Wan raika jelpkaba taun dukia sa baku sin taunra iwi uplika dukiasa. These words in the Miskito dialect, meaning "health is of the people and for the people,” were spoken by a religious leader in the town of Uhi.

Dr. Francisco Medina, Director of Health Region 8, had come there to open a new public health clinic in the remote Gracias a Dios department, or La Mosquitia—the Mosquito Coast, as it is popularly known, the most sparsely populated territory in Honduras and, some say, in all of Central America. Located along the country's northeastern Atlantic coast, Gracias a Dios is Honduras' second largest department and made up of six municipalities, four of which were created at the end of 1996. The population is multicultural and consists of four indigenous groups: the Tawahkas, Pechs, Garífunas, and Miskitos, the latter representing approximately 70 percent of the population.

The opening of a new clinic in Uhi did not escape the notice of the rest of La Mosquitia's nearly 58,000 residents, who are hopeful about the new thrust underway to bring health to a corner of the world whose impenetrable jungle terrain, lack of roads, and a host of other interwoven ethnic, cultural, educational, and economic factors have presented an almost insurmountable challenge to the public health sector.

To visit the Mosquito Coast is to glimpse the innocence of a land filled with natural treasures; a virgin territory of lagoons, mangrove swamps, and extensive river systems that exudes the pure air of the rain forest; a wilderness where humans are a minority among other living things (population density: 1.2 inhabitants per square mile); an area that harbors both light- and dark-skinned people with different features, shapes, and languages; a people who struggle to make ends meet through hunting, fishing, farming, and seasonal odd jobs tied to the land and sea that surround them.

This new reason for hope took place at a critical, and ironic, juncture in La Mosquitia's history. Only weeks after the opening of the Uhi clinic, Hurricane Mitch would include the Mosquito Coast in its rampage across Central America. While, miraculously, no one was killed or seriously injured, the economic and emotional loss here was considerable. During the floods that followed the worst hurricane of this century, the carefully planted garden plots of corn, rice, and beans were washed away. "Now people must work harder than ever before because the hurricane left them without food,” says Elena Marley Cunningham, a professional nurse working in the area.

Despite the Mosquito Coast's ecological abundance, the majority of its inhabitants have long lacked clean drinking water and basic sanitation services. According to a government report, at the end of 1998, only 22 percent of the population had access to potable water, and of the 27 percent who had access to waste disposal services prior to Mitch, only 10 percent still had it afterward.

Because of this situation, public health officials feared disease outbreaks in the disaster's aftermath. Malaria long has posed a serious health problem along the Mosquito Coast. Yet case numbers did not climb significantly during the post-Mitch period, says Dr. Juan Rosado, municipal health coordinator for Puerto Lempira, the departmental capital of Gracias a Dios, because the Honduran Health Secretariat took immediate action to drain and fumigate mosquito breeding sites.

Rosado adds that the area also is ridding itself of dengue fever through a community health project in which all boats docking in La Mosquitia ports are fumigated upon entry and exit.

Health and living conditions on the Mosquito Coast always have been more precarious than for the rest of the country as a whole. The high rate of maternal mortality—461.8 for every 100,000 live births, compared with the national rate of 168—has long concerned health authorities. The leading causes of death are hemorrhages, infections, and hypertension. Furthermore, half of these women die during the course of their pregnancy and the other half either during childbirth or shortly afterward. Of the total number of births in 1998, 56.3 percent were home deliveries, indicating that the majority of women do not use formal health facilities.

The example of maternal mortality statistics suggests the region's economic, educational, and geographical disparities: opportunities are few, and distances are great. The prevalence of midwifery also indicates the importance of traditional medical practices in the region and of creating culturally appropriate health services in the future.

Despite the current setbacks from Hurricane Mitch, the Mosquito Coast has scored significant achievements in health care access over the past five years. Today there are 29 health centers or service posts scattered throughout the department, 12 of which are linked by a radio communications system that has made the exchange of information and increased epidemiological surveillance possible within the region.

The opportunity to build on these first, small, fundamental gains in health came during the previous government administration with the implementation of the Access to Health Services Project on the Mosquito Coast, which Honduras' current president, Carlos Flores Facusse, has extended for four more years.

This action forms an integral part of the New Agenda for Honduras 1998-2002 (in the post-Mitch period, the name has been changed to the Plan for National Reconstruction) following a joint agreement signed by the Health Secretariat and local governments in the Gracias a Dios department.

