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Regarding a
Prepared by Jed Koball
The following is in response to concern among the leadership of Bridges to Community with regard to a medical program that addresses the critical needs of the various communities in Nicaragua in which Bridges is active; that considers the capacity and limitations of Bridges in order to best utilize skills and resources; and, that responds with integrity to the organizational mission of offering ¨service-oriented educational experiences¨ for volunteer groups from North America (in this case, medical volunteers). Likewise, this report takes into consideration the excellent work and reporting of Kenia and Hansell in Siuna (hereto for referred to as the ¨Siuna Report¨). Building upon their investigation and assessment, this report will add further insight into the situation of healthcare in Bilwi as well as offer potential direction for a more comprehensive Bridges medical program by briefly addressing the following subject matters: 1) the status of healthcare and the nature of health concerns in Bilwi; 2) a description of the current Bridges Medical Program in Bilwi; 3) an assessment of the Bridges Medical Program in Bilwi; 4) a Project Proposal for 2005; 5) further remarks regarding a Bridges to Community Comprehensive Medical Program in Nicaragua. The status of healthcare and the nature of health concerns in Bilwi The Siuna Report accurately defines and characterizes the gross nature of medical concerns in the North Atlantic Autonomous Region of Nicaragua. It is without question that Siuna, being a less populated and perhaps more removed municipality than Bilwi, is at a far greater disadvantage in terms of receiving adequate medicines, supplies, and professional help. However, this is not to say that the concerns of adequate and affordable healthcare are not dramatic and extreme in Bilwi. Likewise, the ¨urbanization¨ of Bilwi and its location on the coast present certain systemic health concerns unlike those of any other municipality in Nicaragua. In consulting with healthcare workers from MINSA, the hospital, the Clinica Bilwi (private clinic), IMTRADEK/URACCAN (Institute for Traditional Medicine at URACCAN), as well as other local leaders, it is evident that the concerns reflected in the Siuna Report apply to Bilwi as well, notably: a high infant mortality rate, infant and child malnourishment, parasites, dehydration and diarrhea, basic hygiene and public sanitation. In comparison to Siuna, there may be greater availability of medications; however, the affordability of such medications is beyond the means of the vast majority of the population. For example, one large canister of oxygen (for use in non-emergency surgery or other procedure) costs roughly 700 cordobas (US$ 45); most cannot afford this, and often times, the oxygen itself is not available. The unaffordable costs of medicine are perhaps better understood when taking into consideration the economic status of most healthcare workers in the region. A general practitioner of medicine at the hospital, who works three 8 hours shifts and one 32 hour shift each week, earns approximately $200/month. A specialist in pediatrics may earn $400-$500/month. A full time nurse earns $50-$80/month. These figures apply not only to hospital workers, but clinicians, and other government and non-government health care workers, all of whom work extra uncompensated hours due to the lack of a sufficient number of healthcare workers. As reflected in the Siuna Report, the North Atlantic Autonomous Region is an undesirable place to work due to the extraordinarily high cost of living (compared to the Pacific Coast). Most all consumer items are shipped from the Pacific Coast; thus, the cost of living is often two to three times as high as it is on the Pacific Coast (example: a pineapple in Masaya costs roughly 5 cordobas; by the time it gets to Bilwi it costs 20 cordobas and is half rotten - the ¨half rotten¨ may be an exaggeration but the 15 cordoba mark-up is not). Such inflation applies to sufficient housing as well. Conversation with MINSA officials in Bilwi resulted in similar requests as in Siuna - housing for doctors in order to attract more healthcare professionals to the region. Despite unaffordable medicines, the unavailability of medicines, and the shortage of healthcare workers (including psychiatrists and clinical psychologists of which there are none in Puerto Cabezas, and likely none in the entire North Atlantic Autonomous Region), Bilwi does appear to have a substantial number of health care facilities that are free or reasonably affordable (one hospital, numerous private clinics, one public clinic, as well as dentists and eye-care professionals). Likewise, recent years have seen the development of two new institutions, the AIDS Clinic and the Drug Commission which are addressing two systemic healthcare issues that have arisen in the last decade and that appear to be growing at alarming rates. According to hospital workers and clinicians, the spread of AIDS in Bilwi and surrounding communities is a far, far greater problem than local, regional, or national government officials are willing to acknowledge or address. The frequency at which it is being detected in the hospital continues to grow (according to unofficial reports by doctors). The AIDS Clinic seeks to educate the population about HIV and AIDS and how to protect oneself against contracting AIDS, as well as providing basic care for AIDS patients (however, medication for AIDS and HIV positive persons is highly unaffordable and rarely available). In contrast, the local and regional government officials have little choice but to acknowledge the overwhelming growth of drug and alcohol abuse in the last decade - most notably abuse of drugs in the form of crack cocaine. According to reports (again, unofficial) of the Drug Commission, a particular Columbian drug cartel moves, on average, 8 speed boats of cocaine per night off the coast of Bilwi, moving north to the United States. The cartel has affectively established a path northward that runs through Bilwi and utilizes the local population in its defense against Federal and International Drug Enforcement Agencies. The payment is cocaine; thus, Bilwi is the principal entry point of narcotics (primarily cocaine) for the entire population of Nicaragua. To this