I have been eating lots the past week.
Last Thursday, of course, was Thanksgiving. 8 PCVs gathered in Tounfite to celebrate. We killed 2 turkeys and made a bunch of other food. We invited a Moroccan family that we are close to come and celebrate with us. It was there 2nd Thanksgiving in a row; they like the holiday a lot. I made mashed potatoes: about six pounds of potatoes and nearly a pound of butter. Delicious. The celebration was a lot of fun, but this is the 3rd Thanksgiving in a row that I have been out of America for. Next year I hope to be home.
Saturday was the biggest Moroccan (and Muslim) holiday of the year. The holiday is a celebration of when Ibrahim was told by God to sacrifice his son, Ishmael. Just as Ibrahim was about to make the sacrifice, God told him to sacrifice a sheep instead. It's a story about faith and obedience. Lots of people here are surprised that I know the parable because they don't know that it's a story from the Old Testament.
Everyone in my community slaughters a goat or sheep (or two) for the holiday. Once again, I helped my host family slaughter and skin their goat. There are two especially gross parts. First, after the goat is dead, you cut a little hole in its skin near the foot to start skinning it. You blow a bunch of air into this hold which kind of inflates the goat and makes skinning easier. The second gross part is once the goat has been skinned, getting rid of the innards. In order to flush all of the shit of the goats intestines and stomach, you fill the intestines with water and blow on the opening of the intestine until the water runs out. I did both of these gross things this year. I think it's important to be able to prepare/kill animals if you are going to eat them. Taking part in the slaughter makes me want to go back to being a vegitarian.
My host dad's brother died a week and a half ago. My host "uncle" lived a couple hours away, so I had never met him. My host dad went to stay with that family for a couple days for the funeral. Upon his return, nearly everybody in town has been coming to the house to pay their condolonces. My host mom complains a lot about having to serve them all tea and all the extra work from having guests. But at the same time, she told me that she's counting everyone who doesn't come to the house and she will never talk to them again.
Three more community meetings happened. One with men and two with women. I think they are effective at disseminating information throughout the community. I had a female volunteer come and facilitate the meetings with women. The most encouraging part about the meetings is that the women who attended the midwife training have been very good at explaining the lessons of the training (which was the purpose of the training).
In the next two weeks, I have more community meetings, an educational meeting with sex workers about STIs and I am hopefully going to do a biomass survey of the local forest with another volunteer. The idea is to use current wood usage rates to estimate how many years the forest has left. That work should keep me busy until Colton comes on the 15th and we travel around Morocco together. I'm really looking forward to that vacation.
The only other news is that this year has been exceptionally warm. On Thanksgiving last year, we got a big snowstorm that dropped probably 8 inches. We have yet to have any snow this year. However, the weather has just changed. The last couple days have been quite cold. Winter may finally be here.
Monday, November 30, 2009
Saturday, November 21, 2009
TBA report
Here is the report that I wrote for the workshop I did a couple weeks ago. I'm not allowed to publish the names of the villages, so that's what all the "A" and "A2's" are. It's long and maybe boring (and poorly formatted for blogspot). There is a personal update at the end if that's all you're interested in.
Maternal and Child Health Workshop
October 28th, 29th, and 30th 2009
Duncan Gromko
Outline
Introduction
Participants
Goals and Objectives
Project Timeline
Budget
Workshop Curriculum
Logistics
Highlights
Difficulties
Monitoring and Evaluation
Suggestions for Future Workshops
Conclusions
Thanks
Introduction
This project was very rewarding. The purpose of this report is to help volunteers replicate it in their sites. Although each site poses unique public health problems, maternal and child health is an area that deserves attention in rural Morocco. I welcome questions and criticisms.
Isolated by towering mountains, the communities of XXX face different public health problems due to their geographic location and economic situation. Tounfite is the local hub: a souq town. It has a large health clinic, a maison d'accouchement, and a place for women to stay pre and post delivery. A and T have a small health clinic and are an hour from Tounfite. T2 and L have a clinic and are about two hours from Tounfite. T3 has no clinic and is approximately four to five hours from Tounfite (two hours from the L clinic). There is a health clinic in A2; T4 and B are about seven kilometers from A2. Tounfite is two to three hours away. Communities that are further from Tounfite must be more self-reliant. Generally speaking, the region is underdeveloped due to its lack of natural resources and harsh environmental conditions that make agriculture only marginally productive. The main sources of income for these communities is herding sheep.
Most women give birth in the home, with the help of their mothers or other female relations, resulting in high rates of maternal and infant mortality. The number of pre-natal visits is also low. Furthermore, lack of access to Ministry health care means that common illnesses, such as diarrhea, can be fatal. Therefore, preventive health measures are crucial.
This workshop was the second in two years. Last year’s training, hosted by Mara Hansen, focused primarily on birthing. Given the difficulty of training women to be midwives in three days and other health issues facing the communities, the focus for this year’s training was slightly altered. In addition to pregnancy and birthing, more general health issues such as hygiene, oral rehydration liquid, and family planning were covered. Furthermore, the training focused on enabling the women to be health care advocates in their communities. Thus, the women were asked to simulate teaching exercises in order to build these skills. Finally, without the assistance and support of men in these communities, a comprehensive solution will not be found. Thus, on the final day of the training, community leaders from each village were invited to create a community action plan to be implemented following the training.
Participants/Responsibilities
• Volunteers (Duncan Gromko, Kristen Apa, Taryn Weil, Dan Dutcher, Jed D’Abravanel, Eric O’Bryant, and Falisha Khan) were responsible for recruiting women, planning the workshop curriculum, securing Ministry permission, assisting in lessons, and ensuring that all logistical issues were taken care of.
• Ministry of Health employees (MOH Khenifra representative, two Tounfite sage-femmes, and Agoudim doctor) were responsible for conducting the training. MOH Khenifra representative gave introductory remarks and a quick lesson on hygiene. Tounfite sage-femmes did the majority of the lessons, focusing on birthing and pre/post-natal care. Agoudim doctor did a lesson on basic hygiene, first aid, and oral rehydration. The Ministry also provided a space for the lesson and photocopies of the lesson booklet.
• 25 women from rural communities (A: 5, T2: 3, B: 2, T3: 2, L: 2, T4: 1, A2: 2, T5: 3, Tounfite: 4, A3: 1)
• 7 community leaders were in attendance for the final afternoon session
• Two Tounfite women cooked food for and hosted the women for three days and four nights
Goals and Objectives
Goal
To improve maternal and child health in the villages of XXX by teaching 25 women basic health lessons and creating opportunities for them to become community health advocates.
Training objectives:
• 25 women will demonstrate understanding of the following topics
o The importance of pre/post natal visits to the medical clinic
o Healthy pre/post natal practices in the home
o Identification and referral of high-risk patients to local birthing centers (maison d’accouchement)
o Safe home birthing practices
o Preventing infant diarrhea, oral rehydration
o Hygiene
o Different contraceptive methods (birth control pill, condoms, IUD, the shot)
• Two midwives and one doctor will acquire new instructional methods and increase their ability to promote healthy behaviors among rural populations
• 25 women and 10 community leaders will create community action plans to bring the lessons from the training back to their communities
Long term objectives:
• Number of pre-natal visits to local health clinics (Tounfite, A2, A, and L) will increase
• Number of births in maison d’accouchement in Tounfite will increase
• Number of infant deaths related to diarrheal diseases will decrease
• Contraceptive methods will be used more frequently and with greater efficacy
• Each village will hold community wide meetings, conducted by the women from the training, volunteers, community leaders, and Ministry of Health staff, to disseminate the lessons from the training
Project Timeline
• May – Informally propose project to Ministry of Health
• June and July – Recruit women to attend workshop
• July – Discuss curriculum with doctor and sage-femmes
• September – Formal approval from Ministry of Health
• October 20th-27th Finalize workshop logistics
• October 28th-30th Workshop
• November and December - Community meetings
Budget
Transportation for women - 600 Dhs
Lodging/food for women - 3,000 Dhs
Pay for women - 2,400 Dhs
Photocopies - 400 Dhs (Ministry of Health)
Break food, misc. - 400 Dhs
Using Tounfite maison d'accouchement (In kind)
Time of Tounfite Ministry of Health Staff (In kind)
Printing photos - 60 Dhs
Gifts for trainers - 180 Dhs
Total - 7,040 Dhs
Workshop Curriculum
Day 1
Introductions
Pre-natal care: home
Identifying risky pregnancies
Pre-natal care: sbitar
Day 2
Healthy practices: preparing for birth
Healthy practices: birthing
Family planning
Hygiene
Oral rehydration
Day 3
Post-natal care
Review
Community groups meet to formulate action plan
Community groups present plan to larger group
Logistics
Transportation for the women was fairly straightforward. Mostly, they were responsible for finding their own transport. They were reimbursed at conclusion of training.
Feeding of women was difficult. Having a Moroccan family host and feed the women (women who had no family in Tounfite) was critical. It took a lot of responsibility off of the hands of the volunteer. It was expensive, but well worth the expense. We took care of break food (tea, peanuts, pastries), which was easy for volunteers who were not participating in the training to be responsible for. Having seven volunteers there to take care of various unexpected odds and ends was important.
Highlights
Organizing and participating in this training was very rewarding. The women were very appreciative and enjoyed the training. On the final day, there was a celebration dinner with an ahaydus, where the women sang praises of the volunteers.
