Conducting Peace Corps training in Guinea
Tuesday, March 10, 1998
In conducting a Peace Corps training in Guinea, my approach is to address trainees with a "problem/solution" approach. Real world solutions are emphasized, so the trainee can both successfully address conceptual issues and implement this knowledge in a real-world situation as a volunteer. Ideally, demonstrations of behavioral change techniques will be tested with villagers (real or simulated by trainees), thereby illustrating the theory behind the concepts with a real-life practical experience that each volunteer may encounter on the job. The "whys" of correct solutions are discussed in depth, while the "why nots" of incorrect courses of action are also thoroughly reviewed.
I would begin by assessing the training needs of the volunteers. Using the deficits between what should be known and what is known, content of the training would be generated. Based on the job description of the PCVs, I would consider relevant skills, knowledge and attitudes that the PCV must possess in order to effectively complete both institutional and personal goals and objectives.
As adults, the trainees enter training with their own real life experiences. The trainees will be taught to adapt their previous experiences to the cultural atmosphere, giving them needed confidence and context to initiate change. Using personal experience, maps, demographic data and pictures I will initially introduce each health topic and its relation to environmental, cultural and economic issues facing the citizens of Guinea. As the trainees master this information, I will expand with more complete information to "flesh-out" the scope of the problems and follow this with proven interventions.
At the conclusion of training, the trainees will understand the basis of disease in Guinea and the potential for positive change. Most importantly, they will be equipped with practical problem-solving experience resulting from their participation in numerous simulated interventions.
EXPERIENCE
My qualifications as a trainer range from my experience as a Disease Control Volunteer for the Peace Corps in Mauritania, previous work experience, and my new training in Public Health and Parasitology at the Tulane University School of Public Health and Tropical Medicine.
I first began teaching as a camp counselor on a small Florida island at the age of 18. At the age of 22, I was an assistant teacher at a preschool. My adult training experiences began that same year, as I trained office employees in the use of their new computer system that I had installed. I trained previously computer illiterate employees in the basic functions of the database and accounting software, both individually and in groups. I produced a training manual to be used to teach subsequent new employees.
Working as a disease control volunteer in Mauritania, my most formidable project was the training of welders in the construction of an appropriate technology pump. Approximately ten people were taught to build the pumps through experiential learning, over a period of approximately one month. Each trainee was taught basic welding skills if necessary, followed by repetitive tasks of forming the parts and assembling the pumps, gradually refining their skills. Several pumps were constructed during the session. Trainees were encouraged to discuss amongst themselves different and potentially better ways of constructing and improving the pumps. As director of this training, my responsibilities included the purchase of raw materials and equipment, negotiations with a training site, selection of trainees, arrangement of accommodations, accounting, and most importantly, the education of the trainees in the construction of a viable pump. This training was the largest of its kind ever undertaken by Peace Corps in Mauritania.
If I were a trainer of new Peace Corps volunteers planning to work in Health Education in Guinea-Conakry, without further input from the Peace Corps I would suggest the following training methodologies.
TRAINING METHODOLOGIES
The Problems
We must always remember that the villagers will be there forever: our stay is temporary. Before we begin lecturing villagers about the things they need to do, we must first listen to them. Why do they do the things they do? There are many reasons: economics, lack of western scientific information, and habit. What real problems are there? We must obtain the facts. Some are already available, from the country of Guinea, the World Health Organization, and other NGOs such as UNICEF, Oxfam and others. Peace Corps can also collect its own data, via Baseline Data Surveys. Volunteers, however, should ascertain the presence or quality of already existing data from which to work before duplicating others' efforts. In an informal sense, volunteers should form their own sense of village conditions but should also depend on formal assessments. Emphasis should be placed on the gathering of data that will be useful at present as well as in the future. As such, Peace Corps should maintain a database of information in-country for use by volunteers.
To begin, we must understand the origin of health problems in Guinea. The natural environment in Africa is conducive to many diseases that we do not face in America, and many that we once suffered from. Villagers live much closer to nature than Americans do; therefore, their exposure is much greater than our own. Living in an air conditioned home with a chlorinated water supply and flush toilets frees us from much of the disease that plagues the developing world. In some cases, we have eradicated disease such as malaria in America, but only because we drained many swamplands and used toxic chemicals like DDT to do so. In other cases, western intervention has contributed to the spread of disease in Africa. Dams are constructed for electrical production and crop irrigation, yet everywhere they are introduced schistosomiasis flourishes.
Behavioral Change
Are Americans so different from Africans? Did each of us install our own water supply and treatment systems? Do we always eat right? Do we always practice safe sex? Do we ever pee in a pool, river, or lake?