affect, the National Police in Bilwi officially report having identified 98 crack houses in Bilwi. Likewise, other leaders unofficially note the rate of drug abuse among teenage adolescents in Bilwi to be as high as fifty percent (50%). The efforts by the Drug Commission to prevent drug abuse are minimal in contrast to the force it is confronting. And the network of healthcare facilities has no measurable response to drug addiction and drug overdose. Anything resembling a program for the rehabilitation of drug addicts does not exist in the North Atlantic Autonomous Region. Perhaps further compounding such despairing health concerns is the steady process of ¨urbanization¨ that Bilwi is undergoing. In the last twenty years, Bilwi has grown from a town of 7,000 inhabitants to roughly 50,000 inhabitants today. Part of this growth was due to the Contra War in the 1980´s which saw thousands of people in the northeast region of Nicaragua displaced from their land and left with few choices other than to seek refuge in Bilwi. But, part of this growth is also due to the fact that, despite its dire impoverished status, Bilwi is the center of commerce for the entire North Atlantic Autonomous Region. To that end, numbers of people continue to move to Bilwi in search of work. Unfortunately, there is officially reported over 90% unemployment. And, there is insufficient infrastructure to support such a population. This is a great concern with regard to public health conditions. In the more impoverished barrios of Bilwi, there is crowded housing (often 15-20 people in a household) and few latrines. Likewise, wells for drinking water are often very shallow, uncovered and unprotected from human and animal waste. Also, the rate of the spread of AIDS and the rate of the growth of drug abuse both appear to parallel the growth of population over the last decade, according to various healthcare workers and other leaders. In this same period of time, many healthcare workers and leaders in the community will also note a sharp increase in planned and unplanned teenage pregnancies (resulting in a substantial population of young single mothers with little employment opportunity and little if any financial support from the male partner; hence, high rates of infant and child malnourishment and infant mortality). Interestingly, during this same period of population growth, some doctors will note a seemingly disproportionate number of cases of ovarian cancer and cervical cancer among young women (if or how this is related to any of the above, I have no idea). (NOTE: There is no hard data to support any of the above findings; they are mere summaries of conversations and conjectures). It is important to note that the vast majority of the population of Bilwi is comprised of Miskito Indians (approximately 85% of the population). Of the Miskito population, the majority come from more rural communities and continue to practice many traditional beliefs - including traditional medicine. URACCAN (the university system of the Autonomous Region) and IMTRADEK (Institute for Traditional Medicine within the URACCAN Bilwi campus) have taken the initiative to bring the practice of traditional medicine to the forefront of the conversation regarding how to develop as an Autonomous Region that respects indigenous and cultural rights. The perspective of IMTRADEK is that there are two healthcare systems at work in the Autonomous Region - occidental (western) medicine and traditional medicine. Furthermore, it is their belief that both are legitimate and necessary health systems, that both have the right to develop, that one should not over-ride the other, and that the two should work in partnership. To that end, IMTRADEK has initiated dialogue between leaders of both occidental medicine and traditional medicine to address particular systemic health care concerns in the region. One notable health concern that the dialogue has addressed (and that has not yet been mentioned in this report) is that of ¨crazy sickness¨, or perhaps more formally described as ¨collective hysteria.¨ ¨Crazy sickness¨ is a condition found most often in the more rural communities, wherein 2 or more people (typically young females) exhibit hysterical behavior sometimes accompanied by epileptic-type seizures. Doctors of occidental medicine have not found a cure or treatment for this condition, and through the IMTRADEK dialogues have learned to turn to the ¨crazy sickness¨ specialists among the traditional healers. Likewise, traditional healers are beginning to refer their patients to occidental doctors for conditions of which they have not been able to find a suitable cure (such as cancer). And, together, both traditional healers and occidental doctors are beginning to address the one tragic and prevalent disease that neither can cure - AIDS. The initiative of URACCAN and IMTRADEK is about more than finding adequate cures for disease and sickness (although that in itself is a tremendous effort). It is also about the development of the Autonomous Region with regard to indigenous and cultural rights. To not acknowledge traditional medicine is to dismiss the belief system of the vast majority of the population - and ultimately, to ignore and potentially suppress the rights of indigenous populations. This is not to say that this initiative is merely for the sake of allowing a people to believe what it wants to believe despite how it may or may not affect them, rather it is to acknowledge that 1) without respect for the cultural rights of others, dialogue, consensus and advancement for all are impossible, and 2) no one system holds the entire truth, and there is much to be gained from traditional medicine that has not been given the freedom to develop in recent history. In this vein, such recent history should not be ignored, most especially with regard to the development of occidental medicine in the Autonomous Region in the last fifty years. During the Somoza regime, when there was a strong North American business presence on the Atlantic Coast, the region (now known as the North Atlantic Autonomous Region) boasted of the finest medical facilities in all of Nicaragua. Through the 1960´s up to 1980, the hospital in Bilwaskarma (near the town of Waspan on the northern border) saw patients from Managua and the Pacific Coast in order to give treatment, surgery, etc. This hospital was also a