Case Studies of Two Women's Health Projects in Bolivia
This case study, the second in a series on women-centered health programs prepared for FHI's Women's Studies Project, profiles two programs in Bolivia: La Casa de la Mujer in Santa Cruz and the Kumar Warmi (Health Woman) clinic operated by the Centro de Informacion y Desarrollo de la Mujer (CIDEM) in El Alto. Both programs involve women in the design and delivery of health care, and both offer health care as one of an array of services designed to improve women's quality of life. The La Casa program is action-oriented and works to empower women as individuals and to build solidarity among women from all classes of society. CIDEM's Kumar Warmi project works to transform health care through educational processes; it has a strong basis in gender theory.
Many women suffer from poor health in Bolivia, where rates of fertility and maternal mortality are among the highest in Latin America. Bolivia's total fertility rate was 4.8 births per woman in 1994, with rural rates significantly higher (INE, 1994). According to the 1994 National Demographic and Health Survey, maternal mortality in Bolivia is 390 deaths per 100,000 live births, with ratios as high as 610/100,000 in the altiplano area (MACRO and INE, 1994). A significant number of maternal deaths, an estimated 27 to 35 percent, are related to induced abortion, which is widely practiced in Bolivia, although illegal. Adequate safe medical abortion services are not available (MPSSP, 1989).1 The root causes of women's poor reproductive health status are a near absence of health information, education and services, coupled with limited access to contraceptives.
To respond to Bolivian women's urgent needs for reproductive health care and to help affect changes in policies and practices that have excluded Bolivian women, especially poor indigenous women, from information and decision-making, La Casa de la Mujer and the Centro de Informacion y Desarrollo de la Mujer (CIDEM) have developed women-centered health programs that employ integrated approaches to service delivery. La Casa has worked extensively with women in reproductive health service and education, while CIDEM has developed a new approach to health care practices that incorporates a gender perspective.
La Casa's unique characteristics include its offering of multiple and diverse programs to address the complex needs and experiences of women; its ability to build solidarity among women from diverse sectors of Santa Cruz society; and its emphasis on communication as a way of empowering women. The solidarity of La Casa participants and staff has contributed to an understanding of reproductive health and sexuality as something shared by all women, but experienced by each group of women, and even by each woman, in a unique way, depending on her cultural reality, her class and ethnic position, and her life experiences. Reproductive health services are offered in conjunction with other social services, such as legal services and psychological care, and reproductive health is viewed as one means of improving the lives of both women and men in Santa Cruz.
CIDEM's Kumar Warmi (Healthy Woman) Clinic has developed a new methodology for health care, based on gender principles. The approach includes emphasis on continued education and growth, based on respect for differences; an integrated approach to education and service delivery; and a focus on interpersonal relationships. The project's primary objective is to provide education and health care to women in ways that allow them to share in the knowledge, responsibility and decision-making about their own reproductive health, and to participate in the design of health policies and projects.
CIDEM's approach breaks free of the traditional health service paradigm in two ways. First, it recognizes health as something more complex than medical service and necessarily linked to education, human rights and personal empowerment. Second, it transforms conventional interpersonal relationships, so that doctor and client play more equitable roles in the process of health care.
Although each program is unique, La Casa and CIDEM share some common approaches in their efforts to improve women's health.
Both programs view women as participants in the design and delivery of health care services.
Health care is not viewed as an isolated service. It is integrated with other social services and regarded as a vehicle for women's empowerment.
Programs employ new ways of educating and communicating with women -- ways that are non-hierarchical and non-didactic.
Two factors compelled us to study these two small nonprofit institutions, whose direct demographic impact is limited. First, these institutions have been able to experiment with new approaches and methods that might not be possible in larger health projects or major hospitals. Second, by examining and disseminating information on these innovative approaches, we hope to contribute to efforts under way at other institutions, thereby multiplying the impact and utility of these two programs.
The objective is not to compare the two projects, nor to apply standard evaluation criteria, but rather to illuminate the many challenging issues faced by organizations working to improve women's health and, ultimately, the quality of women's lives. By sharing the histories of the La Casa and CIDEM projects, their visions, their achievements and their frustrations, we hope to enrich the reflections and actions of others who are trying to improve women's condition and status by advancing their reproductive health rights.
At La Casa de la Mujer, women are viewed simultaneously as individuals, as family members and as members of a larger society. Consequently, La Casa's philosophy is that women's health is affected -- often determined -- by relationships, by experiences, and by domestic, political and cultural environments. Health care is one element in an array of services necessary to improve women's quality of life.
As the testimony of one of the participants we met in the clinic illustrates, health is inextricably linked to other aspects of a woman's life. We spoke for some time with Nieves, an energetic woman in traditional dress, whose story offers a glimpse of experiences which, according to La Casa staff, are shared by many clinic participants.
Born in La Paz, Nieves was orphaned at nine years of age and traveled with a brother to Cochabamba to look for work. After making a life for herself in Cochabamba and living there for nearly 20 years, Nieves recently took a bus to Santa Cruz with her oldest child to escape the intense domestic violence she had been suffering.
I just had to escape, I couldn't stand the pain any more. He hit me all the time. When he drank, he beat me. I ran all over trying to protect my kids. I'd leave them at my godfather's, at my mother-in-law's. I didn't have any family of my own left in Cochabamba. My brother was very good and always helped me, but when he died last year, my husband became even worse.
An evangelical pastor helped me. He told me about La Casa de la Mujer, 'There's a place in Santa Cruz where they help women.'
First I went to ONAMFA [National Organization for Children, Women and the Family] in Cochabamba. When they called in my husband, he was just perfect. He said that he wasn't going to do it [beat me] anymore. He signed the papers and all. But two days later he started hitting me again. 'Go ahead now, bring your big men to come and get me,' he said. He beat me so badly that I could hardly move. I could barely drag myself to the bus with my daughter and had to leave my little son with his father.
I arrived in Santa Cruz in such a state, and none of the hospitals wanted to receive me, until finally I went to La Casa de la Mujer. Then I came back to La Casa to see the lawyer. I wanted to divorce right away, but she told me to just start working as if nothing could happen to me until the thing calmed down. 'If the man shows up,' she told me, 'bring him here and we'll have a talk.' So I just went about my life and found a job with a room for me and my daughter.
When I left my work a few weeks ago, I went to live with a friend from Cochabamba, but now they say that it is a crime to keep a married woman in your house. The neighbors are convincing my friend to throw me out. When I came here to La Casa to ask, the lawyer told me that such a law never existed. I also told her that I had to leave my other job because of the pain in my shoulder, and she arranged for me to come to the clinic to see the doctor. Now I've come to check out my shoulder. I guess he [my husband] broke it, but I don't know because he never let me go to the doctor. It must have healed wrong. I worked for two months as a maid, but my shoulder and chest kept hurting more and more.