The final session of the training, with community leaders attending, was the most important session of the training. Hopefully, it will provide the women (and volunteers) with community partners to help with further education efforts. During the session, each community group made an action plan as to how they would disseminate information to the appropriate people. The group was asked to review the lessons of the training and decide which lessons were most important in their community, based upon their health needs. Inviting men and asking them to take a stake in the health of women in their community was critical to the success of the training. It will make future work much easier. At the conclusion of the training, each community group was asking me when I was going to come to their village to do a smaller version of the workshop with them.
Another highlight from the final meeting was a particularly impassioned speech made by a 23 year-old woman from T4, named Turia. She stood up in front of women and men and demanded that people take better care of their women. She said that men had a responsibility to provide for their women. She said that women ought to stand up for one another (and themselves) when they witness oppression. She emphasized the importance of the community helping itself and not waiting for outside help to come and save it. It was a moving speech that was an excellent way to conclude the training.
Difficulties
The most difficult part of the training was the difficulty of sticking to the schedule. Events beyond anyone's control demanded that lessons be moved around. For example, each of the sage-femmes was called away to Khenifra on one of the training days, leaving the other to teach lessons by herself. Another difficulty arose when, on Thursday morning, a woman came into the maison d'accouchement in labor. With only one sage-femme at the center, we were momentarily left without a trainer. But, in this instance and others, we were flexible and made productive use of the time.
Language was a small problem. On the first day, the sage-femme leading the training was a Tamazight speaker, which made the lessons and communication easy. On the second day, the sage-femme and doctor who led the sessions were Arabic only speakers, necessitating a translator. While the translator did an admirable job, it is difficult to have as fluid of a conversation speaking through a translator.
Shame about the health topics covered was a small problem. Males were excluded from the training room for the sensitive training sessions, reducing that problem. On the last day, when men were invited, some people were uncomfortable. One man opened up the training booklet (which contains some graphic pictures), stood up, and left. He was the only one to leave, however. Although people were uncomfortable for this session, I believe that was unavoidable. The only thing I would change is to be sure that the training booklet remains closed.
Some of the women were not actively participating in the lessons. One woman fell asleep. There are a couple explanations. First, asking these women to concentrate for hours on end is inherently problematic. Most of them haven't been in a school setting for years. Second, recruiting women is difficult. It is not easy to predict (especially as a male) who will actively participate in the training. The more time spent before the training evaluating potential trainees, the better.
Organizing the training was a lot of work. Having the help of six other volunteers was critical.
Another challenge during the training was the use of handout (visual aids) that corresponded with the lessons of the training. The trainers did not consistently utilize the materials and the women had a difficult time following along. A large flip-chart, that corresponded with the handouts, would make it easier for trainees to follow along.
A three day workshop is inherently limiting. It was difficult to fit the entire curriculum into the three days an ensure that all of the women were absorbing all of the information. Narrowing the breadth of the training may be necessary.
Monitoring and Evaluation
Monitoring the ability of this training to reach its goals and objectives is both important and difficult. It is important to monitor the success of the training because doing so will inform volunteers’ future work. It is difficult because there are many complicating variables. Furthermore, the success of this training is not entirely captured by measureable numbers. Simply promoting women’s health in such a public manner was a success in itself.
The objectives for the training were mostly met. Most women were actively engaged in the lessons and were able to explain the topics to each other and volunteers when asked. There was a minority of women who did not focus on the lessons for the entirety of the training (one woman fell asleep), but these women were the exception, not the rule. Furthermore, expecting middle age women who have not been in a classroom setting for 30 years (if ever) to focus for three straight days is asking a lot. The women did remarkably well at focusing. The instructors of the training (Ministry of Health staff) deserve credit for making the lessons interesting and engaging. The objective of each community deciding upon a community action plan was also met as discussed above.
It is too early to judge whether the long-term objectives for the training have been met. Pre-natal visits and births in the maison d’accouchment can be measured by comparing Ministry statistics from before and after the training. This will not be a perfect indicator, however, as there could be other factors contributing to an increase in pre-natal visits (ie the Lougagh nurse is new; one can expect that he will get more visits as the community gains trust in him). In addition to comparing Ministry statistics, there is another method of measuring pre-natal visits and births in the health clinic. Each woman was given ten “referral” cards: a small sheet of paper with a picture of a pregnant woman going to the health clinic. Each card has the woman’s name on the back. The women were instructed to give the cards to pregnant women when they recommend a health clinic visit. The pregnant women will then give the card to the health clinic staff, to be later counted by a Peace Corps volunteer. If this system is effective, it will give a clear indication of the training’s reach and effectiveness. Three weeks after the training, early returns from the referral cards are very positive. Ten cards have been turned into the A health clinic (referrals from five different trainees) and two cards have been turned into the L health clinic (one trainee). In addition to providing volunteers with a means of monitoring activity, they also give trainees motivation to make referrals.
It will be difficult to judge whether or not deaths from diarrheal diseases decrease or contraceptive devices are used more effectively. Statistics are not currently kept on this sort of thing. Witnessing behavior change will be the surest way to judge if those lessons were effective.
If the community wide meetings hosted by women from the training, Ministry of Health staff, community leaders, and Peace Corps volunteers are held, that will be a clear indication of the training’s success. These meetings will force the communities to engage about the health issues facing them and how they can be most effectively addressed. If the meetings are well-run, then they will allow other objectives to be met. Three weeks after the training, one community meeting has been held with several others planned for the coming weeks.
Suggestions for Future Workshops
Although the workshop was interactive and engaging, improvements could been made. Any activities that force the women to stand up and physically be involved are positive. If time had permitted, the schedule would have included an entire "teach back" session, where the women are asked to teach other trainees lessons that they had just learned. This would reinforce the lessons in their heads and give them the skills for talking to other women.
Another suggestion for keeping the women engaged is to include stretching breaks with the tea breaks. Anything to get the women to stand up and move around for five minutes.
A final way of addressing the problem of inattentive women is a better recruiting and vetting process. The more time that a recruiter can spend with the women before mentioning the workshop, the better. I mentioned a speech given by Turia at the final session. In addition to that speech, she was critical in bridging the cultural gap between the Ministry of Health staff and the women. Other women were also important contributors to raising the energy level of the training and helping other women understand the difficult concepts. Recruiting is a critical step in making the training a success. Invite active, strong women. Having a variety of ages is also helpful: older women have more experience, but younger women tend to be more active. Invite community leaders who you can imagine working with after the training.
In future trainings, it would be helpful to give the women a "test" at the conclusion of the training to more formally gauge their competencies. Furthermore, having feedback from the trainees at the conclusion of the training would be a good way to improve future workshops.
Conclusions
The workshop was a very rewarding project. Hopefully, it will be a catalyst for creating wide-spread behavior change in a number of communities. It is important to emphasize, however, that the workshop is only a first step. If villages do not follow through on their community action plans, the reach of the workshop will be limited.
For any volunteer that identifies maternal and child health as a community health priority, I recommend considering a project similar to this workshop. It is an effective way of addressing the problem. However, it is critical to tailor the project to the community's assets and deficits. A community that has easy access to a functional maison d'accouchement needs a much different training than one with no access. It is also critical to consider the ability of the Ministry of Health staff to lead the training. In Tounfite, our staff is very capable and did an excellent job with the training. Two of the trainers attended last year's workshop, meaning that they had experience. Furthermore, it is important to have a common language between the MOH staff and the volunteer so there can be fluid communication about the curriculum and problems that arise during the course of the workshop. Another consideration is the size and location of the workshop. This was a large workshop in our souq town. It would be easier to facilitate a smaller workshop in the town of the women. Depending on the situation, it may be easier and more effective to have several small trainings, rather than one large one.
It is also important to consider the strengths of the volunteer. As a man, it was easier for me to persuade community leaders to attend the final session. It was also easier for me to make contacts in outer douars for recruiting. On the other hand, it was more difficult for me to thoroughly vet the women before the training. Also, I was unable to be in the training room for most of the training. An effective training is going to utilize male and female volunteers.
Thanks
This workshop would not have been possible without a long list of people. Rachida, Wafa, and Selua (Ministry of Health staff: Tounfite) did an outstanding job conducting the training; they reached out to the women and made it engaging and interactive. The Ministry of Health in Khenifra, in particular Sidi Aissa gave me permission to use their facilities, workers, and provided training booklets for the women. Sidi Aissa also helped me figure out the paperwork at the Ministry and led an excellent opening session at the workshop. The entire Tounfite health clinic staff was helpful as well, thanks to Lahcen, the Medicin Chef. Mamaksu and Baha worked day and night for 4 straight days to provide the women with food and housing. My programming staff, Mostafa Lamqaddam and Rachid Lamjaimer, provided advice and support. The volunteers who helped on the project: Kristen Apa, Taryn Weil, Dan Dutcher, Jed D’Abravanel, Eric O’Bryant, and Falisha Khan did everything I asked them to do and plenty of things I forgot to ask of them. Mark and Joyce Gromko, Mary Ellen Newport, and Kristin and David LaFever all contributed financially. Kristin and David LaFever and Mara Hansen deserve thanks for showing me how to run a workshop last year.
Update
Had first follow-up community meeting in my village (A) with men. It went quite well. I'm hoping to do similar meetings in 3-4 other villages. And meetings with women as well. I have three scheduled for next week. The main lessons are: pre-natal visits, birth in Tounfite (not in house), hygiene, and birth control.
