Bringing the benefits of better health to the people of Bolivia has long challenged health and government leaders. This historic dilemma is inextricably related to the country's topographical extremes: Bolivia boasts the world's highest navigable lake and capital city and contains both equatorial jungles and Andean peaks. While the country's rugged landscapes may hold special appeal for tourists looking for an off-the-beaten-track adventure, it has posed an almost insurmountable barrier to social progress and improved living standards for the more than 3 million people-39 percent of the population-who live in the small, remote villages that dot mountains, valleys, and plains. Even though they are separated by long distances, few roads, and different cultures, these communities share one commonality: almost all are indigenous, practice traditional ways of life, lack basic public services, have few sources of income, and exhibit the country's most precarious health and living conditions. The health inequities that persist be-tween urban and rural Bolivia are reflected in a 1998 National Demographic and Health Survey, which found that 93 percent of urban dwellers have access to clean drinking water and 82 percent to sanitation services, versus 44 percent and 35 percent, respectively, in the case of their rural counterparts. The lack of these services denies rural inhabitants the basic building blocks needed to achieve a better quality of life.

Over the past six years, the Ministry of Housing has worked with the Pan American Health Organization (PAHO) in promoting the use of new and alternative technologies to reduce Bolivia's water and sanitation inequities, particularly among marginalized populations. In developing strategies, the partnership has focused on the selection of simple technologies that are sustainable over time, culturally acceptable, cost-efficient, and easy to install, operate, and maintain in good working order, which also build community trust and increase understanding about the role of clean water and basic sanitation practices in improving health.

Much of the technical expertise was provided by the Sanitary Engineering Institute of the University of San Andrés and the Center for Research, Develop-ment, Evaluation, and Promotion of Appropriate Technology, which worked with PAHO's Country Office in La Paz in developing a mixed package of simple technologies-some newly created and others already existing-that could be applied successfully to a variety of local climate and topographical situations.

With the launching in 1996 of PROTESA (the Spanish abbreviation for Unidad de Proyectos Tecnológicos en Saneamiento Ambiental, or Unit for Projects in Environmental Sanitation Technology), PAHO provided a decentralized operational arm for implementing and overseeing the development of community water and sanitation projects. To build local interest in these technologies, the PROTESA team of experts sponsored a series of workshops teaching volunteers from selected villages how to drill wells, install water pumps and pipes, and build various types of household and communal sanitary units. The training also included modules on the proper use, maintenance, repair, and replacement of parts and installations, as well as on the importance of personal hygiene in preventing the spread of disease.

By encouraging the formation of microenterprises, PROTESA is providing new sources of income for rural residents, while at the same time serving as a catalyst for a growing sense of community ownership and pride in the improvements made. In many cases, the microenterprises are based either in or near the villages they serve, where the workers already are known and respected members of the community. This proximity also lowers travel and shipment costs. If community members supplement the labor force, further savings are achieved; costs are driven down even further if multiple units are built at the same time. Production costs also are contained because all materials are locally available in Bolivia, and many of the parts are manufactured by the microenterprises themselves.

Labor costs for drilling a well average US$ 10-15 per yard, with usually a minimum of 22 yards of depth required to reach groundwater safe enough for washing, cooking, and personal hygiene. This cost, however, can drop to as little as US$ 3 if the residents help in the drilling. Likewise, significant savings can be achieved if several families use the same well. The price for a water pump averages US$ 50-70-once again, a cost that may be divided among neighbors. Other simple technologies include the manufacturing of cement washbasins, and hot and cold water storage tanks and showers.

To ensure the safety of water for drinking, the microenterprises also produce a home disinfectant system that includes hypochlorite solution, filters, storage containers, and portable hypochlorite generators. Developed by the U.S. Centers for Disease Control and Prevention, U.S. Agency for International Development, and Bolivia's National Health Secretariat, the technology offers communities various alternatives for satisfying their drinking water needs and includes basic instruction in dosage and correct use and maintenance.

