Repressive Society

As my last post mentioned, living in Morocco is different for a lot of reasons. But one of the biggest differences is the social restrictions placed upon people by societal expectations. Not to say that the USA is without such expectations, but it is nothing like Morocco. I should mention that the situation in my village is very different from that in a bigger city.

The biggest example of this is expectations about interaction with the opposite sex. For men, having a friendship with a female is not prohibited, but it would be considered very strange. There is no reason to be friends with a female. For women, on the other hand, its very difficult to be friends with a man. Mostly because people will assume that the relationship has a sexual aspect to it, which would be shameful.

As for romantic relationships, they prohibited. I do not know of any inter gender romantic relationships in my community. If they exist, Im pretty sure that Ill never find out about them. But I doubt that they exist. Women must be chaste before they marry. If a community found out that a girl was having a relationship with a boy, it would be totally damaging to her reputation.

For females, I have no idea what this sort of repression leads to, but for males, its not good. Most males, even married ones, are completely innappropriate with the jokes and comments that they make about women. American men arent perfect, but its nothing like they terrible things that Ive heard here. Mostly they act like 15 year old boys who have never had a real conversation with a woman. In Khenifra, this repression also leads to finding other sources of sexual activity. Men see prostitutes. Often. I am near one of the main hubs of prostitution in Morocco, so it is especially bad in our region. When I go to this particular town, men think that Im going there soley to visit prostitutes. I tell them Im not and they dont believe me. The sex industry here is pretty depressing, certainly a consequence of the unrealistic expectations placed upon unmarried people.

Another aspect of repression is the expectations surrounding alcohol. Moroccans of any age are not legally allowed to drink. But that doesnt mean that people dont drink. It just means that people drink much more irresponsibly. Young men get there hands on alcohol and drink all of it. People do not drink socially here; they drink to get drunk. Strangely, after they get drunk, boys in my village come to public settings and embarrass themselves in front of the community. They act like complete idiots and every talks badly about them.

Obviously, for me, this is one negative aspect of Moroccan society. This repressive attitude may have its roots in relgious rules, but I believe the reason for all the rules go well beyond the relgious. People who are not observant Muslims, who do not pray, still recognize the expectations placed upon them. And its my belief that these expectations lead to very unhealthy attitudes towards certain things (like the opposite sex and alcohol).

Update
Had Thanksgiving in Tounfite with about 20 other volunteers. It was wonderful. We bought two turkeys, fed them for a month, then slaughtered, defeathered, and prepared them ourselves. It was a good experience. I cut a turkeys head off with an axe myself. The dinner and everything was wonderful. Thanksgiving is my favorite holiday and spending it with my friends was awesome. But I really did miss not being home and being with my family.

Everything else is going well. My main projects right now are following up to the midwife project, continuing toothbrushing lessons in schools, and figuring out this big water infrastructure project in my site. The water project involves a lot of political barriers that I have figure out. There have been some very frustrating aspects so far, but Im hopeful that in the end it will work out.

Take care.

Things that are different

A couple months ago I posted an entry about how its difficult for me to know how to explain Morocco in my blog because Im used to things that would be interesting to you all. Well Ive been thinking about those things and compiled a list of them.

Almost all houses in my village and surrounding communities are made of mud and dirt. Its actually a really good thing because the walls are like 2 feet thick and so they insulate really well.

I live at the base of a 10000 foot mountain.

There is one store in my community where I can buy the barest essentials. I buy almost everything on my weekly trip to market, 28km away.

Nearly everyone in my village has farm animals. Mules, chickens, donkeys, cows. Lots of people have big flocks of sheep and or goats. Animals are critical to survival.

People plow their fields here using mules. They know what tractors are.

Bread is eaten at every meal. Wheat is the staple food. People are incredulous when I tell them I dont eat bread in my house.

Most people here pray 5 times a day. I have not yet met a Moroccan who has told me he doesnt believe in God. One more educated guy has been for weeks slowly admitting to me that he doesnt take the whole religion thing very seriously.

Most men see prostitutes fairly regurarly.

Most people in my site cant read. Those who can read read the Koran almost exclusively. My estimate is that I individually have read more books than the combined population of my greater Caid area. A region that includes maybe 20000 people.

I live in a patriarchal society. When there is a marriage, the wife moves into the husbands familys home.

There are men who have flocks of sheep a couple hundred heads big. They spend weeks at a time in the mountains herding.