teaching hospital and became a center for developing occidental medicine in Nicaragua, especially the Atlantic Coast. However, with the removal of Somoza from power, all North American business presence evacuated, and the hospital lost funding, and, therefore, quickly lost its status as a center for medicine in Nicaragua. And while the presence of the Sandinistas brought a significant increase in the attention of healthcare for the more rural and impoverished population of Nicaragua and the Atlantic Coast, they could not fill the void on the Atlantic Coast left by the absence of a highly-rated medical facility. It is in light of this history and the struggle for the development of the Autonomous Region that institutions like URACCAN, IMTRADEK, as well as MINSA, private clinics, public clinics, and NGO´s, like Bridges to Community, address the critical healthcare needs of the North Atlantic Autonomous Region of Nicaragua. A description of the current Bridges medical program in Bilwi Bridges to Community has not taken an initiative to systemically address healthcare concerns in Bilwi. Over the past two years, all efforts by Bridges to Community with regard to healthcare in Bilwi have been in response to meeting the demand of medical institutions in the United States seeking a ¨service-oriented educational experience¨ for medical students. In such time, there have been four ¨medical groups¨ facilitated by Bridges in Bilwi: 2 groups from Washington Medical School in St. Louis (one each in 2002 and 2003), and 2 groups from Indiana University Medical School, also in 2002 and 2003 . Thus, what follows is a description of the ¨experiences¨ provided by Bridges in Bilwi for each group in the year 2003. In the year 2003, Bridges coordinated with IMTRADEK and Clinica Bilwi. Clinica Bilwi is a private clinic that has close relations with IMTRADEK; it operates in four barrios (of 24) within Bilwi, as well as the nearby communities of Kamla and Tuapi. Clinica Bilwi is organized and administrated by Alta Hooker, rectora of URACCAN, and is staffed by four nurses (one for each barrio), a head nurse, Kerry Lamphson, who also coordinates the work of IMTRADEK, and other staff persons. It has two examining rooms, a pharmacy, and a newly developed maternity house for women from the communities in their later stages of pregnancy. Clinica Bilwi also has close relations with the AIDS Commission and the Drug Commission (operated by Jose Hooker, husband of Alta Hooker). The programs planned for the medical groups from Washington University and Indiana University consisted of three parts: 1) participation in the clinical work of the Clinica Bilwi; 2) participation in public health projects (construction of latrines and safe wells) in Barrio Cocal (one of the four barrios in which Clinica Bilwi operates, and considered to be the most impoverished and drug infested barrio in Bilwi); and, 3) introduction to the dialogue between occidental medicine and traditional medicine, as well as the development of the Autonomous Region. The medical groups from both Washington University and Indiana University consisted of about 12 medical students (all first and second year). Each was accompanied by a Medical Doctor from outside of the respective institutions. Washington University was accompanied by Dr. Robert Greenberg of Dartmouth University; Indiana University was accompanied by Dr. Stephen Kelly, practitioner in Westchester County. With this in consideration, the ¨service-oriented educational experience¨ for each group looked as follows: GENERIC ITINERARY Day 1: 5:00 p.m. Arrive in Bilwi
Day 2: 7:00 a.m. Breakfast
Work Team II goes with Jed Koball and other Bridges local hired staff and volunteers to work on a public health project in Barrio Cocal. The project is either building latrines (typically 5 for one week), or digging and/or fixing wells. 12:00 p.m. Break for Lunch
Day 3 7:00 a.m. Breakfast
Day 4 7:00 a.m. Breakfast
Day 5 7:00 a.m. Breakfast
Work Team II goes with Jed Koball and the Doctor to the prison for a general clinic for prisoners. (This has not been done before, but the possibility exists. Also, an experience at the prison will further address the overwhelming problem of narcotics in Bilwi. Guaranteed to be a fascinating experience and will meet a great need as well - conditions at prison are atrocious.) 12:00 p.m. Break for Lunch
Day 6 7:00 a.m. Breakfast
Day 7 7:00 a.m. Breakfast
Day 8 6:00 a.m. Breakfast
Day 9 8:00 a.m. Breakfast
An assessment of Bridges Medical Program in Bilwi An evaluation of the Medical Program offered by Bridges to Community in relation with Clinca Bilwi, IMTRADEK and the Medical Schools of Washington University and Indiana University is based on conversation with Kerry Lamphson, head nurse of Clinca Bilwi and administrator of IMTRADEK, Doctors Stephen Kelly and Robert Greenberg, and student participants from both Washington University and the University of Indiana. REWARDING ASPECTS of the BRIDGES MEDICAL PROGRAM in BILWI: With regard to the work of Clinica Bilwi The Clinica Bilwi, under the leadership of Kerry Lamphson, has not only been incredibly accommodating to the needs of Bridges brigades, but has also provided a very professional and extremely adept staff and environment to work within. Both Kerry and the nurses showed great flexibility in working with the doctors and the medical students, and ultimately created a positive learning experience for the medical students. The relationship between Clinica Bilwi and Bridges is good and has the potential to grow stronger. The work accomplished during the two medical brigades of 2003 contributed significantly to the work of Clinica Bilwi - especially the public health projects. During the two brigades, five latrines were constructed and eleven wells were dug, constructed and/or repaired. This work would not have been done without the Bridges brigades. Likewise, the clinical visits allowed for a significant number of patients to receive medication that they would not have received otherwise. With regard to the work of IMTRADEK IMTRADEK plays a key role
for Bridges in providing an educational experience that opens the eyes
of medical students, not only to the place and role of traditional medicine
in a significant population of the world, but also to create awareness
of the vast discrepancy of health care between first and third world environments.