On Monday I painted two rooms of my host family's house. I liked doing it because it was the first time that I've had a skill that people here valued (I've done lots of painting work before).
On Wednesday the local police (in Tounfite) called me during lunch and told me to come immediately to Tounfite (one hour away). They told me to bring my ID card. I told them that it expired months ago and that I had already applied to them for a new one. They had my old copy. When I got to the office, they asked me for my card. I explained to them again that they had taken my old card. They asked if I had a photocopy of the card, and I told them that it was in their files. They looked through my paperwork and sure enough, there it was. They said I could go home. Very typical.
Maternal and Child Health Workshop
October 28th, 29th, and 30th 2009
Duncan Gromko
Outline
Introduction
Participants
Goals and Objectives
Project Timeline
Budget
Workshop Curriculum
Logistics
Highlights
Difficulties
Monitoring and Evaluation
Suggestions for Future Workshops
Conclusions
Thanks
Introduction
This project was very rewarding. The purpose of this report is to help volunteers replicate it in their sites. Although each site poses unique public health problems, maternal and child health is an area that deserves attention in rural Morocco. I welcome questions and criticisms.
Isolated by towering mountains, the communities of XXX face different public health problems due to their geographic location and economic situation. Tounfite is the local hub: a souq town. It has a large health clinic, a maison d'accouchement, and a place for women to stay pre and post delivery. A and T have a small health clinic and are an hour from Tounfite. T2 and L have a clinic and are about two hours from Tounfite. T3 has no clinic and is approximately four to five hours from Tounfite (two hours from the L clinic). There is a health clinic in A2; T4 and B are about seven kilometers from A2. Tounfite is two to three hours away. Communities that are further from Tounfite must be more self-reliant. Generally speaking, the region is underdeveloped due to its lack of natural resources and harsh environmental conditions that make agriculture only marginally productive. The main sources of income for these communities is herding sheep.
Most women give birth in the home, with the help of their mothers or other female relations, resulting in high rates of maternal and infant mortality. The number of pre-natal visits is also low. Furthermore, lack of access to Ministry health care means that common illnesses, such as diarrhea, can be fatal. Therefore, preventive health measures are crucial.
This workshop was the second in two years. Last year’s training, hosted by Mara Hansen, focused primarily on birthing. Given the difficulty of training women to be midwives in three days and other health issues facing the communities, the focus for this year’s training was slightly altered. In addition to pregnancy and birthing, more general health issues such as hygiene, oral rehydration liquid, and family planning were covered. Furthermore, the training focused on enabling the women to be health care advocates in their communities. Thus, the women were asked to simulate teaching exercises in order to build these skills. Finally, without the assistance and support of men in these communities, a comprehensive solution will not be found. Thus, on the final day of the training, community leaders from each village were invited to create a community action plan to be implemented following the training.
Participants/Responsibilities
• Volunteers (Duncan Gromko, Kristen Apa, Taryn Weil, Dan Dutcher, Jed D’Abravanel, Eric O’Bryant, and Falisha Khan) were responsible for recruiting women, planning the workshop curriculum, securing Ministry permission, assisting in lessons, and ensuring that all logistical issues were taken care of.
• Ministry of Health employees (MOH Khenifra representative, two Tounfite sage-femmes, and Agoudim doctor) were responsible for conducting the training. MOH Khenifra representative gave introductory remarks and a quick lesson on hygiene. Tounfite sage-femmes did the majority of the lessons, focusing on birthing and pre/post-natal care. Agoudim doctor did a lesson on basic hygiene, first aid, and oral rehydration. The Ministry also provided a space for the lesson and photocopies of the lesson booklet.
• 25 women from rural communities (A: 5, T2: 3, B: 2, T3: 2, L: 2, T4: 1, A2: 2, T5: 3, Tounfite: 4, A3: 1)
• 7 community leaders were in attendance for the final afternoon session
• Two Tounfite women cooked food for and hosted the women for three days and four nights
Goals and Objectives
Goal
To improve maternal and child health in the villages of XXX by teaching 25 women basic health lessons and creating opportunities for them to become community health advocates.
Training objectives:
• 25 women will demonstrate understanding of the following topics
o The importance of pre/post natal visits to the medical clinic
o Healthy pre/post natal practices in the home
o Identification and referral of high-risk patients to local birthing centers (maison d’accouchement)
o Safe home birthing practices
o Preventing infant diarrhea, oral rehydration
o Hygiene
o Different contraceptive methods (birth control pill, condoms, IUD, the shot)
• Two midwives and one doctor will acquire new instructional methods and increase their ability to promote healthy behaviors among rural populations
• 25 women and 10 community leaders will create community action plans to bring the lessons from the training back to their communities
Long term objectives:
• Number of pre-natal visits to local health clinics (Tounfite, A2, A, and L) will increase
• Number of births in maison d’accouchement in Tounfite will increase
• Number of infant deaths related to diarrheal diseases will decrease
• Contraceptive methods will be used more frequently and with greater efficacy
• Each village will hold community wide meetings, conducted by the women from the training, volunteers, community leaders, and Ministry of Health staff, to disseminate the lessons from the training
Project Timeline
• May – Informally propose project to Ministry of Health
• June and July – Recruit women to attend workshop
• July – Discuss curriculum with doctor and sage-femmes
• September – Formal approval from Ministry of Health
• October 20th-27th Finalize workshop logistics
• October 28th-30th Workshop
• November and December - Community meetings
Budget
Transportation for women - 600 Dhs
Lodging/food for women - 3,000 Dhs
Pay for women - 2,400 Dhs
Photocopies - 400 Dhs (Ministry of Health)
Break food, misc. - 400 Dhs
Using Tounfite maison d'accouchement (In kind)
Time of Tounfite Ministry of Health Staff (In kind)
Printing photos - 60 Dhs
Gifts for trainers - 180 Dhs
Total - 7,040 Dhs
Workshop Curriculum
Day 1
Introductions
Pre-natal care: home
Identifying risky pregnancies
Pre-natal care: sbitar
Day 2
Healthy practices: preparing for birth
Healthy practices: birthing
Family planning
Hygiene
Oral rehydration
Day 3
Post-natal care
Review
Community groups meet to formulate action plan
Community groups present plan to larger group
Logistics
Transportation for the women was fairly straightforward. Mostly, they were responsible for finding their own transport. They were reimbursed at conclusion of training.
Feeding of women was difficult. Having a Moroccan family host and feed the women (women who had no family in Tounfite) was critical. It took a lot of responsibility off of the hands of the volunteer. It was expensive, but well worth the expense. We took care of break food (tea, peanuts, pastries), which was easy for volunteers who were not participating in the training to be responsible for. Having seven volunteers there to take care of various unexpected odds and ends was important.
Highlights
Organizing and participating in this training was very rewarding. The women were very appreciative and enjoyed the training. On the final day, there was a celebration dinner with an ahaydus, where the women sang praises of the volunteers.
The final session of the training, with community leaders attending, was the most important session of the training. Hopefully, it will provide the women (and volunteers) with community partners to help with further education efforts. During the session, each community group made an action plan as to how they would disseminate information to the appropriate people. The group was asked to review the lessons of the training and decide which lessons were most important in their community, based upon their health needs. Inviting men and asking them to take a stake in the health of women in their community was critical to the success of the training. It will make future work much easier. At the conclusion of the training, each community group was asking me when I was going to come to their village to do a smaller version of the workshop with them.
Another highlight from the final meeting was a particularly impassioned speech made by a 23 year-old woman from T4, named Turia. She stood up in front of women and men and demanded that people take better care of their women. She said that men had a responsibility to provide for their women. She said that women ought to stand up for one another (and themselves) when they witness oppression. She emphasized the importance of the community helping itself and not waiting for outside help to come and save it. It was a moving speech that was an excellent way to conclude the training.
Difficulties
The most difficult part of the training was the difficulty of sticking to the schedule. Events beyond anyone's control demanded that lessons be moved around. For example, each of the sage-femmes was called away to Khenifra on one of the training days, leaving the other to teach lessons by herself. Another difficulty arose when, on Thursday morning, a woman came into the maison d'accouchement in labor. With only one sage-femme at the center, we were momentarily left without a trainer. But, in this instance and others, we were flexible and made productive use of the time.
Language was a small problem. On the first day, the sage-femme leading the training was a Tamazight speaker, which made the lessons and communication easy. On the second day, the sage-femme and doctor who led the sessions were Arabic only speakers, necessitating a translator. While the translator did an admirable job, it is difficult to have as fluid of a conversation speaking through a translator.
Shame about the health topics covered was a small problem. Males were excluded from the training room for the sensitive training sessions, reducing that problem. On the last day, when men were invited, some people were uncomfortable. One man opened up the training booklet (which contains some graphic pictures), stood up, and left. He was the only one to leave, however. Although people were uncomfortable for this session, I believe that was unavoidable. The only thing I would change is to be sure that the training booklet remains closed.
Some of the women were not actively participating in the lessons. One woman fell asleep. There are a couple explanations. First, asking these women to concentrate for hours on end is inherently problematic. Most of them haven't been in a school setting for years. Second, recruiting women is difficult. It is not easy to predict (especially as a male) who will actively participate in the training. The more time spent before the training evaluating potential trainees, the better.