The job as a Peace Corps volunteer is primarily to bring about sustainable behavior change. This is clearly our "toughest job," as referred to in the Peace Corps slogan. For example, hand washing is strongly promoted as a method to combat disease. In my village of Breun, my family washed with soap only when the foreigners came to visit. I realized that I had been accepted only when my family no longer used soap to wash with before lunch. Why didn't they always use it? Soap is expensive, and they were not satisfied that it was beneficial enough to use all of the time. They felt the money was better spent on food or other necessities, such as firewood.
How can we promote change? Ideally, villagers should be able to see the beneficial effects of the desired habits. Unfortunately, better health takes time to materialize. We should try to teach them what the new behaviors will accomplish, but by itself, this is not enough to insure change. For greatest success, the ideas Peace Corps encourage must be legitimized. This can be achieved through the support of influential persons including religious leaders, village chiefs, government officials, and other popular persons. Ideally, volunteers and popular singers could write songs promoting sound health ideas for the native music of Guinea.
Additionally, we should encourage competition: between families, villages, or regions. Humans innately rise to the challenge of competition: we should take advantage of this. Villagers or health care workers that change their habits should be recognized and rewarded. This could range from something as simple as a plaque from the Peace Corps to each family that washes their hands, to a cash bonus to the health director of the village who has the highest reduction in infant mortality. The important thing is to make them feel special: they have accomplished something worthy of reward.
Gaining Credibility
New PCVs will seldom have the credibility to effect change upon their arrival. Villagers will view them as Americans, foreigners, French, Peace Corps, or Christians. Good volunteers will establish themselves in the village over a period of time, and will find a way to gain credibility with the villagers. For instance, a volunteer could introduce a new work and water saving form of cheap drip irrigation previously unseen by villagers. Through the introduction of innovative and valuable ideas, some villagers will gain an interest in the volunteer. Ambitious projects should build upon previous successes: premature failure will discourage the volunteer and the villagers who have given up their time and money to support them.
TRAINING MATERIAL
Like much of the developing world, Guinea has excessive rates of maternal and infant mortality. I would address these issues as follows.
PRENATAL CARE
Family Planning
A sensitive issue, family planning should be carefully addressed by volunteers. Current cultural practices should be examined and acceptable methods sought. In Mauritania, I discussed the subject of contraception with my adopted village mother. She told me that God says that contraception is wrong. I asked her if she thought God approved of men and women having so many children that they could not afford to feed, clothes, or pay attention to them. Stumped, she agreed with me. The ability to discuss these issues comes with time and experience with the culture.
Research shows that despite the culture, more highly educated women have fewer children. Efforts to lower birthrates should always accompany strides in the education of women.
Contraceptives such as condoms and the pill should be promoted in situations where it is acceptable. Where they are unacceptable, unavailable or deemed too expensive, Guinean women should be taught the calendar method of birth control. In this manner, they may choose to practice this method and thereby take control of their own situation without economic cost.
Young girls must have other options if they are to avoid pregnancy. Again, education must be available to them. Older women should be encouraged to use some sort of contraception to space their pregnancies. Their bodies must have time to recuperate, and they will be better able to provide for their children if there are two or more years between births.
Nutrition
How are women viewed in Guinea? Are pregnant women given a larger portion of food to ensure their health and that of their growing child? If not, a consensus must be reached among villagers that they want their women and children to be healthy.
If they are not already available, donations should be secured to purchase a scale for the village health center. In this way, the weight of pregnant women and their children can be tracked.
If the women are eating enough food, is it the proper food for them? To avoid or treat anemia in the woman and prevent congenital anomalies in the infant, expectant mothers should be strongly advised to eat foods rich in folic acid, such as peanuts, green leafy vegetables, and red meat. If these foods are available, must they be bought or are they grown? People that grow their own foods eat better than do those who must purchase them.
Villagers must understand that pregnant women can be worked to death. Groups of concerned village women should be organized to take part of the workload of the pregnant women. Hopefully, the husband could also be encouraged to lessen his demands on or even assist his pregnant wife.
Malaria
In malaria endemic areas, expectant mothers should take extra care to avoid mosquitoes. Bednets impregnated with permethrin should be provided for them, and a mixture of 1% neem oil added to their kerosene lamps as a mosquito repellant. If possible, the village health center should provide a prophylaxis of Proguanil and Chloroquine. Other anti-malarials are contra-indicated in pregnancy. Pregnant women diagnosed with malaria should immediately be referred to a qualified medical physician. All pregnant women should be provided with folic acid supplements, especially those diagnosed with malaria.
STDs
In the interest of screening for other high-risk pregnancies, village health workers should be trained to diagnose the presence of STDs, including AIDS. Creative and tactful education programs should be created to educate women and others of the risk factors for and prevention of STDs.
