Livings ReportLivings Report
IV - THE HEALTH AGENTS PROGRAM
V - THE WORK IN OTHER LOCALITIES
VI - OUR ROLE IN ILHA RASA LOCALITIES
I - THE TRAINEES SELECTION
The elective traineeship in Guaraqueçaba city had 80 days length and the Communitarian Health Department of Paraná State Federal University directed it.
It initiated in January 1995, and was composed by two groups until now, with three components in each group. The first one acted from January to April, and the second from April 6 to June 15.
This group opted to work in this traineeship because we were stimulated by the first group and also by the desire of living a different reality we used to live inside the School-Hospital.
II - THE GROUP ACTIVITIES IN THE CENTER OF THE CITY
One of the agreements between the Guaraqueçaba's Mayor and University was that the group should work in NIS-I a half period (4 hours), supervised by the local Doctor.
The daily amount of people looking for medical consults was about 25 persons. The morning was reserved to the habitants of the center of the city, and in afternoon to the rest of it. The most thankful to the group was that we could be present in all sequences of treatment, and because this enforcing the doctor-patient bonds.
We could also perceive, though the living with people, that the patients disguise their real live conditions when they look for medical service. For example, they put their best cloths in the day of consult, make their corporal hygiene and, by shinny or prejudice, they can lie about their real live conditions.
We could also perceive that a great part of persons that look for consults are women and that they prefer a woman as doctor to confide their and their children problems. Once of the positive points in these consults was the fact of we had a big quantity of medicines from CEME or from others laboratories, letting us unafraid when prescribing because we knew the patient would have the medicine and a guarantee of great part of success of treatment. In other hand, we had poor or inefficient diagnostic resources that damaged some patients.
The living with NIS-I functionaries was harmonious respecting always the work of each other.
The work in the seat crèche just initiated in the last 30 days of traineeship. We tried help to solve basic problems, but of great incidence among the more than 50 children in our weekly visit. The most common problems found were scabies, louses and intestinal worms. We examined all children one by one looking for these diseases. In case we find other type of diseases, the child was examined more carefully, treated and transferred for a specialized service if necessary. We tried to make the parents conscious about the importance of giving good health conditions to their children in communitarian reunions. We made a public letter about the importance of elimination of each and all parasites to make guaranteed the health of their children and all family. We asked to them to get feces samples to avail the children intestinal worms rates.
Another activity of this work was a value of the development of weight and height of children using a tendency curve. Using these data we propose a more elaborated work with more time, to compare the rates actually found with the rates in the end of work.
We perceived a need of training of the workers of the crèche with intention of best taking care not just of the children's health, but of their human developing, giving them love, caress and attention.
III - THE ACTIVITIES IN ILHA RASA (SHALLOW ISLAND)
With the time, the group perceived that was necessary to work with two communities to make a more intensive work. For that we should solve the problems of weekly regular transport to these visits.
In a reunion with Doctor Jonatan Löschner (local doctor and clinic director of local Hospital) and Ms. Marta Peña (social assistant of SPVS), it was decided that the SPVS had interest that we trainees go belong them to their regular visits to Ilha Rasa (Shallow Island) weekly on Wednesdays and Dr Jonatan offered the hospital resources to the transport of another community preferably in the continent with intention of the group perceive the real differences between communities, both economic and cultural. It was also decided we should work with women in these communities because the important social female role in the Guaraqueçaba's social context.
The visits to Ilha Rasa were of a regular continuity because the weekly transport was rigorously supplied by SPVS, and the community just counted on a previous conscious work done by SPVS. The community had a good acceptance for the group and we perceived that the work that was fundamental having a mind that this community is one of the most needy of the city. The orientation of the social assistant Marta was of great importance to make real this work. The work with another community wasn't possible to do because the absence of transport.
This community divides itself in three others: Almeida, Ponta do Lanço (End of Lance) and Ilha Rasa.
According to the Social and Cultural Diagnostic of Ilha Rasa, Medeiros de Baixo and Massarapuã Communities (Research Report of SPVS), the community of Ponta do Lanço actually is in an accelerated process of decadency, with just few residing families. There were 40 families living there at least about 50 years ago. Step by step this number was regressive and the migration to Paranaguá city accelerated in the last decade.
