Disembolso

February 25, 2012 - Well it was a busy week. I feel like I'm starting to get into a rhythm with my work. Also, the Spanish is coming along. It is most difficult for me when I'm out with friends, especially if the music is loud or the restaurant is crowded.

I wanted to share about the disembolso ceremony I got to watch this week. Disembolsos are loan disbursement meetings, where the women come to get their loan money either at the beginning of their membership or at the start of a new loan cycle. The loan cycles last six months. To bless the money so that it will help them prosper, they perform a small ceremony. What I first noticed was the smell of something burning, but I thought it was something coming in from the window. Then I saw the small charcoal fire burning in a cast iron "pan" type thing on the floor. After awhile, when the fire was good and smoky (and I was starting to have a hard time breathing, but the 20 or so women and handful of kids in the room seemed just fine) the women began one at a time pouring what looked like small seeds over the fire and then waving the bills and a bag of coins over the smoke. One-by-one, starting with the oldest women in the group, who looked about 80 to me but is probably only 60, they each took a turn "smoking" the money. Some said a few words, including the jefa of the center who blessed them to prosper and be able to pay their loans back without problem. I thought the ceremony was quite touching and appreciated that Pro Mujer not only allows them to perform it but actually facilitates it. I understand the ceremonies don't take place in every group or every center, but where it is tradition, Pro Mujer honors it.

Afterwards, the women celebrated with a large bottle of Inka Cola and wafer cookies, at which point I excused myself and wished them good luck, feeling grateful to have had a glimpse into this aspect of their culture.

Roller Coaster Ride

February 21, 2012 - I almost posted a whiny blog yesterday about my frustrating day, but I decided to sleep on it and, sure enough, today was better. My time in Peru has definitely been like a roller coaster with many ups and downs and twists and turns. So rather than subject you all to my whininess, let me just summarize. Yesterday I was feeling a severe lack of support for my research. I got stood up for a meeting that someone else had scheduled (not the first time) and was thinking I was getting nowhere. However, today I had a very productive meeting with a different colleague to discuss recruitment for my interviews. Based on that meeting I put together a plan of action and quickly got approval from my preceptor. I’m so glad to see a path forward for my interviews, since they are my primary reason for coming here. Then I had a nice chat with my new faculty advisor who talked me down from what was probably a terrible plan to try to do, as she put it, “two CEs within one.” (CE is what GW calls our theses. Technically a mini-thesis, although that label doesn’t make it seem any less daunting.) So, I think I’m on the right path.

I’m sure the roller coaster will continue to jolt me throughout the next eight weeks (whose counting) but I have been trying to keep things in perspective. Professional frustrations exist in the States too, of course, and are nothing compared to the major life problems faced by the clients I’m working with at Pro Mujer. Or even those faced by other development professionals. For example, I finally just started reading The Blue Sweater by Jacqueline Novogratz, founder of Acumen Fund, which I have been meaning to read forever. Her stories of being completely rejected by colleagues in several countries in Africa make my experiences look like a breeze. At least I’m not being poisoned by co-workers, and my reports haven’t been lost mysteriously because they don’t want to hear what I have to say. And the fact that she struggled so much and now runs a highly regarded international organization gives me plenty of hope!

La Playa

February 20, 2012 - This weekend we Tres Gringas escaped to the beach to enjoy some warm weather and sun! I left Friday with Lisa for the 5-5.5 hour journey to Ilo. What an experience. We took a colectivo/cooperativa/combi, which is basically a 12-passenger van. Not the most comfortable of journeys but I fortunately had lots of leg room as I was right behind the driver.  We arrived at the office at 1:30 for our 2 p.m. trip. Well we didn’t end up boarding the van until 3 p.m. and leaving until 3:30. Apparently they just wait until it is full, even if that takes FOREVER. So eventually we excitedly get on the road only to stop a few blocks away for the driver to get a new spare tire. Which turned out to be good because we needed it not too long into the drive. Finally we are on the road around 4 p.m. The views were beautiful as we left the city, passed the lake, and wound around curvy roads with green hills and bizarre rock formations. Then, slowly, the vegetation turned drier and more sparse as we left the altiplano and headed for the mountains. We made one more stop along the way (in addition to the tire change) to pick up an extra passenger. Yeah, just some guy with a suitcase waving down the combi who had to squish in the back with two other adults and two children. Felt a bit like a train in India.