I never fell in love with my husband. I was deceived. I lived in a little room and worked as a maid, and the gardener of the house had a brother who stopped by sometimes. One day they invited me to dinner, and since I am always obedient, I accepted, and we went to eat at the brother's house. There they served me a beer and another and after that another, and then I don't remember anything else until I awoke the next day with a man at my side, and I said to myself, 'Now I'm pregnant, and my baby won't have a father.' So I just married him. If he finds me now, he'll destroy me. Until his rage passes, I have to hide.
La Casa de la Mujer is a private nonprofit organization for social development whose mission is "to improve women's quality of life, especially in poor sectors of the society, and to strive for more equitable gender relations for all women through training, services and organizational strengthening aimed to achieve structural changes." The organization seeks to empower women as individuals and to create solidarity among women -- steps it deems necessary for the collective survival and structural transformation of society.
La Casa de la Mujer was founded in 1990 and grew out of a local women's movement, which joined with other social and political movements working toward democracy. Over time, the group defined its own agenda. Overcoming sexual, class and ethnic discrimination was considered a fundamental challenge for development. The organization sought to advance women's health rights, which initially took the form of responding to health needs of poor urban and rural women through direct assistance and service. Today, La Casa approaches women's health in the context of broader social needs, which also include education, potable water, nutrition, healthy environment, preventive health, legal rights, citizenship, reproductive rights and secure livelihood.
One characteristic that makes La Casa unique is its diverse array of programs, which integrate health with other social services necessary to women's well-being. Another characteristic is the development of novel and creative methods to facilitate communication among professionals, outreach workers and grass-roots program participants.
This case study is based on interviews and discussions carried out in February 1996 with different individuals involved in La Casa's activities. Staff members who were interviewed include: Marie Claude Arteaga, head of research; Wilma Ayala, environmental educator; Mar?Luz Bacarreza, nurse in health education and services; Maritza Camargo, psychologist in education and clinical services; Marina Mor??law student in legal services; Estela Sejas, nurse in health education and services; Adela Ramirez, lawyer in legal education and services; Miriam Suarez, journalist and director of La Casa; Ane Mie Van Dyck, nurse and volunteer from Belgium; and Dr. Lourdes Uriona, gynecologist in health education and services.
In the women's health clinic we met the following individuals, who spoke with us about their life experiences and their participation in La Casa: Aida, Eugenia, Marta, Mar?Elena, Nieves, Shirley and Reina. To maintain confidentiality, and as approved by each participant interviewed, we cite only first names.2 We also reviewed documents from the organization, including the La Casa de la Mujer three-year plan for 1992-95 and the new three-year plan, still in revision.
Cultural, socioeconomic tensions
With a population of nearly 1.5 million, Santa Cruz is Bolivia's second largest city. In comparison with other Bolivian areas, Santa Cruz has the highest contraceptive prevalence rate, the lowest infant mortality rate, and one of the country's lowest maternal mortality ratios.
The composition of Santa Cruz society is complex. This is due in part to old tensions, rising from colonial and national history, and due in part to the economic boom of the 1970s and 1980s. During this time, one sector of society grew very rich very quickly, large numbers of migrants came to the urban center from tropical colonies and hinterlands, and countless rural families migrated from distant Andean regions.
Today, tensions abound between natives of the eastern lowlands of Santa Cruz, who are called 'Cambas,' and migrants from mountainous Andean regions, who are called 'Collas,' and who suffer discrimination and exploitation on account of their ethnic identity. These ethnic conflicts intersect with contradictions between the extreme wealth and the acute poverty of different sectors of the population, and with the unequal impact of environmental degradation and contamination in different urban neighborhoods.
In spite of class and ethnic differences, much of Santa Cruz society is marked by dominant cultural attitudes, which create conflicting views of women's sexuality. On one hand, sexual relations are a hot topic of conversation and interest in Santa Cruz, and women's sexuality is publicly emphasized to a far greater extent than in other parts of Bolivia. On the other hand, significant effort is exercised on the part of husbands, fathers, the church and other social institutions to control female sexuality, both physically and psychologically.
At La Casa, ethnic and sexual tensions are seen as important factors affecting women's health. Most health services in Santa Cruz are delivered in a climate perceived by female clients as dangerous and threatening, and the efforts of those who work in the fields of reproductive health and sexuality are often censured. Sanctions include the ousting of reproductive health educators by local men and the public denouncement of sex education and abortion. Santa Cruz media disseminate stories and images in which police burst into abortion clinics, dragging both doctor and client to jail. Several women we interviewed expressed terror of clinics, saying they were frightened by newspaper photos that showed a female client arrested while still undressed on a clinic cot.
Participants in La Casa activities expressed fear of lascivious doctors and had heard rumors of sexual abuse of clients. Some men prohibit their wives from going to clinics because "the doctor could see her and touch her in her private parts." Irrespective of the validity of the rumors, these stories reflect a widespread sexualization of the doctor-client relationship. This attitude interferes with health care on numerous levels and restricts women's access to health services, as well as to other social institutions and activities.
Women who do seek health care services may encounter conflicts at home. While La Casa encourages women to take responsibility for their health, sexuality and fertility, its efforts to change women's attitudes often meet resistance from husbands and other family members. La Casa staff members affirm that some men criticize their wives' participation in educational activities on sexuality and reproductive health and try to demean La Casa's efforts by spreading the word that "women only go there to talk about whoring." Workshop participants have even encountered violence when they try to express new ideas and attitudes in their homes. In one case, a woman obtained condoms in order to space her pregnancies, and when her husband found out, he accused her of sleeping with another man.
A central issue for La Casa is the extreme poverty that limits the fulfillment of health rights for many individuals. La Casa's three-year plan explains, "Santa Cruz has a population of 1,351,200 inhabitants, 60 percent of whom live in unacceptable conditions of poverty. ... Particularly in Santa Cruz, the cost of survival has risen in terms of increased paid work for women and increases in their unpaid work. Increasing numbers of women are heads of households, and because of cuts in social services, they mostly have to get by without any help from the state" (Casa de la Mujer, 1995:12, 13).
La Casa sees the women's movement as an important impetus in the struggle to confront these broader social problems. La Casa emphasizes the need to assure that the democratization processes being forged in Bolivia today increase women's participation in the construction of policies that reduce the gap between rich and poor, between city and country, and between men and women.
La Casa's beginnings
A radio program planted the seeds for the idea of La Casa de la Mujer. Radio Santa Cruz, a Jesuit organization, worked for years in grass-roots education and literacy and, in 1983, with the goal of supporting women's lives and organizations, created a new program called "Women of the Pueblo." The radio program aired six days a week for 90 minutes each day, providing information and education for women and facilitating communication among different groups of women. With this program, Radio Santa Cruz provided key support to women organizing in neighborhoods and rural communities and helped them identify their needs and objectives.
