The challenge of bringing vital health information and education to remote rural villages has perplexed many a health worker and decision-maker in developing countries. Bolivia, Latin America's highest and most isolated nation, is a classic case in point. A glimpse at its transportation infrastructure, for example, reveals only six main highways in a geographical area larger than that of France and Spain combined. Many secondary roads have never appeared on maps, which makes reaching obscure places a matter of knowing "how to get there from here."

The altiplano highlands, which make up some 30% of the nation's land and contain more than half of Bolivia's population of 8 million, present a formidable barrier: the air is thin and the region boasts four Andean peaks rising above 20,000 feet. The lush rolling valleys of the isolated and underpopulated Los Yungas form a transition zone between the icy peaks of the Andes and the steamy rain forest and swamplands along the Amazon Basin, which occupies much of the country's north and east. Finally, there is the hot, inhospitable, and sparsely populated Chaco plains along the Paraguayan and Argentine borders.

The extremes of Bolivia's topography have conspired to enclose thousands of rural Bolivians in pockets of virtual self-containment and greatly limited contact with the outside world. Except, of course, for Bolivia's armed forces. For them, the country's numerous tucked-away places are all too familiar.

Captain Henry Laredo of the national military police has visited a number of these dots on the map. He has seen the small impact the modern world has had on them, much less that of modern medical advances and thinking. He has encountered little awareness of basic health issues and even less trust in professionally trained doctors. Instead, the roughly 55% of Bolivia's population who are descendants of Quechua and Aymara pre-Columbian cultures cling to the traditional values and beliefs of their ancestors.

"Most indigenous peoples I have met still strongly believe in the power of magic and mysticism," he says. Because it is so deeply imbedded in their culture, they believe their gods are what make them sick or keep them healthy, not behavior and common practices.

"The Matacos, who live in remote areas near the Argentine border, do not know what the human organism is about," he continues. "In another rural area, the Santiago de Machaca people do not visit hospitals, even if they are nearby, because they are fearful of them."

A few years ago, as a medical consultant in the Bolivian Ministry of Defense, Dr. Janette Vidaurre became greatly concerned about this situation. She wanted to find a way to reach these populations, wherever they happened to be, and improve their access to health care and quality of life.

In 1987, she hit upon an idea. At the same time Captain Laredo was performing his officer's service, Janette Vidaurre was putting together a plan. She enlisted the support of UNICEF's then-chief of health and nutrition in Bolivia, Guido Cornale; colleagues at the National Fund for Social Investment; and local officials of the Pan American Health Organization (PAHO) and the World Health Organization (WHO). Together they began working on a low-cost, effective way to bring basic health messages to the country's rural communities.

Thus was born the Sentinels of Health program, whose basic premise is that military conscripts can be valuable resources in the ancient fight against disease and misinformation and become effective health communicators in Bolivia's scattered towns and villages.

Over the next four years, a number of studies were conducted to test this premise. All pointed to the fact that young soldiers, within their first year of service, are well known and respected and frequently called upon by the townspeople to assist them in a variety of matters, including health issues.

Among the findings of these studies was that it already was common for soldiers to help deliver babies in the countryside. The creators of the Sentinels of Health program saw this as an opportunity to take advantage of this existing bond of trust by arming the soldiers with health information they could teach to people who might not believe any other voice from the outside world.

In 1991, the program was incorporated into the Bolivian military system and the first group of soldiers received official certification following their two-week Sentinels of Health training course.

Down to Basics

When soldiers begin their training, they are given a copy of the booklet Para la Vida (Facts for Life in its English-language version). Produced by UNICEF, WHO, and UNESCO, the manual's simple language presents over 50 basic health messages in the areas of home hygiene, nutrition, oral health, safe water and disposal of wastes, immunization, respiratory infections, oral rehydration, prenatal care, family planning, and childhood growth and development. Soldiers learn about malaria, yellow fever, tuberculosis, goiter, tetanus, and diarrheal diseases.

To ease the learning process, basic military terminology is used. Soldiers are urged to fight the "enemies of health" and "protect the frontiers of the body," and are taught to use intelligence, strategy, and special tactics to defend health problems. AIDS, for example, is a "powerful, mortal enemy that directly attacks our defenses; it is a specialist in the art of camouflage." Charts and demonstrations with volunteers help those in the ranks who are illiterate and add variety and levity to the instruction.

"In the beginning," says Vidaurre, "I was convinced I had to use doctors to teach the program. But in a fluke incident, I used a military officer and the results were astonishingly different." Conscripts achieved higher test scores--above 90%--when taught by regular military instructors, versus 75% (the mininum passing score) or lower when they received their training from military doctors.

"I received 98% on my exam," says Christian Murillo of the military police's First Division proudly. "There was a lot of interaction and the instructors used jokes and acting while teaching us. They would repeat things to see if we understood, and everyone was interested in what was being taught."