My village has had electricity for about 13 years. There are nearby villages and homes that do not have electricity or running water.

Speech here is full of references to God.

The best and easiest way for men in my village to get ahead in life is to join the army. They serve for several months a year, but when they come home they are the richest people in town.

It is entirely impossible for me to date someone from my village. I would have to get married.

Update

Things are going well. I feel as though I have less time for writing for the blog, but thats because Ive got more of other stuff going on. So thats good. This past week I travelled with a man from my neighboring village to another village where people are working on a similar project. I think it was a good trip.

The big news in my village is that about half of its population is gone. Apparently everyone who has big herds of sheep leaves the village for the winter and goes South with their sheep. I guess there is no grass for them to eat during the winter here. People say that they will be gone until May. In related news its getting kind of cold in my site. I use my wood stove a lot.

Hope all is well.

Community Health Assessment

This is basically a summary of what Ive learned over the last 6 months, in terms of health in my community. Names of towns changed to letters A through I.

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

Election

On Wednesday morning at 5 am local time, I stepped outside to walk to my room and go to bed. I had just watched Obama's acceptance speech. The mosque nearby sounded the morning call to prayer. Half a world away, I've never been prouder to be an American.

This week 55 volunteers and I had a mandatory "In-Service Training" to discuss our successes and challenges from our first 6 months in site. This meant that we were all together in a hotel in Azrou to watch the election returns come in. About 40 volunteers stayed up to watch the returns come in. Not surprisingly, Peace Corps volunteers are almost all Obama supporters: I believe only one person amongst us voted for McCain.

When the election was called, everyone stood up and cheered and hugged and screamed. As we waited for the speech, we sang Our Country Tis of Thee and America the Beautiful. I'm a fairly unpatriotic person, but that changed Tuesday night. And then Barack gave his speech. It was the same sort of stuff that he's been saying the whole campaign, but it was a beautiful speech. America has plenty wrong with it, but this was an accomplishment for the country.

Living abroad makes me even more appreciative of the victory. Lots of people in Morocco have talked about the election. Mostly they are pro-Obama, but there are also lots who say they don't like Obama because he is black (there really isn't any stigma attached to racism here). But the vast majority of people that I've talked to have told me they don't think that Americans would vote for Obama because he is black. It is hard to understate this: by electing him, we have sent a message to the rest of the world at a time when our standing has fallen significantly. Now that Im back in my community, everyone wants to talk about the election and whats going to change. They say, mbruk Obama (congratulations). They all know that he is the first black president. There are lots of jokes about the black man in the White House.

So its exciting to be here. I know that there is no way that Obama can live up to the expectations people have for him, but so what?

Update

Just got back from week long IST, which was fun. Got to see all the people that I had training with and hadnt seen in 6 months. But Im also really glad to be back in my site.

My Host Family

My Host Family
When I first met my host family, I was unhappy with the situation. I had just spent my Peace Corps training with an awesome family full of kids and life. They were relatively wealthy and life there was good. My host family in my site, however, was different. My host dad is 72-years-old and very difficult to understand. He looks angry. My host mom is 38-years-old, his sixth wife. Obviously not a relationship based upon love. No kids. The food was pretty bad. Most dinners we had either milky rice or pasta. My first week with them, I was really worried about the rest of the time that I had to spend in the house. When I was sick at one point (probably from their food), it was the closest I’ve been during my service to thinking I wanted to go home.

As I got to know them better, things improved. It turns out my host mom is super nice. She wants to help in any way she can. She also speaks clearly and is good at understanding my shitty Tamazight, which is a relief. Beneath his rough exterior, my host dad is also a great guy. He can be totally hilarious at times and he always stands up for me in town, which is nice. The best example of this was, early in my service, he went with me to the local political leader and police when someone in town harassed me. It was a long frustrating day and it was really good to have him accompany me. The whole time he said things like: “if that guy says another word to you, I’m gonna …”

Nonetheless, during my three months in homestay, I was frustrated. The food got a little better, but not much. I really hated eating the same shitty thing day after day after day. More than that, there are parts of Moroccan cultural interactions that really got on my nerves. For example, at meals my host family was always telling me to eat more. At first it’s hard to know how to say no. And even when you figure out to say no, they keep insisting that you eat more. Something else that got to me was that my host mom and dad started fighting amongst themselves frequently. It was never violent, but it was unpleasant to be around. They would fight in front of me and ask me to take sides. One day my host mom told me that if I wasn’t staying at the house she would have packed her stuff and moved back home. Mostly, it was just tough having to spend so much time with these people – I’m sure I would have been frustrated with most people.