During this time, three women, who would later be key in founding La Casa, became involved in a program to educate women in ecological practices and environmental protection. Since the group had no guide for working with women, and moreover, were working with Guaran?ndians who did not speak Spanish well, the women faced extraordinary methodological challenges. In order to communicate, they developed educational techniques involving theater, mime, games and drawings. This experience marked the birth of a creative approach to communication, which would later characterize many La Casa activities.
Miriam Suarez, La Casa's current director, worked with Radio Santa Cruz and also with the environmental education program for Guaran?omen. She recalls that talk began about creating a place for women "where their rights are defended, their organizations are strengthened, they are educated, they have fun, they celebrate birthdays, and they get together simply to be together." In 1988 the idea was discussed at the First Departmental Congress of Domestic Employees, and participants there joined the movement. As momentum grew, the Dutch organization HIVOS financed the opening of La Casa de la Mujer as a social development organization. "Before opening La Casa there was a period of communication and coordination between various women's groups who shared the struggle for democracy and equality," Miriam remembers. On May 1, 1990, hundreds of women marched through the streets, arriving at the doors of La Casa. It was the International Day of the Worker, we were workers, and with the opening of La Casa we gave new value to our role."
In this era, members of women's groups in Santa Cruz were discussing feminism, and La Casa offered a space for reflection and debate, as well as an opportunity to put new visions into practice. When La Casa opened, participants identified three immediate and fundamental needs of women in Santa Cruz: legal rights, sexual education and labor training. They developed programs and activities in these three areas, and over the years, have started to explore the connections among them.
During the first five years, the organization functioned in rented spaces. Recently, La Casa took the significant step of building its own center. With special funding, La Casa built a center with clinics, offices, rooms for meetings and workshops, and even a residential area for domestic workers participating in courses. The new center was dedicated on International Women's Day, March 8, 1996, in a moving ceremony that was aired on television and radio, drawing attention to themes of women's rights and violence against women. Currently, La Casa has a team of 26 employees, most of whom work part-time in a variety of institutional activities.
While the new center has permitted the organization to consolidate its programs, this year has also been one of change. La Casa is currently undergoing organizational and program changes in attempts to better integrate its activities and to clarify the relationship between the organization's philosophy and its practices. This year, the principal donor, HIVOS, recommended that La Casa reduce its services in order to focus more on development activities designed to foster strategic changes in society, such as training, preventive health education and the strengthening of local organizations. HIVOS' recommendation corresponds with concerns of La Casa staff, who had also begun to ask whether their services were too assistance-oriented and how they might continue to respond to the great demand for services in ways that also promote more lasting structural change.
In La Casa's reproductive health program, health care and health education are complementary efforts. Staff believe that efforts to provide services and education must include efforts to improve women's self-esteem.
One La Casa staff member who sees self-esteem as vital to women's health and well-being is Dr. Lourdes Uriona. Lourdes was working in the State Maternity Hospital in 1990 when she heard about a new center for women and stopped by to offer to help in a Pap smear screening. Recognizing the importance of follow-up care based on Pap smear results, she volunteered to work periodically at La Casa. Since the organization had only a small space at that time, a corner of a room was partitioned off so that Lourdes could meet with the clients. From the start, the doctor was well received by the women. She is from Sucre and gained the confidence of migrant clients by speaking Quechua and understanding their perspectives. Lourdes joined La Casa staff part-time and is now in her fifth year there.
Lourdes brought to La Casa an unusual socially-oriented approach to medicine. In her first job as a doctor, she spent 18 months in Yapacani, a poor tropical area populated with isolated settlements. There she teamed with a social worker, and as the two visited communities together, they developed an approach sensitive to local realities and based on an integrated understanding of the health and well-being of the families.
From her point of view, the greatest achievement of La Casa's health program has been to strengthen the clients' self-esteem and sense of self-worth.
"These women have become concerned about their own health. A woman often forgets that she is an important person herself, beyond being a mother, daughter and wife. I tell them, 'Think about yourself, too, because if you take care of yourself, you will have the opportunity to look after your children.' I explain to women that their genitals are their daily bread, that we have to look after them and protect them from infection or aggression because they are very important to a couple's relationship."
Many clients learn about the clinic by word of mouth. We met Reina on her first visit to the clinic, and she told us that she trusted La Casa's good reputation because three different people had advised her to come. Reina migrated from Oruro a year ago with her three children and works as a street vendor whenever she finds child care. "I heard that there was a clinic and a center where they would help me, that it wasn't expensive, the care was different, and they could take care of the problems that we have."
Other women learn about the clinic through workshops, Pap smear campaigns, and pamphlets distributed by La Casa staff. Mar?Luz explains, "When we are walking down the street, sometimes we see people that seem to need help. They are poor, they have three, four, five kids, and we personally invite them to the clinic and give them a pamphlet about La Casa."
Clinic clients include young and mature women from diverse backgrounds. In the clinic we met 17-year-old Shirley, who is studying to be an accountant's assistant and was visiting La Casa for the third time. Shirley, who originally came on the advice of her mother, a nurse's aide at a hospital, commented, "The doctor is nice and gives me information. I tell my friends to come here to get information about birth control methods and everything. The difference is that in La Casa they pay more attention to us. There aren't many places where young people can learn about sexuality. We hear from our friends, and it's not always right."
Aida, a 55-year-old housewife, told us, "It's my sixth visit to La Casa clinic. The doctor heals me. She's the only one I trust. At my age, it's difficult to deal with intimate problems, and with a man, it simply doesn't work. On the other hand, with a woman doctor, one has more confidence. They listen to me here, and in other clinics, they just want our money and don't listen to us, especially to an older person like me. Dr. Lourdes gives me courage, and I can talk to her about all my problems. I had a secretion for a long time and was embarrassed to tell a male doctor."
Eugenia, a 41-year-old farmer, lives in Sombrerito, a village where she tends less than an acre of land, producing manioc, bananas, oranges and avocados. "It's a lot of work, but it's our only option because we don't know anything else." Eugenia has visited the clinic five times, each time walking three miles to the road and then riding a bus for about two hours to Santa Cruz. She initially came because she heard on the radio that La Casa had a woman doctor who offered gynecological care. "That news pushed me to go to the clinic about a problem I had suffered for a long time but kept to myself. The doctor gave me confidence, and so I keep coming back. I tell all my friends in the countryside to get motivated and come here, and some have come and liked it. In other clinics they give out numbers at seven in the morning, and women who come from the countryside arrive late and have to wait all day."
Throughout the years, the clinic has adjusted its hours and costs in response to client demand and to La Casa's economic resources. Currently, the clinic is open only one day a week, on Thursdays. The clinic is so well attended that the doctor often sees clients until 10 o'clock at night. She and the nurses feel a need to offer more hours of care in response to client demand. La Casa's limited clinic hours are due in part to its desire to avoid taking on responsibility for health services that are the government's obligation, and in part to the organization's increasing focus on education and institutional strengthening, rather than services.