The Ilha Rasa community, located on the island of same name, formerly was named Ponta do Lanço de Baixo (Down End of Lance). The old residents tell that it started from a transferring of residents from Ilha das Gamelas (Gamelans' Island), sited beside this locality.
With reference to the number of resident families, just a few ones arrived from out of it. Some was marring and staying, though there is a bigger number that leaved to Paranaguá City searching better life conditions.
The Almeida's community is also located in Ilha Rasa and is resulted from a more recent structure. Others communities of the island tell that Almeida was a very small community with no more than 8 to 10 houses until about 20 or 30 years ago. Today it's the most populous community: about 40 houses and 200 inhabitants. The local research shows that there are no old residents (with more that 60 years old) native from Almeida. The great part of inhabitants of it was born and married in other locality and, in determined moment, migrated to Almeida. The most important origins of these people are Itaqui, Taquanduva, Tromomô, Engenho and Caçada, though Engenho and Caçada don't exist anymore.
The mayor city built a water reservoir in Almeida. However, as so as there's no enough water of quality, great part of residents use well water that is insufficient and salty. The other two communities (Ilha Rasa and Ponta do Lanço) just have well water to use.
We observed a poor water service in all communities of Guaraqueçaba, being this one of the most important needs. The existence of good water services is one of the principal demands of residents.
The electric energy is another service needed by communities. A project from COPEL (Energy Company of Paraná) to electrify the Ilha Rasa communities is ready and all residents are registered.
The basic sanitation in relation of an appropriated destiny of dejects is a really serious problem. There are no sanitary pits and the feces are deposited directly on the floor or in improvised bathrooms with any kind of treatment. This problem added with the precarious water service has been significantly contributed to the high rates of intestinal worms infestation in the region.
The skin problems are also expressive and certainly are corrected to water and sanitation problems.
With reference to health services, there's just a mini-post in Ponta do Lanço that offers first help services and has some medicines, helps in vaccination programs and is useful to medical consults. The community also has one health agent, but she doesn't have qualification or much interest for her work.
With reference to education services, just Ilha Rasa community doesn't have a school for fundamental instruction. The teachers are generally lay but passing for annual periods of recycling. The SPVS is actually making an important work in these communities implanting teaching for analphabetic adults in Ponta do Lanço and visiting the communities twice at week.
The communities also have a telephonic post in Ponta do Lanço.
The most important economic activity is the artisan fishing. The people of Almeida dedicate themselves to the crab extracting and Ponta do Lanço and Ilha Rasa to the manjuba fishing. The fishers claim the poverty of sea products, that is to say the quantity of captured fish have been progressively decreasing, as so the price of the product in the market is no rarely insignificant. These and others activities done by local community are done by familiar work.
The role of women in productive and reproductive activities in the heart of community is very important to maintain this traditional living way. They are responsible with the care of family, health and education, and also assimilating the reproductive activities in the familiar unit. They don't restrict them actions only to the physical space of the house (washing clothes, cooking, cleaning the house, sewing) but also do it around the house (raising, firewood cutting, among other domestic activities), as so as helping their husbands in the fishing activities.
Another important and relevant point to the success of our work was the receptivity of this population have to changes, always being willing to hear or to confide their problems to their doctor, not only related to their health.
One of the important things in the relationship between these three artisan fisher communities was the importance of family as an unit of production, consumption, maintaining and production of economic, social and cultural relations. The social organization of researched communities is fundamentally centered in relative relationship that exists between familiar units, extensively involving grandparents, uncles, and brothers-in-law, or in a nuclear mode, involving just parents and sons. These relationships guaranty the solidarity and cooperation.
The familiar buddies are other important relation present in researched communities.
There are no walls or other visible marks physical spaces, but only familiar units do it. When a son marries or a relative arrive in community their new home would be constructed nearby the familiar kernels. These spaces are legitimated by the tradition of use. Because this, the living in a community is a kind of harmonious.
