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Jennifer Kasper, MD, July 1996
The third week in March we held a seminar for the midwives. It was an opportunity for all of us to get acquainted and plan for future weeks of study. The age range of the women was 35 to 70 years and they had between 5 and 45 years of experience, mostly empirical. Only a handful have had the most rudimentary formal education in midwifery, and essentially none of them can read or write. They became midwives because they realized there was a need in their communities, and their work is completely voluntary. We discussed various ways to practice their art, their health beliefs, and those of their communities. The origin of myths and how they are perpetuated is intriguing. I have come to realize that if I want to have an impact on people's lives I need to be cognizant of these ideas so that I can incorporate them in a preventive medicine scheme.
The most fascinating, yet jarring, discussion we had was regarding women's rights. Their responses to the question, "What are the rights of women?" were focused on the right to care for their husbands and children and perform domestic duties. Their attention was focused outward, on others; it had not entered their consciences that they had rights, personal rights-the right to an education, to health care; the right to be treated humanely, todecide their destiny. I guess it is not surprising, given the amount of work they have to do on a daily basis, that they do not have time to sit and think about their lives, their wants or needs. It is so foreign to me - I who grew up with a multitude of possibilities and experiences-to think that a woman has to ask for her husband's permission to leave the house or go to the clinic when she is ill; that she does not have the right to use contraception because her husband will take it to mean she is having sexual relations with another man.
Still, in the midst of my cloudy musings is this silver lining: The midwives are thrilled at the prospect of receiving an education in midwifery, as well as learning to read and write. Education as enlightener and liberator. These thoughts were with me the following week during the week of study for the general health promoters. They are a very committed group of individuals. Most have compañeros (common law husbands) and children, so working in the clinic-school in El Tablón one week a month and attending a week of classes every six weeks is a considerable sacrifice. In addition, they are responsible for various projects within each of their communities. Like the people they serve, they are struggling to live a dignified life. The majority either fought in the armed conflict or were refugees. Many of them have had no prior formal education save educación popular taught by members of the FMLN. But with the education they have received over the past three years in this organization, they are probably at about a sixth grade level. In spite of this disadvantage, they are certainly making up for lost time. We reviewed the pediatric physical exam, how it was different from that for adults, and practiced with the instruments. I found I had two bridges to gap: the knowledge gap and the language gap, both equally formidable. It was wonderful to find that we crossed both successfully.
Health Promoters are the heart of our work in El Salvador. They are the connection
with the community and will remain there even if MDM has to leave. Since we began, we have
trained 11 general health promoters to give basic medical care, teach prevention and refer
serious illnesses to the nearest hospital (a class of 20 more started May 26th); 13 mental
health promoters to help people deal with the devastation of a 12-year civil war; and 19
midwives to help deliver babies and promote women's rights. We are also in the process of
training 7 visual health promoters. All the Promoters are selected by their community's
"directiva" for being intelligent, self-sacrificing and trust worthy.
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