Director Miriam Suarez explains La Casa's philosophy as one that focuses on, not just managing obvious symptoms, but remedying the root causes of ill health.
"While the Ministry of Health tries to treat the illness, La Casa tries to prevent it, attacking the causes through education, information and empowerment of women," she says. "Illness has multiple causes: lack of power over one's body, domestic violence, uncomfortable or degrading sexual experiences, depression, lack of legal protection, labor abuses, unemployment and low earnings. Working with the causes is a longer and more complex process, but the impact is more sustainable."
Miriam emphasizes a lesson learned, which has been central for many women's health programs: "We realized how important it was to work on women's self-esteem as a fundamental basis for all educational and transformational efforts."
According to nurse Mar?Luz Bacarreza, the alliance of health care with health education has helped improve the quality and efficiency of the clinic, in part because the clients have gained improved knowledge and confidence that allows them to trust health providers and to participate more fully in the healing process. "By going to the neighborhoods to give workshops, we've helped to build confidence to the point where women come to the clinic and share the whole story of their lives."
Educating health workers
A repressive social environment and a strong sense of female guilt about sex make talking openly about many reproductive health issues difficult. Ane Mie Van Dyck, a nurse and volunteer from Belgium, found that in Santa Cruz even health care professionals are embarrassed to talk about reproductive health. Once she visited several pharmacies to check types and prices of condoms. "One pharmacist gave me a big drawer of different condoms to look through, but when another client -- who was a man -- came in, the pharmacist took away the drawer and hid it behind the counter until the man left. If even the pharmacist feels such shame and fear that someone may see him with condoms, imagine how the domestic workers feel when they need to buy them!"
In order to work effectively with women, La Casa sees communication between health care providers and clinic participants as crucial. The staff has sought to develop new strategies for encouraging and facilitating communication -- strategies that enable women to speak openly about their needs and concerns.
"Ninety percent of the pain experienced by my female patients is rooted in impotence to express their feelings," says Lourdes. "The stress and oppression that women experience in their lives are often manifested in physical problems, especially gynecological problems.
"In order to respond to this situation, we prioritize conversation. Every consultation begins with an open conversation in which the patient has the opportunity to express her problems in narrative form. We often talk in Quechua, and the patient tells me about her life, and I get a glimpse of where the tensions arise. After that, I gently ask her if she is ready to be examined. Sometimes the patient freezes. I don't insist but try a different approach. Sometimes we draw the body, and I tell her, 'I'm like this and so are you. We are both women and our bodies are like this.' Using the drawing, she shows me just where and how the pain is. Sometimes I go on to do the examination, and sometimes we wait until the next visit."
The doctor's conversational method allows the client and doctor to understand a constellation of symptoms and causes in a holistic manner, rather than focusing on a specific illness. This holistic approach helps avoid situations such as those described by Dr. Rana Bang in a health district in India, where research revealed that 92 percent of the female clients at clinics in two villages had gynecological infections or diseases, which were neither detected nor treated as part of the family planning service (Bang, 1989, cited in Corr?and Petchesky, 1994).
Lourdes has developed a simple and effective communication technique that facilitates conversation in settings where power differences exist. This technique works in the clinic, between doctor and client, as well as in families, between husband and wife. The basis of the technique is never to lecture or impose information, diagnoses or decisions, but instead simply to open a discussion by asking about the issue of concern. Lourdes suggests to female clients that they try to reduce marital conflict by avoiding unilateral decisions and impositions. She tells them, "When you know something, when you have some information or decide on a plan of action, do not impose your decision or lecture like a teacher. This makes your man feel insecure. On the contrary, you must begin by asking him about the subject -- for example, 'Do you know anything about how the rhythm method works?' -- so that he gets a chance to establish common ground on which the discussion can unfold."
Lourdes emphasizes the importance of interpersonal relations in the clinic, as well as at home. "We can't act cold and superior. We have to share examples from our own lives. I tell the women, 'I work, you work. We owe each other respect.' I don't hide the fact that I also cook, have my baby, which helps build solidarity with the clients. The health staff here is close, and we share a health care philosophy that prioritizes personal relationships. The nurses also converse with the clients and treat them with respect when they are signing in and waiting for their turn. The situation in which we live tends to isolate each one of us, forcing us to seek out interpersonal relationships, so we offer that in the clinic."
Participants in La Casa programs also develop positive relationships and mutual support among themselves. In 1992, for example, a group of domestic workers participating in a health workshop decided to set a shared goal of zero pregnancies in the entire class during the first year after training. In the workshop, they learned about sexual rights and responsibilities and about contraceptive use. After the course they met at the center on Sundays to discuss their experiences and exchange advice, support and friendship. The domestic workers say that solidarity gives them courage, allowing them to discuss and deal with uncomfortable issues. They also value the chance to laugh together, for example, about the nurse's suggestion that they always carry condoms in their apron pocket, 'just in case.'
Participatory education
La Casa has increasingly linked health services with education, building a strong educational program in reproductive health and sexuality. "It is a mistaken effort to treat gynecological problems without providing sexual education," says Ane Mie Van Dyck. "In the public health framework it is incomprehensible to treat but not prevent illness."
The La Casa team has developed strategies and techniques to respond to two central challenges: first, the ineffectiveness of conventional education courses; and second, resistance to the subject, especially on the part of men. Mar?Luz explains, "Giving courses didn't work because people didn't listen, they just dozed off. Men didn't even want to hear about health education for their wives, much less workshops on sexuality."
La Casa's response has involved, on the one hand, developing entertaining activities, games and skits and, on the other hand, trying to involve male partners in these activities. "We're always accepted when we start with games and humor," says Lourdes. "We did a comedy about AIDS and sexually transmitted diseases that made everyone laugh. La Casa brings together very different women, and the games create a space for open dialogue and interaction in which they can connect with each other. Games and drama also allow men to participate with their own points of view without feeling embarrassed or threatened."
Marie Claude Arteaga, current head of research, defined the basic principles which characterize La Casa's learning climate: (1) use simple language and conversational style, (2) create a relaxed atmosphere that promotes interpersonal relationships, and (3) incorporate the lessons in the daily lives of the participants.
La Casa staff facilitate health workshops in poor neighborhoods, with parents of children in child care centers, with domestic workers, with students, and others. The topics include ovulation and menstruation, hormones and the female reproductive cycle, the female body, female hygiene, male sexual organs, wet dreams, male hygiene and circumcision. While each educational module has a clearly defined content, the varying perspectives, language and attitudes of participants make each experience different. Ane Mie explains, "In the high schools we use the correct names of organs like 'the testicles,' but with mature women in the neighborhoods it's better to say 'the man's balls,' explaining that they are a seed factory."