In other hand, there's some rivalry between communities, especially concerning to politics and economic status. The Ilha Rasa community has a better economic and social structure. They were the first registering to receive electric energy. They were also the first to organize a Local Resident Association. In other side, Almeida is quite disorganized and needy and its female population more dependent and idle. We could take the example of what a Ilha Rasa's woman said when the group invited her to participate in reunion: "We, the women of Ilha Rasa, cannot participate because we help our husbands with the manjuba. The women of Almeida, that don't do anything, can go."
The religion is an element else of social agglutination in and out the communities. Normally the women decide which church they would like to congregate, and after they initiate a conviction work with other members of family. This is a space of basically women domain, but the men have functions of cult leader or responsibility over the faithful. The religion is the expression of certain world conception and designates the rules of social relationships, exercising its classical role as ideological regulator of the social group. It's also classic the association between religious and political powers in human societies.
The fact of Almeida belong with four different religions took our attention. In this community the Catholic, the Adventist, the Baptist and the God's Assembly Churches are present. These churches reflect not only the migratory flux that occurred in the last twelve or thirty years, but they also bring serious social organization problems. The ideological differences of each church, as so as the power that the church's leader has over the population, make serious confronts inside the communities.
Ilha Rasa and Ponta do Lanço communities have the same religion: the Catholic. The church is in Ilha Rasa.
IV - THE HEALTH AGENTS PROGRAM
The health agent became an important element in the care of public health in the last years in Latin America. Too many religious and non-government entities make the training of these health promoters. But in a great part of rural villages people still turn to healers and blessers.
The Latin-American Health Ministries didn't take knowledge about these amatory labor or even tried to eliminate it until recently. The doctors, with their medical training based in industrialized countries concepts, born and educated in the big cities, present themselves a bit anti-economic about the cost-benefice ways of treatment, as also refuse themselves to work in rural area.
Taking count of this, it became clear that only professionals could not make the health assistance in far rural zones.
Actually in Brazil the Health Ministry had launch a program of training and use of these health helpers in far rural communities and suburb neighborhoods, that execute an important role in health cares of these critical areas.
There are twenty health agents contacted by Guaraqueçaba Town Hall acting in the city distributed in different localities and being trained by SPVS according the agreement done with the local health secretary.
These trainings last three days with arguments about the problems faced by each locality as: diagnostic difficulties, disease treatments, medicines, work schedules and remuneration. It is chosen basic health subjects, looking for enlarging the knowledge of the agents.
The group had participated of the 7th training realized between May 16 and 18, where have attempted 9 health agents. The chosen subject was the women health cares, involving themes like: Preventing Risks to the Women, The Family and the Women, Familiar Planning, Gynecologic Cancer, Medicinal Plants and Some Medicines Uses and Risks.
The agents showed great interest in the subjects and participated facilitated by the interactive methodology used during the training. In despite of it, we perceived some cultural differences between the agents that made difficult the conscience process, once that just a few demonstrated being sufficiently active to work with the community. We could also perceive the fear they feel about public denouncing of health problems that exists inside the community, that could be exposed in one of the group dynamic proposed, that was a creation of a Mural Newspaper. The name of the mural newspaper was chosen by election: The City Daily. The color, which it'd be written, was also voted. The agents wrote the occurrences of their localities, being so fixed in a polystyrene panel. The occurrences varied between the city-hall carrying outs (the reform of the school of Ilha Rasa, some access roads in Rio Verde, vaccination against B hepatitis to children younger than one year old, the health post in Tagaçaba); some news of Resident Associations conquests (electricity in Tagaçaba de Cima); and about some accidents occurred (a little girl that fractured her arm and stayed with some deformity in her arm after orthopedic treatment, about the death of an forty four year old man in NIS-I by fulminate heart attack and about two girls that ingested a great number of Phenobarbital pills and staying about one day in coma).
After fixed these occurrences, it was voted the place where the panel should be exposed. Appeared three proposals: in NIS-I, in City Hall or in the bank of he city. After the arguments about advantages and disadvantages of each one of these places, the proposals were voted; being hindered the NIS-I and the City Hall proposals. In despite of all process have been made together, the health agents didn't want to put their names on the panel.
In the last day of the training the health secretary and the municipal social assistant went there and read the occurrences on the panel. Then we could perceive the fear the health agents felt printed on each one face, specially when the municipal social assistant read the new about the death of that man in NIS-I and asked rudely who had wrote that. In face of it, the health agents didn't want the panel exposed anymore in the City Hall.