But now that I’ve moved out of their house and into my own, I couldn’t be happier or feel luckier to have them as my host family. In addition to being really nice, my host mom has turned out to be helpful with work. She attended the midwife training that we put on last week; in fact, she was instrumental in helping me recruit and organize women from our village to go to it. She is my link to the female world and I learn a lot from her. Moreover, she likes me a lot and I know that she does nothing but tell her friends how good I am. It is partly thanks to this, I believe, that I’m having warmer relationships with other women and girls in town.

The best part about my dad is that he is hilarious. He always sings these songs in this traditional Berber style. I used to think that he was singing some old songs, but no. As my language improved I realized that he just improvises songs about the things going on around him. For example, “Sma3eel (my name) just said he’s full” or “Mina (my host mom) hit the cat with the stick” or “I’m hungry, bring the tajine.” Or he’ll repeat what someone else just said in song. It’s funny, trust me. In addition to the songs, he also has some great nicknames for me. The most recent one started when I was sick about a week ago. He called me “buhulu.” Having the prefix “bu” attached to a noun means owner of that noun. For example, buautomobile would mean owner of the automobile or butahanut means owner of the tahanut. But I didn’t know what hulu meant. I asked and they pointed to their noses and sniffed. It means snot. So he was calling me owner of the snot. Now whenever we greet each other we call each other buhulu. Besides being funny, my host dad is nice and helpful.

The lesson is that once I got a little space from my host family, I really got to like them. I just don’t want to live with them. When I’m in town (which is nearly always), I go over to their house pretty much every day and spend a couple hours there. It’s a nice thing to do when I have some down time, but I don’t want to sit all alone in my house. I feel completely comfortable there. I end up spending a little more time there than I’d like to: they normally guilt me into staying for a meal or tea or something. But I’m so thankful to have a place where I can go and be with people and be comfortable. I like going outside and talking to whatever guys are hanging around there, but there isn’t the same level of intimacy. The conversations in my host family’s house are much better, probably because we know so much more about each other. The most amazing thing is that I’m finally starting to understand my host dad, which is an accomplishment itself. Out of all the people in the world, a 72-year-old, uneducated, rural, toothless, Tamazight-speaking man is probably one of the most difficult to understand.

Update
So things are still going well. I can’t help but count the time since I was last sick: it’s been about 7 weeks now (which, uncoincidentally, is about when I left my host family’s house). Back in town after the midwife training, the women are still super excited. They greet me around town like I’m the best thing since sliced bread (which hasn’t yet made it to rural Morocco). Now the job is to organize a forum for the women to talk to other women in town. I know that this is happening informally – a woman came into the sbitar on Monday for a pre natal checkup and said that one of the women from the training had convinced her to do it. That was awesome. My adult tooth brushing campaign in my village just ended on Tuesday. I think it went well. People stop me around town and ask me about it. I’m still going to go to the schools and make the kids brush their teeth. Having work is an awesome feeling. Also, two women from the midwife training helped a woman give birth the other day, which went well. So thats pretty cool.
The big thing in my volunteer life right now is that Sunday is the first day of IST – In Service Training. It’s definitely a big milestone in PC service. Everyone from my training group will meet in Azrou for a week. (Azrou is about 3 or 4 hours north of my site. The disappointing thing is that the training was originally planned for Agadir, which is beach paradise). We’ll have more (lame) training sessions and hopefully a few good ones. We all have to write a “community health assessment,” which is basically a report on what we learned during our first five months in site. I’ll be posting that report in this space in a few days. It’s pretty dry, but it also gives a pretty comprehensive look at the health problems of my community. IST is also exciting because I’ll get my first extended break from my site since I’ve been here and I’ll get to see the friends that I made during training whom I haven’t seen since.

Midwife Training

Midwife Training

This past week three other volunteers and I hosted a traditional birth attendant (TBA) training in Tounfite. It was the culmination of several months work. There were some problems, but I think it was an unqualified success.

