Like having a doctor

A manzanera makes her rounds carrying her own baby from house to house. The volunteers’ job is to promote healthy practices and encourage residents to utilize available health services.

“Volunteers go through a cycle,” says Sarah Arnez, one of the program’s founders and a member of El Alto’s city council. “People burn out and leave, but they leave with the advantage of having been trained and sensitized.”

PAHO’s Amado agrees, although he believes that the program should offer more incentives for the manzaneras— for example, providing them with more educational materials. Each volunteer now receives only the special green jacket that allows neighborhood residents to identify her.

“You cannot pay the volunteers,” Amado says. “This is voluntary work and must continue to be so. Otherwise it loses its reason for being.”

Once a volunteer has been elected and trained, her first task is to take a census of the manzana where she will “market” health services door to door.

She then begins her work of providing health education to residents, including telling them about the warning signs of health problems in pregnant women and children under 5. She tells mothers-to-be what to do in case of bleeding during pregnancy, prolonged labor and childbirth, or a high fever after giving birth. She tells parents what to do if a child has diarrhea or if there is a foul odor around a newborn’s navel. She also provides detailed explanations of childhood vaccination schedules.

Each manzanera decides when she will visit her manzana, although most make their visits at mid-morning or in the early afternoon, after feeding their own families.

“First we cook for our spouses and our children, then we can leave to do our rounds,” explains Susana Quispe, a manzanera from Health District III, also known as the Centennial District in honor of the 100th anniversary PAHO celebrated in 2002.

Quispe’s manzana has 20 houses, all two- or three-room adobe-and-brick structures packed closely together along dirt and cobblestone alleyways. One of these is home to 21-year-old Lizet Silva, who has relied on Quispe throughout her first pregnancy and with whom she made her first visit to a health center. “It’s like having a doctor at home,” says Silva.

For El Alto’s health authorities, the manzaneras have achieved what traditional strategies have failed to produce: a lower risk of death from complications of pregnancy and childbirth, and a higher number of institutional or attended deliveries. How have they done it? By restoring “power to the people,” says Tórrez and other supporters of the program, and by drawing on the natural social inclination for neighbors to want to help one another—both strongly rooted cultural features dating back to Bolivia’s precolonial Quechua and Aymara cultures, and still passed on from generation to generation.

Abdel Padilla is a reporter for the Bolivian daily newspaper La Prensa.

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