As night fell we climbed up snowcapped mountains and it started to snow. A few hours later, unbeknownst to us at the time because it was dark, we entered the desert. And finally we arrived at the beach. So within just a few hours journey we encountered four unique geographies and went through huge temperature drop and then climb back up.

Exhausted, we arrived in Ilo at our quaint little hotel, delighted by the warm breeze coming in the window. One of the best feelings was taking my socks off for bed, instead of putting on an extra pair, and sleeping under only a sheet. Ahhh…..

Saturday morning I woke up early and went for a run on the boardwalk. Ilo is definitely a port town, but with gorgeous views. The juxtaposition of desert and ocean is beautiful and jarring.


After my run, I returned back to the hotel to find out that we had no water, a common theme here in Peru, and had to wait two hours for a shower. But at last, I was clean, and we were ready to explore. Lisa and I had a nice breakfast at the market consisting of watermelon and churros. Then we wondered over to the Plaza de Armas, which is friendly and flower-filled. I couldn’t resist an helado on the street next to the plaza, which has probably five ice cream shops and five chifa restaurants. Then we headed to the beach. Again, bizarre because of the desert setting, you have to take a taxi about 10-15 minutes through industrial parks and vacant desert hills until you turn down a long dusty road that ultimately ends in a beach. With hundreds of colorful umbrellas and chairs, it didn’t look so different than Ocean City, MD, except for the desert behind you.

We were quite conspicuous as gringas but ignored the stares and plopped ourselves down for several hours of sun bathing. The water was cold but refreshing, and the sun was super strong. After a few hours, we settled in at a cevicheria off the beach but were disappointed with the quality of the food. Then finally Angela arrived from Arequipa, just as the sun was starting to fall in the sky and the wind was picking up. At first we worried that we’d be cold that night but once we got back to the city we found it was still pleasantly warm and perfect for a walk to a restaurant for dinner and then home. We also watched the movie 50/50, which is very good if you haven’t seen it.

Sunday I woke up early again and read my book until the other girls got up. Then we ventured off to find breakfast. Finally fed and satisfied with coffee, we went to get our tickets home. However, there were no buses until the evening and they were all full anyways. Ugh. So after some running around we determined we’d have to take the combi again, from Moquegua, the hub in that area. But first we’d have to take a bus there. We had a few hours to spare so we relaxed in the grass near the boardwalk, soaking in our last few hours of sun. We had a quick lunch – and were pleased to find some good ceviche although the service was not good – and then headed to the bus station. Worried we’d be late, we had to laugh when we showed up on time and were the first people on the bus.

The hour or so drive to Moquegua was so interesting because it revealed the beautiful desert we’d driven through Friday night without even knowing it. Moquegua, on the other hand, left much to be desired, so we tried to get out of there as fast as possible. However, we were again stuck on a combi waiting one passenger. “Uno para Puno” we heard for over an hour as they tried to fill our van. At one point a passenger, a young guy, got out and joined in the advertising. Finally we got our uno para Puno and headed off. This trip was also interesting although it was quickly too dark to see much of the countryside, but the sunset over the desert hills in bright reds was breathtaking. We made one stop about halfway and the stars were so bright and plentiful, I could have stayed their gazing for awhile but was quickly hurried back in by the other passengers. At last we arrived back in Puno. I was happy to see the city lights and get off the bus and back to my room, but I was not happy to be welcomed back by frigid temperatures. We may have to take another beach trip soon!

Test, Test, and Test Again

February 15, 2012 - I learned a very valuable lesson today. In class our professors (especially Dr. Baird) always talk about the importance of testing surveys, and of course I would never do one without testing, but that said, nothing prepared me for how horrible my first few results were going to be. Several respondents skipped entire pages. They answered no but still marked selections for the "if yes, then" questions. I realized one entire section of questions only had responses for never, in the last year, or in the last two years, leaving anyone who had done the procedure more than two years ago with nothing to select. I found out indirect questions like "edad" were confusing when "cuántos años tiene" is much easier. Only six people tested it and I changed almost every question in the survey, even if only slightly.

So, later this week I'll hopefully have my new and improved survey approved and ready for more testing. Then next week, pending IRB approval, I'll be able to "poner en marcha" (start collecting surveys) during the two major health campaign days at the centers.