Sanitary facilities and waste disposal units, of both fixed and movable types, are available both for single- and multiple-family use in a variety of materials. Similarly, permanent facilities have been developed for use in schools, health posts, markets, and other public places, while portable varieties are available for use during community-wide events, such as agricultural fairs and religious celebrations. PROTESA and PAHO also have collaborated on the design of lightweight, collapsible multi-units that may be easily transported and quickly assembled in areas affected by disasters. This technology was utilized successfully in the aftermath of an earthquake in 1998 in central Bolivia that disrupted basic services in Aiquile and Totora, leaving the townspeople vulnerable to the risk of disease outbreaks.

In addition to promoting clean water and sanitation services, PROTESA also works with the microenterprises to help townspeople improve health and living standards by upgrading their homes. The replacement of dirt floors with cement, filling in and plastering of interior walls, and installation of closed roofs reduce the dust level, thus lowering the risk of respiratory infections and allergies, particularly for in-fants and young children, and discourage the entry and breeding of disease-carrying insects, rodents, and other animals. These projects also are being carried out in schools and other public buildings in conjunction with community demonstrations that highlight the relationship between good personal hygiene and disease prevention.

From the Guaraníes in the east to the Urus in the altiplano, the majority of PROTESA projects to date have focused on isolated indigenous groups in the Andean region of La Paz, Oruro, and Potosí, as well as those residing in the valley area of Cochabamba and Sucre, where historically there has been little institutional presence to generate environmental health services. According to Alfredo Rojas, municipal mayor of Cliza (in Cochabamba Department), access to clean drinking water has fulfilled one of the longstanding aspirations of Bolivia's sizable indigenous community. "Before, we didn't have any fresh water," he says. "We just drank salt water from the lake. Now this institution comes and helps us..."

Without a doubt, children are the group most affected by inadequate water and sanitation conditions. Speaking of his Guaraní village, Efraín Rivera says: "A year ago, diarrhea was everywhere among our children. We suffered tremendously. But when the wells were drilled, the situation calmed down. Now there is a lot less diarrhea, so maybe the children will have a better chance."

When the microenterprises come to install services, the members readily share the health promotion techniques they learned during their PROTESA training. They particularly are interested in showing mothers how reliable water and sanitation sources can make their lives easier and provide better health opportunities for the entire household. "We would bring water for our families from very far away," notes one woman from Cochabamba. "The places we dug were no good; they only produced salt water." Having water in the home, she says, has made things more convenient and saves women time, since traditionally, "we are the ones who must find water and carry it home to our families."

PROTESA also works with schoolteachers to help raise awareness about health in the classroom and has produced three handbooks to date: "School Hygiene and Health," "Water Quality and Use," and "Use and Maintenance of Sanitary Units." Five new titles are also in the works: "Hygiene at Home," "Medicines: The Friends of Health," "First Aid," "Nutrition and Food Safety," and "Accident Preven-tion at Home." The underlying premise of the publications is that teachers, as health educators, can serve as an important catalyst for behavioral change among Bolivia's new generations. When children share these messages at home, parents are provided with a social stimulus-how to improve the family's overall well-being-which leads to greater self-esteem among all its members.

In a country whose rural poor have few opportunities to improve their lot, the microenterprises encourage small-scale rural economic development and offer greater self-sufficiency, but more importantly, tangible and sustainable improvements in health status and living conditions. To date, 7,000 wells have been drilled, and more than 200 communities have benefited from the work of the 35 microenterprises formed during PROTESA's first three years of operation. Not only is the strategy spreading rapidly throughout rural Bolivia, but is taking root in other coun-tries with similar difficulties in reaching geographically isolated populations, as well. Thirty-four microenterprises have been created in Peru, Ecuador, Panama, and Honduras, and rural residents from Mexico, Nicaragua, Colombia, and Para-guay also have received training that will enable them to bring these life-saving technologies to their own communities.