Doctors had been using complicated medical terms to instruct, while military officials did not, and this helped boost the learning curve. On the other hand, it was soon discovered, military doctors could lend support to the Sentinels program in another important way. Their technical support has been largely responsible for the training of 4,600 instructors to date.

Upon graduation, each soldier receives a certificate issued jointly by the Ministry of Defense and the Ministry of Human Development that bears the emblems of UNICEF, WHO, and PAHO. When he completes his military service, he becomes registered in his hometown and receives a formal introduction to the director and personnel of the local clinic, where he will form part of a health team. The communities fill out a standard form showing how Sentinels are used and at periodic meetings, district health authorities evaluate Sentinel activities and their impact.

As soldiers continue to graduate from the Sentinels program, more citizens become available to forge that vital link between the health sector and the community. More than 200,000 young men have taken the training so far.

Military Seal of Approval

Military civic duties usually involve construction of public works, such as roads, schools, latrines, and other types of manual labor. The involvement of soldiers in the Sentinels of Health signifies a tremendous leap forward in education and civic participation.

According to General Reynald Cáceres, commander-in-chief of the National Armed Forces, "The Sentinels of Health program fits in well with the Bolivian Armed Forces's mission, part of which always has been to remain attentive to civil needs, the population's health status, and the need for development."

What first attracted the program's coordinators to the military was its emphasis on order and discipline and the fact that the military was ideally suited to undertake massive educational campaigns."In no other situation," says UNICEF consultant Dr. David Tejada, "would you have the fortune of educating 35,000 to 40,000 people every year about health."

Health officials feel they are getting an excellent return on their investment and efforts, and government officials feel they are making even better use of their resources.

The program is not only sustainable, adds Tejada, but low-cost: "International funding organizations spend only US$ 3 per month per conscript--a remarkably low sum." The rest of the funding comes from fixed government allocations to the military.

Agents of Cultural Change

In Bolivia's rural communities, traditionally it is still the man who has the final say over family matters. He is most likely to decide whether his wife will deliver a child at home or in a hospital, and if his children will be vaccinated or not. The woman still remains responsible for daily household activities and childcare, but her husband's word dominates.

This is why Janette Vidaurre believes the recently graduated soldier can play a fundamental role in reeducating traditional rural Bolivian society about health.

Once Christian Murillo goes home, he will receive greater respect from his community. He will be seen as someone who is vigilant about dangers to health, the same way an army sentry posts guard against a possible invasion. While aware that he is not trained as a doctor, he is more confident that his newly gained knowledge will enable him to defend better the health of his future family.

At some point in his life, Murillo will most likely face an emergency health situation.

Cadet César Efraín already has, and is grateful for having participated in the Sentinels of Health program. Though he has not yet finished his service, Efraín already has been called upon to think quickly on his feet when his cousin suddenly became ill. "I was able to help her," he said, "because of what I learned in the program.

Ten years ago, most young men would not have possessed this confidence. Most lacked the correct information to advise loved ones in health matters, much less perform a delivery. The nation's high rate of mothers who die while giving birth (1 for every 200 deliveries in 1994) and child deaths from diarrhea (41 per day) reflects a tragic situation that needed to end, according to Vidaurre.

"We will have [Bolivians] capable of responding to health situations . . . and we will be able to improve aspects of human development, particularly in health," said Dr. Joaquín Monasterio, who was National Secretary of Health when the agreement to incorporate the program into the military was signed.

"The last thing we imagined when we first started," Vidaurre notes, "was that the Armed Forces would like the program. We thought it was going to have to be implemented by a special executive order."

To her surprise it was, and still is, widely accepted. To crown its success, it is the only program--out of some 800 presented to the Armed Forces in recent years--to become institutionalized into the military training of conscripts. It is the only agreement to be co-signed by all three highest ranking officials in the Armed Forces and by the National Secretariat of Health, the Ministry of De-fense, and the Ministry of Human Development.

Moving On and Out

Health and military officials and young soldiers are proud of the program's success to date and are convinced it could work in other countries, too. "There is an interest in the Sentinels of Health program in Paraguay, Peru, Ecuador, Belize, and Nicaragua," says Vidaurre, "But I still want to maintain the excellent success rate in Bolivia--the first, and only place so far, where it has been implemented."

Every corner of the nation now has a Sentinel of Health, someone like Christian Murillo knowledgeable in health issues and working to benefit his community.

If soldiers like Murillo do not become the town mayor, or the director of health services, or form part of the town's vigilance committee, they will nonetheless be more responsible, health-conscious parents and husbands. The average rural citizen will be better trained to fight the enemies of health, build a solid defense against disease, and stand strong for a higher quality of life.

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Debbie K. Becht is Editor of the Bolivian TIMES weekly English-language newspaper in La Paz, Bolivia.