The FUNCOL Program for Primary Health Care, Colombia

Author

In January 1984 I visited two indigenous communities in the Llanos area of eastern Colombia and prepared an evaluation of the primary health care program sponsored by the Foundation of Colombian Communities (FUNCOL). The report outlined the objectives and organization of the program and assessed its effectiveness. The overall conclusion was that the program had been well accepted and was providing basic medical services to indigenous communities in a culturally sensitive manner. Following this report FUNCOL received additional funding from Cultural Survival.

Over the past three years FUNCOL has continued to sponsor village-based health promoters in the Llanos. In 1986 FUNCOL received additional funding to carry out an epidemiologic study of disease prevalence in the indigenous communities. That study is currently in progress.

In order to assess the effectiveness of the program and review the preliminary results of the epidemiologic survey, I visited Colombia again in March 1987. My original intent was to spend several days in the same indigenous communities that I visited in 1984. Unfortunately I could not accomplish this goal; the FUNCOL staff believed that the region would not be safe for a foreign visitor due to its remote location and increasing guerrilla activity. As a result, the entire evaluation was carried out in Bogota. The inability to make a site visit made it more difficult to objectively assess the effectiveness of the primary health care program. The information contained in this report is based on extensive discussions with FUNCOL field staff and review of statistical data collected from the villages. Despite these limitations, a large amount of information was obtained to form the basis for several recommendations.

Overview of the Program

The FUNCOL program was organized in 1978 to provide basic medical treatment and community health education to a group of indigenous communities in the Llanos region. The program was designed to maintain cultural integrity and encourage the continued use of traditional practices along with Western medical treatment when appropriate. Its specific objectives are to:

1. Contribute to improved health status in participating communities.

2. Stimulate community participation in the design, execution and evaluation of the program.

3. Train an indigenous person form each community in basic medical treatment appropriate for the needs of the community.

4. Encourage public health practices to prevent disease transmission while considering the cultural beliefs regarding such practices.

5. Furnish medical supplies required for the most common illnesses in each community.

6. Respect and maintain traditional medical practices in each community.

7. Encourage the continued use of botanical medicine and attempt to establish the efficacy of medicinal plants.

8. Avoid the substitution of Western medicine for traditional medicine whenever possible.

Each community selects one or two individuals who will receive basic medical training to provide voluntary medical care for the community members. The only requirement is that the health promoters be able to read and write in Spanish as well as in their own native dialect.

Health promoters attend a 15-day training course on the diagnosis and treatment of the most common medical problems in the indigenous communities. The first part of the training course focuses on acute injuries: lacerations, hemorrhages, burns, fractures and snake bites. There are practical sessions on would cleansing, suturing and fracture immobilization. The second part of the course includes basic instruction in the diagnosis and management of respiratory problems, gastrointestinal complaints, skin infections and simply eye problems. Instruction is also given regarding management of malaria, hypertension, abortion and pre-eclampsia (a complication of pregnancy). Practical sessions include sterile technique, intramuscular injection and preparation of oral dehydration formula. Each student receives a textbook with simple text and drawings to illustrate appropriate procedures.

After successfully completing the training course, the health promoters return to their communities. They live and work with the other community members as before, providing medical services when the need arises. Each community is provided with a dispensary containing an assortment of medications and basic medical supplies (bandages, syringes, thermometer, suture material, etc.). Each individual is expected to pay for medications dispensed by the health promoter at cost. The health promoters themselves receive no payment for their services.

The FUNCOL program serves a representative sample of indigenous communities in the regions of Arauca, Meta and Vichada. A variety of cultural groups live in this area, the most prominent of these being the Tunebo, Guahibo and Piapoco. The FUNCOL staff estimate that their program reaches 25 percent of the indigenous communities in Arauca and a lower percentage in Meta-Vichada. In both Meta and Vichada the communities are remote and the populations more dispersed, making access difficult.