And, to that end, IMTRADEK helps to draw connections (and subsequently
responsibilities in responding to such connections) between North America
and Nicaragua (and the vast majority of the world).
With regard to the ¨service-oriented educational experience¨ Again, the Clinica Bilwi and IMTRADEK, along with the conversations with Dr. Myrna Cunningham and the traditional healer, Priscilla, as well as meetings with the AIDS Commission, the Drug Commission, the Prison, and walking tours of the hospital, and Bilwi in general provide excellent contexts and material in which to discuss the economic disparities and the implicit connections (historical, political and other) between the U.S. and Nicaragua and subsequently the dramatic differences and approaches in medical care. Furthermore, reflection sessions address the responsibility and the need of North Americans to confront these matters (particularly the economic disparity, political connectedness, and cultural imperialism) through their vocations in the context of the U.S. with respect to the larger world. With regard to the overall work of Bridges in Bilwi The concentration of Bridges work in Bilwi is Project Esperanza - a multi-purpose community center that evolved out of a partnership between the Hudson River Presbytery of New York and the Central District of the Moravian Church based in Bilwi. The partnership is facilitated by Bridges to Community, and is the primary purpose for staffing a Bridges person in Bilwi. The medical brigades are able to use the facilities of Esperanza as needed. Likewise, many of the local volunteers who assist with Project Esperanza groups, also work with the medical brigades and are thereby introduced to some critical concerns and issues in their own community. Ultimately, the medical brigades open the eyes of people involved in Project Esperanza to the potential for further community work. Furthermore, by using Esperanza people to help with the medical brigades, the name of Esperanza is brought to a larger number of people in the community (as is the name Bridges). CHALLENGING ASPECTS of the BRIDGES MEDICAL PROGRAM in BILWI: With regard to the work of Clinica Bilwi The public health projects, while serving a great need and providing good experience and interaction for the medical students, presented several challenges. The work is done in an area (Barrio Cocal) that Bridges has no relationship with. While the Clinica Bilwi has established itself as a positive presence in the Barrio, Bridges is unknown. Therefore, when we enter the community with materials and a construction project, we enter as an unknown entity. Tension with the community has occurred on a couple of occasions because of this. Related to this, there is a lack of willingness on the part of the community to work side by side with the Bridges brigades. The only Nicaraguans working with the med students are the Esperanza volunteers, contracted workers and occasionally Clinica Bilwi staff. Also, the projects (latrines and wells) while rather simple, are not an ongoing project that Bridges does, so there is a lot of experimentation and trial and error with each group. It does not allow for a smooth flowing process that helps to give us more credibility as a community development organization. The clinics are generally
a positive experience as well, however there are still challenges
related to the presence of North American doctors and the distribution
of medicines. The Clinica Bilwi has its own doctors (not full time) who
will see patients as needed (although they cannot hold clinics in the manner
that a Bridges brigade can). There may be a question if the presence of
the North American doctor and medical students undermine the authority
of the Nicaraguan doctors (although, the Clinica Bilwi insists this is
not the case). Furthermore, the distribution of medicines is somewhat questionable
on two levels: one, most of the medication distributed is for temporary
pain relief (aspirin); two, there are traditional medicines that are believed
to serve the same purpose. While many of the patients do believe in traditional
medicine, they have also learned about western medicines that may be stronger
and so they line up simply wanting a few days of pain relief. The question
is whether that is how Bridges wants to use its resources (to relieve pain
for a few days, while there are also traditional medicines that may serve
the same purpose).
