individual villagers to gain their approval. A local public health nurse helped her to determine which villages would be selected. (For a list of these villages, see the Appendix.) She implemented a village-driven training program that was largely based on the concepts presented in David Werner’s medical reference book, Where There Is No Doctor: A Village Health Care Handbook, which has been translated into 80 languages.^[5] The residents of 5 selected villages chose certain people to be trained, based on qualifications suggested by authors Werner and Bower in Helping Health Workers Learn,^[6] such as good “moral character,” exemplary personal health behaviors, good health, and — with some exceptions — an education level between primary grades 3 and 6 (people with education levels higher than grade 6 have been shown to be more likely to abandon their villages for further education and/or job advancement).

Conducting a simple health survey, Nelson posed the following question to the villagers: “What was the biggest problem you faced in the past year?” Some of the major obstacles to healthcare that surfaced were inadequate or nonexistent diagnosis before treatment; unnecessary, overpriced, or ineffective treatment; and the pervasiveness of superstition, ignorance, and quackery. Furthermore, poverty itself proved to be a major barrier to healthcare — villagers could not afford to eat properly or buy nutritional supplements or appropriate medications. They often could not afford to travel to reach a clinic or hospital, and due to fear of medical costs, they would often remain in the villages and die.

The responses to her survey enabled Nelson to determine the most significant healthcare need for each village, and to center her training efforts around these needs. Malaria, AIDS and other STDs, tuberculosis, pneumonia, measles, diarrhea, goiter, malnutrition, worms and other parasites, lack of prenatal care, limited access to immunizations, and lack of clean water and sanitation were among the most prevalent problems she encountered. Her treatment goals emphasized correct and limited use of medications, minimal use of injections, and the use of home remedies to minimize costs. One such home remedy, which has been very successfully used, involves adding an iron nail (or bolt or horseshoe) into the cooking pot with beans or tomatoes, or whatever is being cooked. This increases the iron content in the diet, helping to correct the chronic anemia of people who suffer from repeated bouts of malaria and frequent pregnancies. (Cast-iron cooking pots would be ideal for this purpose, but seem to be unknown in Uganda — they use cast aluminum or steel pots.)

Natural Remedies Promoted to Villagers

Corn silk brewed with tea: Difficulty urinating
Garlic: Hypertension, pinworms, vaginal infections
Oral rehydration with water, sugar, and salt: Dehydration caused by diarrhea and other illness
Papaya milk or papaya seeds (dried, crushed, and mixed with water and honey): Intestinal worms
Papaya fruit: Digestive problems
“Quinine” tea: Malaria
Soap and water: Skin and wound infections
Vegetable oil and lemon: Gallstones
Water: Urinary tract infections

Although no medications have been donated to the villagers thus far, a few medical supplies that a friend of Nelson’s brought when she was visiting from the United States were distributed to two of the villages. A small private donation partly subsidized the heavily discounted purchase of Werner’s book, Where There Is No Doctor, for some of Nelson’s students. The general lack of donations has forced her to be resourceful and to teach her students how to improvise. For instance, she made tape measures out of strips of paper or fashioned them from pieces of string or woven grass (knotted at the points of measurement), and used these measuring devices to assess nutritional status of children aged 1 to 5 years by determining their upper arm circumference. In this manner, Nelson and her students were able to observe malnutrition rates that corresponded to those cited in professional studies (25% to 30%). Another diagnostic method she taught her students was how to recognize anemia by looking at the color of mucous membranes.

Fruits of Their Labor

Results of Nelson’s educational efforts and the villagers’ implementation of her teachings have been encouraging. Cases of malaria, now a leading cause of mortality in Uganda (25% to 40% of outpatient cases, 20% of hospital admissions, and 9% to 14% of inpatient deaths are attributable to malaria, and 90% of Uganda’s population live in highly malaria-endemic areas),^[7] have been successfully treated and cured by students who were able to recognize its symptoms and treat it with chloroquine, quinine, or fansidar. Myths about malaria had to be debunked. Villagers, who often referred to malaria as “bewitchment” had to be educated about transmission and treatment of the disease.

(Widely held superstitious beliefs cause the villagers to blame malaria and other illnesses on witchcraft. People who are driven by revenge, jealousy, and anger over such issues as land disputes inflict curses and spells on their enemies — or, if a very powerful curse is desired, they hire witch doctors to cast the spell. These spells, which are believed to cause convulsions, illness, demon possession, and even death, can only be broken by a paid witch doctor or by prayer from a strong Christian pastor.)

“We see now a big change in [our] village,” said Kiviru-J, Village Chairman of Kikelege. “Malaria is no longer a major problem because the workers [Nelson] has trained treat it cheaply and keep going around the village teaching people about diseases and how to prevent them.” Kiviru and the other leaders of Kikelege’s village council appreciate Nelson’s work and recognize that a good number of villagers have become well-trained health workers.

Severely malnourished children have been restored to health simply by teaching mothers how to properly combine the foods that are readily available. For example, by increasing water consumption and intake of vegetable proteins, nursing mothers who could not supply breast milk because of malnutrition were able to gain weight and resume milk production. Many malnourished infants whose mothers died during childbirth (or soon after) have been nursed back to health by elderly women who take certain herbs that cause them to lactate.