Organizing the training was a lot of work. Having the help of six other volunteers was critical.
Another challenge during the training was the use of handout (visual aids) that corresponded with the lessons of the training. The trainers did not consistently utilize the materials and the women had a difficult time following along. A large flip-chart, that corresponded with the handouts, would make it easier for trainees to follow along.
A three day workshop is inherently limiting. It was difficult to fit the entire curriculum into the three days an ensure that all of the women were absorbing all of the information. Narrowing the breadth of the training may be necessary.
Monitoring and Evaluation
Monitoring the ability of this training to reach its goals and objectives is both important and difficult. It is important to monitor the success of the training because doing so will inform volunteers’ future work. It is difficult because there are many complicating variables. Furthermore, the success of this training is not entirely captured by measureable numbers. Simply promoting women’s health in such a public manner was a success in itself.
The objectives for the training were mostly met. Most women were actively engaged in the lessons and were able to explain the topics to each other and volunteers when asked. There was a minority of women who did not focus on the lessons for the entirety of the training (one woman fell asleep), but these women were the exception, not the rule. Furthermore, expecting middle age women who have not been in a classroom setting for 30 years (if ever) to focus for three straight days is asking a lot. The women did remarkably well at focusing. The instructors of the training (Ministry of Health staff) deserve credit for making the lessons interesting and engaging. The objective of each community deciding upon a community action plan was also met as discussed above.
It is too early to judge whether the long-term objectives for the training have been met. Pre-natal visits and births in the maison d’accouchment can be measured by comparing Ministry statistics from before and after the training. This will not be a perfect indicator, however, as there could be other factors contributing to an increase in pre-natal visits (ie the Lougagh nurse is new; one can expect that he will get more visits as the community gains trust in him). In addition to comparing Ministry statistics, there is another method of measuring pre-natal visits and births in the health clinic. Each woman was given ten “referral” cards: a small sheet of paper with a picture of a pregnant woman going to the health clinic. Each card has the woman’s name on the back. The women were instructed to give the cards to pregnant women when they recommend a health clinic visit. The pregnant women will then give the card to the health clinic staff, to be later counted by a Peace Corps volunteer. If this system is effective, it will give a clear indication of the training’s reach and effectiveness. Three weeks after the training, early returns from the referral cards are very positive. Ten cards have been turned into the A health clinic (referrals from five different trainees) and two cards have been turned into the L health clinic (one trainee). In addition to providing volunteers with a means of monitoring activity, they also give trainees motivation to make referrals.
It will be difficult to judge whether or not deaths from diarrheal diseases decrease or contraceptive devices are used more effectively. Statistics are not currently kept on this sort of thing. Witnessing behavior change will be the surest way to judge if those lessons were effective.
If the community wide meetings hosted by women from the training, Ministry of Health staff, community leaders, and Peace Corps volunteers are held, that will be a clear indication of the training’s success. These meetings will force the communities to engage about the health issues facing them and how they can be most effectively addressed. If the meetings are well-run, then they will allow other objectives to be met. Three weeks after the training, one community meeting has been held with several others planned for the coming weeks.
Suggestions for Future Workshops
Although the workshop was interactive and engaging, improvements could been made. Any activities that force the women to stand up and physically be involved are positive. If time had permitted, the schedule would have included an entire "teach back" session, where the women are asked to teach other trainees lessons that they had just learned. This would reinforce the lessons in their heads and give them the skills for talking to other women.
Another suggestion for keeping the women engaged is to include stretching breaks with the tea breaks. Anything to get the women to stand up and move around for five minutes.
A final way of addressing the problem of inattentive women is a better recruiting and vetting process. The more time that a recruiter can spend with the women before mentioning the workshop, the better. I mentioned a speech given by Turia at the final session. In addition to that speech, she was critical in bridging the cultural gap between the Ministry of Health staff and the women. Other women were also important contributors to raising the energy level of the training and helping other women understand the difficult concepts. Recruiting is a critical step in making the training a success. Invite active, strong women. Having a variety of ages is also helpful: older women have more experience, but younger women tend to be more active. Invite community leaders who you can imagine working with after the training.
In future trainings, it would be helpful to give the women a "test" at the conclusion of the training to more formally gauge their competencies. Furthermore, having feedback from the trainees at the conclusion of the training would be a good way to improve future workshops.
Conclusions
The workshop was a very rewarding project. Hopefully, it will be a catalyst for creating wide-spread behavior change in a number of communities. It is important to emphasize, however, that the workshop is only a first step. If villages do not follow through on their community action plans, the reach of the workshop will be limited.
For any volunteer that identifies maternal and child health as a community health priority, I recommend considering a project similar to this workshop. It is an effective way of addressing the problem. However, it is critical to tailor the project to the community's assets and deficits. A community that has easy access to a functional maison d'accouchement needs a much different training than one with no access. It is also critical to consider the ability of the Ministry of Health staff to lead the training. In Tounfite, our staff is very capable and did an excellent job with the training. Two of the trainers attended last year's workshop, meaning that they had experience. Furthermore, it is important to have a common language between the MOH staff and the volunteer so there can be fluid communication about the curriculum and problems that arise during the course of the workshop. Another consideration is the size and location of the workshop. This was a large workshop in our souq town. It would be easier to facilitate a smaller workshop in the town of the women. Depending on the situation, it may be easier and more effective to have several small trainings, rather than one large one.
It is also important to consider the strengths of the volunteer. As a man, it was easier for me to persuade community leaders to attend the final session. It was also easier for me to make contacts in outer douars for recruiting. On the other hand, it was more difficult for me to thoroughly vet the women before the training. Also, I was unable to be in the training room for most of the training. An effective training is going to utilize male and female volunteers.
Thanks
This workshop would not have been possible without a long list of people. Rachida, Wafa, and Selua (Ministry of Health staff: Tounfite) did an outstanding job conducting the training; they reached out to the women and made it engaging and interactive. The Ministry of Health in Khenifra, in particular Sidi Aissa gave me permission to use their facilities, workers, and provided training booklets for the women. Sidi Aissa also helped me figure out the paperwork at the Ministry and led an excellent opening session at the workshop. The entire Tounfite health clinic staff was helpful as well, thanks to Lahcen, the Medicin Chef. Mamaksu and Baha worked day and night for 4 straight days to provide the women with food and housing. My programming staff, Mostafa Lamqaddam and Rachid Lamjaimer, provided advice and support. The volunteers who helped on the project: Kristen Apa, Taryn Weil, Dan Dutcher, Jed D’Abravanel, Eric O’Bryant, and Falisha Khan did everything I asked them to do and plenty of things I forgot to ask of them. Mark and Joyce Gromko, Mary Ellen Newport, and Kristin and David LaFever all contributed financially. Kristin and David LaFever and Mara Hansen deserve thanks for showing me how to run a workshop last year.
Update
Had first follow-up community meeting in my village (A) with men. It went quite well. I'm hoping to do similar meetings in 3-4 other villages. And meetings with women as well. I have three scheduled for next week. The main lessons are: pre-natal visits, birth in Tounfite (not in house), hygiene, and birth control.
On Monday I painted two rooms of my host family's house. I liked doing it because it was the first time that I've had a skill that people here valued (I've done lots of painting work before).
On Wednesday the local police (in Tounfite) called me during lunch and told me to come immediately to Tounfite (one hour away). They told me to bring my ID card. I told them that it expired months ago and that I had already applied to them for a new one. They had my old copy. When I got to the office, they asked me for my card. I explained to them again that they had taken my old card. They asked if I had a photocopy of the card, and I told them that it was in their files. They looked through my paperwork and sure enough, there it was. They said I could go home. Very typical.
Friday, November 13, 2009
STRIKE!
First to respond to the question: I got in touch with The National through an alumnni friend. He found out about my blog and suggested that I write an article.
STRIKE!
I came back to my site after 12 days away to find out that "the children are on strike against the teachers." This demanded more explanation.
The quality of education that kids get in my site (and much of Morocco) is bad compared with American education. There are two classrooms for six grades. In the morning, 1st and 2nd grade share one classroom (and one teacher) and 3rd grade gets the other teacher. 4th gets its own classroom in the afternoon and 5th and 6th grade share the other.
That was last year, when there were 4 teachers. This year there are three. Two of those remaining teachers do not speak Tamazight, only Arabic. The young kids don't speak any Arabic, so they mostly are just learning Arabic in the first two years.
Beyond the cramped learning conditions and language barriers, another issue is the pedagological methods used. Rote memorization combined with capital punishment for mistakes make learning difficult. Last Spring I tutored some 6th grade kids in basic math and they had a very difficult time. They were unable to think creatively and apply rules they had learned to real world situations.
The teachers don't have it easy either. They live several hours from their homes. The female teachers spend all of their time in the classroom or home; they have few friends in town. For someone from a modern city like Azrou or Khenifra, this would be very difficult. So the teachers leave frequently to go home. The director who oversees them is not around very often either.
Which brings us to the strike. Two of the teachers had left town without permission, leaving one teacher in charge of six grades. Impossible to accomplish anything so the kids "went on strike" in response. They were directed by their parents to take this action. This got the attention of the director, who came back to town. He is helping with teaching duties until the other teachers return.