Mara Hansen, a fellow volunteer, started organizing this workshop several months ago, before I was even in Morocco. In her community, she had been moved by several stories of death during childbirth. Since her community is isolated and the government provided medical facilities are lacking, most women give birth in their homes, with the help of other women. We have little power to change the services provided by the Ministry of Health, so the idea is to empower local women as midwives so that the community can be more self-sufficient. Ideally, the government would be providing these services, but some of these villages are so isolated that it is difficult for them to do so. When I got to my site, Mara worked hard to include me on the project. My community is equally isolated, so there is a similar problem here as in her village. I set up some meetings and she came to my site to recruit the women. I spoke with the men who had concerns about sending their women away and Mara talked to the women. The other two volunteers involved were David and Kristen LaFever, a married couple in Tounfite. They traveled to a village much more isolated than either Mara’s or mine and recruited two women from there.

Still before the training, there was a ton more work to do. We had to find ways to feed all these women and places for them to sleep. We had to set the program with the nurses who would be running the training. We had to go to the Ministry of Health and get their approval. Etc etc etc, a lot of boring stuff. But onto the training. I wasn’t able to observe the actual training (because I’m a man) so I’m just going to give my perspective on things, supplemented with what I was told about the training.

On Sunday morning, the transit that I had arranged for arrived in my village to pick up the women. It was raining and the transit was early so the women weren’t ready. One told me she couldn’t come that day; could she come tomorrow? It was an inauspicious start and it was clear that a lot of the women were worried about leaving their houses for so long.

When we got to Tounfite, there was time to kill so the women went there separate ways. All the women and us volunteers met later that day for dinner at David and Kristen’s host family. The LaFever’s host family is just their host mom (who is widowed) and their host sister (who is divorced). The two women make a living by cooking for weddings and other events, so they were the perfect family to help us host the training. The opening dinner went well. Some of the older women are pretty feisty and love to joke around. 70-year-old Rkiya Kouru saw me dancing in the kitchen and came up and danced alongside me. Rkiya is pretty hilarious; she’s constantly making jokes. Talking with the women from Mara’s site, they were amazed to learn that I helped with harvest in my site – men in their community do not do that sort of work. At the end of the night, we accompanied some of the women back to the places they would be sleeping. Rb-Ha, who is probably 72 years old, cried when we dropped her off at her house, thanking us for our generosity.

Monday morning we all met in the sbitar (health center) to start the training. Two professional midwives would be leading the training, with a younger local girl helping with translation (the midwives don’t speak Tamazight and most of the women don’t speak Arabic). Mara and Kristen would sit in on the training and help out when they could, while Dave and I were relegated to kitchen duty. We spent a lot of our time preparing tea and food, cleaning up, running errands, and the like. The role reversal was obvious: the women were the focus of the training, learning and being served, while the men were working behind the scenes.

Mara and Kristen were ecstatic with the success of the first morning’s session. The midwives leading the training were really good at what they were doing. Moroccan pedagogy is generally based upon rote memorization, but the trainers were leading an interactive workshop and engaging the women. Given that most of these women hadn’t been to school in maybe 30 or 40 years (if at all), having such competent trainers was crucial. It was a big relief that the quality of the training wasn’t something that we had to worry about.

However, we had our first and biggest problem to deal with. 10 women had spent the night at David and Kristen’s host family’s house. We had told the host family that they could expect 5 or 6. Furthermore, many women told us that morning that they couldn’t stay with the family whom they had stayed with the night before and had nowhere to stay. We panicked a little bit. Before the training, I had asked all of my women if they had a place to stay in Tounfite during the training. I explained to them that it was easier for us if they could stay with family, but if not, we would find a place for them. Every single one of them told me that it was not a problem, but here they were telling me that they could no longer stay with that family. Maryam, a 23 year old from my village told me that she was ashamed to stay with the people she had stayed with last night. Maryam has already been divorced twice, meaning that she’ll probably live with her family for the rest of her life. Her explanation was that it was unacceptable for a woman to be out all day long and then come back for dinner, expecting food without having worked. My host mom, Mina, didn’t know anyone in Tounfite. I had asked a family in Tounfite (whose mother was already attending the workshop) if she could stay with them. So I had the permission from the man of the house. But Mina was ashamed to stay there – the man of the house was out of town and she didn’t feel like it was appropriate to impose on them.

I was frustrated. I think we were all frustrated. If we had known before the training that this would be a problem, we could have planned for it and arranged for more housing. But here we were, stuck with about 15 women who needed somewhere to stay and only an afternoon to arrange it. And why had they said previously that they had a place to stay? At times like these it’s really easy to chalk up such miscommunication to “cultural differences” and leave it at that. I’m not sure if I have a more nuanced explanation. I’m sure that there was a problem in the way I asked or the way I listened or something.