With regard to the work of IMTRADEK While the experience with IMTRADEK has been positive, informative and consciencitizing, it has lacked the presence of the voice of occidental doctors in Nicaragua who are engaged in the dialogues between occidental medicine and traditional medicine. Certainly, there will be skepticism from the perspective of those from a culture of occidental medicine; however, the presence of an occidental doctor who has respect for the traditional medicine may further help North American doctors, med students and Bridges to better understand how Bridges brigades can interplay with the traditional medicine. With regard to the ¨service-oriented educational experience¨ This is the strength of the Bridges medical program in Bilwi. The service aspect can be enhanced by finding a project that fits within a program that systemically address health care in Bilwi With regard to the overall work of Bridges in Bilwi Perhaps the greatest challenge of a Bridges medical program in Bilwi is with regard to its relation to the other work of Bridges in Bilwi. As mentioned earlier, the primary focus of Bridges work in Bilwi (to date) is Project Esperanza. The medical programs have very little to do with Esperanza. While this in and of itself is not a problem, it does make certain aspects of the medical program challenging when Bridges is only relating with medical issues two times a year (for example, the construction projects in Barrio Cocal). Likewise, it is difficult to maintain relations with Clinica Bilwi and IMTRADEK when Bridges is only working with them for two weeks out of the year. While the programs have run smoothly, they can be enhanced greatly (as can the work of Esperanza in relation with Bridges) if there is an integrated project that incorporates the work of Esperanza and a comprehensive medical program that maintains an ongoing relationship with Clinica Bilwi and other institutions vital to healthcare in Bilwi and the surrounding communities. A project proposal for the year 2005 The following proposal for a Bridges project in Bilwi (to commence in January of 2005) addresses the status of healthcare, the nature of health concerns, and the challenges of the current Bridges medical program in Bilwi (including the desire to integrate a medical program with the work of Project Esperanza). The OIKOS Housing Project
Introduction Purpose: to address the housing, healthcare, economic, and social concerns of single mother families with little or no employment opportunities or income. Participants: Bridges to Community, Project Esperanza, Clinica Bilwi, URACCAN, CIUM-BICU (Moravian University in Bilwi), and others (both Nicaraguan and North American, NGO and government as they feel called and/or are invited to participate) Concept: to create secure, safe and sanitary housing compounds in the neighboring communities of Kamla, Tuapi and Lamlaya, and to provide education and skills development for women and their children in areas of public health, nutrition, gardening, community living, women`s rights, as well as baking, sewing, and computer literacy. Further history, rationale, detailed concept, and timeline of the OIKOS Housing Project The vision of the OIKOS Housing Project for single mother families originated with Anecia Matemoros, President of the Board of Directors of Project Esperanza. It is her dream to fulfill the work and the intention of Project Esperanza to address the needs of women and youth in Bilwi and the surrounding communities. History and Vision of Project Esperanza Project Esperanza is a multi-purpose community center and recreational complex that evolved out of a partnership between the Hudson River Presbytery of New York and the Central District of the Moravian Church of Nicaragua, based in Bilwi. This partnership and the creation and work of Project Esperanza is facilitated by Bridges to Community. The project's purpose is to address critical needs of women and youth in Bilwi (many of which are referred to in the above section on ¨the status of healthcare and the nature of health concerns in Bilwi) by creating a safe place for youth to recreate, congregate and grow through the hosting of regular activities that meet the interests of diverse youth (including activities in sports, music, arts, drama, etc.); by enhancing educational opportunities available in the region, through offering computer training, a volunteer tutoring program, skills training in baking and sewing, a scholarship program for high school and university, as well as participation in school renovation projects; by training future leaders in the church and society through creative workshops and programs that address the needs and challenges of youth and young adults in the region, continuing to participate in the exchange of youth and adults from the Hudson River Presbytery and Bilwi, and by establishing an environment of volunteerism and service-oriented participation in the community to learn of the needs of the region and how to creatively address them; and by participating in the transformation of a divided, war-torn and impoverished region through offering its facilities for workshops, programs, presentations, etc. that participate in the re-creation of the Autonomous Region of the Atlantic North, and by modeling a community of equality, reconciliation and hope through the leadership and governance of the project. Currently, Project Esperanza is nearing the end of Phase II of a projected four phase process. Phase I - 1997 -- 1999. Initiating contact and establishing a relationship between the Hudson River Presbytery and the Central District of the Moravian Church. Facilitated by Bridges to Community. PhaseII - 1999 -- present. Agreeing upon the project, and constructing a fully operational community center. Upon completion of the building, it is to be self-sustaining within a three year period through the revenues of a bakery, sewing center, snack bar, rental space of an auditorium, computer classes in the library, and a cinder-block making factory. The building has been funded by the Hudson River Presbytery and Bridges to Community, and it was built with the volunteer support of church groups from Hudson River Presbytery and volunteer and employed workers from Puerto Cabezas, all facilitated by Bridges to Community. To date, the building is 98% complete with only electrical repairs needed to enable its full operational capability. However, the sports complex (a soccer field, running track and softball field have not yet been constructed - do to lack of funding). The goal is to have the building fully operational by the end of the 2003 calendar year. Phase III - 2004 - 2005. ¨Serving to Learn; Learning to Serve.