Unrelated note, I can now add "graffiti remover" to my resume. Never a dull moment!

Music, Fireworks, Dancing & Rain

Today and tomorrow are the last two days of the Candelaria festival so I thought I'd post some pictures and share a bit about it. I think once it is over I will miss spontaneous parades and dance parties in the streets of Puno!

Last weekend we went to see the dances in the stadium, which was a fun experience although as far as watching dances the parades are more up close and personal. Interestingly, Pro Mujer had its mobile medical clinic at the stadium in case of any health problems and it was so unexpectedly warm that day that the major health problem was that many of the dancers had gone barefoot and burned their feet.

Dances at the stadium

Sporting our "Yo <3 Candelaria hats"

Adorable little boy dancers

 Our friend Marita danced with a group. We didn't get to actually see her dance, but here she is in here awesome costume. (Check out the shoes. They make them out of recycled rubber from tires.)

Marita in her dance costume.

When the parade moved to the streets it seemed to lose some of the refined cultural and turn into more of a drunken celebration. So much so in fact that we called it an early night because the crowds were a little too raucous and we stuck out as Gringos.

I was waiting for the horses to charge the crowd at any moment. They did not seem happy.

This weekend the city is filled with many more tourists, however, so we are certainly not the only Gringos. Friday night the music and fireworks continued well into the night. I finally fell asleep at 1:30 and it was still going on at 6:30 when I woke up. Apparently it never stopped and they just partied throughout the night! Last night we watched parades again. The costumes were more colorful, many featuring masks, devil horns, and short skirts for the girls - an interesting contrast from the traditional rural outfits of last weekend. Unfortunately my camera battery died so no pictures. :( Last night was the presentation of the bands and my there were many bands! At one point we were literally standing in between a band playing on one side of the park ("we're with the band") when it suddenly started down pouring. Not uncommon here in Puno. So we raced backed to the safety and dryness of Angie's apartment and stayed in for the rest of the night. No fear though, there will be more dancing today and tomorrow! And Monday is a "día libre" in other words the office is closed. Although I'll probably spend the day writing my CE proposal and applying for jobs.

How Things Really Work: Lesson 2

February 7, 2012 – What an eye-opening day I had today. I spent the day at the two Centros Focales in Puno. It was fascinating to observe the work of the obstetrices and talk with them about the challenges they face.

I began my day at Laykokota with Rosmery, a bubbly, charismatic woman who may be more excited about healthy breasts and uteri than anyone I’ve ever met! She is resilient despite facing the daily challenge of trying to get the women who come to repay their loans to also come see her in the Consultorio for whatever health problem they may have or to get diagnostic tests done including PAP smears, breast exams, blood pressure measures, glucose measures, and BMI measures. It seems to me she is driven by two things – her genuine desire for the women to be healthy and the metrics she must meet each month. However, her job is more challenging than I ever imagined.

The women come to pay their loans once a month and this process is incredibly hectic. There are several groups in the office at a time and all the women want to get in and out as quickly as possible. Which is understandable, in many cases they have traveled quite a ways to get here, and they have businesses and families to run. So getting them to even listen to you for a few minutes is a challenge.

Another challenge is the pressure they face during this repayment meeting. For example, in the first meeting I sat in on five women didn’t show up, so all the group members were frantically calling to remind them and had to wait for several hours until nearly all arrived. If not, they would have had to make up the difference and pay for their group members who were missing. You might think this would give you plenty of time with a captive audience to talk health, but not so much. The women are counting and recounting money and herding their small children who are running around. Not to mention they are likely worried about the fact that they may have to pay extra this month, and the repercussions that may have on their families and businesses, and the reaction from their husbands. That immediate threat likely outweighs any concern they might have of their long-term health.

Despite these challenges, Rosmery does her best, enthusiastically explaining the importance of these diagnostic tests and taking care of their health. Unfortunately, likely because of the goals, much of her promotion efforts are more about testing than actual preventative health information. At the end of each short session, she tries to get women to make an appointment. Not many do. They are afraid, can’t afford it (despite steeply discounted prices), or simply don’t believe they need these tests. When women do come for their tests, and in some cases get positive results, they rarely do anything about it. The obstetrices recommend follow up tests, oncologist visits, and diet changes, but very few women take these next steps.

