Stories From the Field:

El Salvador

Improving Oral Health and Nutrition in El Salvador

Dr. Jennifer Kasper, a Pediatrician at Chelsea HealthCare Center was granted a Center for Global Health Travel Award to spend two weeks in El Salvador working to improve oral health and nutrition.

I am very grateful for the generous MGH Center for Global Health Travel Award. Because of it, I was able to mentor a Harvard dental student in the field and work on two very important activities related to my organization Doctors for Global Health (http://www.dghonline.org/) (DGH) and our partner NGO, Asociación de Campesinos para el Desarrollo Humano (CDH - Peasants for Human Development). The purpose of my travel was two-fold:

  1. To travel with Harvard School of Dental Medicine student Nicole Oparaeke to Estancia, a rural mountainous area in the province of Morazán, in northeast El Salvador, to conduct an oral health needs assessment for DGH’s partner CDH.
  2. To make a site visit to a well-established child nutrition project in Guatemala, and take lessons learned back to Estancia, El Salvador to strengthen CDH’s child nutrition project.

Doctors for Global Health (DGH) is a 501(c) 3 all-volunteer not-for-profit organization (i.e. no office or paid US staff) that has been working in Estancia, El Salvador for two decades. In 2004, DGH helped community members form Asociación de Campesinos para el Desarrollo Humano (CDH - Peasants for Human Development), a Salvadoran non-profit organization. CDH represents 10 isolated communities, with a population of approximately 5,000 people; 80% live in extreme poverty (1 USD/day), with high rates of illiteracy, food insecurity and preventable health problems. They have limited access to government-run public clinics: the nearest Ministry of Health (MOH) clinic, hospital, and children’s hospital are one, one and a half, and eight hours away, respectively. DGH supports CDH with community health and development projects, including the local community health center Centro de Atencion Integral, Prevencion, y Educacion en Salud (Center for Integrated Attention, Prevention and Education in Health, CAIPES) and Centers for Integral Child Development, a vehicular bridge, water and sanitation, nutrition and food security, microcredit, elderly health, women’s health, youth groups, and high school scholarships. Dr. Juan Carlos Martinez, a recent graduate of the Latin American Medical School in Cuba and the Medical Director of CAIPES, and community health workers play a crucial role in caring for the community’s health.

When Nicole and I landed in San Salvador, Ramiro Cortez, the Executive Director of CDH, and Dr. Martinez picked us up and we all traveled to Santa Ana. There we learned about a successful oral health project run by the local NGO ASAPROSAR Asociación Salvadoreña Pro-Salud Rural (Salvadoran Association for Rural Health) for the past two decades. Here, community health promoters work in collaboration with the Ministry of Heath dentist to provide oral health and nutrition education, toothbrushes and toothpaste to all family members, fluoride treatments three times a year, and annual dental exam to prevent caries in children. They have a partnership with Colgate, who supplies toothpaste and toothbrushes. They conducted a study of their program from 2004-2010 and found that mothers developed a deeper understanding of causes and how to prevent caries; children had decreased consumption of sugary beverages; and there was less mouth pain, tooth decay, and malnutrition. This visit was an opportunity to hear lessons learned and introduce CDH to ASAPROSAR’s work for future collaboration and support.

We also met with the local Ministry of Health physician and dentist in Cacaopera, Drs. Garcia and Herrera respectively. They spoke of the overwhelming need for dental care, lack of dental equipment and supplies (e.g. anesthesia) to perform extractions, and the amount of terrain they cover making annual oral health care visits to all 24 schools (as part of the Salvadoran government’s Escuelas Saludable – Healthy Schools - Program) and rural communities throughout Estancia. The MOH clinic staff has a positive, collaborative working relationship with CDH.

In Estancia, the health staff of CDH (Dr. Martinez and health promoters Etelvina, Abraham and Julia) worked with us to ensure that the survey questions were relevant and understandable and that we all felt comfortable interviewing. I hiked to homes in some of the most remote communities in Estancia to conduct interviews with Etelvina, the CDH community health worker, and Nicole. Being in people’s homes reminded me anew of the poverty and limited access to care they face. The number of edentulous adolescents and children with very poor oral health confirmed the importance of this survey. Participants in the survey said they would welcome better access to dental care and more education regarding how to care for their teeth and their children’s teeth.

As pertains to malnutrition, Estancia has some of the highest rates in the country: nearly half of 1st graders are stunted. CDH is addressing this problem through its program, Siete Semillas (Seven Seeds), which consists of preparation of a caloric and nutrient dense powder made from local seeds; collecting anthropometric data on malnourished children; and educational activities. As pertains to the second goal of my trip, I traveled to San Lucas Toliman, Guatemala to study a well-established nutrition program that incorporates economic opportunities to improve food insecurity and malnutrition among children less than five years of age.

In San Lucas, I met the team of 30 committed, energetic community health workers and the leadership team. They have been working in their communities since 2003 and initiated their malnutrition project in 2010. The indigenous population of the San Lucas area is similar to Estancia, with high rates of poverty and limited access to health care. We discussed the role of CHW in child malnutrition and the components of the malnutrition program, including anthropometrics of children from birth through five years of age, treatment for parasitic infections, and provision of ready-to-use formulas. They are in the planning stages of establishing cooperatives and possibly a microcredit project to improve economic security as a way to address food insecurity. I will share this experience with the CDH team and our current DGH volunteer who is working with CDH on their current microcredit program to help them strengthen their Siete Semillas program.