This occurrence well reflects the fear and the work instability that health agents are exposed. This fear blocks their political actions as health promoters and implementers of a better society.
Another important activity was the explanation of the health women vigilance, which the agents would make the registry of all women of their locality, including data about prevention of gynecologic cancer, pre-natal exams and other. In this same way we intended to accompany the attempting of the women in the health program referring to them, and the health agent would have an important role searching actively the absenting women, beyond promoting awareness and give health explanations that they were prepared.
Finally, We could conclude that the continuity and efficiency of this project would need a broad integration between the City Hall, the University and SPVS.
But what is the really role of the health agents at last? We wonder if the health agents were being faced as a health and citizenship of their own people or just as a quick and cheap way to solve the harmful effects of a whole fail social system?
We thought that the health agents didn't understand their really function in their communities. It seemed to us those government organs, community and even themselves, look at them as just a guardian of the mini-posts and of medicines there, without any effective actuation. This fact is clearly shown when they faces dispirited to engage the active search to integrate the health programs of the city, restricting themselves only to make the collect of the vital data of the people those would take the medical consult or just giving the medicines.
Face the health agent just like a medicine distributor is burying their true mission that's much bigger.
Facing them like this is just substituting the doctor by a cheap labor decreasing the State onus. The Brazilian law says that promoting the act of cure without legal license is a crime (quacking). We wonder if face the health agents as simple medicine giver was not legalize a new type of State "quacks"?
If the health agents are not acting as they should as citizenship constructors, who have the fault? The State? The Health Ministry? No. It's our own fault, when we forget to fight for our people and for ourselves. We forget to do the small things that we can do. We forget to remember the health agents their true role.
V - THE WORK IN OTHER LOCALITIES
In the first week of the training it was made an itinerary to the visits of the eleven localities of the city. These visits should be done on Tuesdays and Thursdays using a transport from the city hall, where the group should accompany the doctor and the nurse to consults and vaccinations. Two facts took our attention: the poor quantity of these visits, and that the sea as a life source and at same time as a trouble, since it brings serious problems with transport: there are communities that would only be visited in the high tide (just like Medeiros)
Because of politic problems this itinerary was not fully followed because the missing of transport, food for the group and people missing made that some localities weren't visited in the great part of times.
The experience was very thankful in the rarely times we could make these visits.
MASSARAPOÃ: Abadom made five visits to this community that's far about thirty minutes far from the center of the city using the boat with stern motor, the last one he made with Jaque that picked samples to the prevention of gynecologic carcinoma. The community has twenty-seven families and it's sited on the continent, but with access only by the sea. There's no mini-post or phone-post (like Ilha Rasa), but the social and economic level is very similar. The thing that more took our attention was the caress way we were treat.
ILHA DAS PEÇAS (ISLAND OF PEACES): This locality is about one hour far from the center of the city using a boat with stern motor. There's a mini-post, health agent and phone post. We couldn't make any clinical consult and so it's difficult to have any impression of it. We just went to know the island.
TAGAÇABA DE CIMA: It's a locality sited on the continent, far about forty minutes from the center of the city using a car. What took our attention was the facts of the houses are precarious buildings, but too many houses have parabolic aerials, and also too many bars. The local health agent said that region is a quite violent. There's mini-post and phone-post.
DISPENSáRIO DE TAGAÇABA (TAGAÇABA DISPENSER): It's a continent sited locality far about thirty minutes from the center of the city. There's a mini-post, phone post and health agent. It was constructed a modern health post near the mini-post, even with a childbirth room. This place has a newly contracted doctor in permanent shift. There are many superfluous or dangerous medicines if used without medical indication in this mini-post, being under responsibility of the health agent like, for example, clomiphen acetate and medicines composed of masculine hormones.
BARRA DO ARARAPIRA (STRIP OF ARARAPIRA): This is the most distant locality of the city. It's sited on the border between Paraná and São Paulo States. Beyond we became moved to the beautiful local scenery we could perceive that community much more organized with better life conditions than we used to see. There are mini-post, phone-post and health agent there.
