Thomas Wartinger, MD, Winter 1987: Many village healthcare workers noted that they are still having trouble gaining the respect of the village residents in some villages. To examine this situation we set up a role-playing session at our last VHW meeting. The VHWs played villagers and were instructed to raise questions and complaints that are raised when they have a pitso (village meeting).
Mamorero (a young woman of 20) was to play a new VHW just returned from her first two-week class at the District hospital. The staged meeting was a picture of feigned disrespect, impoliteness, and abrupt discourtesy. When a certain complaint seemed prevalent, we would stop the meeting and discuss how one effectively responds. The VHWs relished this playacting opportunity, which seemed natural in this absolute television vacuum.
One of our first male VHWs, a man of approximately 50 years, referring to Mamorero said, “Why did you send us such a young person who knows nothing?” We explained how they, the village, had chosen the VHW and how a young person would have certain advantages, including the many years she would have left to dedicate to the village. To this the older VHW objected, “How do you know how long we will live?” Some of the female VHWs shouted, “The only reason she was chosen is because she is having an affair with the chief.” Mamorero was asked questions like, “What did you bring us?” and “What will you give us?” She spoke about the need for latrines to prevent disease, to keep feces away from water supplies and human contact. To this the villagers (VHWs) replied, “Why build latrines? Everyone knows disease comes from airplanes, not feces.”
The outcome of the meeting was a decision to have the nurse-clinician, Meseabata, travel to the villages with Mamorero and the local VHW over the next year and hold pitsos, the intent being to help the VHWs gain credibility for implementing their programs. It has also been decided that the VHW, rather than lecturing to the village about what she/he has learned, should allow the village to choose one project to accomplish over a defined period of time.
Mamorero Mohapi: From the 13th of January, I make visit to twelve villages to make a discussion with the villagers and the chief about their problems and among those problems they mentioned, we choose the problems which affect the majority of the villages, and some of those problems which affect the majority are some things like spring protection, latrines and poor sanitation.
This month I studied my driver’s manual and I even went to Quthing for learner’s driving test.
In February, I had one-day course for all the teachers in our area. The purpose of the course was to explain my work to them and ask them to work together with me hand in hand, because they are considered as extension workers like me. They were satisfied with what I have said and have given me permission to go to their schools to give lectures to the students. So right after the course I made school visits to all the schools in my area.
March, by holding needs assessments pitso the villagers decided what they wanted most is spring protection. I helped them survey the area for the best place for a spring. I then instructed the people on what materials they need to collect, like stone and sand. After they collect these things, I will return to supervise the construction of the spring protection. Plenty Canada has offered to let a mason accompany me since he has experience and to insure it is being built correctly. These villages I have started the Projects in are Ha Lazaro and Ha Leroma.
I have been driving with Wendy about three times per week. I am quite good now.
Apart from that, I am planning to have two weeks course to train some people here in Ha Makoae area, to teach then how to build latrines, which is one of the problems that affect the villagers. The number of the people are going to be trained is 25 and the trainers are from Quthing.
Wendy Day: Our clinic serves 73 villages. Sixty volunteers are active in the ongoing training for VHWs. The VHWs are given a basic introduction to several aspects of healthcare in an initial two-week course. Then they continue by attending fortnightly classes that cover such topics as nutrition, breastfeeding, and weaning foods, immunizations, treatment, and prevention of diarrhea, hygiene, sanitation, and treatment and prevention of household accidents.
Thomas Wartinger, MD, Winter 1986: My intent in presenting an introduction to our first Village Health Worker/Traditional Birth Attendant training class was to establish the preeminence of the mother and the village health worker in their roles as the caretakers in the health and wellbeing of the people. Of equal importance to me was to demystify and bring into perspective the peripheral role played by the Health Center and the hospital doctors. In this way, I hoped to be able to begin to replace a system that concentrates medical power and knowledge centrally, with a system emphasizing local village responsibility and self-sufficiency for health.