¨ This phase of the project entails the start-up of all operations within Esperanza including learning opportunities for the community: the bakery, the sewing center, the library and computer classes. Also, this phase will initiate the Esperanza School Outreach Project which will provide tuition scholarships for high school education, as well as school building rehabilitation projects. In this effort, individual churches, Sunday School Classes, Youth Groups, Adult Ed groups, etc. within the Hudson River Presbytery or a particular church (as part of the partnership) may pledge to provide one or any number of scholarships for one year or longer ($125/year for one student - students will be selected by Esperanza leadership based primarily on need, as well as the desire of the student to study). Or, a church may choose to sponsor the rehabilitation of a school building within Puerto Cabezas. Such a pledge would also initiate a relationship between the church/ group and the individual student or school that is receiving the support (Esperanza would facilitate this relationship via e-mail and regular mail). Furthermore, this phase will also see the continued development of an Esperanza Youth Activities Group (a leadership development initiative). This group will be comprised of any youth in Puerto Cabezas seeking to be a part of Esperanza, but most especially and certainly all scholarship recipients. Participation in this group will make one eligible for possible future exchange opportunities to New York (in cooperation with the Silver Bay youth conference and the Hudson River Presbytery and participating churches). Young people involved in this program will work in cooperation with a Youth Activities Coordinator; they will plan recreational activities for youth and the community, and they will participate voluntarily in the project work of Bridges to Community and Esperanza (including the school rehabilitation projects and other efforts). Phase IV - 2005 - indefinite. This phase of the project will see the continued work of Phase III including the development of a volunteer tutoring program and an internship program to further enhance educational opportunities for youth in Bilwi. Also, this phase will initiate the OIKOS Housing Project. Furthermore, this phase will provide opportunities for organizations and entities outside of the Hudson River Presbytery and the Central District of the Moravian Church to become involved in the work of Project Esperanza, facilitated by Bridges to Community. Rationale for the OIKOS Housing Project The OIKOS Housing Project not only fits within the vision and goals of Project Esperanza but it provides a project that allows Bridges to integrate its work in health care, education and housing. As referred to in the above section on ¨the status of healthcare and the nature of health concerns in Bilwi¨ the growing population of single mothers with little or no income nor employment opportunities is a critical concern that is directly related to the high-infant mortality rates and malnourishment. Also there is a direct correlation to overcrowded housing and unsanitary living conditions, such as exist in Barrio Cocal, wherein 15-20 people live in one household with few latrines and shallow wells that are unprotected from human and animal waste. Furthermore, it can be argued that the economic instability of such families and the subsequent lack of educational opportunities contributes to the high rates of drug and alcohol abuse, the spread of sexually transmitted diseases, the repeated cycle of planned and unplanned teenage pregnancy, and, ultimately, the continuation of economic instability from one generation to the next. As the population of Bilwi continues to grow, and as the unemployment rate of 90+% will likely not change dramatically in the near future, it is incumbent upon us to address matters of housing, healthcare, and economic instability with respect to the growing number of single mother families. A more detailed concept of the Housing Project: Through Project Esperanza, single mothers in dire need of economic support (and other) will be made aware of the Housing Project. A group of three to five mothers and their families will work with Esperanza in organizing themselves into a cooperative body of families to occupy one housing compound. Each housing compound will consist of three to five houses. The houses will be half concrete block and half wood, roughly eighteen by twenty feet in space. The houses will be situated around a common well. The well will be approximately 15-20 feet deep, lined with concrete, capped and sealed, and fixed with a hand crank pump. Behind the houses will be a four stall, concrete block latrine. The latrine will be built such that it can be used to turn the waste into fertilizer. (Plans for each of these constructions can be provided upon request). The total cost of materials for three houses, one well and one latrine is approximately $10,000. The additional costs of hired labor and acquisition of land, could place the cost of one three house compound in the neighborhood of $11,000 - $12,000 (A budget can be provided upon request). The land for each compound will be acquired from the nearby communities of Kamla, Tuapi and Lamlaya. Available and un-crowded space within the limits of Bilwi is difficult to find and obtain, and as the population continues to grow it will only become more difficult; thus, it is important to begin looking outside of Bilwi and into the neighboring communities where land is more available and where the distance from Bilwi is not a critical concern. It is important to note that this housing project differs significantly from the Bridges housing projects in Masaya and Ticuantepe. First, this housing project is not about relieving one family from poverty housing by constructing a new house for that family in the same location within one community; rather, this housing project is about relieving a family of a particular demographic from an over-crowded and unsanitary housing situation and providing adequate, secure and sanitary housing in a different location. Second, this housing project does not occur within one community, wherein the community must organize itself and determine who will receive houses in what order; rather, this housing project is about bringing together particular families to organize themselves and live together in one compound. In some respect this different approach to a housing project raises obvious concerns and questions about community living, relocation, safety, etc. Addressing these