Villagers have also been taught how to more safely deliver babies, even in primitive conditions, by adopting sanitary practices (eg, use of clean water and gloves during delivery) and practicing regular prenatal care. Nelson encountered potentially harmful practices that had to be discouraged, such as dusting the baby’s severed umbilical cord with ashes or soaking the pregnant woman’s vagina in water filled with certain herbs. She has instructed the villagers on signs and symptoms of postpartum infections and neonatal gonorrheal infections, and on how to recognize at-risk women who should be referred to hospitals for delivery.

These improved sanitary practices have not been limited to childbirth. According to Kigozi-John, Village Chairman of Kyampisi, “Ever since Margaret Nelson started her lessons in our area,… people have improved on their hygienic standards and general home sanitation. The residents can now give first aid to their fellow village mates.” Kigozi added that the incidence of many infectious diseases has decreased because of the seminars that have been taught in Kyampisi.

Ntege-Mike, Village Chairman of Kigombe, also commented on the improvements in hygiene and their contribution to reduced incidence of certain diseases. He noted that the villagers now know how to treat hookworm, especially in children. “I am so happy because people are able to treat themselves at their homes when they get sick.” They no longer have to travel long distances for medical care, he said, because they now have their own clinic, which they set up with Nelson’s guidance.

One of the villages is developing its own drug shop, based on what they learned in the training program, for the prevention and treatment of malaria and other diseases. Since malaria is considered to be the biggest health problem for most of the villages, and given the limited ability of health workers to purchase medications, prevention of further attacks of malaria is crucial. Nelson has heard several testimonials from patients who were properly treated for chronic malaria (ie, with chloroquine, quinine, or fansidar) and instructed on cause and prevention, who reported that they have not had any further attacks. (Chloroquine has been the drug of choice for treating malaria, as it is very cheap and very effective. Unfortunately, malaria in Eastern Africa is quickly becoming resistant to chloroquine because of improper usage.)

One of her students started an experimental garden to demonstrate the use of fertilizer and natural preventives for eliminating insects and other damaging forces, to help improve nutrition and to increase the quality of the food being grown. According to Nelson, this woman so passionately believes in what she is doing with her demo garden that she recently ended up in the hospital and nearly died from exhaustion and overwork. Even though many of the villagers already know that there are benefits to fertilizing their gardens, they feel too overworked to take on another physical task. But when the results are demonstrated and explained to them, they seem more inclined to adopt this practice. (Some people in Wales, UK, have donated 100 pounds toward this type of garden project, to increase the use of vegetable proteins in the diets of people in third-world countries.)

What Lies Ahead?

This past March, 123 students graduated from the training program. Nelson is conducting monthly follow-ups to monitor their progress and to help them with short- and long-range goal planning. She has found that most of the newly trained health workers are very motivated to practice what they have learned. They have the desire to improve village health, which in turn can decrease some of the grinding poverty. But the poverty itself is a deterrent to them. Financing the purchase of medications is their biggest obstacle. Most illnesses can be successfully treated without medications, but some, like malaria, must have proper medications — otherwise patients can die or suffer chronic poor health. This is not always an issue, however, since most illnesses can be successfully treated without medications. Nelson advises her students on how to make profits and how to work together in support of each other and the community. She has encouraged them to start their own training programs as well. One of her students has expressed the intention of bringing his newfound knowledge to his tribe, who lives in a very remote area 200 miles north of Kampala.

This project is only the tip of the iceberg for Margaret Nelson, who plans to shift her focus to helping Ugandan women work through spiritual issues and develop better life skills, which include much of what she has taught her students. Women bear the brunt of the workload, and are often driven to prostitution as a way to earn money for college or for other life needs. Rape is common. As a result of the widespread prostitution, rape, and their husbands’ multiple sex partners, women are often infected by HIV and other sexually transmitted diseases. She would like to see more people with medical knowledge and expertise come to Uganda and get actively involved in any kind of healthcare programs — especially in the rural areas, which are particularly deficient in both education and treatment. She hopes to see more contributions of drugs, supplies, equipment, and money, so that we can begin to fill the overwhelming financial need in this area of the world. Tax-deductible financial contributions may be sent via New Life Center at 6830 Highland Drive, Everett, WA 98203. Margaret Nelson’s name must be indicated on a separate piece of paper, attached to the check, if the contribution is to be tax deductible. Mail safety is a concern, so it is not advisable to send either money or other contributions by mail. Those who wish to contribute supplies of any kind can contact Missions Pastor Glen Grove at New Life Center for information (425-355-9330; e-mail glen@nlcenter.com).

References

International Development Research Center. Institution: Adventures in Development. Medicinal plants (Uganda).
World Health Organization. Press Release: WHO Issues New Healthy Life Expectancy Rankings: Japan Number One in New ‘Healthy Life’ System. Released in Washington, DC, and Geneva, Switzerland, June 4, 2000.
World Health Organization. Uganda reverses the tide of HIV/AIDS.
UNAIDS, World Health Organization. AIDS Epidemic Update Report, June 2000.
Werner D, Thuman C, Maxwell J. Where There Is No Doctor: A Village Health Care Handbook. Berkeley, Calif: Hesperian Foundation; 1992.
Werner D, Bower B. Helping Health Workers Learn: A Book of Methods, Aids, and Ideas for Instructors at the Village Level. Berkeley, Calif: Hesperian Foundation; 1982.
World Health Organization. Roll Back Malaria: a global partnership. Country update, January 2001: Uganda.