Ane Mie and Mar?Luz say, "the lessons officially deal with biological topics and hygiene, but we always take off from there to discuss questions of pleasure and sexuality. Many women say, 'It's nothing for me, my husband comes quickly and goes to sleep,' and we explain to them that female sexuality is different, using metaphors from everyday life. 'If you consummate the relation quickly, it is like eating raw cake batter. For a woman it's necessary to stir, taste, season, bake and frost, then we savor the cake with much more pleasure.' Examples like this make everyone laugh, and laughter is a good way to let off steam because we often tense up on these topics."
As an example of their educational approach, Mar?Luz and Ane Mie described a recent workshop about ovulation and menstruation, which they conducted with a dozen participants from a neighborhood mothers' club. "We started with a warm-up activity, in which the women joined in pairs and used paper and markers to draw a naked woman with her genitals. Of course, there was a lot of giggling, and when they finished, each pair presented their drawing to the group. We used this forum to evaluate the knowledge and attitudes of the participants. In this case, for example, there were a couple of drawings with only one hole which served for urination, menstruation and childbirth. After discussing the drawings without criticizing, we took out an anatomically correct drawing and went over it.
"We always start the drama part by saying 'let's play!' With some verbal directions, but mainly by participating physically, we helped the women to form a circle with their bodies, telling them that the circle represented an ovary. Several women crouched in the center of the circle to represent ova. One ovum slowly stood up, growing until it reached maturity, then it broke out of the circle in a move that represents ovulation. Once the mature egg left, we joined hands to close the circle again, and waited an imaginary month until another egg became ready. Once the women became familiar with the game, we moved on to the uterus.
"We arranged ourselves in another circle, which was the uterus, or womb. One woman stayed outside -- she was the ovum. Each of us making up the womb held a sweater or blanket, and during an imaginary month, we slowly pushed it out in front of us to form a soft cushion on the inside of the womb. In the first round of the game, the egg entered the womb but did not meet a sperm, so it exited by way of the vagina, and the members of the circle pushed their sweaters out too -- that represents menstruation. In the next round, the womb prepared another soft cushion, and when the ovum entered, it met a thin woman playing a sperm. They joined hands to form a fertilized egg, and rested against the soft cushion. In the end, we linked both games to show how ovulation is related to fertilization and menstruation.
"After 'playing,' we always do that part of the session we consider the most important -- reflecting and discussing the experience. We began with a game called 'the little bench' in which everyone must run to sit on the 'agree bench' or the 'disagree bench' in response to each topic mentioned. In this case we asked, for example, 'Is menstruation bad blood?,' then asked those sitting on each bench to express their opinion. We always try to reinforce correct observations and gently correct mistaken impressions, often using tangible examples from everyday life. In this case we asked, 'When you are preparing for an esteemed guest do you set the table with rotten food?' Of course they said no, they put out the best, and we explained that the body also prepares its best for the baby. The healthy soft cushion, which is expelled as menstruation, only becomes rotten when it isn't cared for. We give an example of liver, which is largely blood. Fresh liver is good and nourishing, but when it rots it smells bad and attracts bugs. Menstruation is also good when it is fresh, but if we don't keep clean it begins to smell and breeds smaller bugs."
La Casa has published health education materials, designed to promote participation and creativity. One example is the book, Physical and Mental Health of Women in Poor Neighborhoods (Health Team, La Casa de la Mujer, 1992b), which presents the results of a survey in the form of a comic book with photos of women and men expressing responses to the questions, often through hilarious gestures and poses. The introduction of the book reads, "Dear friend, in this little book we want to talk about health. Why? Because it's a very important topic which relates to so many fundamental things: life, death, happiness, sadness, strength, weakness, enthusiasm to participate and lack of motivation. We are going to talk specifically about women's health. Why? Because we women grow up, feel, think and live in our own way. Our experiences, our illnesses, our problems and our joys are specifically feminine. For this reason, we decided to ask a lot of women to share their experiences and opinions about everything having to do with physical as well as mental health. In this little book, 300 women from different neighborhoods in Santa Cruz talk about health. Your experiences could be similar to or different from theirs. Our idea is to reflect together, to get to know ourselves better, to better understand other women, and to relate amongst ourselves."
Involving men
La Casa de la Mujer was initially conceived as a space and a set of activities organized by women, for women, with the purpose of empowering women. Nevertheless, teams involved in all programs discovered that their practical efforts working with women alone rarely solve women's problems, and in some cases create even more conflicts for them.
Like many other women's organizations, La Casa is caught between its commitment to help and strengthen women and the necessity of working with men. "Perhaps working with women alone is not sufficient, especially if we talk about health care," says Marie Claude. "Nevertheless, it is necessary to work with women alone in certain instances and efforts -- we need to build their self-worth and empowerment first. Although we are considering gender relations, which implies not forgetting or marginalizing men and the male perspective, we feel it is important that the women participants themselves involve men from their own perspective and their own point of view."
La Casa now seeks to involve husbands and partners of female participants in certain dimensions of learning processes and actions for change and to direct special efforts at youths of both sexes. Such efforts have frequently met with resistance. Men oppose sexual education for their wives and daughters for a number of reasons. Not only are they afraid the women will become promiscuous, they also fear that the women's new knowledge of sexuality will lead others to think they are promiscuous, bringing shame to the family.
"When the man doesn't participate, problems arise," Ane Mie explains. "A woman learns something new that the husband doesn't understand, and he doesn't like to feel stupid in front of his wife."
In health education, as in health services, getting men involved has been one of La Casa's greatest challenges. "In one campaign, we did Pap smears on 47 women, and there was only one who didn't have an infection," says Lourdes. "We've seen that working only with women doesn't solve the problems. In many cases, if the man isn't treated at the same time, our efforts are in vain. In medical terms, the sexually transmitted infections are not cured, and in the family, reproductive health should involve both partners.
"Now, women come for a Pap smear, and we make an appointment for both partners to come in for the results. At first men said, 'Listen, women's infections have nothing to do with us,' but we refused to give the results if they didn't come. We demand that the men come, and they often come in a bad mood. But we don't attack them, just inform them with respect."
Lourdes sees communication problems between couples as a health issue. In one case, a woman said that when she tried to practice the rhythm method, her partner hit her for not letting him have sex during ovulation days. Later, when he found out she was pregnant, he hit her again. Lourdes has found that this type of tension can often be avoided if knowledge and responsibility are shared by both partners. "It doesn't always work, but I've had many cases in which the man comes once to the clinic, and then he becomes a protagonist, learning about everything and even insisting that his wife come for checkups."
La Casa tries to provide a non-intimidating environment, in which professionals relate to men and women equally. Estela Sejas, a nurse in health education and services, has observed positive changes in men's participation, although these cases are still a minority. "Some men come into the clinic with their wives, which is good because they learn about their wives' health issues, and take better care of them. This is a significant change for families in which fertility and sexuality have been points of conflict and resentment."