Health Promoter Training and Background

Since 1979 a total of 42 indigenous people from 33 communities have completed the two-week training course in primary health care. In addition, a group of teachers completed the training course in Meta-Vichada so they could assist the health promoters as needed and include health education in their curriculum. At the present time 10 communities actively participate in the program and receive regular visits from the nurse trainers. Five of these communities have two health promoters in residence, allowing continuity of care when one is sick or absent. An additional seven communities in Meta-Vichada have FUNCOL-trained health promoters in residence but do not receive medical supplies or routine follow-up from FUNCOL staff.

In the past three years FUNCOL has held two training courses - one each in Meta-Vichada and Arauca. Twenty-two individuals successfully completed these courses. Six of these no longer provide medical services because they (1) migrated to a different community, (2) were rejected by the community or (3) refused to work without a salary. Since health promoters are selected by the community (or community leaders) and work on a voluntary basis, FUNCOL has no control over the provision of medical services following the training course.

Government Health Promoters

The Ministry of Health also employs health promoters who work in the same region as the FUNCOL promoters, but serve different communities. There are few government-sponsored health promoters, and each covers a widely dispersed population of approximately 5,000. Their training is more extensive than that of the FUNCOL health promoters and includes six months of hospital-based training. The government health promoters travel from village to village and spend most of their time on health education. They carry few or no medications and often refer individuals to the regional medical post for medical care. On some occasions the Ministry of Indigenous Affairs has supplied medications for the government health promoters, which were then distributed free of charge in several communities. This practice has created conflict with the FUNCOL health promoters, who ask patients to pay for dispensed medications at cost (although no patient is denied treatment due to inability to pay).

Unlike FUNCOL health promoters, none of the government health promoters in Arauca and few in Meta-Vichada are of indigenous descent. As a result, they lack familiarity with the cultural beliefs and practices related to illness and health care among the indigenous people.

Factors Contributing to Poor Health

The indigenous groups of the Llanos exist under difficult environmental conditions. The winter months are marked by heavy rains and floods; the summer months are very dry. Most communities in the region of Arauca have wells, which supply water during the summer. In Meta-Vichada, most communities rely on rivers and other natural sources of water; and access to water is a problem during the summer months. The water from wells and natural sources alike is generally contaminated, but cannot be boiled routinely because firewood is scarce.

During the winter, water is plentiful but serves as a source of disease transmission. Malaria-infested mosquitoes breed in the stagnant water, and widespread flooding contributes to fecal contamination of food and water. In addition, immigrants from other parts of Colombia have usurped much of the land adjacent to river and streams, limiting indigenous access to flowing water.

Under these conditions, adequate hygiene is difficult even for those who are highly motivated to prevent the spread of infectious disease. In the indigenous population the problem is exacerbated by certain cultural traditions and resistance to change. Since the concepts of microorganisms and disease transmission are foreign to these groups, they frequently reject recommendations about hand washing, food preparation, clean water and use of latrines.

Other environmental and social factors also contribute to poor health among the indigenous communities. Migrating settlers from the mountain regions compete for land and create a demand for Western products, particularly in the region of Arauca. Alcoholism has become a problem in some communities and consumption of refined sugar has led to widespread dental disease. Injuries and poisonous snake bites are also important causes of morbidity.

Malnutrition is endemic. Hunting and fishing have historically provided seasonal protein sources for the indigenous people of this region. The availability of fish and game, however, has decreased with recent immigration of settlers from other parts of Colombia. Yucca and plantain now serve as the principal sources of calories, supplemented by corn, which is seasonal (September to November), and a variety of fruits. Children commonly suffer form protein-calorie malnutrition. Infants are breastfed for a prolonged time (up to age three) to compensate for lack of other food sources. Older children do not receive enough protein in their diet.

Cultivable land is scarce: many people have migrated from the mountains in search of arable land and have usurped the land that was formerly cultivated by indigenous groups. Prior to this colonization, the indigenous people employed slash-and-burn agriculture, migrating periodically to avoid overutilization of the land. With the increasing migration and demand for land, communities have had to locate permanently, and retain little of their former land. Slash-and-burn agriculture continues, but the fertility of the soil is low and each parcel must lie fallow for several years after only one or two crop cycles.