I began the discussion through a translator by asking the group of thirty village health worker trainees, “Who is the most important person in the care of the family’s health?” Some, falling into my trap, answered, “Ngaka (the doctor).” Others, trying to guess my intent responded, “The village health worker.” I replied that on the contrary, the mother, commonly thought of as the main recipient of healthcare, was the centerpiece of any primary healthcare system As I explained this further, I tried to remove any residual sense of special identity the village health worker might have with any outside medical authority, while swinging their allegiance more properly toward the mother.
I then asked, “Who is the next most important person in caring for the health of the village?” Some answered, “The chief.” Others said, “Ngaka,” and one said, “The children.” I thought this last answer was a good one, but not what I had in mind. So we talked for a while about the importance of health education for children and their role in contributing to the health of the family before I revealed my intended answer — the village health worker. I went on to describe how the health worker is responsible for learning as much as possible about common health problems and their care, and teaching and organizing public health measures, and advising the mothers.
Following my pre-planned, logical progression for minimizing the significance of the Western concept of the centralized medical hierarchy, I asked for guesses about who would be the next in the chain — someone with less responsibility, yet a vital part of the team, especially with regard to serious health problems. By now, many were starting to catch on to my drift and answered, “The nurse,” or “The clinic.” I then explained the role that a good clinic should perform in the training of village healthcare workers, as a primary healthcare information center, and as a referral center for difficult cases. But, I was careful to point out, a health center is only as good as its relations with the villages and its network of village health workers and traditional birth attendants.
Now I felt they were ready to understand how minimal was the value of the doctor in maintaining the health of the village in this carefully-orchestrated lesson, so I asked, “Who is the person least involved with the healthcare of the family? Who rarely comes into the village, and who knows almost nothing about the family and its health concerns?” I waited, anticipating what I expected to be the now-obvious answer. Instead, the entire group, without hesitation and entirely in unison called out, “The father!” I was stunned, and then we all broke out in uproarious laughter at the truth and irony of their spontaneous reply.
Though humorous, the scene I’ve described points out an all-too-prevalent condition in much of the developing world, with special acuteness in Lesotho, where over half the men spend most of the year living as migrant workers in South Africa. As noted by UNICEF in The State of the World’s Children 1986, “The majority of the developing world’s women have too large a share of responsibility for family wellbeing and too small a share in the decisions which affect it.”
The conversation with trainees that day provided further disturbing insights. One woman revealed that she was pregnant and that her husband was beating her. She was overcoming her shame to ask for advice. Her courage inspired the other trainees to reveal that every single one of the women had been beaten by their husbands at some time during their marriage, many recently. These were some of the most well-respected women in their villages. When asked if Lesotho needed a law to punish men who beat their wives, they all enthusiastically agreed. On second thought, however, they all felt that punishment (i.e. jail) would only make their husbands worse. And, as they stated, marriage in Lesotho is for life. In the end, there were no final answers, but we offered what support we could. We did suggest that the pregnant woman, whose husband was beating her, go to live with relatives until her baby was delivered.
It is obvious that healthcare becomes secondary to social change in such cases. In many developing countries, this social change needs to occur at the level of national and international recognition of basic human rights and equality. More often, though, the struggle depends more directly on cultural adjustments within families and villages. The need to empower women and establish at least a collaborative alignment with the men is a ringing priority for any successful healthcare program.
Wendy Day October 1988: Before my departure, I distinctly remember sitting in front of my stone hut catching some of the last warm sun rays before the approaching winter and listening to the bells of the goats and the singing of a herd boy on the nearby slopes. I was feeling the sweet sadness of leaving a country that had been my home for the past two-and-a-half years and realizing that I may never see those beautiful mountains or friendly faces again.
Personally I had chosen to take the opportunity to work in Lesotho partly to take a break from the fast pace of city life and the job I was becoming burned out in, to show my child another way of life, and to do some fulfilling type of work. Although it wasn’t achieved without difficulty, I think I experienced more richness than I ever imagined. Professionally, I was to set up a primary healthcare program and devote most of my energy to education.
The unpredictable surprise was how much the community taught me about truth, cooperation, and selflessness.