Village life in Laos

In the June issue of World Health, Ruth Seitz described the part that women are playing in developing their communities in Laos. This month, she shows how the authorities in Laos are building up a health delivery system from scratch, with the village health centre forming the cornerstone of a national network. Village Life in Laos ven in the tropical noon heat, Pak Ou is pleasant. In this rural Lao village of 200 homes, life-sustain- ing activities go on under the shade of the tamarind trees. A woman deep-fries food to sell while her neigh- bour arranges smooth clay pots for dry- ing. Underneath a house on stilts, an old man hammers out a cutting tool hot from the forge . A woman weaves cloth that will become a sinh, the long skirt that is the national dress in Laos. Sounds from the boat landing are a reminder that this Indochina village or ban is still linked to the outside world. The wide, muddy Mekong River is its highway to Luang Prabang, the provin- cial capital about 30 miles downstream. There Pak Ou's teacher and health work- er were both trained, and there the vil- lage goods are sold for the cash that is necessary to buy oil, salt and matches. Much ofPak Ou village life is healthful. Work proceeds without industrial noise and pollution. The setting supplies a wholesome diet- fish and crabs from the river, vegetables and rice from the earth, and fruits from the village trees. Pigs and poultry give additional protein. Piped spring-water flows by gravity from the mountains to several faucets. But medical services in Pak Ou are conspicuously undeveloped. When a hacking cough or fever drains the strength of a child, there are no phar- The wide, muddy Mekong River is the "high- way" linking the rural Lao village of Pak Ou with the provincial capital. (Photo B. Seitz ©) by Ruth Seitz maceuticals at the health centre. Since only aspirin and some weighing scales are available to the newly trained health worker, babies are not immunized, and people fight malaria, the leading disease, through body resistance. In Laos, Asia's only underpopulated country, 80 per cent of the people are rural dwellers, niany of them living in settlements like Pak Ou. The plight of the health services in Laos can be traced to several causes- war, poverty and un- derdevelopment. As a result, the Lao People's Democratic Republic is today expanding the health delivery system beyond the cities which are well- provided with hospitals. The aim of the four-year-old Govern- ment is to provide a network of commu- nity health and referral services. The Cabinet of the Ministry of Public Health provides supervision and support at all levels. The World Health Organization stands by "to give technical support to the primary health care aspect and to devise methods that will have greater output from local resources", according to the WHO Programme Coordinator in . Laos, Dr Roger Leclercq. The cornerstone of the national system is the village health centre. In a village like Pak Ou, the Ministry of Health is selecting one to three volunteers for between three and six months' training in basic health care. They will serve through 9,300 health centres where vil- lagers go for first aid, health education and referrals. In 1977 there were 2,900 of these ban health centres. But even at the end of 1979 many were still as poorly equipped as the thatched one at Pak Ou, which boasted of only an examining table, the rusty weighing scales and a few health education posters. By 1981 , UNICEF assis- tance will have equipped 3,100 centres for emergency and symptomatic out- patient care. . At the next level is the tasseng dispen- sary of five to seven beds, which serves the 6,000 people in an average commune. Here people can receive treatment, immunizations and pre- and post-natal care. Three nurses- trained respectively in general nursing, midwifery and tradi- tional medicine- observe patients, make diagnoses and run the preventive pro- gramme. Such a dispensary is primarily an MCH centre. The staff forms the commune health committee which is responsible for coor- dinating public health activities within the tasseng's 10-15 villages. Members of the commune, who farm collectively, pay their salaries. The Ministry has plans for a 30-bed hospital in each of the country's 130 districts or muongs, which average 30,000 inhabitants. Besides providing basic laboratory services, these institu- tions will give in-patient and out-patient care for referrals from the district's tasseng dispensaries. Eventually, a complete staff will com- prise up to three assistant doctors and one nurse; 15 auxiliary nurse-midwives (with two years' training after primary school) ; one sanitary agent, one assistant laboratory technician and one tradi- tional medical practitioner. 21 However, many muong hospitals are functioning with fewer skilled personnel. One of those which I visited had only one employee, a nurse, who had had formal medical training. No assistant doctors were available to fill those other slots. In 1979, UNICEF supplied equipment- 124 items ranging from a kerosene refri- gerator to suture clips- for 11 district hospitals. At the top of the institutional totem pole are three central hospitals for referred patients and teaching purposes. (At present Laos has one medical school from which doctors can graduate and three institutions which train assistant doctors.) There had been 15 provincial hospi- tals, one in each of the 13 provinces and two additional ones in the capital, Vien- tiane. However, seven were bombed and need major construction work. For ex- ample, patients receive treatment under a partial roof at Xieng Khouang in the Plain of Jars . All except one of the exist- ing hospitals are very old. In Laos, there are compound difficul- ties in organizing and standardizing a health delivery system from scratch. Thirty years of war displaced people, destroyed property and curtailed train- ing. The absence of a transportation sys- tem still hinders the flow of services and 22 goods. There is no railroad, and seasonal climatic conditions often make the few roads impassable. Drug shortages are common. Under a policy of "state medicine with communi- ty participation", the Government con- trols the supply of pharmaceuticals. However, several factors make it difficult for the Ministry of Public Health to maintain an adequate supply- the lack of funds for imported medicines, long distances to the ports used by this land- locked country and the slow process of manufacturing plant-based medicines. One of the greatest drawbacks to deve- loping a health delivery network has been the departure of thousands of health employees. In one weekend four nurses from one hospital left the country to become