Vital Statistics of Indigenous Communities

Since 1984, FUNCOL health promoters have attempted to keep records of births and deaths in each community. Since the populations of the communities fluctuate and the data are incomplete, birth and death rates can only be approximated. Nevertheless, these data represent the best (and only) estimates of birth and death rates in the indigenous populations.

Data are available from four communities in Arauca for the period 1984-1986. There are 73 live births from a total population of 269. There were 26 deaths, yielding a crude death rate of 32 per 2,000 population per year. Ten (38 percent) of the deaths occurred in children of age five or less. Of all deaths, four were due to poisonous snake bites, five to respiratory infections, five to presumed tuberculosis and 10 to epidemic measles. The causes of the remaining two deaths, both in children less than five years old, were unknown.

Mortality data are available from four communities in Meta-Vichada for the period 1984-1986. There were 43 live births from the total population of 284. There were 14 deaths, yielding a crude death rate of 16 per 1,000 population per year. Of the 14 deaths, three were due to poisonous snake bites, three to presumed tuberculosis and three to respiratory infections. Two deaths occurred when both a mother and neonate died during childbirth. Two additional deaths were attributed to "parasitism" and one to an injury. Of the 14 deaths, six (43 percent) occurred in children of age five or less.

The mortality data for children less than five years old in both regions can be compared with the overall mortality data for this age group in Colombia in the eight indigenous communities, a total of 16 children up to five years old died from 1984 through 1986, yielding a death rate of 5 percent per year (95 percent confidence interval 1 percent to 9 percent). For Colombia in 1973, the death rate for children less than five years old was 2.1 percent. The standardized mortality ratio was 666 percent for children in the surveyed indigenous communities compared to children of the same age range in Colombia.(1) That is, the yearly mortality rate for children less than five was 6.7 times greater in the indigenous communities compared to Colombia as a whole. The graph illustrates the difference in death rates overall and for children less than five years old.

Disease Prevalence in Indigenous Communities

Clinical Features of Major Parasitic Diseases

The hookworm (Necator americanus) is an intestinal parasite transmitted when larvae come in contact with the skin after hatching from eggs in the stool. The larvae penetrate the skin and travel through bloodstream to the lungs, where they migrate up the respiratory tree. From there they are carried into the digestive tract, eventually reaching the small intestine. Symptoms during acute infection may include skin lesions and respiratory symptoms. Chronic intestinal infection can produce bleeding from the intestinal wall. Iron-deficiency anemia may be severe. Hookworm infection is most prevalent in communities that lack adequate sanitary disposal of human feces. The larvae are easily transmitted during rainy or moist conditions, but are quickly destroyed by drying of the soil surface.

The roundworms (Ascaris lumbricoides) is transmitted by fecal-oral contamination. Food may be contaminated by (1) a polluted water supply, (2) unclean handling by infected individuals or (3) droppings of flies or other insects. Larvae hatch in the small intestine and migrate through the intestinal wall to enter the liver and lungs. After further development the larvae migrate through the respiratory passages to the throat. After being swallowed, they mature in the intestine and cause chronic infection. Intestinal ascariasis tends to be well tolerated unless the infection is heavy or nutrition is poor. In the latter case malnutrition might worsen and growth might be impaired. Periodic deworming of children in highly endemic areas, however, can lead to improved growth and development. Roundworms also can cause intestinal obstruction in children if the worm burden is very high.

Another roundworm, Strongyloides stercoralis, penetrates human skin in the same manner as the hookworm: the larvae are carried by blood vessels to the lungs, where they migrate up the respiratory tree and eventually reach the intestine. Unlike the hookworm, however, in the majority of cases the infection is benign. More severe cases can cause abdominal pain and diarrhea.

