This is basically a summary of what Ive learned over the last 6 months, in terms of health in my community. Names of towns changed to letters A through I.
Community Health Assessment: A
I live in a douar called A, located in the Eastern High Atlas Mountains. We are located about 70 km South of Boumia and 30 km South of our souq town, Tounfite. We are a small community with a population of approximately 450 people.
The A Commune covers seven other douars: C, B, E, F, D, G, and H. I have also been working in I, which is part of the Anemzi Commune. The combined population of the Commune is approximately 4,500 people. A and B are the most centrally located douars. The other douars are anywhere from 7 to 28 km away from A, with G being the furthest. There is a road passable by cars available most of the time to all douars except H.
The region is primarily an agricultural community. Wheat is the primary crop, although barley, corn, potatoes and some vegetables are also grown. Donkeys and mules are critical to agricultural production. Most families own cows, chickens, and turkeys for milk, eggs, and meat. However, nearly all agricultural production is sustenance farming – little produce is sold outside of the community. Herding sheep and goats is the primary source of income for the community. Flocks range in size from 5 to hundreds of animals. Men often spend several weeks at a time in the mountains, tending their flocks. Tourism and artisan work bring in a modest amount of money to select community members. A few community members work at the Commune. Other work by community members is mostly done outside of the community: construction work in bigger cities, conscription in the military, etc. The Commune has a 90% illiteracy rate. Students that continue their education in the college in Tounfite all fail out because they are poorly prepared.
A and B (only 1.5 km apart) are the best off of all the douars. They are closest to Tounfite and have the most consistent transport. There is a sbitar located in A that is well staffed and reasonably well run. Some douars, especially I, G, and H are very isolated and lack access to reasonably close sbitar. There is another sbitar in F that serves F and E. D is 8 km away from that sbitar, which means that people from D rarely make it to the sbitar. Likewise for C, which is served by the A sbitar, 7 km away.
The bulk of my community assessment involved talking to many different community members in a variety of settings. In A and B, it is much easier for me to have casual conversations with people about the health situation in our community. Sitting and talking with people about our community in informal situations was extremely helpful. Additionally, I had more formal assessment conversations with key community members, such as the nurses, association leaders, and Commune members.
In the outer douars, it is more difficult for me to have casual conversations with people as I do not have the same level of acceptance in those communities. For some douars, such as G, I was connected to important community members through people in A. Having established the contact, I was able to meet and discuss my work. In other douars my strategy was a little more haphazard. I would walk into the douar and ask to talk to the moqadem. We would sit and have tea and have basic conversation. I would generally try and wait until my second visit to introduce the topic of health in his community. I also have made it a point to try and meet as many teachers as I am able to. I am still trying to establish contact with association leaders in many douars.
In addition to communication with community members, observation has clearly played a large part in my community needs assessment. Many problems are obvious to the naked eye and become more apparent the better I get to know people. I have tried to identify as many water sources as possible, how they are used, and how the sanitation surrounding them is.
The biggest hole in my methodology is my lack of communication with local women. Having my host mom has helped somewhat, but I am largely ignorant of health problems specific to women.
While there are different needs in each individual douar, for the most part, there are many overlapping problems.
• General Attitude Towards Health – As a health worker in this community, I will face some resistance towards my attempts to improve the community’s health. Generally speaking, health is not a top priority for people in my villages. For example, when given a prescription for medicine that they will have to pay for, people most often do not get the medicine. Even families who can afford the thirty dirhams that the medicine costs might choose to spend it on something else. In I, doctors came for a day and did checkups on all school aged children. Those children with problems that required further attention from a doctor were given a slip of paper instructing their parents to take them to the clinic in Tounfite. I believe that no parents took their children to the clinic; they had little interest in even understanding what their child’s problem was. It is my observation that the reluctance to use resources to treat illness is even greater if the sick person is a woman. Their health is not highly valued in the community; changes that require even small resource investment may be difficult to implement. Unfortunately, many health complaints of women are the result of their difficult, work-filled lives. Solving many of their health problems would necessitate wholesale lifestyle changes.
• Understanding of Modern Medicine – People have a poor understanding of how modern medicine works. When someone is sick or injured, pills, of any kind, are seen as the cure all. A good example is when I met with a man from my community at the pharmacy in Tounfite. His child had a severely swollen ankle and he asked me to help him buy some medicine to help. I told the pharmacist about the ankle and we got some anti-inflammatory pills; I thought that the issue was resolved. To my dismay when I went to the house to see how the child was doing, I found that the father had bought several other medicines, none of which would affect the child’s ankle. The child had been taking all of the medicines except the anti-inflammatory, which had been lost.