Our immediate solution was a bad one. Before the break for lunch, Mara and I told the women that if they had any place to stay, they needed to stay there. We said that we couldn’t impose so many people on the LaFever’s host family so please find somewhere else to stay.

We left the sbitar on our way to lunch brainstorming all the people in Tounfite that we knew whom we could ask to host a woman. We had a long list of people to ask. But when we got back to the LaFever’s house we made an important decision. No matter whom we asked and how willing they were to host someone, the women would feel ashamed to stay there. If we wanted the women to feel comfortable we only had one choice: to put them all up at the LaFever’s host family. This meant a huge increase in our spending that was unbudgeted for – so it would have to come out of our stipends. But it was the only option if the training was going to succeed.

When we returned from lunch, I realized that our decision was the right one. Many of the women had skipped lunch because they felt too ashamed to impose on someone. They were angry with us and their focus was not on the training. Even after we told them that we had solved the problem and that they were all welcome at the LaFever’s host family, the insult hung in the air for a little while. The silver lining was that, despite the insult and lack of food, no one had gone home. They were committed to the training.

That afternoon came another problem of a different sort. The midwives leading the training had received a letter from the Ministry of Health (their boss) saying that they had failed to evacuate a room in response to a request from Peace Corps volunteers (us). This letter was inaccurate: the room in question was empty and we had not made any requests. Our assumption is that the head of the sbitar in Tounfite made the complaint to the Ministry (there is a lot of friction between the head of the sbitar and the midwives). It was disheartening to witness the women that we were working with (who were doing an excellent job), being undermined by their superior on our behalf. So we wrote a letter to the Ministry saying that there was no problem.

The rest of day one was pretty uneventful, mostly we were reassuring women that they were welcome and that anyone who didn’t have family to stay with could stay with the LaFever’s host family. I was worried that some women would go home rather than impose themselves on someone. Luckily nobody did.

Day two saw more success in the training room. Sitting in our tea preparing room, Dave and I could hear constant clapping and laughter. I really wish that I was able to witness the training, but that was out of the question. One woman, Itto, who is 56 and from my village, had to go home for a day. The wife of her son was sick, so she had to take care of the house. She apologized profusely and I told her to come back the next day if she was able (she did come back). Hanou, 54 and from the most remote village that we recruited from (one of the most remote villages in Morocco) was feeling ill, so she stayed at the host family’s house in the morning, but came to the afternoon sessions.

That day the women doctors who work at the sbitar prepared food for the tea break. They were very involved in the training and excited to help in any way that they could. It seemed that they would come over to the training whenever they had a spare moment. They also promised to make lunch for all of the women on the following day. It was great to see so much enthusiasm on the part of Moroccan health workers. At my local sbitar, I see mostly disdain for the community that I work with. So it was awesome to see the doctors and midwives interacting with the women as equals and treating them with respect.

David, Mara, and Kristen all had other things to take care of that evening, so I was the only volunteer who went to the dinner that night. I’m really glad I did as it gave me an opportunity to interact with the women in a way that I hadn’t before. They were totally comfortable around me and we started joking right away. A ‘representative’ from each community would try to convince me to marry someone from their tribe. Naima from Mara’s community said that I to marry a girl from her tribe because they have lots of apples (which was persuasive). They would extol the benefits of their tribe and I would agree to marriage. Immediately women from another tribe would get ‘angry’ and start arguing about which community was better. The women finally agreed that the most remote tribe was bad (it is really poor) and that I should choose between the other two communities. I said I couldn’t choose, so they came up with a way for me to choose randomly and I ended up choosing Mara’s community. Well, there just happened to be two unmarried women from Mara’s tribe at the dinner! Naturally the next question was: which one do I want to marry? I said I couldn’t choose and that my host mom should make the decision for me. It was pretty hilarious: she made this big show of inspecting the women and asking them all these questions. She ended up choosing Rkiya, who is about 25. Rkiya has one child and is widowed. Her husband was murdered in Rabat because he failed to pay the people he was bribing for his job there. She is pretty quiet. The whole time the women were apologizing for joking around, but it was really enjoyable. It was especially good to spend time with them because I had been worrying about how they were feeling after we told them they couldn’t stay at the LaFever’s host family. Now that they had a place to stay, they seemed to be over it and feeling comfortable.