issues, as well as economic stability and health care, Bridges and Esperanza will work in coordination with Clinica Bilwi, URACCAN, CIUM-BICU and other government and non-government organizations to help address the critical needs of the families. Upon beginning the process of organizing themselves to live in a compound, the mothers and their families will be invited to (or perhaps required) to participate in workshops at Esperanza (sponsored by organizations like Clinica Bilwi, URACCAN and CIUM-BICU) with regard to community living, public health, and nutrition. Also, each mother will be invited to participate in free classes in baking, sewing and/or computer literacy at Esperanza. Furthermore, their children will qualify for scholarships to go to school (as funds are available through the Esperanza School Outreach project), and they will be invited/encouraged to participate in the Youth Activities Group of Esperanza. Also, as the project evolves, free workshops will be offered in women`s rights, multi-culturalism, gardening, traditional medicines, small business cooperatives (in case a compound wants to form a sewing or baking cooperative), and other relative and pertinent issues and concerns. And, regarding healthcare, because the compounds will be located in the communities of Kamla and Tuapi, Clinica Bilwi will have an ongoing relationship with these families. A flexible timeline for the OIKOS Housing Project September 2003 - create proposal for Housing Project and present to Bridges to Community October 2003 - meet individually with community leaders of Bilwi and surrounding communities (including: mayor of Bilwi, vice mayor of Bilwi, rector and vice rector of URACCAN, rector and vice rector of CIUM-BICU, Myrna Cunningham, regional counsel members, representatives of Tuapi, Kamla and Lamlaya, others) November 2003 - host gathering of community leaders to present and discuss in full the Housing Project December 2003 - further discuss Housing Project proposal with Bridges in New York January 2004 -- begin process of organizing women and families July - November 2004 - construct first ¨model¨ compound (without groups) December 2004 - first families move into compound (in time for Christmas) January - April 2005 - construct second compound with groups (including med groups who will build well and latrine). Process of organizing families and offering workshops, etc. is ongoing. May 2005 - second group of families move into compound (in time for Mother's Day) July - November 2005 - build third compound December 2005 - third group of families move into
compound (in time for Christmas)
The OIKOS Housing Project allows Bridges to Community to integrate its work in education (with Project Esperanza), its work in healthcare (with brigades of medical students in partnership with Clinica Bilwi), and its work in housing (which has been successful in Masaya and Ticuantepe). Integrating these aspects of Bridges into one project provides not only for a more comprehensive service to the community and a broader educational experience for the volunteers, but it also utilizes the resources and skills of Bridges staff and volunteers and community leaders and volunteers more efficiently. Likewise, such a project enables Bridges to tailor an experience for a group of volunteers in order to better bring critical issues to their attention. In other words, through the same project, we can create a framework of an experience for a medical group, a college group, a church group, a business, etc. that allows for each group to understand and interpret the issues through the lenses of their various vocations or sector of society. Relative to Bridges Medical Brigades, a week long program would have the following components: Group Project: construction (from beginning to end)
of one concrete well and/or one cinder-block latrine in a housing
compound. (Note: the amount of time that a medical group spends on a
construction project is significantly less than an ordinary group, due
to the amount of time spent doing clinical work - therefore,
the group project is of a smaller magnitude).
Other remarks regarding a Comprehensive Medical program in Nicaragua Most of the remarks that follow are personal reflections on a philosophy for a Bridges to Community Comprehensive Medical program. Obviously, these reflections do not come from a medically trained perspective, solely limited experience in working with medical brigades and interacting with the network of healthcare professionals in Bilwi. My basic premises for a Bridges to Community Comprehensive Medical program are: 1. Bridges has distinct skills, gifts and resources
There are a plethora of needs that Bridges can address. There are limited resources, gifts and skills that we can offer. It is true that we must first listen to the voice of Nicaragua to discern what the needs are; we are in no position to dictate what the proper course of action should be to systemically better healthcare in Nicaragua. However, we are in a position to say that there are certain needs that fall outside of our immediate capacity to address. And, furthermore, we do possess particular knowledge and experience that can be offered to the conversation of how to systemically address healthcare in Nicaragua (and the world). For example: medicine. Yes, there is a desperate need for more and affordable medications (occidental). I agree that there is a philosophical question regarding whether or not we should be dispersing handfuls of aspirin to temporarily relieve chronic pain. I also acknowledge that the Clinica Bilwi (despite its efforts to work with traditional medicine) would be more than grateful for a large supply of aspirin (as would the hospital, the public clinic, etc.). However, I question if it is the best use of Bridges resources, gifts and skills to expend energy supplying clinics and pharmacies with as much aspirin (or any other kind of medicine) as possible. Case in point: During the 2003 Washington Medical School brigade (accompanied by Dr. Stephen Kelly) to Bilwi, the Clinica Bilwi informed us of a young man (24 years of age) who was in a serious health condition. Dr. Kelly went with Clinica Bilwi staff to the young man's home where they found him chained to a bed (braces around his ankles and wrists attached to the posts of the bed, as well as a chain around his neck attached to another chain that ran the course of the bed - seriously, this is almost of Biblical proportions, Mark 5:1-20). He had been chained to the bed for ten years, since the age of 14. He had been using crack cocaine in his early teenage years, and apparently it induced a state of paranoid