 

The parasite Entamoeba histolytica, like the whipworm and roundworm (Ascaris), is transmitted by food or drink contaminated with infected feces. The amoeba invades the wall of the intestine. Symptoms of amoebic infection can be mild or severe, in the forms of fever, abdominal pain and diarrhea. Some individuals remain asymptomatic.

The intestinal parasite Giardia lamblia is transmitted by swallowing viable cysts from contaminated food or drink. It causes no disease in many individuals. In some cases the parasite will invade the intestinal wall, causing abdominal pain and chronic diarrhea.

Malaria is a parasitic infection of the blood, caused by one of four species of Plasmodium and transmitted by mosquitoes. In eastern Colombia malaria is endemic; transmission is facilitated by the large areas of standing water that attract mosquitoes during the rainy season. Acute malaria causes severe illness in those who have not developed immunity. Children generally experience the most severe attacks. Their anemia may be severe. Those who survive develop a significant amount of immunity. Malaria attacks in adults tend to be of short duration and usually cause only fever and fatigue. Malaria attacks during pregnancy pose a serious threat to the mother and increase the risk of fetal complications or death.

Epidemiologic Survey of Disease Prevalence

In 1986 FUNCOL initiated a study of representatives indigenous communities to obtain information on the prevalence of different diseases in this population - the first time that morbidity data has been collected from these populations. A national study of morbidity in Colombia was done from 1977 to 1980, but no data were collected from the Llanos region (except Meta, which was grouped with the mountainous zones of the eastern Andes). The FUNCOL epidemiologic survey was designed to assess the most important causes of morbidity in the indigenous populations. Hopefully, this information will provide a basis for the development of appropriate public health interventions in the future. It should also be useful for the village health promoters, who lack diagnostic tests and must rely on symptomatology and empiric therapy. Knowledge of disease prevalence will help them direct their effort toward those diseases that occur frequently and cause the greatest morbidity, although therapy will continue to be empiric for individual cases.

The epidemiologic survey is being completed in two stages. For the first stage, all participating indigenous communities were surveyed during the rainy months of July to November 1986. In the second stage (currently in progress), the same communities were surveyed a second time during the dry months of January through May. (These data are in the process of being compiled.) Data collection in two seasons was arranged to allow comparison of disease prevalence during different environmental extremes, although the chronic nature of most parasitic infections will make interpretation difficult.

The study is being carried out in six communities in Arauca and six communities in Meta-Vichada. The community of Sunape in Meta-Vichada was surveyed Catholic mission with a higher level of sanitation, improved nutrition and a nursing assistant supplied by the Ministry of Health. All other communities in the survey (except one in Arauca) have at least one FUNCOL-sponsored health promoter.

FUNCOL staff members, including two nurse-clinicians and a microbiologist, visited each community to carry out the survey. In each village a census was completed of the entire population, and all members were asked to participate. The following epidemiologic information was recorded for each individual: age, sex, weight and height and current symptoms. All participants were examined for dental decay and missing teeth. Stool, urine and blood samples were obtained. The specific laboratory analyses are listed in Table 1.

Table 1

Blood Urine

hematocrit specific gravity

WBC and differential pH, Protein, glucose, heme

sedimentation rate (Wintrobe)b bilirubin, urobilinogen

reticulocyte count (if Hct (c)34) microscopic exam

Stool

Consistency, pH, color

exam for ova and parasites (including concentrated specimen)

Additional tests were added when appropriate: thick smear for malaria in patients who reported fever, KOH exam for fungal elements and gram stain when skin infections were noted.

Since the second stage of the study is still in progress, a complete analysis of the data has not yet been undertaken. The following represents a partial analysis of data collected during the first stage (rainy season).

In the region of Arauca, 308 (78 percent) of the 396 community residents participated in the survey. In Meta-Vichada, 532 (84 percent) of the 635 total inhabitants in the participating communities were included. No information in available regarding the characteristics of those who did not participate. Table 2 illustrates the prevalence of different conditions among participating children and adults.