In the afternoon I went to Bellavista and talked with Zelmira, a very different personality. She is quieter, more serious, but still very nice and obviously committed. She vocalized many of these same challenges as Rosmery. She has a half dozen flipcharts for sessions on various topics but said she rarely has time to use them with the women. She explained that the “mass” education sessions (which I had read about in the official Pro Mujer manual) rarely actually happen and really boil down to these frantic sessions squeezed into payment meetings like I observed with Rosmery.

So an eye-opening day indeed. I closed the day feeling a mixture of frustration and inspiration to help. I have some ideas about referral programs and incentives, but would love ideas from all of you, especially my fellow MPHers who may have seen similar situations around the world. How do you incentivize women to seek health services? How do you reach them with preventative health messages when formal health education seminars and training sessions aren’t really an option? Please comment here or email me with ideas. Thanks!

Whirlwind Weekend

February 6, 2012 – Wow, what a weekend. I had a wonderful 30^th birthday celebration with my new friends that included dinner at Mojsa, one of the nicest restaurants in Puno, cake, a house party, and dancing at a club. Then Saturday I enjoyed a lazy day catching up with family via Skype. Sunday was the first big day of dances for the festival so we went to the stadium and watched for a few hours. It was a beautiful day and I even got a little sunburned. After the dances we went to a cevecheria and I braved the ceviche – ¡Qué delicioso! That evening we watched more parades in the streets. So much music and dancing I felt like I was on sensory overload. But overall I feel like I’m really starting to get settled in here and enjoy all the people I’ve met.

Today was an interesting day at work. I spent some time in the morning with one of the obstetrices who answered all my questions about the consultorio (health center) and reviewed my surveys. Then I met with my preceptor to discuss surveys and interviews. Good news is he liked all my questions. Bad news is the process is going to be much more of an undertaking than I thought. First, there is not a complete database of customers like I thought, so I’ll have to try to recruit them in person at the centros focales. We decided to hold off on the client satisfaction survey (which is a good approach I think, and means less work for me) but the lifestyles/health behavior survey I drafted is now top priority. Plus it is no longer just a simple survey I can hand off to the obstetrices to give to the clients. My preceptor wants a statistically significant sample, which means 350+ surveys, so I have to try to recruit clients during their loan payment meetings. Luckily, I’m ahead of schedule for my work plan so hopefully I can get this survey rolling before my interviews go into full swing. I’m still a little concerned about convincing women to spend an hour with me for the interviews, but the good news is Doctor Alfonso liked my interview guide and made only grammatical corrections and no major changes.

Tomorrow I’ll be at the centers all day and then Thursday I’m going to one of the mobile clinics/health fairs. So that should be exciting, always nice to get out of the office.

Work Hard, Play Hard

February 2, 2012 - It has been an interesting few days, chugging along at work and getting to know how things work and also enjoying the festival at night. (Or in the morning, like on the 1^st when fireworks and music started at 4 a.m., although I can’t really say I enjoyed it).

Had an interesting conversation today with Angie about how the integration between micro-finance and health can be messy. She put it quite well, that when you try to talk in health terms like quality of care, the majority of Pro Mujer staff (even in the health department) talk in “the language of micro-finance” with costs, risk, return, and sustainability being their number one priority. Which is an interesting perspective, not right or wrong, just interesting. It seems Pro Mujer, like many micro-finance organizations I’ve read about, is still struggling to find that balance. Pro Mujer was started with a broader social goal than just micro-finance, so it’s health focus is not new per se, but it is definitely secondary. For example, the micro-finance side have dozens of staff while health has two. I’m hoping that my work will help contribute to a better understanding of how successful (or not) the health side is and what improvements can be made.

Another interesting thing I noticed is that in my epidemiology research I have been looking for information specific to Peru or atleast Latin America. Today my supervisor said he is less worried about context/culture specificity and more worried about evidence-based medicine. So I guess he’d rather try to adapt an idea that has worked in another country and is well documented than go with an idea that only has one small study backing it up but is context specific. Again, not sure the right answer, but tucking it away to think about later. Maybe like everything you need a balance.

Also wanted to share this link with pictures of the festival yesterday. This was the most religious day, where the Virgen is paraded into the streets.