The final day was by far the most chaotic. For the afternoon session, we had invited moqadems and sheikhs (community leaders) to come and talk with the women. The idea was that the women and the moqadems would make an emergency action plan in case there was a problem in birth that the women were unable to deal with. Inviting these people meant that we had to remind them that they were coming and provide and extra good tea break. Plus we had invited even more people to a closing dinner to be held that night. And there was lots of other running around to tie up odds and ends.

When the men finally showed up (some were late, others didn’t come), it led to what I think was a really productive meeting. It quickly became apparent that there had never been communication between these community leaders and the health staff at the hospital. The protocol for getting and ambulance to the village was unclear. There was a lot of important information passed between the two groups. It’s absurd that it took a foreign association (Peace Corps) to bring these people together in the same room. The sad part was that the meeting made clear that many of these isolated communities are pretty much on their own when it comes to dealing with such things.

We eventually split up into smaller groups, with each community meeting to talk about its specific problems. My sheikh and moqadem were both in attendance, which I was thankful for. They were very helpful in talking about an emergency action plan. Additionally, a doctor who was just assigned to my community last week came. She was instrumental in leading the conversation. My women really like her (she’s a breath of fresh air compared to what they’re used to dealing with). Even beyond working on this project, I’m hopeful that she can bring a lot to my community. The meeting ended with tea and some spectacular break food.

Our final piece of work was to make sure the concluding dinner went well. With the LaFever’s host family helping us, it wasn’t that hard to pull off. They were so helpful the entire week and we couldn’t have done the training without them.

At a café before the dinner, I met the nephew of one of the women attending the training. Moha is 30 some years old and living in Tounfite, although he works at the government building in my community. He had been hosting his aunt, Hada, 50, who lives in Taararte. Taararte is about 28 km down the road from me and pretty much without any help from the government in terms of health care. They have a sbitar in their community, but it is unstaffed and locked shut. Hada was very relived by my doctor’s presence, because she will be making rounds in a van to outer communities.

The dinner was the most fun that I had all week. I had been working behind the scenes most of the time, so I didn’t get to interact with the women that much. Even during the dinner, I had to spend most of my time in the men’s room, entertaining the men we had invited. But I took a couple trips to the women’s room, where they had drums and everyone was dancing. The doctors and midwives from Tounfite had come and everyone was enjoying themselves. I danced a little bit, which everyone thought was hilarious. One of the songs they sang had lyrics that went, “Sma3eel (my Moroccan name) is like the moon.” It’s pretty much the best compliment you can give someone. Even though the celebration dinner wasn’t the real success of the training, it was the best opportunity I got to get a feeling for the mood of the women. They were overflowing with joy and very thankful.

Reactions

Like I said, I think the training was an unqualified success. I can’t imagine it going better. I’m extremely lucky to have capable volunteers around me who helped to include me in the project. The next step is to facilitate meetings between the women we trained and the rest of the women in the community. I also hope to host another training with women from different communities, although that probably won’t happen for a year.

I believe this is the most valuable thing that I’ve done as a health education volunteer so far. The ironic part is that I did very little education myself. My role was primarily bringing people together and making sure the meeting ran smoothly.

The real effect of the training won’t be known for sometime, if at all. There aren’t statistics about maternal or infant mortality during birth, so there’s no way of quantifying the effect the training has had. Something that is completely unquantifiable is the way that we empowered these women. Helping with births and women’s health in general is not highly valued here. I think it was important to let these women know that we value the work that they are doing. I also think it was a good example for the men in my community to see an American man take such action and put women’s health as a priority.

A common refrain amongst volunteers is how unwilling people here are to change their ways. Yet these (mostly older) women, who were sick, tired, and in a completely foreign environment, were willing to sit down and learn for three days. Even though the midwife trainers were wonderful, it would have been really easy for the women to ignore them – they’re young and only speak Arabic. But the women engaged themselves and everyone benefited from the experience. There were women from other communities who heard about the training and showed up to ask if they could watch. At the end of the training, even though they were really tired, the women said they wanted more.

Brush Your Teeth!

Brush Your Teeth!