Roundworms were significantly more prevalent in adults and children of Meta-Vichada compared to indigenous groups of Arauca (p < .002, chi-square). The prevalence of roundworms in the community of Sunape was intermediate between Meta-Vichada and Arauca. The majority of patients with evidence of roundworms were infected with Ascaris. In Meta-Vichada, 19 (11 percent) of the 179 children (including those in Sunape) had evidence of infection with Strongyloides. Few had whipworm (exact number not available). Since the data were not broken down by organism, the relative prevalence of infection with Ascaris, Strongyloides and Trichuris cannot be determined.

The prevalence of roundworm infection differed significantly between two different cultural groups in Arauca. Of 202 Guahibo villagers, only two (one percent) had evidence of roundworm infection compared to 28 (26 percent) of the 106 Tunebo villagers (p < .002, chi-square). This difference was present in both children and adults. No such trend was noted between the two major cultural groups (Piapoco and Guahibo) in Meta-Vichada.

Hookworm infection was common in every group except adults in Arauca. Of 140 adults (over 15 years old) sampled in Arauca, 80 (57 percent) had evidence of hookworm infection compared to 86 (40 percent) of 212 adults in Meta-Vichada (p < .01, chi-square). Prevalence of hookworm infection among Sunape children was similar to that in children in the indigenous communities.

Eosinophilia was very common in both children and adults of each region. It is a nonspecific indicator of parasitic infection. Anemia was found more often in children than adults, although the definition of anemia was not clearly specified for each age. The prevalence of anemia in children might be falsely elevated if appropriate adjustments were not made for age. In Meta-Vichada only 19 (7 percent) of 272 individuals had a hematocrit less then 33 percent; in Arauca 12 (7 percent) of 160 had a hematocrit less than 33 percent (breakdown by age not available). Thus, anemia was usually mild when present. Dental decay and missing teeth were common in both children and adults, although the significance of missing teeth in children is unclear because they lose teeth as part of normal development.

The prevalence of malaria was not determined in this survey. Only those patients who reported a recent fever had a thick blood smear performed for evidence of malaria. Overall, there were 12 cases of malaria identified in Meta-Vichada and none in Arauca.

FUNCOL collected data on the prevalence of other gastrointestinal parasites in the indigenous communities, but interpretation is difficult. Individuals with Entamoeba histolytica infection were grouped with those who had Entamoeba coli and Entamoeba nana in stool samples. While E. histolytica is an important cause of gastrointestinal disease, the latter two organisms are commensal (nonpathogenic) and do not cause illness. Similarly, persons with Giardia lamblia infection were grouped with those who had Chilomastix or Trichomonas in the stool - both harmless commensal organisms.

Significance of Epidemiologic Data

The results demonstrate that intestinal parasites are very common in the indigenous communities of the Llanos, although there are regional and age-related differences in the prevalence of some parasites. The vast majority of individuals in each age group and region had a high eosinophil count, reflecting chronic exposure to parasitic disease. Roundworms, including Ascaris, were much more common in Meta-Vichada than in Arauca. These may contribute to malnutrition and growth impairment.

Hookworms were common in all groups except adults living in Arauca. The high prevalence in children is of particular concern since chronic infection leads to iron deficiency anemia and may contribute to growth impairment. Mild anemia was very common in children. Other factors that contribute to childhood anemia include malnutrition and recurrent malaria infections. Dental disease was very common in all groups. This may be related to the dietary changes that have occurred with increasing exposure to Western culture and sucrose-containing foods.

The high prevalence of these parasitic diseases indicates that fecal-oral contamination of food and water provides a continuing source of parasitic infection. In addition, fecal contamination of living areas and lack of footwear permits infection with parasites that penetrate the skin. Clearly, both difficult environmental conditions and particular sanitation practices contribute to disease transmission.

