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Health as Reconciliation: A Key to Post-War Rebuilding in El Salvador

By Michael Eric Bronner

Morazan, El Salvador-It is an overcast June afternoon in Morazan, and already rain is visible in the next valley. The Rio Chiquito, a major tributary of the mineral blue Rio Torola, is lightly swollen and chocolate with erosion. Laughter from the rocks above the river precedes the sound of small feet running, then two young boys in faded bathing suits fall through the humidity. Muddy water swallows them, then runs from their faces as they swim to shore.

One hundred meters upstream the boys' fathers carry cement and heavy stones that will form the trusses of a permanent bridge across the Rio Chiquito. At least five people have drowned here since 1994, and many more before them. Now the guarantee of safe passage between the Chiquito's banks has become the cornerstone of plans to establish five community day care centers and a new health clinic. The local builders and lead engineer are among the many volunteers working with Medicos del Mundo-El Salvador (Physicians of the World-El Salvador; MDM-ES), the Salvadoran mission of the French physicians' group, Medicins du Monde (MDM-France).

MDM-France established its presence here as an emergency response team in the thick of war. MDM-ES, a unique extension of that group, has remained to help infuse sustainable health and community oriented primary care into the shaken rural communities of Morazan, a particularly imperiled department in Northeastern El Salvador and the setting of the war's greatest adversity.

Some 60 miles east of San Salvador, the land of Morazan is mountainous and rough. Valleys are flecked with adobe and bamboo homes, stitched with crops and veined with cloudy rivers. There are two small harvests of corn a year, in May and August, and a steady supply of pita, a fiber of the Henequin plant used in weaving hammocks. In the rainy season, wild weeds work incessantly to erase the impressions that humans have made here, from their cultivated rows to the residual craters of bombs. When there is no rain the land is desiccated by the sun. The effect is exacerbated by deforestation, resulting in soil that ranks among the poorest in El Salvador.

More fertile than the land they live on is the resolve of much of Morazan's population to improve conditions in its communities; indeed, local leadership and initiative are the lifeblood of MDM-ES's efforts. The fact that there was prolonged war here remains evident, however. It is evident in the form of severe poverty, in the eyes of anemic children and in homes that are missing husbands and brothers. These indirect craters of war constitute chronic jeopardy for the people of Morazan, and dictate the contours of MDM-ES's work.

The El Salvador mission was among the first projects of MDM-France, which worked with Salvadoran refugees in Honduras as early as 1981. The group made a courageous contribution through 1988, but was compelled to leave El Salvador amid death threats and general mayhem. MDM-France returned in 1989 upon the invitation of numerous NGO's to begin a new mission in Ciudad Barrios (the birthplace of Archbishop Romero), albeit in a context of continued violence.

With the signing of the Peace Accords in Chapultepec, Mexico, Jan. 16, 1992, a creative, young U.S. physician, Dr. Clyde Lanford "Lanny" Smith, came to El Salvador and laid the groundwork for a prolonged MDM contribution within the ambitious framework for reconstruction set forth in the treaty. After meeting with some 25 NGOs and former MDM-France volunteers, Smith was invited by Asociacion de Desarollo Comunal Salvadoreno (Association for Development and Coordination in Eastern El Salvador; ADECOSAL) to El Tablon, a small village in Morazan, where he saw strong potential for promoting health as a means of reconciliation. The MDM-ES clinica popular (community health clinic) now sits atop a hillside in El Tablon and serves as a base for the mission. A devoted, predominantly Salvadoran corps of physicians, medical students, local health promoters and volunteers comprise the marrow of MDM-ES, and make its continued existence possible.

MDM-ES health promoters, in their late-teens to early-twenties, are the region's future with respect to health. They complete three months of intensive training with the doctors, and have an ongoing commitment of one day's work each week in the clinic. The cases they see are for the most part elementary, ranging from upper-respiratory and external infections, to diarrhea and arthritis.

On days away from the clinic the health promoters give consultations within their communities. This is the principal extension of their training. Each health promoter maintains a botiquin, a small medical kit that is kept at home and stocked with supplies from the clinic's pharmacy. Ultimately, a look into a health promoter's botiquin reveals much about common country health concerns.

Standard botiquins contain an oral rehydrating drink, a powdered mixture comprised primarily of sugar. Of 426 childhood deaths reported in a poll of 444 women in the region, diarrhea (which depletes the body's liquids) ranked among the top five causes of death, and general dehydration exacerbates symptoms in cases of parasitic illness for people of all ages. Parasitic illness is widespread in Morazan, a condition that health promoters combat with Mebendazol. Injectable antibiotics such as penicillin are also common among botiquin stock, as are soy beans for protein deficiency and iodized salt to prevent endemic goiter, a condition that MDM-ES found in 64 percent of 2,400 people examined in Morazan.

No medication or procedure is administered without an accompanying charla, an informal explanation of the treatment's function and of preventive measures that can be taken the next time. In this respect the health promoters are particularly indispensable, as they speak to their communities from common experience. More than half of the female health promoters are single mothers, for example, and nearly all of the health promoters come from families left incomplete by the war. In short, their participation bridges the gap between sophisticated medicine and the realities of daily life in Morazan.

MDM-ES health workers consider their assistance in preventive projects the most vital element of their presence here. Since MDM-ES began its current phase of work in Morazan, the group has assisted communities with nine major health projects, addressing issues as diverse as women's sexual health and reproductive rights, mental health in children, the de-parisitization of livestock, latrine-building and sanitation, water treatment, malnutrition, in addition to widespread iodine deficiency and the need for a bridge over the Rio Chiquito. In addition to starting work on the bridge, an iodine drive was initiated; a visiting veterinarian taught people to breed rabbits for protein; frequent lessons were given on latrine-building for sanitation; cattle received injections; kindergartens were organized for children, and condom use was even demonstated using bananas. It is the identification of these tangential issues, discerned through community interaction, that distinguishes MDM-ES's work from mere utility.

A sense of sober fortitude runs through Morazan, as constant as the Rio Torola itself. There is a saying here: Si se bana en el Rio Torola, siempre regresa a El Salvador (if you swim in the river Torola, you will always return to El Salvador). Medicos del Mundo-El Salvador has immersed itself in the country's vitality and its adversities. Its presence is intimate, constant, and indeed invaluable.