• Water – A and B are the only douars with running tap water in houses. There is a chateau that is filled by pumped water from a well. The water in the chateau is treated with chlorine. However, the nurses and teachers at the school have doubts about its potability. I would like to do an analysis of the water’s potability. Despite the presence of tap water, people often drink water from springs and wells, which I believe may be a cause of illness. Members from the local water association approached me about doing work on the water system. The pipes that run from the chateau are old and filled with sediment. They need replacing. The pump that fills the chateau uses lots of electricity and is expensive. The association would like to capture water from a nearby spring in order to reduce the amount spent on electricity. It seems to me that the infrastructure for doing so is already largely in place. Some douars, such as H, have public fountains fed by spring water. In the other douars, water is gathered from springs, wells, and streams. This is a certainly a cause of health problems. The nurse in F told me that he believes that many illnesses are related to poor drinking water there. In some douars, the infrastructure (chateau, pipes, etc.) is already in place for running water, but the community cannot afford to pay the electricity for the well pump. Given that the region is full of mountain springs, it seems that restoring running water may not be a costly project.
• Dental Hygiene – It is clear from observation that dental hygiene is an issue in my community.
• Vaccination – This issue is variable from douar to douar. In A and B, I feel fairly confident that nearly all children are vaccinated. The nurses are organized and there is a regular vaccination that is well attended. For douars such as H, D, G, C, and I, the distance to the sbitar makes vaccination occur much less often. The nurses have spoken of an equipe mobile, but I haven’t seen it during my five months here.
• Nutrition – Nutrition is a large problem in my community, from my observation. Diet is unvaried, consisting primarily of bread, tea, potatoes, carrots, meat, onions, and tomatoes. The vegetables that are available are invariably overcooked. Nutrition for infants and young children is especially a concern. Additionally, women’s diets are often even less varied than men’s. Hypertension is common, presumably from diets high in salt. Knowledge about the need for a diverse diet is either completely lacking or very basic. Related to the issue of nutrition is the high prevalence of goiters. Several people have approached me and asked me if I know of medicine for goiters.
• Birthing Practices – Given the lack of access to a birthing center (Tounfite is the closest), most births occur in the home. Although there are no statistics available at the commune, I believe that infant and maternal mortality is a problem. A man from G told me that both his sister and mother have died in childbirth. Having spoken with two women about how they assist in birthing, I worry about the safety of home births. The problem is even greater for the more isolated douars, such as I, H, and G. Additionally, my female nurse reports that many women fail to seek pre or post natal care in the sbitar.
• Trash Disposal – Trash is often disposed of near the river. I am less concerned with the eyesore that it creates as the possible contamination with drinking water. An association leader and another community member have told me that this is a problem. He believes that a project of “sensibilization” about the impact of trash disposal would be beneficial to the community. We have applied for a grant from the Foundation of France to build a trash container and are waiting for a reply.
• Hygiene and Sanitation – Many people are largely ignorant about basic hygienic practices, from my own observation. Community members have told me that they know about hygiene, but that others don’t. An association leader has told me that sanitation is a problem. I believe that the lack of hygiene in the home leads to disease transmission.
• Sexually Transmitted Infections (STIs) – Knowledge about STIs is variable, but even those community members who are relatively well informed could still use some education. Some people know close to nothing about STIs. People are sometimes embarrassed to discuss the issue, especially SIDA. The issue is an important one as many men in my village visit prostitutes in Boumia and Tounfite. I have been in the sbitar when people come in with STI problems. Also, my nurse has told me that female patients come into the sbitar with STIs. Presumably they have contracted the STIs from their husbands.
• Access to Bathrooms – Mbarek, the secretary general of the Commune told me that 10% of people have bathrooms in their house. Thus, many people go to the bathroom outside, which is certainly a vector for disease transmission.
• Specific Illnesses – Diabetes, hyper and hypotension, rheumatism, chronic headaches, goiters, respiratory illness, diarrhea, and itchy, irritated skin (possibly related to presence of fungus) have all been reported to me as diseases that are prevalent in my community.