In each community both height and weight data will need to be tabulated for each age group to provide a relative index of the prevalence of malnutrition compared to other populations. Data on many intestinal parasites were categorized so that harmless (or probably harmless) parasites were grouped with those that clearly cause disease. FUNCOL will need to analyze the prevalence of individual gastrointestinal parasites to determine how many individuals harbor disease-producing organisms.

Impact of Colonization on Indigenous Communities

Increasing pressure from immigration of outside settlers contributes to poor health among indigenous communities of the Llanos. Although the indigenous communities have been given legal title to some land, their right to cultivate that land has not always been upheld. Additional difficulties have arisen from the need to maintain communities in a single permanent location. Groups that were previously mobile now find themselves surrounded by immigrant ranches. This has led to isolation and more difficult access to running water. Little has been done to address these problems.

Conflicts have arisen between indigenous groups and immigrant settlers. The Tunebo and Guahibo have no concept of ownership or personal property. Within their culture no prohibition exists against taking fruit or vegetables from land cultivated by others. Immigrant settlers view this activity differently, however, which leads to misunderstanding and, in some cases, violence.

For the indigenous communities, increasing contact with Western culture has created a demand for money and products. In order to acquire these products the indigenous men work on the fincas for low wages. FUNCOL staff report that workers may be paid with liquor rather than pesos, contributing to alcoholism among the indigenous groups.

At the present time acculturation problems are most severe in Arauca. Most parts of Meta-Vichada are remote, and immigration from distant areas has been limited. In the future, however, the pressure of colonization will be increasingly felt in both Arauca and Meta-Vichada. Oil exploration, currently in progress, could have a profound impact on the rate of outside development in the coming years.

Traditional Medicine

The use and knowledge of traditional medicine varies greatly in the indigenous communities. All community members have some knowledge of home remedies and herbal medicine. In addition, some communities have specialized practitioners, which include chamanes (shamans), yerbateros (herbalists) and culebreros (healers of snake bite). These traditional practitioners coexist with the Western medicine provided by FUNCOL volunteers. In general, the community members are able to distinguish illnesses that require a shaman from those that require Western medical treatment.

In one community, Mabriel, the FUNCOL-sponsored health promoter is also the village shaman. He is the son of a highly regarded shaman in Meta-Vechada, and was a shaman before participating in the FUNCOL training course. When a patient seeks care for an illness, the shaman decides if the problem is culture-specific or one that can be treated with Western medicine. This arrangement has been well accepted by community residents.

Respect for traditional medicine is an important aspect of the FUNCOL program, one that has not been incorporated in the government-sponsored health promoter program. According to FUNCOL staff, their acceptance of traditional medicine has made community residents more open to education and more willing to utilize the health promoter program.

The Program's Impact

Although health conditions continue to be poor among the indigenous communities, individual patients have clearly benefited from the work of FUNCOL. FUNCOL has had a positive impact on those adults and children who received effective treatment for a variety of medical problems, such as respiratory infections, skin infections, symptomatic parasitic infections and minor lacerations. Without the care provided by the FUNCOL health promoters, individuals with these problems would have had to travel a great distance to a government medical post or rely exclusively on local remedies.

Despite the presumed benefit, no data have yet been presented to document (1) the distribution and variety of acute illness episodes, (2) the treatments - both Western and traditional - actually employed by health promoters and (3) the outcomes following those treatments. This information would be extremely useful for documenting the impact of the program on the entire population. Part of these data (i.e., records of cases seen and treatment prescribed) have been collected by health promoters in some communities. Unfortunately, the information has not been collected or reviewed by FUNCOL.

One positive effect of the FUNCOL program is the health promoters' interest in educating community members about practices that promote health and prevent disease. The health promoters are sensitive to local practices and beliefs, and they use episodes of illness as opportunities for education. Mothers of children with diarrhea and dehydration are taught about oral dehydration formula and shown how to prepare it from local materials. Patients with parasitic diseases are taught about the need for cleanliness. Changes have been made in some communities: cooking areas have been separated from living areas and standard of hygiene have improved. The process of change is slow, however; only through gradual education and positive reinforcement will certain traditions be modified to accommodate basic public health needs. As FUNCOL demonstrates, this education is best accomplished when it comes from within the community.