It's a sad situation. In order to continue school past the 6th grade, kids have to go to Tounfite, an hour away. Of the few kids who get their parents' support to go to Tounfite, most fail out. They haven't been prepared. Parents in town complain about how bad he teachers are, but they invest little energy in their kids' education themselves. I wish the teachers were a little more invested in jobs, but I also understand their complaints. It all adds up to another generation of sheep herders.
Update
Winter is just around the corner. Nights around 0 degrees Celsius, but days are still warm - often very sunny. This fall is definitely warmer, and less rainy, than last year.
I've spent this week organizing meetings in 4 different communities. It's time to put the plans made during the workshop into action.
Early returns from the workshop are very encouraging. While I was away in Marrakech, seven pregnant women came to the health clinic for pre natal visits with a referral card from one of my trainees. In one week. Compare that to six visits for the previous month (which was unusually high) for the four clinics in my region combined. After a week there is already measureable success. The referral cards turn out to be an effective motivator in addition to a measuring tool because the trainees know their work is being monitored.
This surge of referrals is certainly due to post-workshop excitement. Hopefully community meetings can institutionalize the behavior change.
Arranging the post-workshop community meetings has been a headache. Here is what I've gone through in my village (one of four). I returned from Marrakech on Saturday evening. On Sunday, the association president asked where/when we were going to do the meeting. I told him I wanted him to make those decisions. He told me we should have it in the school on Thursday; I should go to the school director's house to seek permission. Monday at 10 I went to school; the director was not back from his weekend vacation. Tuesday at 10, I found him. He told me I couldn't have the meeting in school, so I went to the association president. He told me to try the Commune. I went to the Commune; the person in charge was not there. On a whim, I told the Khalipha (local Ministry of Interior figure) my problem. He told me that he would talk to the director and get me permission. Wednesday I went to another town. Thursday I went to the Khalipha's office, but he was gone. So I called him. He said that the director had given me permission, but not at the time I had suggested (now moved to Monday morning). A teacher had told me the classroom would be free then. So I went back to the director and asked what was up. He told me I could use the classroom, but only Sundays or after 5 pm. So I went to the association president and we decided on this Thursday at 5 pm. Then back to school for final permission from the director.
I'm doing well. The work is exciting, if frustrating. I'm getting questions from other volunteers who want to replicate the training, which is cool. On November the 12th, a new training group of volunteers swore in. The next time a new group swears in, that group will contain my replacement. This means that my training group are "seniors" - the "oldest" volunteers in country. I also found out my COS date - the date that our service is over: May 19th. I leave Morocco in just over six months.
STRIKE!
I came back to my site after 12 days away to find out that "the children are on strike against the teachers." This demanded more explanation.
The quality of education that kids get in my site (and much of Morocco) is bad compared with American education. There are two classrooms for six grades. In the morning, 1st and 2nd grade share one classroom (and one teacher) and 3rd grade gets the other teacher. 4th gets its own classroom in the afternoon and 5th and 6th grade share the other.
That was last year, when there were 4 teachers. This year there are three. Two of those remaining teachers do not speak Tamazight, only Arabic. The young kids don't speak any Arabic, so they mostly are just learning Arabic in the first two years.
Beyond the cramped learning conditions and language barriers, another issue is the pedagological methods used. Rote memorization combined with capital punishment for mistakes make learning difficult. Last Spring I tutored some 6th grade kids in basic math and they had a very difficult time. They were unable to think creatively and apply rules they had learned to real world situations.
The teachers don't have it easy either. They live several hours from their homes. The female teachers spend all of their time in the classroom or home; they have few friends in town. For someone from a modern city like Azrou or Khenifra, this would be very difficult. So the teachers leave frequently to go home. The director who oversees them is not around very often either.
Which brings us to the strike. Two of the teachers had left town without permission, leaving one teacher in charge of six grades. Impossible to accomplish anything so the kids "went on strike" in response. They were directed by their parents to take this action. This got the attention of the director, who came back to town. He is helping with teaching duties until the other teachers return.
It's a sad situation. In order to continue school past the 6th grade, kids have to go to Tounfite, an hour away. Of the few kids who get their parents' support to go to Tounfite, most fail out. They haven't been prepared. Parents in town complain about how bad he teachers are, but they invest little energy in their kids' education themselves. I wish the teachers were a little more invested in jobs, but I also understand their complaints. It all adds up to another generation of sheep herders.
Update
Winter is just around the corner. Nights around 0 degrees Celsius, but days are still warm - often very sunny. This fall is definitely warmer, and less rainy, than last year.
I've spent this week organizing meetings in 4 different communities. It's time to put the plans made during the workshop into action.
Early returns from the workshop are very encouraging. While I was away in Marrakech, seven pregnant women came to the health clinic for pre natal visits with a referral card from one of my trainees. In one week. Compare that to six visits for the previous month (which was unusually high) for the four clinics in my region combined. After a week there is already measureable success. The referral cards turn out to be an effective motivator in addition to a measuring tool because the trainees know their work is being monitored.
This surge of referrals is certainly due to post-workshop excitement. Hopefully community meetings can institutionalize the behavior change.
Arranging the post-workshop community meetings has been a headache. Here is what I've gone through in my village (one of four). I returned from Marrakech on Saturday evening. On Sunday, the association president asked where/when we were going to do the meeting. I told him I wanted him to make those decisions. He told me we should have it in the school on Thursday; I should go to the school director's house to seek permission. Monday at 10 I went to school; the director was not back from his weekend vacation. Tuesday at 10, I found him. He told me I couldn't have the meeting in school, so I went to the association president. He told me to try the Commune. I went to the Commune; the person in charge was not there. On a whim, I told the Khalipha (local Ministry of Interior figure) my problem. He told me that he would talk to the director and get me permission. Wednesday I went to another town. Thursday I went to the Khalipha's office, but he was gone. So I called him. He said that the director had given me permission, but not at the time I had suggested (now moved to Monday morning). A teacher had told me the classroom would be free then. So I went back to the director and asked what was up. He told me I could use the classroom, but only Sundays or after 5 pm. So I went to the association president and we decided on this Thursday at 5 pm. Then back to school for final permission from the director.
I'm doing well. The work is exciting, if frustrating. I'm getting questions from other volunteers who want to replicate the training, which is cool. On November the 12th, a new training group of volunteers swore in. The next time a new group swears in, that group will contain my replacement. This means that my training group are "seniors" - the "oldest" volunteers in country. I also found out my COS date - the date that our service is over: May 19th. I leave Morocco in just over six months.
Thursday, November 5, 2009
Out of the Woods
I just got an article published in The National, a newspaper in the UAE. Here is that article. You can also view the article at http://www.thenational.ae/apps/pbcs.dll/article?AID=/20091105/REVIEW/711059984/1008.
I live in rural Morocco. Jbel Ayache – one of the tallest mountains in North Africa – and several other gigantic peaks tower over the village I call home. Though the mountains are beautiful, I cannot look at them without noticing how denuded they are. Almost every large tree has been cut down. Little new growth exists. The small trees and bushes that remain cling to jagged rocks.
Because of the altitude, our winters are extremely cold: we rely on wood harvested from the forest to heat our houses. In the past, the forest came up to the edge of the village. Men would cut down massive trees right by the side of the road, then sell them to big logging companies. This was a major source of village income, but those trees aren’t around anymore. Instead of picking up logs by the side of the road, the loggers now purchase harvesting rights for land deeper into the mountains. Every morning we see big lorries rumble by; in the afternoon, they rumble by again loaded high with wood.
My 73-year-old host dad has no sons, so he is responsible for collecting the family’s wood. He wakes up at five or six in the morning, rides his mule for two hours, then cuts down oak and cedar trees with an axe for at least four hours. Usually he gets back at two or three in the afternoon, eats a meal, then immediately falls asleep for the rest of the day. Waking for the evening meal, he complains about his sore joints. I once went with a friend to try my hand at cutting. Oak, I discovered, is a very hard wood, and the tree must be cut into pieces that fit on a mule’s back. Now I pay someone else 50 Moroccan dirhams (Dh24) per mule load to cut my wood for me.
The primary means of income in my village is the herding of sheep and goats. When I hike in the mountains, it is difficult to be alone; I inevitably run into a shepherd and his sheep. These animals – there are hundreds of thousands of them – eat any shoot poking out of the ground, effectively destroying the next generation of trees. But people have lived and herded in these mountains for centuries without placing undue stress on their resources. I asked my host father, who loves to talk about the past, what had changed. “The road changed everything,” he told me. Twenty-five years ago, lorries couldn’t reach the forest. Selling sheep at souq meant crossing a 10,000 foot mountain, which cut into profits. Anyway, there was a much lower demand for meat in urban Moroccan markets, as few people could afford it.
A village 28 kilometres away from mine has already cut down all the trees from the land near their village. The wealthiest residents buy their wood from neighbouring towns. Most people, however, can only burn small, dried-up bushes that barely produce enough heat to cook food, let alone heat a house. I have been to this village in winter. The herders and their flocks are gone in search of warmer weather. Those who remain wear thick wool jellabas to attempt to keep out the cold. During the day, people rarely leave the house, and most conversations focus on how cold it is. Nights are spent huddled together in a common room.