From my Western perspective, dental hygiene is a problem in my community. I wish that I could do a preliminary survey and find out how many people here brush their teeth, but I don’t think that is an appropriate thing to do. If I had to estimate, I would say that in my entire 450-person community, maybe 5 people use toothbrushes on a regular basis. But there’s really know way for me to know and it could be as low as 0. It’s not just my community; I’d say that the idea of dental hygiene is one that is fairly new in Morocco.
So I’ve decided to make dental hygiene my first, independent, education project. It doesn’t take a large investment of resources or time. I also think that people can see the benefit of their behavior change fairly easily (maybe except for those people whose teeth are too far rotted brushing may just push the teeth out).
In the schools I’ve been talking to the kids about brushing their teeth. Basically I tell them that if they don’t brush their teeth, their teeth will rot and fall out, just like the older people in my community. I try to be very blunt about it. I brought in a hard-boiled egg soaked in Coke, which made it turn brown, and then had the kids use toothbrushes to clean the egg. I also brought in a model clay mouth for the kids to practice brushing teeth on. (Side note, hands-on education is not apart of the teaching pedagogy here; it’s all about rote memorization.) Since doing the education, I’ve been coming into the school on a regular basis during their recess and having all the kids brush their teeth in front of me. It’s pretty funny to watch 30 kids slobber spit and toothpaste all over themselves and realize that this is my job. I think that an activity like teeth brushing is something that, if you’re a child, you need to practice doing over and over and over again until it becomes a habit.
The second aspect of my education is a lot more uncomfortable, although I think that I’ve unnecessarily imposed some of that uncomfortable feeling upon myself. Working with a local association (which basically means talking to one guy), I’ve divided my community up into six different groups (groups made by dividing the community by geographic proximity). On the day of a meeting, in the morning, I tell the people that we’re going to meet in the afternoon. When people slowly show up for the meeting, I tell them about what I’ve been doing in the schools. Then I tell them that my parents reminded me to brush my teeth twice a day every day and that they need to do the same. I feel a little uncomfortable telling grown adults to brush their teeth; telling them to help their kids is sort of a roundabout way of suggesting the idea to them. In the better meetings, the adults have asked about their own teeth and if they too can brush their teeth.
Finally, I’m going to supply the local store with toothpaste and toothbrushes so that once people run out of what I’ve given them, they can easily buy more.
That’s pretty much the plan. I still have one more meeting with adults. And I’m going to keep going into the school and making the kids brush their teeth in front of me. The big question is: will people change their behavior? Well I’m of two minds about that issue.
When I’m feeling pessimistic, it’s easy to be very negative about the impact of this work. Speaking generally, people here are very conservative and don’t easily change their ways. Pretty much everyone does everything the same way, which is the same way that their parents did it. Not just with hygiene practices, but also in many different aspects of life, people can’t imagine that there is another way of doing things. People are incredulous when I talk about things in America. Furthermore, I think that a habitual act like brushing your teeth is hard to change. For people to change their habits, they need constant reminders. I can do that to some extent with the kids, but it’s not as good as parents reminding them every night. Which brings up another cultural obstacle that I’m facing: parenting in the way that we think of it is not really a duty of being a father or mother here. Kids pretty much run free and do whatever they want. They don’t really listen to adults and adults don’t try to speak to them. So I’m not just introducing the idea of brushing teeth, I’m introducing the idea of parenting. Which may be harder to change.
When I’m feeling optimistic, I feel as though people might actual end up brushing their teeth. With the kids, I’m planning on really drilling the idea of dental hygiene into their heads. When I see kids on the street I ask them if they brushed their teeth (they tell me they did, but who knows if they’re lying). Kids (and everyone) are going to remember the American who lived in their community for a long time – if I go to the school every week and make the kids brush their teeth, they will remember that. In terms of adults, the most positive thing is that people who weren’t able to come to one of my meetings are approaching me on the street and asking me if I have any toothbrushes or toothpaste. We go to my house and I make them listen to my spiel before I give them the goods. This makes me think that people are talking to each other about what I’ve said and that they’re at least curious. People do complain about how their teeth hurt, so they recognize a problem. Another positive thing is that having my host mom as an ally is a great way for me to reach girls and women that I would otherwise be unable to speak to. Girls have asked her about getting toothbrushes/toothpaste from me (they are too afraid/embarrassed/ashamed/ to approach me). Once I resupply on toothpaste, I’m going to give her stuff to give to people and teach her how to teach others how to brush their teeth. It’s possible that having my host mom work like this will reach more people in a more meaningful way than I am able to.
I believe this idea of toothpaste and toothbrushes is either a) completely new to people here or b) something that people think of as a luxury item only for Westerners. People are always surprised when I say that I bought the toothpastes and toothbrushes in Tounfite (the market town, 28 km away) and how inexpensive they are. So hopefully if people see that it’s something they can afford they will buy into it. It’s also something that people are not at all ashamed to speak of. I felt weird teaching adults how to brush their teeth and worried about being condescending, but I’m going to stop letting the feeling hold me back. People are open to talking about the issue.
Balancing these two conflicting feelings, I guess I want to believe that people will change their behavior. There are many things working against me, but if I concentrate on this issue, some people will come around. Even if people don’t immediately change their behavior, introducing the idea of dental hygiene is the first step towards ultimately changing things. Change might not come immediately, but maybe I’m laying the foundation for behavior change in the next generation – at least that’s what I tell myself. Some volunteers are very negative about changing Moroccans behavior and I think they let that negativity limit what they try to do. I came here to do health education and I’m going to try and do it. Plus it gives me something to do and some feeling of efficacy.

