[Leah Gordon]
During the month of July, I had the pleasure of acting as project coordinator for UNC’s Collaborative Sahsa Health Initiative (CSHI) in rural Nicaragua. A combination of grants allowed UNC students from the medical school, nursing school and school of public health to perform a month of fieldwork in Tasba Pri, one of Latin America’s most isolated and marginalized regions.
CSHI group 2009
We collaborated with both University of Nicaragua-León medical students and local community members to collect demographic and health data from households throughout the region. The results will be used to establish an epidemiological surveillance system, create badly needed maps of the region, and help design future interventions.
After a punishing 27-hour bus ride, the 11 UNC students, one Duke pediatrics resident and I arrived in Sahsa, the region’s capital which served as our base of operations. Known as “the Africa of Central America,” Tasba Pri is severely underdeveloped when compared to the rest of Nicaragua, which is already the second poorest country in Latin America. It has been historically neglected by the national government and surprisingly little is known about the people who live there.
In an effort to fill that knowledge gap we spent the next three and a half weeks interviewing women from 28 randomly selected communities about water quality, diarrhea, family planning, prenatal care, and vaccinations.
After ten months of living and working in Nicaragua I was fairly confident that I had seen the extent of the country’s poverty, but the deprivation in Tasba Pri is of a different breed. I was surprised by the lack of begging children or homeless families that I’ve grown accustomed to seeing in the streets of Managua.
The region’s poverty stems from its almost complete isolation. While every child is fed and housed, there is a lack of even the most basic medicines and barely any roads to make the journey to the hospital, over 5 hours away. There is no potable water, no phones and electricity is scarce. A single clinic in Sahsa serves the entire region and the smaller, understaffed health posts are few and far between.
From left: Omar Awan (UNC), Leah Gordon, and Adonis (community guide)
The UNC students and I split our time between helping in the clinic and our interviews in the field. Along with the dedicated community members acting as our guides and Nicaraguan medical students helping us with the language barrier, we traveled to remote communities by truck, boat, borrowed horses and of course on foot. Many of our interviews were just an hour’s drive from Sahsa, but some of the most inaccessible communities were almost a day’s journey away. In these cases we would sleep in families’ houses and on church pews, eat in their homes and get a chance to talk more intimately about their lives.
Students interview a woman at her home, accompanied by Santiago, a community guide
It opened up a dialogue that was not bound by our survey questions and allowed us to really get a sense of the needs within their community. It also forced us to confront the limitations of the project. We came to them with pens and surveys when what they really needed were water filters, latrines, medicines and doctors.
Setting up a yearly surveillance system will go a long way to helping the clinic in Sahsa better serve the region’s needs. However, in some communities a trip to Sahsa is an impossibility even for the sickest children. The barriers to care run deeper than the enormous cost, the inaccessible transportation, and the nonexistent or flooded roads. I met a woman with three dying children who declined our offer to take her to the clinic. Many of the people we talked to have never stepped foot outside their community. Others had heard horror stories of poor treatment by doctors or traveling all that way just to be turned away at the clinic doors. Even after we had arranged for transportation, food and accommodations for her children, this woman was too scared to make the journey.
These experiences gave us a chance to think in a broader way about what the needs are in these communities and what we can bring to the table. In the end this was the most valuable part of CSHI. One of the UNC medical students was fond of saying, “We are not simply cogs in a well-oiled machine.”
The project is only in its second year of existence so we were actively involved in not just applying the instrument, but designing the survey and planning the fieldwork. There were many kinks to work out, problems to solve, and logistics to organize. Working together with University of Nicaragua and clinic staff, we initiated contact and forged relationships with the community health leaders. We engaged our community member guides and empowered them to take ownership of the survey.
Leah debriefing the team
And now, after all our experience on the ground, we are in an excellent position to make recommendations for improving the project and refining CSHI’s goals. Overall, it was exhilarating to be both profoundly touched by our experience with the project, while also having a hand in its future.
- Leah
Students and community members play basketball after a hard day's work