Lourdes also encourages couples to explore questions of sexuality and sexual satisfaction together. "Women don't tend to see sex as something good for them. They say that it is an act that they have to perform when their husbands want it. A wife must receive her husband, or she is accused of being involved with someone else." Lourdes' approach is to talk with the woman and the man, so that they see that sexual relationships involve both of them.
The La Casa team is convinced that education with couples is optimum, yet they still have much more acceptance and success working with women than with men. "It's difficult to convince men to participate. With youths, it is easier than with older men," says Mar?Luz. "Nevertheless, once they get involved, men often come up with a hundred questions and are very active in the workshops. In the neighborhood called April 26th, for example, La Casa organized a reproductive health workshop with parents from a child-care center. Only one man came to the first workshop, and when he saw there were no other men he went home saying, 'This is a ladies' thing. What am I going to do here?' But several men participated in the second workshop, and more in the third."
In developing the concept and practice of reproductive rights, Third World women have changed the definition of the term (Corr?and Petchesky, 1994:3). Together with other institutions, La Casa has developed an understanding of reproductive rights that is broader than fertility regulation and encompasses multiple dimensions of feminine health, such as conjugal relationships, psychological well-being, legal rights and citizenship. Important to this understanding is the consideration of structural conditions that can enable or impede the fulfillment of individual rights, a consideration that has motivated La Casa to respond to problems such as unemployment, lack of potable water, environmental contamination, illiteracy and inadequate child-care facilities. La Casa programs include not only health care but other social services that promote the fulfillment of women's reproductive rights.
Legal support
La Casa's legal center functions full-time Monday through Friday. The team includes a lawyer (Adela Ramirez), a law student (Marina Mor?? and an extension worker (Rosa Chambi). The majority of the women who come to the center for help have problems with either domestic violence or child support. "In most cases, it is women who come with legal problems, and when the problem involves a couple, we always insist that the man come to discuss the problem in attempts to reach an accord by consensus," says Adela. "Some men come for legal aid, and occasionally a man will request help in contacting a woman and children who have left him, or whom he abandoned."
The opening of the new center has created so much publicity for La Casa that requests for legal assistance have doubled in the past few months. Due to the increased demand, the team decided to give priority to cases of domestic violence. La Casa usually encourages a victim of violence to obtain a certificate of injury from a forensic doctor and, in serious cases, victims are taken to the police station to file assault charges. Nevertheless, many women do not want to file charges but prefer other forms of conflict resolution. Marina explains, "We must listen to what they want. Many women come to cry, but don't want to divorce, nor to take legal action."
Physical abuse within the family tends to coexist with psychological and/or sexual abuse, and the legal team frequently encourages victims to visit the gynecology and psychology clinics. Adela observes that when a woman wants to break off a relationship completely, she tends to resist further assistance, but when she hopes for a reconciliation, she is more willing to participate in counseling sessions.
Conflicts involving child support are the next most common type of case. Since a man is only responsible for children that are legally registered as his offspring on a birth certificate or a "certificate of recognition," many women begin the struggle by getting men to sign those certificates. Later, when a family separates, a judge may fix a monthly support payment, but it is rarely fulfilled and nearly impossible to enforce. The legal team usually approaches the problem by seeking an agreement between the separated couple.
In addition to helping women respond to immediate crises, La Casa tries to prepare them to face future problems. Reproductive health is an important aspect of this preparation. In situations of domestic instability and violence, in which the birth of another baby might intensify a woman's conflicts and challenges, legal staff encourage her to meet with the doctor to discuss family planning. Legal and health services also work together in efforts to strengthen participants' self-esteem, enabling them to take more responsibility for reproductive health and welfare.
One important La Casa program is the Training Center for Domestic Workers, comprised primarily of young women who have migrated to Santa Cruz from the countryside or other parts of Bolivia. During a two-week live-in program, the women participate in workshops on legal issues, health, sexuality and environmental management. During and after the program, many of the participants arrange for private visits to La Casa service centers. And after finishing the course and taking jobs obtained through La Casa's placement program, some of these women return to the center on Sundays to "hang out" together in their space.
La Casa's domestic worker program demonstrates the multifaceted support offered by the legal team. According to Adela, "what we try to do is educate these women, improve their contacts, help them to know their rights as workers, citizens, women. We educate domestic workers about their rights, and when they have trouble they come back to see us. We work mostly on labor problems, such as failure to pay salary or bonus, physical or sexual abuse, and accusations of theft. We've also done a lot with citizenship rights and documents: A national ID card is crucial, even though it doesn't guarantee full rights of citizenship. We had an arrangement with the Civil Registry to obtain ID cards more easily, but now they've changed the law and it has become a very lengthy and expensive legal process." Other legal problems experienced by domestic workers include unethical and exploitative employment agencies and employers. La Casa tries to promote clear arrangements between employer and employee, using a domestic labor contract with 16 clauses that define salary, work hours, trial period, tasks required and other terms.
La Casa's legal efforts also extend to advocacy. During the past few years, La Casa, together with other institutions, has worked for passage of a new law against domestic violence. Staff members and participants marched, signed petitions, and joined the Departmental Committee for the law's approval. In 1995, after a long debate, the Bolivian legislature passed a law against violence in the family and domestic sphere. The law defines as a public crime physical, psychological and sexual violence within the family or domestic sphere; imposes sanctions in the form of an initial fine, and of arrest for cases of delinquency or aggravation; establishes simplified and cost-free procedures for denouncing, testifying and proving the crimes; and establishes brigades specialized in protection against domestic violence to provide help to victims. Adela affirms that "while the law and the publicity surrounding it are clearly motivating more women to denounce aggression, we have yet to see whether the expectations raised by the law are fulfilled by state judicial systems, and whether the law really helps to reduce the violence."
Psychological counseling
Psychological counseling developed as part of La Casa's health services is offered in coordination with gynecological care. In the psychological center, as well as the health clinic, prevention and cure, causes and symptoms, are closely related. For psychologist Maritza Camargo, "The principal objective of my work at La Casa is both diagnosis and treatment -- knowing the causes and knowing the therapeutic response are inseparable."
Maritza gives talks on sexuality to domestic workers and neighborhood groups, focusing on family dynamics. Describing a series of innovative methods she uses to facilitate conversation and reflection, she explains, "In workshops with domestic workers, we start talking about how the young women imagined Santa Cruz before they came here as migrants -- their fantasies about money, freedom, social life -- and from there we get into their hopes and desires about boyfriends and sex." Maritza's approach is well-received; so many participants have requested additional sessions that Maritza has organized open workshops at La Casa one Sunday a month to discuss aspects of sex and sexuality.
Maritza finds some advantages in La Casa's reputation for helping women in trouble because it attracts people at times when their tensions and conflicts have become unbearable. "When women come to La Casa, they are often in a state of crisis. We make every effort to get their partner involved at that crucial moment of crisis, when there is more potential for change. When a conjugal relation is in equilibrium, it is very difficult to change."