The example of our neighbours is just one of many reminders of the dangers of resource depletion. The scope of the problem – dwindling forests, scarce grazing land, water washing away unanchored topsoil – is obvious to anyone who is remotely involved in community life. Yet next to no action has been taken. Morocco’s department of water and forest has even offered villages like mine a deal: they will plant trees if everyone agrees to stay off the land for five to 10 years, until the trees mature. Furthermore, they will compensate the community to the tune of 250 Moroccan dirhams (Dh120) per hectare per year. But very few communities, including mine, have accepted the offer; even when they have, the promise to stay off the land has typically been broken.
Because enforcement is lax, no individual has any incentive to change his consumption. This applies even to would-be conservationists: unless everyone is on board, one family’s sacrifice won’t protect the resource. If, for example, my friend Driss reduced his flock from 200 to 100 sheep, it would make his family much poorer. And without similar action from other community members, it would make no difference: someone else would probably respond by increasing the size of their flock. It wouldn’t be hard: giving away sheep is a common government practice. Just recently, the King distributed a gift of 5,000 sheep to the residents of our nearest market town. Even if an entire community wanted to sign on to the government deal, they would surely be wary of neighbouring villages taking advantage of their now-unguarded grazing land. This is partially a standard tragedy of the commons, and partially bad blood: before the French colonised this part of Morocco, these tribes often fought each other.
The solution is elusive, and there’s no quick fix. Topsoil takes a long time to build up to the point where it can support trees. All I can see when I climb these mountains is loose rock. This autumn, there have been heavy thunderstorms, and there is no soil to absorb rainfall anymore, so the water rushes downhill. Our rivers run brown with the last dregs of our soil. Last Saturday, some nearby fields were completely washed away, their corn completely destroyed. Several families lost their apple crops. Within the week, the men will be back in the forest, doing the only thing they can to stay warm: cutting down more trees.
Update
Im in Marrakech now, helping with In Service Training (IST) for newer volunteers. They've been in site for 6 months now, so this training is supposed to help them think about how they can use what they've learned about their sites to implement projects. Me and 5 other volunteers from my training stage were invited to talk about our projects and how the lessons we've learned are applicable in others' sites. It's been a good experience; I believe that I've been helpful.
One very positive thing about IST has been seeing the other 5 volunteers from my stage. I'm sometimes negative about Peace Corps and the small impact that volunteers have, but these 5 have all successfully implemented substantial projects in their sites. I'm also hearing about others who aren't here who have done some cool projects. It looks like, when we leave this country, my training group will have a long list of positive projects to point to, which is a good feeling.
One negative thing is that I question the unintended consequences of some of the projects. Specifically, trash and waste management. One volunteer has implemented a project in their site where the community gathers trash in a central location, then burns the trash in an incinerator purchased by a Peace Corps grant written by the volunteer. Burning trash is illegal in America because it releases dioxins (carcinogenic) into the air. When volunteers talk about the health impact of leaving trash laying around, they talk about flies and water contamination, which are products of food and animal waste, not plastic. The project may be creating a public health problem where little/none existed (plastic sitting on the ground does release polycarbons on a slow time scale). I'm not going to get into more detail because I don't want to be overly critical.
Finally, the big news from IST is that we got to hear Hillary Clinton speak. She was in Marrakech for an international forum on Middle Eastern business climate. Us PC volunteers went over to the palace where the forum was, and she found 30 minutes to talk to us and State Department staff. CNN covered the event: http://edition.cnn.com/2009/WORLD/africa/11/03/morocco.us.peace.corp.senior/index.html?section=cnn_latest.
It was pretty fun. Several people shook her hand (I was stuck in the middle of the row, far from the lucky ones in the aisle). As always, I can't help finding a negative side to any positive story. It sucks that Clinton focused on the oldness of one particular volunteer, rather than the productiveness of all volunteers. I hope I don't sound like a bitter guy saying this and I do think being an 85 year old in PC is pretty cool. But I believe that PC is generally perceived as this quirky organization that doesn't accomplish anything tangible. It would have been nice for Clinton to talk about the work that volunteers do in Morocco, rather than the age of one. Do I sound bitter?
Hope all is well! Going back to my site today and tomorrow.
I live in rural Morocco. Jbel Ayache – one of the tallest mountains in North Africa – and several other gigantic peaks tower over the village I call home. Though the mountains are beautiful, I cannot look at them without noticing how denuded they are. Almost every large tree has been cut down. Little new growth exists. The small trees and bushes that remain cling to jagged rocks.
Because of the altitude, our winters are extremely cold: we rely on wood harvested from the forest to heat our houses. In the past, the forest came up to the edge of the village. Men would cut down massive trees right by the side of the road, then sell them to big logging companies. This was a major source of village income, but those trees aren’t around anymore. Instead of picking up logs by the side of the road, the loggers now purchase harvesting rights for land deeper into the mountains. Every morning we see big lorries rumble by; in the afternoon, they rumble by again loaded high with wood.
My 73-year-old host dad has no sons, so he is responsible for collecting the family’s wood. He wakes up at five or six in the morning, rides his mule for two hours, then cuts down oak and cedar trees with an axe for at least four hours. Usually he gets back at two or three in the afternoon, eats a meal, then immediately falls asleep for the rest of the day. Waking for the evening meal, he complains about his sore joints. I once went with a friend to try my hand at cutting. Oak, I discovered, is a very hard wood, and the tree must be cut into pieces that fit on a mule’s back. Now I pay someone else 50 Moroccan dirhams (Dh24) per mule load to cut my wood for me.
The primary means of income in my village is the herding of sheep and goats. When I hike in the mountains, it is difficult to be alone; I inevitably run into a shepherd and his sheep. These animals – there are hundreds of thousands of them – eat any shoot poking out of the ground, effectively destroying the next generation of trees. But people have lived and herded in these mountains for centuries without placing undue stress on their resources. I asked my host father, who loves to talk about the past, what had changed. “The road changed everything,” he told me. Twenty-five years ago, lorries couldn’t reach the forest. Selling sheep at souq meant crossing a 10,000 foot mountain, which cut into profits. Anyway, there was a much lower demand for meat in urban Moroccan markets, as few people could afford it.
A village 28 kilometres away from mine has already cut down all the trees from the land near their village. The wealthiest residents buy their wood from neighbouring towns. Most people, however, can only burn small, dried-up bushes that barely produce enough heat to cook food, let alone heat a house. I have been to this village in winter. The herders and their flocks are gone in search of warmer weather. Those who remain wear thick wool jellabas to attempt to keep out the cold. During the day, people rarely leave the house, and most conversations focus on how cold it is. Nights are spent huddled together in a common room.
The example of our neighbours is just one of many reminders of the dangers of resource depletion. The scope of the problem – dwindling forests, scarce grazing land, water washing away unanchored topsoil – is obvious to anyone who is remotely involved in community life. Yet next to no action has been taken. Morocco’s department of water and forest has even offered villages like mine a deal: they will plant trees if everyone agrees to stay off the land for five to 10 years, until the trees mature. Furthermore, they will compensate the community to the tune of 250 Moroccan dirhams (Dh120) per hectare per year. But very few communities, including mine, have accepted the offer; even when they have, the promise to stay off the land has typically been broken.
Because enforcement is lax, no individual has any incentive to change his consumption. This applies even to would-be conservationists: unless everyone is on board, one family’s sacrifice won’t protect the resource. If, for example, my friend Driss reduced his flock from 200 to 100 sheep, it would make his family much poorer. And without similar action from other community members, it would make no difference: someone else would probably respond by increasing the size of their flock. It wouldn’t be hard: giving away sheep is a common government practice. Just recently, the King distributed a gift of 5,000 sheep to the residents of our nearest market town. Even if an entire community wanted to sign on to the government deal, they would surely be wary of neighbouring villages taking advantage of their now-unguarded grazing land. This is partially a standard tragedy of the commons, and partially bad blood: before the French colonised this part of Morocco, these tribes often fought each other.
The solution is elusive, and there’s no quick fix. Topsoil takes a long time to build up to the point where it can support trees. All I can see when I climb these mountains is loose rock. This autumn, there have been heavy thunderstorms, and there is no soil to absorb rainfall anymore, so the water rushes downhill. Our rivers run brown with the last dregs of our soil. Last Saturday, some nearby fields were completely washed away, their corn completely destroyed. Several families lost their apple crops. Within the week, the men will be back in the forest, doing the only thing they can to stay warm: cutting down more trees.
Update
Im in Marrakech now, helping with In Service Training (IST) for newer volunteers. They've been in site for 6 months now, so this training is supposed to help them think about how they can use what they've learned about their sites to implement projects. Me and 5 other volunteers from my training stage were invited to talk about our projects and how the lessons we've learned are applicable in others' sites. It's been a good experience; I believe that I've been helpful.
One very positive thing about IST has been seeing the other 5 volunteers from my stage. I'm sometimes negative about Peace Corps and the small impact that volunteers have, but these 5 have all successfully implemented substantial projects in their sites. I'm also hearing about others who aren't here who have done some cool projects. It looks like, when we leave this country, my training group will have a long list of positive projects to point to, which is a good feeling.
One negative thing is that I question the unintended consequences of some of the projects. Specifically, trash and waste management. One volunteer has implemented a project in their site where the community gathers trash in a central location, then burns the trash in an incinerator purchased by a Peace Corps grant written by the volunteer. Burning trash is illegal in America because it releases dioxins (carcinogenic) into the air. When volunteers talk about the health impact of leaving trash laying around, they talk about flies and water contamination, which are products of food and animal waste, not plastic. The project may be creating a public health problem where little/none existed (plastic sitting on the ground does release polycarbons on a slow time scale). I'm not going to get into more detail because I don't want to be overly critical.