The project's gains to date are impressive: the population's first-time access to health care rose from 23 percent in 1993 to 84 percent in 1998. As was the case in the opening of the new health center in Uhi, regional health director Medina says these accomplishments stem from the financial support and combined efforts of local communities; municipal governments; nongovernmental organizations; the Honduran Health Secretariat; the Pan American Health Organization (PAHO); the Governments of Sweden, Japan, and Spain; and other governments and agencies.

The project goals include the extension of drinking water and waste disposal services; the construction of maternal and child health care clinics, primary health care centers, and floating health units; and the implementation of community rehabilitation strategies, including helping those who lost homes and livelihoods during the hurricane to cope with an even more uncertain future.

The King Alfonso XIII Diving Clinic, located in the village of Cauquira, is another example of community rehabilitation. There are more than 5,000 men in La Mosquitia for whom lobster diving represents a quick, albeit seasonal, source of income. Yet sooner or later, many will succumb to decompression sickness, or "the bends,” which is caused by diving too deep or swimming to the surface too quickly, thus depriving the brain of oxygen and producing chronic pain, neurological disorders, full or partial paralysis, and even death. The clinic has a hyperbaric chamber to help stabilize the condition of those injured and offers services to raise awareness of the occupational hazards involved and how to prevent them with proper equipment and diving techniques. The project is supported by the National Development Foundation (FUDENA), the Governments of Spain and Honduras, and the community itself, concerned for the well-being of its husbands, sons, and fathers.

Another example of the partnerships being formed is one between the Health Secretariat, the Indigenous Socioeconomic Development Association (BAYÁN), the mayors' offices in the municipalities of Juan Francisco Bulnes and Brus Laguna, and local labor associations, all of whom have agreed to share management of a private hospital recently opened in the village of Palacios.

According to Dr. Houshang Sabripour, BAYÁN Executive Director, these collaborations are changing the way people think about health. The population stands to benefit, he says, because "people who need treatment will no longer stay at home; they can go to the hospital,” and thus have a new resource, which he feels may play an important role in reducing the area's inordinately high rates of both maternal and infant mortality.

Olegario Martínez, an advisor for the mayors of the Mosquito Coast, also is buoyed by the changes coming about. "Today, the completion of our agendas is starting to shift away from a traditional dependence upon the helping hand and charitable donations. Now local legislators are talking about 'joint management agreements' and 'social participation' as the new strategies to improve our communities.”

Both of these strategies clearly are at play in the work of the Puerto Lempira Hospital, which, despite its limited personnel and logistical resources, reaches out to a population of over 30,000 in 14 communities. "This is a hospital with open doors,” says its director, Telma Soliman Herrera.

Another hurdle being overcome, despite the fact that most villages lack electricity, is the preservation of vaccines and the cold chain—the constant low temperatures required to ensure the vaccines' effectiveness—through the use of solar energy and kerosene to power refrigeration systems in health posts and centers. During an April 1998 immunization campaign, health workers were able to vaccinate more than 85 percent of all children under the age of 5. Coverage for children under age 1 reached 100 percent for poliomyelitis, measles, mumps, rubella, and tuberculosis, and 93 percent for diphtheria, tetanus, and pertussis (whooping cough)—all leading killers of infants during the first year of life.

Knowing that diseases do not respect national boundaries, regional health authorities also are working with local populations along the Mosquito Coast's border with Nicaragua, and stepping up disease control through reinforced epidemiological surveillance and training of health workers in the treatment of diarrheal diseases, acute respiratory infections, malaria, and other common illnesses.

The ground along Honduras' Mosquito Coast is fertile for continuing the unfinished work prior to Mitch, as well as ameliorating the sense of loss left in the hurricane's wake. There are fields to plow; seed to buy and plant; crops to care for; homes, churches, schools, and clinics to rebuild; lives to put back together again.

The villagers themselves marvel at their "natural resistance to adversity,” as they call it, recalling a long, turbulent history of alternating invasion and isolation stretching back to the 1640s when a group of shipwrecked West African slaves landed near Cabo Gracias de Dios and settled among the indigenous villages lining the Coco River. The Miskito would survive three bloody wars fought during the 18th century between the English and Spanish for control of their coastline, as well numerous boom and bust cycles—rubber, bananas, gold, lumber—that attracted pros-pecting foreigners to their land.

Today, the challenge is reconstruction after Mitch, and the Mosquito Coast residents are doing what they've done before—building from the ground up, if need be, welcoming the help of strangers from other parts and other countries, and always striving to make the Mosquito Coast a better place to live.