La Casa workshops and counseling consider women to be part of complex systems that include the couple, the children and the family. "It is not just one person involved in the abuse," Maritza says, "it is always a dynamic of two people, at least. Often a woman will want a man to change within an existing pattern. I help them to see that there are neither angels nor devils, that both are participants in the conflict so they both need to change. For example, women frequently feel depressed and worthless because they are not valued. We see women who complain because they are not valued, and yet at the same time they tell their kids, 'Your father is a drunk. Your father is a lazy bum.' I tell them that first, a woman must value herself as a person, value other women and also value her husband."
Miriam Suarez agrees that psychological counseling must consider women as part of complex social networks. "Our psychological workshops are based in the perspective that a woman is a historical subject who interacts with others within a given system," she says. "The principal relations of that system are patriarchal, shaping women who reproduce attitudes and values which respond to that model. For this reason, even situations of machismo and family violence involve men and women."
Maritza's office is decorated in a homey fashion, with rugs and floor pillows that create an informal conversation space. During sessions, she doesn't sit behind her desk in an authoritative posture but moves through the conversational space, trying to connect with clients through gestures. Breaking from the model in which the psychologist asks questions and the client responds, Maritza encourages women and men to participate with her in representations, which help to understand and change the situation. For example, they may use mime or skits to act out what happens when the husband arrives home from work. One of Maritza's favorite positions is seated on the floor at the feet of a client, like a child listening to narratives. It is a position that drastically changes relations of knowledge and authority, empowering clients and giving them more confidence in their own voice and their own story. These communication methods reflect an effort to overcome the differences of class, culture and power that normally separate participants in a therapy session.
Environmental education and action
Wilma Ayala, head of La Casa's environmental program, says there is an urgent need to see the connections between environment and health. "We frequently treat the symptoms of illness and don't bother to look for causes, such as contamination of food, air and water. There is a strong relationship between health and environment. If we burn garbage, it obviously provokes sore throats and conjunctivitis in our children. We try to encourage people to question their conditions, and demand their rights to a healthy environment."
Wilma explains that for women in poor neighborhoods and for domestic employees, environmental protection is much less pressing than things such as money, which help them respond to immediate needs. "We ask, 'How can we link quality of life to environmental protection?' The work which interests us most is practical work in which local people can be protagonists, can see connections between their actions and their personal well-being and verify the results of their efforts." Thus, much of La Casa's work is at the household level, promoting management practices that directly benefit the family, such as teaching people to separate garbage and sell what has value (bones, newspapers, plastic, cans). La Casa teams demonstrate composting to improve garden soil and growing medicinal herbs and vegetables that are not contaminated with pesticides. Participants learn safer (and often cheaper) ways to use detergents, agrochemicals, toxic materials and insecticides, and they come to appreciate the immediate impacts of these practices on their health and that of their children.
La Casa's team has developed practical educational methods geared to the interests of participating groups. With mothers' clubs, for example, reproductive health education is linked with environmental information in workshops that teach nutrition and natural medicine. There is enthusiastic participation in these courses, says Wilma. "They know many different things about natural medicines. We trade recipes and ideas, and we prepare cough syrup and calming teas together. In all the workshops, we try to value the practices of participants, their parents and grandparents. At the same time, however, we raise the possibility that some traditional practices may be problematic today in our changing environment. Everyone used to burn garbage, for example, but there was very little garbage -- people went shopping with baskets and clay pots. Now, our purchases come in plastic bags and jugs. We ask the people to explain the changes, and they say, for example, that people used to burn bones to frighten away illness, but now there is so much contamination that this doesn't work anymore."
According to Wilma, an important challenge for the environmental program is to respond to the diverse cultural processes of different groups in Santa Cruz. For example, migrants from the altiplano tend to cut down shrubs and trample their yards into hard dirt. In the hot humid climate of Santa Cruz, dwellings with no vegetation become ovens, and in the tropical rainy months, yards turn into mud puddles that breed insects -- problems unfamiliar to highland migrants.
La Casa's environmental program reflects its interest in supporting other organizations with common goals. The La Casa team has organized participatory environmental education activities with neighborhood committees, parent-teacher associations, student organizations and mothers' clubs. Historically, most instances of information and organization for environmental issues have included few women and have virtually excluded poor sectors of society; they also have ignored the class and gender implications of environmental problems. La Casa tries to develop these dimensions in order to promote a more complete vision and a more integrated strategy for environmental education and action. La Casa coordinates with the Ecological Association of Eastern Bolivia (ASEO), the League for Environmental Defense (LIDEMA) and International Habitat, often working with families involved with these institutions. La Casa also participates in the Departmental Forum on the Environment, promoting the participation of poor sectors and women in marches and letter-writing campaigns.
Wilma shared with us a dramatic experience with community action. "The neighborhood called 'July 16th' had the bad luck to be near the dump where Santa Cruz municipal garbage trucks unloaded tons of garbage a day. Residents suffered a range of problems: flies formed clouds in their yards and invaded their kitchens; the drinking water they carried from shallow wells was contaminated with parasites and chemicals; children suffered chronic diarrhea and other illnesses. Finally the situation exploded when a whole family died after eating pancakes prepared with poisoned flour which they had found amongst the garbage heaps.
"Women from the neighborhood led a search for alternatives, going from office to office, to denounce the atrocities and demand their rights to a healthy environment. A mothers' club leader, an elderly woman named Margarita Campo, came to our center. Together we came up with the idea of blockading the dump entrance so that the garbage trucks could not get in. The July 16th mothers' club organized the blockade, and La Casa called in the media -- we brought radio and television stations, journalists and photographers to witness the event so that officials could not negate or disqualify the voices of women protagonists. The mayor had to come and negotiate, and finally they decided to create another dump site further from the city. They compacted and covered up the garbage heaps in July 16th, but there are still contamination problems, and the children are still sick. La Casa helped to arrange for a professional analysis of the water, which confirmed high levels of contamination, and later we helped with a potable water project. Nevertheless, there is still a lot to do. With Adela Ramirez, La Casa's lawyer, we are planning to study environmental laws and city ordinances in order to better support the people's struggle."
All of La Casa's environmental activities are characterized by participatory techniques, such as drawing, theater and hikes with children and adults. "We have never just taught classes in environment," says Wilma. "On the contrary, we've always worked through participative activities to learn together. In a game about watershed, some participants form a group that is soil, behind them stand a line of people who are trees, and behind them a group representing water. When the water comes running from behind, they break between the trees and carry off the soil. In a second round more people play trees, and they stand together holding onto each other tightly. When the water comes running down the hill it can't break through the trees and get to the soil." After participating in gender workshops, Wilma has begun to adopt some activities to facilitate exploration of gender dimensions of environmental issues.