• Illnesses Related to Cold – Located at 2,000 meters, my community gets quite cold during the winter. It is difficult for me to speak about this issue in a specific way, as I have not experienced winter here. However, many people tell me that respiratory illness is common during the winter.
• Environmental Problems – In order to cook their food, bake their bread, and stay warm during the winter, people in my community use wood stoves. This means that a large amount of wood is being taken from the surrounding environment. Additionally, outsiders from Boumia and Tounfite cart truckloads of wood from our region on a daily basis. Multiple community members have told me that the over harvesting of wood is a problem and that the supply dwindles each year. Another tragedy of the commons problem involves herding of sheep and goats. As these herd animals are the best way for community members to invest surplus money in order to see a return, herds often grow beyond the need of the owner. This has led to overgrazing and further destruction of the environment. This is another issue that I learned about from community members. Finally, I have been informed that the amount of water available to my community has decreased over the course of the past twenty years. Although this problem is worrying in the long-term, I do not see it directly impacting lives in the short term to the scale it does in other communities, such as Boumia.
IV. Health Priorities
As clear from above, there are a myriad of problems across the entire spectrum of health care. Working on anyone of them would be valuable. The following are the issues that I deem to be priorities because a) the dramatic impact they have on the community and b) they have been emphasized to me by community members as problems and thus the community will hopefully be more receptive to the work that I do.
• Safe Birthing Practices – This is a severe problem that can be addressed immediately. Several women from my community have attended the safe birthing practices workshop organized in conjunction with Mara Hansen and Kristen and David LaFever. In conjunction with the new doctor in the sbitar, I have started to organize discussion amongst women following the workshop in order to disseminate information throughout the community. I hope to conduct further trainings in the course of my service.
• Dental Hygiene – This is another obvious problem. So far my work has been well received. First, I have done education in the schools in coordination with the local teachers. Second, I have held several meetings with parents of the school children where I have stressed the importance of helping their children with dental hygiene. My local association leader has helped me to organize the meetings. He is very motivated; as the tahanut owner he is also going to sell toothbrushes in his store.
• Water – I could spend my entire service working on issues surrounding water and not come close to solving all of the problems. The primary issue is water sanitation. In A and B, the best way of addressing this issue is to work with the local water association to insure that the water is clean. Additionally, lessons on drinking water from other sources would be useful. Another association is interested in doing a sensibilization project in regards to the effects of trash disposal on water sanitation. In the surrounding douars where the drinking water is untreated and does not come from such a central source, a larger project of water sanitation education is necessary. I would also like to do analyses of different drinking water sources. The secondary issue is water distribution and collection. Some villages have running water, but most do not. In A and B, the water association is motivated to work on fixing the problems that face running water. I am working on a project in conjunction with the Commune and the water association in order to a) change the collection point of water and b) ensure the water’s sanitation by replacing the pipes. In I, F, and E infrastructure such as chateaus and water pipes already exist. Thus, the temptation to try and bring water to these villages is high, as it would have a relatively low cost. I am working with the Commune and the water association in E/F on a project to collect water from a spring and have it piped to an existing chateau near the villages.
If it’s unclear from the above report, there is a lot of work to do in my community. In addition to doing health work, I’m interested in working on the environmental issues mentioned above as well as assisting a local tourism association. At the beginning, my priorities will lie in A and B. I am most trusted in those communities, which should make the work easier. Hopefully I will be able to gain a similar level of confidence in the outer douars and expand my work as my service progresses.
Thankfully, the work in A and B will be helped greatly by the enthusiasm of local associations. So far, the associations’ members have exceeded all expectations in terms of motivation and work ethic. They defy the stereotype of the Moroccan association. Down the road, the potential for capacity building of the local associations is great.
On the other hand, as mentioned above, there is a general lack of interest in solving health problems and even being healthy. I will face frustrations when my enthusiasm for change exceeds that of my community. Furthermore, many of the problems that face my community are more deeply rooted than a health worker can address, which is disheartening. The life of poor people in a cold, agricultural community is physically and emotionally demanding, especially for women.
I realize that this document is supposed to be merely a community assessment, but thanks to the help of surrounding volunteers and the motivation of association members and local teachers, I have already begun to implement some of my projects in my community. So far it has gone better than I could have hoped for. I am excited for the next 18+ months of work. It’s hard to believe how quickly the first 8+ months in country have gone by. God willing, my work will be fruitful.