A more subtle but no less important benefit of the FUNCOL program is its position as an advocate for the welfare and rights of these indigenous groups, a role which no other institutions have assumed. The government contributes little to the indigenous populations of the Llanos. Missionary groups provide some services to the communities, but evangelism also contributes to loss of cultural integrity and can foster dependency. In contrast, FUNCOL encourages independence, self-sufficiency and the maintenance of cultural integrity.

The high dropout rate of health promoters after training is a problem that must be addressed. The health promoters are supposedly chosen by their respective communities and have expressed a willingness to provide medical services on a volunteer basis. However, some health promoters do not volunteer but are drafted instead. Since they are not obligated to provide services, it is not surprising that many of these individuals do not continue in the program. Others move to communities that are not served by FUNCOL - communities that do not benefit a great deal from the presence of a health promoter because they have no medical supplies or medications.

Some type of economic incentive for the health promoters might reduce the dropout rate by increasing their motivation to serve the community. This economic incentive should not be so large that the health promoters do not need to work along with other community members.

A more organized approach to important public health problems should be considered for those communities that are open to change. Separation of human waste from the water supply and use of flowing rather stagnant water whenever possible are tow changes that might be feasible in some communities. A more ambitious and difficult project would involve use of a water purification device. Such a device - based on solar heating and sand filtration - could be constructed from readily available local materials.

FUNCOL, in collaboration with the Srevicio Seccional de Salud, has implemented a vaccination program in four communities in Arauca: their entire infant population was immunized against polio, diphtheria, pertussis and tetanus. Vaccination programs in Meta-Vichada have been more difficult to carry out due to geographic isolation and logistical problems.

Improved vaccination coverage for childhood measles, an important cause of death in both regions, is crucial for an improvement in child health. Vaccination programs sponsored by the Servicio Seccional de Salud have been sporadic; population coverage is uneven and record-keeping poor. A major obstacle to improvement is that the measles vaccine is stable for only a few days at room temperature and cannot be stored without refrigeration. Despite these difficulties, a successful vaccination campaign could be accomplished every one or two years with additional resources and improved organization. Continued efforts to collaborate with the Servicio Seccional de Salud might help achieve this goal.

Recommendations

1. During the data-analysis phase of the epidemiologic survey, FUNCOL should analyze height-weight data as an index of malnutrition in children.

2. FUNCOL should consider analyzing data on individual pathogenic (disease-producing) parasites rather than groups of parasites that include harmless organisms.

3. FUNCOL may wish to review data from health promoters on number of cases seen, diagnoses made and treatments prescribed. For a sample of communities it would be helpful to ask health promoters to report on the outcome following treatment.

4. If resources permit, FUNCOL should increase efforts to improve environmental conditions: cleaner water, improved nutrition and prevention of oral-fecal contamination.

5. Collaboration with the Servicio Seccional de Salud to implement an effective vaccination program in both regions should be a high priority. This is particularly important for measles, a major cause of childhood morbidity and mortality.

6. Increased involvement of schoolteachers in the primary health care program would be beneficial both for the purpose of patient care as well as health education.

7. FUNCOL should consider adding a modest economic incentive for health promoters. This would increase the incentive to provide services and decrease the dropout rate.

8. If additional resources become available, the program could be expanded by adding support to those communities that already have a health promoter in residence but lack medications and follow-up.

9. Based on the high prevalence of roundworms and hookworms in children, it may be beneficial to treat all children with mebendazole every six to 12 months (if resources permit and community members agree).

In conclusion, although improvement in overall health is difficult to document, there is no doubt that the FUNCOL primary health care program remains the only significant source of culturally appropriate medical care for Llanos communities. The program provides important services and should receive additional support from organizations concerned about the welfare of indigenous populations.

Article copyright Cultural Survival, Inc.

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