schizophrenia. The family consulted with various doctors, traditional healers, and clinics who could do nothing for him. His behavior became very violent, and so they had no alternative but to confine him to a bed in order to prevent him from violently attacking (and potentially killing) members of the family. After ten years of confinement he had become relatively unresponsive to human interaction. Upon showing the young man to Dr. Kelly, the Clinica Bilwi asked his assistance in obtaining any kind of medication that may improve the young man's condition. In a very conscientious response, Dr. Kelly sent to me a package of Zyprexa (Olanzapine) tablets, which I was finally able to give to the Clinica Bilwi in late July. As of early September, the Clinica Bilwi reported to me that the medication was having a very positive effect - that the young man was less violent, was sleeping and resting better and was more responsive to human interaction (and the family had never felt better nor been so optimistic in over a decade); however, they believe he needs a stronger dose than is prescribed, and of course a long-term supply. The question before Bridges now is whether we can supply a medication like Zyprexa for long-term period (potentially a life-long supply -- obviously this is an extreme case).While we have entered into this particular relationship, which I believe puts a certain amount of responsibility upon us to respond, I am not sure this is the kind of relationship we want or are able to establish with Clinics, Hospitals, etc. This is not to disregard the need for medicines, rather it is to turn our attention to a different strength of Bridges - our growing network of relations, primarily through the volunteers and institutions we bring to Nicaragua. While addressing the critical need of a lack of affordable medications may not be an issue that Bridges in and of itself can adequately respond to, it may be likely that a group of volunteers or a particular institution that has traveled with Bridges may seek to take that on as its own project (which Bridges could help to facilitate) - for example, it would be wonderful if the practice of Dr. Kelly would want to take it upon themselves to provide a life-long supply of Zyprexa for the young man in question above. Furthermore, we know that the lack of affordable medications is not merely a question of charitable giving, it is also a political and economic question. These are questions that Bridges addresses with groups while they are in Nicaragua. Now, with the first Fall conference in September of 2003, these are questions that can be addressed and discussed in more depth beyond the Nicaragua experience. Simply brainstorming, it could be that a group of volunteers (after a Bridges trip, or in response to a Bridges stateside conference) seeks to take on affordable medication as an issue to address on a larger scale, stateside. Such an initiative could lead to a cooperative effort with a group like ¨Doctors without Borders¨ or ¨Kids for World Health¨ (based in Larchmont). At this point, we are likely talking about medications other than aspirin, rather medicines for AIDS, and other deadly epidemics. Likewise, such a conference could spur conversation stateside about indigenous and cultural rights to develop a traditional healthcare system. The possible initiatives that could develop off of and outside of Bridges (in response to Bridges work) are endless. I believe it is important that Bridges keeps within itself - that we acknowledge what our strengths are, and utilize the gifts and resources we have. Networking and consciencitizing are definite strengths of Bridges. Another distinct strength of Bridges is the ability to develop community projects - for example, housing in Masaya and Ticuantepe. These projects meet concrete needs of the people. We can continue to do such projects that incorporate issues of healthcare; I like to think that the OIKOS Housing Project proposal would be such an initiative. Therefore, what makes a Bridges Medical Program in Nicaragua ¨Comprehensive¨? I believe first and foremost, a medical program is comprehensive when it begins by listening to the voices of Nicaragua and assessing the broad scope of health concerns. Such concerns may range from chronic pain, maternal care, child malnourishment, parasites, malaria, dengue, to drug abuse, sexually transmitted diseases, to mental disorders, to basic public health concerns such as clean drinking water. The scope of health concerns are broad, as are the various systemic issues that create and/or perpetuate such concerns - from economic and political and cultural to familial, genetic and personal. I believe Bridges is very good in assessing all of this in a manner that is sensitive to the culture and context in which we work. But, a comprehensive medical program is about more than identifying and assessing the issues, it is also about responding. Again, I believe how we respond must be faithful to who we are as an organization (the gifts, skills and resources we possess, the limitations we face, and the network of relations that we are a part of). We are good at community projects - housing and public health. We are good at educating and consciencitizing volunteers on the broad scope of concerns and issues that the people face. We are good at working with Nicaraguan organizations who are already addressing such concerns. We are good at opening ourselves to new and challenging ideas (such as traditional medicine). I believe we can become better at all of these and more if we do the following (in the near or distant future) with regard to a Bridges Medical Program: 1. Hire a Nicaraguan Healthcare
worker (a general practitioner or pediatrician) to work with the healthcare
workers already present and active in the communities in which Bridges
is active. This person would be accountable to Bridges to inform and educate
us on the approaches to healthcare being taken in the communities and the
needs we can address. Likewise, such a person would provide additional
support to the healthcare workers already present. (He or she would not
take a supervisory role to their work).
To conclude, I think Bridges is on the right path in terms of addressing health care in the communities in which we are involved - particularly in the North Atlantic Autonomous Region. Likewise, I feel a good strategy is to be true to ourselves, recognize what we do well, and continue doing it even better. It may be simple and trite, but that's about all I have to add to the conversation. Very humbly submitted, Jed Koball.
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