Update
I’m legitimately busy now. It’s getting to the point where I can’t do everything that I want and have to prioritize. So that’s really nice. Hopefully it will last. It’s not just dental hygiene; there are a couple of other projects that I’m working on.
By some amazing coincidence, someone who I don’t know in America read my blog and is interested in helping fund a water project in my community. So I’ve been trying to press local association people to work with me and get the ball rolling. On Thursday we went up into the mountains and found a spring. We measured the flow and made estimations about how far it is from a village. The village that it would serve already has a chateau (water tower), but it is empty because people cannot afford to pay the electricity needed to pump the water. The idea is that if we can reroute the water from the spring to the chateau, there will be no need for a pump (which pumps water from a well). If this project came through, it would bring running water to over 1,000 people and be a huge success. Right now women and children spend hours a day collecting water and having tap water would eliminate that work. Furthermore, because people collect water from wells and streams, there are many water borne illnesses. If the water is captured from a spring it starts off cleaner. Then we can treat the water in a centralized place (the chateau) and hopefully greatly reduce the frequency of water related disease.
Another project that I have been fortunate enough to latch onto is culminating next week. The midwife training, largely organized by another volunteer, is happening on Monday, Tuesday, and Wednesday. 12 women from three different villages in my commune will be attending. I am very excited for this training and I think it may be the most important thing that I do in my two years here. If it goes well, I plan to do another training next year and get women from other communities to come. There is a lot of bureaucracy and detail work involved in pulling off the training. We had a meeting with the Caid (mid-level government official) on Friday. I have to make sure that all the women have somewhere to stay in the town where the training is held. I have to make sure they all know when the training is and provide transportation for them. We’ve had to meet repeatedly with the nurses giving the training and go to the provincial capital (Khenifra) to meet with the Ministry of Health. We had to set up the building that will be used for the training. We had to write the grant for the project and then beg our family and friends for money (thanks again, by the way). And more. All the while dealing with a subject that makes people a uncomfortable. I think that talking about it over and over with certain people has reduced the taboo surrounding the subject and that itself has some value.
Finally, on a non-work related note, (although everything I do in my village impacts my work) I held a sadaqa at my house. Basically a sadaqa is when someone hosts a meal and feeds people as a way of giving thanks to god. The local religious leader normally says a blessing. It’s traditional to do when you move into a new house. I also felt like it was a good way of thanking certain people who have been especially helpful to me here. My house being small, my sadaqa was small, only 8 people (not including my host mom, who doesn’t count by most people’s standards). But it went very well. It was super expensive: I spent more than what I normally spend on two weeks worth of groceries. The food was good and people were excited to be invited into my house. It was especially important for my host family to know that they are welcome in my house, even though I’m sure they will never come over. Early on I had the idea that I would cook American food, but if I’d done that everyone would have been pissed. So, unfortunately, I had to enlist my host mom’s help (I don’t know how to cook Moroccan style food) and she did most of the cooking. I feel pretty awful about perpetuating the gender divide of labor here, but I’m not sure if there was any way around it. I tried to get her to eat with the men, but she refused. It’s probably better that way – everyone but me would have felt uncomfortable. It was a fun night. The only down side was that the next day some people who weren’t invited complained.
So things are good. My mom and sister are coming in about two months and that’s very exciting. The election draws near and it looks better and better for Obama. I’m hopeful. I’m going to bring my absentee ballot to my community and have people see how the voting works. It’s getting cold and I should be getting a wood stove for my house very soon. Hope all is well.