refugees. However, other health professionals are committed to nation-building despite the odds. Today 89 physicians serve the 3.3 million population. The most prevalent diseases- parasitic infections and bronchopulmonary ail- ments- stem from a poor environment and unsafe water, conditions that have existed for many decades. Children are hit hardest. Forty-nine per cent of the people who will die this year in Laos will be infants aged less than one year. Malaria is a major cause of child mortal- Left: Health education posters in the thatched clinic at Pak Ou emphasize "the three cleanli- nesses" and explain how to reduce malaria. Right : Imported medical drugs are expensive. This market stall sells medicinal plants gathered by traditional practitioners. (Photos B. Seitz ©) ity and morbidity. Surveys made in two provinces indicate that one out of every three persons suffer from active malaria. Sixty-five per cent of the people infected with malaria are harbouring falciparum, the most dangerous of all existing types. To fight mosquito fever , as the Government calls malaria, a control committee operates under the health committee at each administrative level, One of their goals is to spray the walls of each habitation once a year with DDT; complete country coverage would require 100 tons ofDDT. Only 10 per cent ofthe nation's houses have been sprayed in the past two years, but among those who lived in them infection was reduced from 30 per cent to between five and seven per cent. To break through other obstacles to health, the Ministry is developing a model health delivery system in one dis- trict in order to use it as a training ground for other areas . Situated 80 miles to the north of Vientiane, Phone Hong District was selected because its 35,000 people belong to several ethnic groups, and its hospital is centrally locat- ed. It is fairly typical in that, for instance, the_re is no electricity, and most babies are born at home. Soon after the staff at Phone Hong's eight tasseng dispensaries received some upgrading, a system for motivating and evaluating performance was introduced . Nurses received a list of standards and learned that monthly surprise visits from the muong health committee would check that these criteria had been met. Many of the 31 questions on the list deal with professional responsibility in the most basic situations. For instance, "How many deliveries did you assist throughout?" reminds nurses to give positive help during a childbirth rather than leaving the woman unattended. The question, "How many working days were you present?" strikes at absentee- ism, which can be detrimental to high- quality care. The commune dispensary with the highest rating:-the total num- ber of staff points-"--is awarded the honour of hosting the next seminar. Then health workers from all the com- munes can observe their model dispen- sary and try to emulate it in future . An important item at Phone Hong is the teaching of record-keeping skills. Two months after the inauguration of death certification in the district, tasseng nurses and ban health workers were al- ready recording half of the known deaths. The Health Ministry looks to this small beginning as a means of eventually establishing national infant and maternal mortality rates. The objective at Phone Hong is to build a practical model rather than a showpiece. For example, the health tech- nology remains at a level that is manage- able for the staff and the budget. Dr Kheo Phimpachanh, Cabinet Chief of the Health Ministry, persuaded muong leaders to accept a US$ 250 cart and horse instead of a $9,000 jeep. After a few days of training by the previous own- er, a driver began hauling cartloads of medicines and supplies from the district hospital to the tasseng dispensaries. The "H/C unit", as it is dubbed in reports, also transports personnel for teaching and supervision. It will be used to haul construction materials for digging wells and latrines around the district. A WHO adviser explained the rationale behind the focus on the muong. " To reach the rural areas, you must have intermediate levels functioning for super- vision and evaluation." The concerted effort at Phone Hong is already paying off. A survey in three communes re- vealed that the malaria parasite rate had been "reduced considerably" . Vigilance in health matters has improved at the ban, tasseng and muong levels. In traditional medicine, the Ministry has found a valid resource. The Govern- ment has integrated its practitioners, regardless of how much formal educa- tion they have had, into the primary health care system. Plans call for one to be posted at each dispensary and at least one at each hospital. Their knowledge is being woven into health education at all levels . During a nine-week training course in Muong Hatsaifong, coopera- tive health workers learned traditional remedies for fevers, diarrhoea, snake- bites and colds. WHO has requested a 68-year-old pro- fessor at Vientiane's Institute of Tradi- tional Medicine, Dr Thit N oan Dam, who also directs the Phone Hong Tradi- tional Medicine Hospital, to provide a list of medicinal plants that can be culti- vated at dispensary sites. Since its open- ing in: 1976 by the Government, the Insti- tute has manufactured several medicines including an expectorant, a tonic and an anti-diarrhoeal agent. Of all the services included in health delivery, education is one of the most dif~ ficult, especially to such a dispersed pop- ulation. Some of the teachings of health workers who teach on a volunteer basis may sound strange to their pupils because they are contrary to long-held cultural practices. They insist, for in- stance, that the water from soaking the day's rice should be used in cooking in- stead of being thrown away. According to a nutrition survey, throwing away that water causes 80 per cent of the thiamine, 70 per cent of the riboflavin and a signifi- cant amount of niacin to be lost. This contributes markedly to a lack of B vita- mins in the Lao diet. In spite of numerous and complex ob- stacles, Laos is steadily establishing a health delivery system. The real situation still lacks many of the drawing-board plans that were formulated a few years ago. But the structure is sound and in- tact, while the substance grows stronger with each day that passes. • Editor's Note: We have been asked to point out that the AKAP movement in the Philip- pines, referred to by Ruth Seitz in her article "Self-help in the barrios" (January 1980 issue of World Health) is not a church organization, although it works in close cooperation with health projects of both the Catholic and Prot- estant churches. 23 A smiling village girl in Laos fisHes for crabs in the Mekong River. See page 21. (Photo B. Seitz ©)