VI - OUR ROLE IN ILHA RASA LOCALITIES
The principal objective of our training is the communitarian health, because this, the group opted to make a preventive medicine kind in the beginning. But we quickly perceived that this would be a kind difficult because the immediate necessity of cure of the population's problems and, if we deny this we could be rejected.
We establish so our work strategy: we would attend older and with locomotion difficulties people in their own homes by the morning, trying to make them conscientious about their necessity of health improvement. At afternoon we would attend in the local mini-post and also make reunions with the community.
In the beginning the people asked us to attend in their own home, as we expected to happen, with the excuse that the mini-post was too distant. We had to give limits to them so, because this type of service is not of quality and very tiring.
In the beginning we also made the call upon to the reunions that were made in the mini-post with subjects concerning to the women health. Some times we used other places like the school, the Adventist Church and even some resident home. Firstly the number of participants was very low and the participation of them depended of an incisive call upon it. With the time, the women began to participate more of the reunions and could talk about problems that were taboos to them and they even could leave their adolescent daughters have a reunion about sexuality, what wasn't permitted to them at first.
The kind of people that normally went to mini-post looking for medical consults were almost exclusively composed by women with their sons, just like we quoted in the beginning of this text. They also preferred women like doctor to trust their or their children problems. The problems were very variable and we could perceive many types of diseases, since the more complexes like mental diseases, congenital misshapenness, alcoholism and depression, as so as the more simple diseases just like scabby and louses. The men asked medicines through their wifes. This reflects not only a chauvinistic behavior but also a distribution of tasks in the community. The men, because of their work, didn't look for the doctor. In the last day of attending a fact took our attention: two men came to the consult. They were so cause of laughs and teasing by the women. Over there, they were put in the last to consult.
We won the liking of the community. We were always very welcome on the domiciliary visits, and when we weren't we could perceive that was because the mystic that involves the doctor in the popular imaginary. The link between the group and the community was felt more intensive in the two days that we passed camped in Ilha Rasa, maybe because the people could feel us closer and really worried about their problems.
One of factors that worried us the most was the abusive use of medicines by the people. They forgot the teaching of their antecessors, specially concerning the use of medicinal herbs. Maybe it could be worked with them.
VII - THE TRAINEESHIP DIFFICUTIES
The first big difficulty we found in this traineeship was the fact of many time we didn't have a doctor to supervise us in the visits in localities. This was felt intensively in the first week when that man died of a heart attack in NIS-I. This time was very difficult because we had to think about in all legal implications this traineeship was exposed, as so as we turned conscientious about the care we must have to each patient, because the community is not receptive to a work just preventive. So, it was decided with the supervision of our communitarian health professors that the attending in localities, when not companied by the doctor, should be only of basic consults of simple diseases, because the health agents themselves routinely to do. Chronic patients and more serious diseases should be taken to the hospital.
Another difficulty specially felt by the trainee Abadom was the refuse he suffered by the female people. He was constantly rejected because of taboos, prejudice and even their chauvinism, that's very evident in these populations.
The lack of a place to live was another factor that disturbed a kind, because we moved four times in the eighty days of traineeship: when we were beginning to set we had to move.
The missing of transport was that a great part of the traineeship was difficult, because we couldn't have any idea of other communities and analyze the social, cultural and economic differences between them.
The difficulty with money to our basic spends, just like our breakfast and ticket to go to the city from Curitiba, weren't totally compensated for. The experience of feeling that we were working to the community, trying to make a serious work, without any compensation just to our basic spends causes too much indignation, when we know that in this country the public money is lost.
The political divergences between the City Hall and SPVS disturbed our work some times. We perceived that if there was a better dialogue between them it should be better to the community.
The orientation of the trainees by the Paraná State Federal University was a quite fail. We know that this is a new experiment to the Communitarian Department and that the professors have many other activities. But we suggest that the professors responsible to the traineeship could be closer to the trainees, specially in the beginning, where many times we didn't know what kind of attitude take face to some situations.
Finally, we really want to say that, in despite of all difficulties we found, this experience maybe will be unique in our lives and it make us grow up, not only as professionals, but also as human beings sensitive to the problems of the community.
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