Pre-eclampsia and Gestational Diabetes
If possible, blood pressure should be monitored with local equipment. If the clinics do not have sphygmometers, donations of them should be sought. Village health workers should be trained in the proper usage of the equipment and documentation of data. Hypertensive patients should be referred to a physician. Urine dipsticks should also be available in the clinics to screen for glucose tolerance and albumen presence. If these factors are present, the patients should always be referred to a physician for treatment. Women with these symptoms, weighing less than one hundred pounds (45 kilos), under twenty years of age, or having their first child should be strongly advised to give birth in a hospital with advanced medical care.
Neonatal Tetanus
The majority of women without these risk factors can safely give birth in the village, but precautions must be taken to ensure a safe delivery. Experienced birth attendants should be present, and to avoid neonatal tetanus, they should observe the three cleans: clean birthing surface, clean birth attendant, and clean (new or sterilized) razor blade to cut the umbilical cord.
INFANTS AND CHILDREN
Breastfeeding
New mothers can not be encouraged enough to breast-feed their children: it is free, it is good for her, and it is good for the child. If possible, villagers should be shown a picture used by UNICEF that depicts a mother with twins who breastfed one child and bottle-fed another, who subsequently died.
The provision of water should be strongly discouraged, as it contains no nutrients, fills up the child before it drinks enough nutritious milk, and is a source of diarrheal disease. Children should be exclusively breastfed for a minimum of six months, and for as long as possible.
When the children do begin to drink water, the utmost care should be taken to provide them with safe water, either boiled or treated with chlorine in appropriate amounts.
Nutrition
Food for infants, adults and children should be served hot and protected from flies. A variety of meat, fruits and vegetables should always be served. For this reason, attempts should be made to grow a variety of fruits and vegetables in the village. If adequate food is not available, a few drops of oil should be added to the food of children for energy and as a solubilizing factor for vitamins. Iodized salt should be promoted for use among all villagers to prevent goiter.
Safe Water
Safe food will do much for the prevention of diarrheal disease, but efforts must be taken to provide a safe water supply. In areas where wells or springs are present, they should be sanitized and capped, using a pump or spigot as the safe source of drinking water. In areas where this is not available, water can be purified by exposure to the sun several hours, allowed to sit covered for a couple of days, filtered, or treated with chlorine. If chlorine treatment is pursued, efforts must be taken to use easily teachable and locally available measuring devices. In addition, some trees such as Moringa oleifera are effective in the treatment of water. They can be grown in each yard, and a branch broken off and immersed for an hour or so in the water to be used.
Diarrheal Disease
Despite many precautions, children in the developing world will still suffer from diarrhea. Villagers must be taught to detect a case of severe diarrhea, which must receive qualified medical attention. Volunteers should focus their efforts on teaching villagers to prepare and administer oral rehydration solutions on their own. These solutions must always be with boiled or treated water. As with the use of chlorine, measurements should be simply performed with commonly available measurements. Mild bacterial diarrhea will heal itself within a few days, especially if ORS/ORT is provided and the child is well nourished.
New research has shown that Giardia may be cured by eating oregano, guava or mango. These can be as effective as or superior to the commercial product Tinidazol.
Sanitation
Improper sanitation is the major source of all diarrheal disease. Volunteers should continue to promote the construction of VIP or Ventilated Improved Pit latrines. However, in arid areas poorly constructed latrines can actually lead to an increase in diarrheal disease. If the latrines cannot be properly constructed, villagers would be much safer to defecate in the bush and cover it up with sand. High temperatures, low humidity and the action of beetles and ants all contribute to the disinfection of human waste.
Regardless of where they dispose of waste, villagers and PCVs should always wash their hands with soap immediately afterwards, and before eating. Soap can be purchased or locally produced, and some trees such as the endod tree can supply a natural source of soap.
Along with filthy hands, flies are a major source of contamination. They breed in the latrines, and carry this filth on their feet, regurgitate, or defecate it on exposed food. Volunteers should teach the construction of low-cost flytraps that can be used by villagers, to trap flies that can supplement the diet of their chickens as well as prevent disease.
Immunizations
The volunteers should assess the vaccination status in their villages for effectiveness. Who is performing the vaccinations? Are they doing it correctly? Are they maintaining the cold chain? Are they using the needles multiple times, or improperly disposing of them?
Immunizations with bad vaccines are more than worthless: they give false hope to those who adjust their behaviors and take the trouble to bring their children to be vaccinated. It is precisely this sort of mistake that causes people to lose faith in the health measures with which we are attempting to excite them.
Furthermore, if needles are used more than once or left lying about, disease will be spread by them. They should always be burned and buried far from the village.
CONCLUSION
Though comprehensive, the preceding list of health interventions is in no way complete. It is merely meant as a preview to my philosophy that Peace Corps volunteers must be trained to teach sound, sustainable methods to better health. Above all, they must have hope that they can bring about positive change. My remarks concerning incentives to promote change are hard earned knowledge: I wish my trainer had stressed these issues to me.
Thank you for your consideration.
Respectfully,
William Carr