Finally, the big news from IST is that we got to hear Hillary Clinton speak. She was in Marrakech for an international forum on Middle Eastern business climate. Us PC volunteers went over to the palace where the forum was, and she found 30 minutes to talk to us and State Department staff. CNN covered the event: http://edition.cnn.com/2009/WORLD/africa/11/03/morocco.us.peace.corp.senior/index.html?section=cnn_latest.
It was pretty fun. Several people shook her hand (I was stuck in the middle of the row, far from the lucky ones in the aisle). As always, I can't help finding a negative side to any positive story. It sucks that Clinton focused on the oldness of one particular volunteer, rather than the productiveness of all volunteers. I hope I don't sound like a bitter guy saying this and I do think being an 85 year old in PC is pretty cool. But I believe that PC is generally perceived as this quirky organization that doesn't accomplish anything tangible. It would have been nice for Clinton to talk about the work that volunteers do in Morocco, rather than the age of one. Do I sound bitter?
Hope all is well! Going back to my site today and tomorrow.
Monday, November 2, 2009
Maternal and Child Health Workshop
First, thanks for the comments. I enjoy sharing the experiences that I've had in Morocco and I'm glad that other people enjoy reading about them.
On the 28th, 29th, and 30th of October, I hosted a Maternal and Child Workshop for 25 local women in my souq town. I'm going to write up a long report of it at some point and post that report here, but in the mean time, here is an account of the workshop.
I started thinking about this workshop one year ago, when Mara Hansen, another volunteer, hosted a similar one that I was involved in. In June and July of this year, I started recruiting women for the workshop. This involved riding my bike a lot to different villages, trying to find interested women. Luckily I had built up relationships in these villages in the past year. Early in the summer I also started talking with the doctors and midwives about the curriculum for the training and when we ought to host it. Simultaneously, I was working with the Ministry of Health in my provincial capital to make sure that we had there support.
After some miscommunication and scheduling difficulties with the Ministry, the training was officially scheduled for October 28, 29, 30. So I had to go back to each village to tell the women the details. Then, a week before the stage, I had to start working on logistical details for the women.
Tuesday afternoon (27th), there were some 10 women in Tounfite. We had dinner with them at a family's house who was hosting the women for the week. They were in a good mood. I was feeling very nervous. There were still 15 women missing! I knew that some of them would be staying with family in Tounfite and that others would be coming early tomorrow morning, but, throughout the training, I was often worried about things that I could not control.
Wednesday morning we met at the health clinic. Two Ministry midwives were supposed to be leading the training, but just that morning one had been called away to Khenifra for a Ministry meeting. The one who had been called away (named Wafa) was at last year's training, so she was going to be taking the lead; this was a disappointing development. The other midwife (Rachida), although inexperienced, spoke Tamazight, which is a big help because it means that the training can move more quickly and fluidly without waiting for translations. The other headache of that day was that the Ministry of Health officials (who were giving introductory remarks)coming from Khenifra were 45 minutes late. They also didn't bring the right number of booklets for the women. Besides these two difficulties, I think the first day went really well. At dinner that night, women who had attended last year's training told me that they liked Rachida a lot because she was a Tamazight speaker. The main lessons for that day were pre natale care and birthing.
Thursday was filled with more complications. Today, Wafa was in Tounfite, but Rachida was called away to Khenifra. After 30 minutes of Wafa leading the session, there was a minor emergency. A woman came into the health clinic: she was in labor! Wafa obviously had to go take care of the situation, so me and the other volunteers quickly talked about what we were going to do to fill the time. We didn't know how long Wafa would be gone. We decided to break the women up into small groups and have each volunteer lead a small review session. The session with my small group went really well; the women were engaged and on top of the material. My group happened to have my host mom in it; she was ashamed at times to be talking about birthing stuff in front of me.
The woman in labor ended up needing more attention than the Tounfite health clinic could provide her, so she was driven to Midelt in an ambulance, with Wafa staying behind. (I was relieved that the woman was having complications and needed to be driven away - how awful is that?) Wafa returned to the training room and got things going again. The rest of that morning went well.
Thursday afternoon, the doctor from my village came and did basic hygiene and first aid lessons with the women. She was visibly impatient with their lack of focus, but on the other hand, she did a good job of calling women out and making sure that they understood the lessons. Later in the afternoon, myself and other volunteers led two health lessons. In the first lesson, we did a skit where a man (me) coming back from the bathroom doesn't wash his hands with soap and he gets sick. When we asked the women why he was sick, they were quick to say that he hadn't washed the microbes off of his hands. This was a great confirmation that they had understood the doctor's lesson from earlier that afternoon. (Throughout the training, at meals, the women consistently washed their hands with soap. This doesn't sound like much, but it's a huge deal. And if a woman didn't wash with soap, the others would yell at her.) The other lesson was about making oral rehydration liquid, which is for people with diarrhea. I had been nervous about having volunteers lead lessons, but I think we did a really good job of it. Our lessons were more interactive than the ministry's lessons and I think the women enjoyed seeing us up there.
Friday morning, the women covered post natale care and family planning. I wasn't present in the actual training room, but female volunteers who were there told me that a condom was passed around (a big deal). Family planning is a critical lesson because lots of women don't understand how to take birth control correctly, resulting in unwanted pregnancies. In my opinion, the best way to reduce maternal and infant mortality is to prevent unwanted pregnancies.
Friday afternoon was the big finale. I had invited men from every village. The men I invited were those who had helped me recruit women from their village. We broke into 4 different groups, clustered by tribal relationships (Ait Moussa, Ait Fadouli, Ait Sliman, and Ait Tounfite). In the small groups, with the help of a volunteer facilitating the discussion, the women were supposed to quickly summarize the five most important lessons of the workshop (importance of seeking pre natale care, importance of birthing in the health clinic, hygiene, oral rehydration liquide, and family planning). Then, the men and women were supposed to discuss amongst themselves what the biggest health problems were in their village and which lesson best applied to that health problem. They were supposed to discuss the idiosyncrasies of their village (eg Ait Sliman is especially far from a health clinic) and what that meant for their ability to implement the lessons from the training. THEN, the group was supposed to decide what was the best course of action. Working first with the Ait Moussa group, our discussion went really well. One of the men took the lead (I'd asked him to do so beforehand) and did a great job of directing the conversation. We decided that we needed to have one meeting with men (mostly about importance of pre natale visits) and one meeting with women (about a range of lessons). The man would be in charge of inviting people. Our doctor will be invited and I will help her and the women communicate the lessons. After finishing with Ait Moussa, I helped Ait Sliman, which was (unsuprisingly) a little more difficult. However, in the end, they came to the same conclusion: that they needed to do community meetings and education with the help of me and their nurse. I was really nervous about this part of the workshop, but it could not have gone better. I believe it was the most important session and that it will be the catalyst to significant behavior change in my communities...we'll see.
After meeting in the small groups (and tea), we reconvened in a big group. A representative from each group had to explain their group's community plan. Tounfite, Ait Moussa, and Ait Sliman did a pretty good job of explaining to the others what they wanted to do. A woman from Tounfite did an excellent job; the work that will happen in Tounfite as a result of this training should be very good. Finally, was Ait Fadouli. No men from their villages had shown up, so it was mostly up to this 23 year old woman from a particuraly isolated village to lead the charge. She is unmarried and has worked in Rabat and Casablanca; clearly an anomaly in her village. She has a very strong personality.
She stood up and made the best speech that I have ever heard in person. The theme of her speech was that people in these villages need to help each other; the government is corrupt and sitting on its hands. Basically, it's up to us to help ourselves. She told the men that it was shameful for them sit not take care of their women; that the women were the heart and soul of the family and that they deserved proper care. She told the women that it was shameful for them to be witness to the oppression of their sisters, friends, and themselves and not stand up for themselves. She told the women that they had to be more assertive and less afraid. I'm so glad that my Tamazight has gotten to a level where I could understand what she said, because it was amazing. Sitting there in the room at the culmination of the training, I was fighting back tears.
It's hard not to feel really good about the training. I felt like I was taking a risk by inviting the men and asking them to engage with womens' problems, but they did. The whole time I was nervous because I had very little control over whether or not people were going to invest in the training. But I think that's a good sign that I'm doing development work: in the end, people have to help themselves.
But this is really just the beginning. I have 6 villages that are now asking me to come smaller, one day versions of this workshop in their community. That, ultimately, was what I wanted from the training, but it's going to be a lot of work. If those meetings happen, I think it will validate the training. Another way we have of measuring the impact of the training is that we gave each woman a "referral" card, which has a picture of a pregnant lady going to the health clinic. Each card has the name of the woman on it. The idea is that the woman will give the card to her pregnant woman to remind her to go to the health clinic, who will then give the card to the doctor at the clinic. That way we will be able to count a) if people are making referrals and b) which women are making those referrals. I'm a little unsure about whether people will buy into the idea of referral cards, but I think it's worth trying. Another way to measure the effectiveness of the training is to compare number of pre natal visits before and after the training, but that's not a great method of measuring
In conclusion, it was a great week. The women were happy all week long and I think they absorbed some valuable information. I want to thank: the volunteers who helped me run the training (Kristen, Eric, Jed, Falisha, Taryn, and Dan), the volunteers who built my capacity to do this (Mara, Dave, and Kristin), the Ministry of Health staff who helped run the training (Selua, Wafa, and Rachida), the Ministry of Health people in Khenifra who gave me the stamp of approval (mostly Sidi Aissa), my PC programming staff (Mostafa and Rachid), the family who housed and fed the women for the training (Mamaksu and Baha) and most importantly, the women and men who came, participated, and engaged.
Update
I'm in Marrakech, leading sessions for IST (in-service training) for volunteers who have been in the country since March. I have a lot of free time here in between sessions and unlimited computer access (with Internet), so I'm going to be working on my grad school apps.
On the 28th, 29th, and 30th of October, I hosted a Maternal and Child Workshop for 25 local women in my souq town. I'm going to write up a long report of it at some point and post that report here, but in the mean time, here is an account of the workshop.
I started thinking about this workshop one year ago, when Mara Hansen, another volunteer, hosted a similar one that I was involved in. In June and July of this year, I started recruiting women for the workshop. This involved riding my bike a lot to different villages, trying to find interested women. Luckily I had built up relationships in these villages in the past year. Early in the summer I also started talking with the doctors and midwives about the curriculum for the training and when we ought to host it. Simultaneously, I was working with the Ministry of Health in my provincial capital to make sure that we had there support.
After some miscommunication and scheduling difficulties with the Ministry, the training was officially scheduled for October 28, 29, 30. So I had to go back to each village to tell the women the details. Then, a week before the stage, I had to start working on logistical details for the women.
Tuesday afternoon (27th), there were some 10 women in Tounfite. We had dinner with them at a family's house who was hosting the women for the week. They were in a good mood. I was feeling very nervous. There were still 15 women missing! I knew that some of them would be staying with family in Tounfite and that others would be coming early tomorrow morning, but, throughout the training, I was often worried about things that I could not control.
Wednesday morning we met at the health clinic. Two Ministry midwives were supposed to be leading the training, but just that morning one had been called away to Khenifra for a Ministry meeting. The one who had been called away (named Wafa) was at last year's training, so she was going to be taking the lead; this was a disappointing development. The other midwife (Rachida), although inexperienced, spoke Tamazight, which is a big help because it means that the training can move more quickly and fluidly without waiting for translations. The other headache of that day was that the Ministry of Health officials (who were giving introductory remarks)coming from Khenifra were 45 minutes late. They also didn't bring the right number of booklets for the women. Besides these two difficulties, I think the first day went really well. At dinner that night, women who had attended last year's training told me that they liked Rachida a lot because she was a Tamazight speaker. The main lessons for that day were pre natale care and birthing.
Thursday was filled with more complications. Today, Wafa was in Tounfite, but Rachida was called away to Khenifra. After 30 minutes of Wafa leading the session, there was a minor emergency. A woman came into the health clinic: she was in labor! Wafa obviously had to go take care of the situation, so me and the other volunteers quickly talked about what we were going to do to fill the time. We didn't know how long Wafa would be gone. We decided to break the women up into small groups and have each volunteer lead a small review session. The session with my small group went really well; the women were engaged and on top of the material. My group happened to have my host mom in it; she was ashamed at times to be talking about birthing stuff in front of me.
The woman in labor ended up needing more attention than the Tounfite health clinic could provide her, so she was driven to Midelt in an ambulance, with Wafa staying behind. (I was relieved that the woman was having complications and needed to be driven away - how awful is that?) Wafa returned to the training room and got things going again. The rest of that morning went well.
Thursday afternoon, the doctor from my village came and did basic hygiene and first aid lessons with the women. She was visibly impatient with their lack of focus, but on the other hand, she did a good job of calling women out and making sure that they understood the lessons. Later in the afternoon, myself and other volunteers led two health lessons. In the first lesson, we did a skit where a man (me) coming back from the bathroom doesn't wash his hands with soap and he gets sick. When we asked the women why he was sick, they were quick to say that he hadn't washed the microbes off of his hands. This was a great confirmation that they had understood the doctor's lesson from earlier that afternoon. (Throughout the training, at meals, the women consistently washed their hands with soap. This doesn't sound like much, but it's a huge deal. And if a woman didn't wash with soap, the others would yell at her.) The other lesson was about making oral rehydration liquid, which is for people with diarrhea. I had been nervous about having volunteers lead lessons, but I think we did a really good job of it. Our lessons were more interactive than the ministry's lessons and I think the women enjoyed seeing us up there.
Friday morning, the women covered post natale care and family planning. I wasn't present in the actual training room, but female volunteers who were there told me that a condom was passed around (a big deal). Family planning is a critical lesson because lots of women don't understand how to take birth control correctly, resulting in unwanted pregnancies. In my opinion, the best way to reduce maternal and infant mortality is to prevent unwanted pregnancies.
Friday afternoon was the big finale. I had invited men from every village. The men I invited were those who had helped me recruit women from their village. We broke into 4 different groups, clustered by tribal relationships (Ait Moussa, Ait Fadouli, Ait Sliman, and Ait Tounfite). In the small groups, with the help of a volunteer facilitating the discussion, the women were supposed to quickly summarize the five most important lessons of the workshop (importance of seeking pre natale care, importance of birthing in the health clinic, hygiene, oral rehydration liquide, and family planning). Then, the men and women were supposed to discuss amongst themselves what the biggest health problems were in their village and which lesson best applied to that health problem. They were supposed to discuss the idiosyncrasies of their village (eg Ait Sliman is especially far from a health clinic) and what that meant for their ability to implement the lessons from the training. THEN, the group was supposed to decide what was the best course of action. Working first with the Ait Moussa group, our discussion went really well. One of the men took the lead (I'd asked him to do so beforehand) and did a great job of directing the conversation. We decided that we needed to have one meeting with men (mostly about importance of pre natale visits) and one meeting with women (about a range of lessons). The man would be in charge of inviting people. Our doctor will be invited and I will help her and the women communicate the lessons. After finishing with Ait Moussa, I helped Ait Sliman, which was (unsuprisingly) a little more difficult. However, in the end, they came to the same conclusion: that they needed to do community meetings and education with the help of me and their nurse. I was really nervous about this part of the workshop, but it could not have gone better. I believe it was the most important session and that it will be the catalyst to significant behavior change in my communities...we'll see.
After meeting in the small groups (and tea), we reconvened in a big group. A representative from each group had to explain their group's community plan. Tounfite, Ait Moussa, and Ait Sliman did a pretty good job of explaining to the others what they wanted to do. A woman from Tounfite did an excellent job; the work that will happen in Tounfite as a result of this training should be very good. Finally, was Ait Fadouli. No men from their villages had shown up, so it was mostly up to this 23 year old woman from a particuraly isolated village to lead the charge. She is unmarried and has worked in Rabat and Casablanca; clearly an anomaly in her village. She has a very strong personality.
She stood up and made the best speech that I have ever heard in person. The theme of her speech was that people in these villages need to help each other; the government is corrupt and sitting on its hands. Basically, it's up to us to help ourselves. She told the men that it was shameful for them sit not take care of their women; that the women were the heart and soul of the family and that they deserved proper care. She told the women that it was shameful for them to be witness to the oppression of their sisters, friends, and themselves and not stand up for themselves. She told the women that they had to be more assertive and less afraid. I'm so glad that my Tamazight has gotten to a level where I could understand what she said, because it was amazing. Sitting there in the room at the culmination of the training, I was fighting back tears.
It's hard not to feel really good about the training. I felt like I was taking a risk by inviting the men and asking them to engage with womens' problems, but they did. The whole time I was nervous because I had very little control over whether or not people were going to invest in the training. But I think that's a good sign that I'm doing development work: in the end, people have to help themselves.
But this is really just the beginning. I have 6 villages that are now asking me to come smaller, one day versions of this workshop in their community. That, ultimately, was what I wanted from the training, but it's going to be a lot of work. If those meetings happen, I think it will validate the training. Another way we have of measuring the impact of the training is that we gave each woman a "referral" card, which has a picture of a pregnant lady going to the health clinic. Each card has the name of the woman on it. The idea is that the woman will give the card to her pregnant woman to remind her to go to the health clinic, who will then give the card to the doctor at the clinic. That way we will be able to count a) if people are making referrals and b) which women are making those referrals. I'm a little unsure about whether people will buy into the idea of referral cards, but I think it's worth trying. Another way to measure the effectiveness of the training is to compare number of pre natal visits before and after the training, but that's not a great method of measuring
In conclusion, it was a great week. The women were happy all week long and I think they absorbed some valuable information. I want to thank: the volunteers who helped me run the training (Kristen, Eric, Jed, Falisha, Taryn, and Dan), the volunteers who built my capacity to do this (Mara, Dave, and Kristin), the Ministry of Health staff who helped run the training (Selua, Wafa, and Rachida), the Ministry of Health people in Khenifra who gave me the stamp of approval (mostly Sidi Aissa), my PC programming staff (Mostafa and Rachid), the family who housed and fed the women for the training (Mamaksu and Baha) and most importantly, the women and men who came, participated, and engaged.
Update
I'm in Marrakech, leading sessions for IST (in-service training) for volunteers who have been in the country since March. I have a lot of free time here in between sessions and unlimited computer access (with Internet), so I'm going to be working on my grad school apps.
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