The environmental education team presented some of its innovative learning techniques in a cloth flip chart and guidebook to facilitate participatory learning about everyday environmental practices. The kit focuses on safe, environmentally sound management of water, food, garbage and detergents and is especially appropriate for women and families. La Casa uses these materials in workshops where participants paint the flip chart, make up stories, and hold discussions in reference to the pictures. They have sold a hundred of these teaching kits to other institutions and are currently preparing more. The team hopes that these materials motivate dialogue and reflection that will change attitudes about daily life, but Wilma warns that the materials alone do not guarantee participatory learning. To fulfill its potential, the chart and guide must be used as tools to empower participants, enabling them to share in information, decision-making and action.
In the past five years, La Casa has achieved a number of important goals. Here we will focus on two achievements, unusual in health programs and whose impacts on reproductive health issues have not been sufficiently examined: La Casa's ability to build a large participant base and its ability to build solidarity among diverse groups.
La Casa has built a broad participant base by involving women from many different sectors of society. It has become a reference point for women in many life situations -- those who are looking for services and support, as well as those who are seeking an opportunity to serve others. La Casa's broad coverage draws in many women, whose experiences and perspectives have enriched the organization's development. In turn, these diverse participants bring La Casa's approaches and perspectives back to their different social groups.
Building on this broad participation, La Casa has been able to construct solidarity among women, expressed in the strong supportive relationships that currently characterize the organization. In the social context of Santa Cruz, the simple act of establishing relations among women of different social classes is an achievement. Some women in Santa Cruz have criticized La Casa's efforts to build a cross-class women's network, saying, "they're taking people out of their proper roles" and "they are only making the scum uppity."
Miriam describes the internal impacts of solidarity among women: "It's a great achievement for La Casa to have consolidated a space for and of women that maintains its original social components, which are diverse women's groups interested in constructing equity. Many staff members have only a few years of formal schooling, nevertheless they are sound professionals, they have grown and developed valuable practices enriched by their human quality. The team also includes professionals and university graduates, and the human growth of all the participants has taken place within an environment of solidarity and sorority among women." Yet even inside the organization, it has been a challenge to deal with prejudices, myths and mistrust among women. "In the beginning there were communication problems, some women refused to participate in the workshops, and saw professional women as their enemies," says Miriam. "But over the years, in spite of our different life histories, we have come to share experiences and discussions which are meaningful for each of us, proving that we can change ourselves, and that we can make changes together."
Working with women from different social, economic and ethnic backgrounds allows a better understanding of reproductive health and sexuality. As a reality shared by all women on the basis of their biological functions, reproductive health and feminine sexuality are universal themes. At the same time, it is increasingly clear that each group of women, and even each woman, experiences her reproductive health and sexuality in an unique way, influenced by her cultural reality, her class and ethnic position and her unique life experiences.
New methods of learning, communication
One of the first things La Casa teams learned was that it is not easy to educate and provide services to women whose language, perspectives and experiences are different from their own. This awareness has motivated staff members to experiment with new approaches to learning and communication, designed to overcome the life differences among health professionals, well-educated feminists, outreach workers, migrants, adolescents, domestic workers, women from poor neighborhoods and others.
It is not just a matter of finding a common language or using the same terminology. La Casa sees a need to transform the interpersonal dynamics of conversation and learning. Miriam describes the impact of experiments in mime, skits, games, bodily expression, therapeutic drama and especially humor: "In sum, it has made learning a rich process with delicious moments in which folk-knowledge comes together with academic approaches to give birth to a political position that is eminently feminine, in terms of respecting diversity and in terms of constructing more equitable interpersonal relations."
La Casa's evolution
La Casa's first phase was shaped by its work in responding to women's needs. Now it is evaluating past experiences in order to plan for the future.
A significant challenge for La Casa is to close the gap between the organization's political goals, foremost of which is to promote gender equity, and its practical work with women, which constitutes the staff's everyday tasks. "We are involved in every single women's issue," says Marie Claude. "As soon as someone calls us or we hear of some problem, La Casa comes up with a position or action. This attitude demonstrates great commitment, but it drains both the staff and the organization. We need to prioritize, and right now I think that La Casa's maturity permits us to focus better."
La Casa's diverse experience provides a broad basis from which to construct a theoretical framework that links the multiple dimensions of women's lives. Marie Claude identifies several steps necessary to advance this process. "We've been writing reports, which are no more than lists of activities, which don't include personal reflections or qualitative evaluations. The first thing we need to do is to organize and write down the experiences that are in the heads of all the participants and staff. Next we need to systematize those testimonies, evaluate our efforts and reflect on our experiences. Finally, we will be able to define a theoretical framework that will sustain our future efforts."
La Casa is known for responding to women's immediate demands with concrete and specific actions. Its new three-year plan prioritizes internal growth, based on philosophical and political reflection, and places less emphasis on action. The plan states, "We want an internal training program, which will allow us to question the role of assistance as a meaningful response to women's problems" (La Casa, 1995:4). La Casa has begun a process of internal education and reflection; its goal is to analyze the institution's processes and its relation to the world around it, to seek coherence between La Casa's utopian vision and its day-to-day practices.
In its health program, La Casa plans to focus more on analysis of and response to the causes of health problems, especially through education and empowerment of women and work with women's organizations. At the same time, however, the organization resists abandoning the health services it has provided for years. A poster in the center addresses the push on the part of La Casa's primary donor for a relative reduction of services: "The reality around us and the experience of work carried out in La Casa's programs demonstrate a massive demand for our services (910 beneficiaries during the 1994-95 period), which means that La Casa must take up the challenge of continuing these services with its own resources."
Another central goal of the new plan is to clarify La Casa's feminist position and principles. La Casa originally was conceived as a program by women for women, and its feminist perspective has principally focused on empowering women. Yet as one staff member put it, "in some instances our position is in danger of degenerating into a sort of inverted machismo." This type of concern is fueling a growing interest in gender. Some members are currently participating in gender training seminars, and La Casa plans to create an internal forum in which staff can share what they have learned and explore possible applications of gender theory to the organization's work. While the need for more gender-balanced programs is clear, so is the resistance of some members to give up the hard-earned solidarity of their all-women organization. In the next years, La Casa will have to face numerous decisions and changes if it follows through on a move toward internalizing gender perspectives.
Restructuring the institution
Parallel to the evolution of its goals and vision, La Casa has designed a new organizational and work structure. Staff began to recognize a troublesome isolation of its different programs. Staff also identified as a problem the lack of sufficient fora for exchanging experiences, exploring interrelations between programs and coordinating efforts.
In July 1995, an external evaluation confirmed the need to introduce changes in the organizational structure and in program development. Shortly afterwards, La Casa organized a three-day workshop for all employees to discuss the institution's origins and evolution and to discuss plans for a new phase of growth that incorporates concepts of gender and sustainable development. The results of this workshop became the basis for a draft of a new three-year plan.
According to the new plan, work will be carried out by a series of interdisciplinary teams in the fields of education, research and services, and mechanisms will be established to guarantee interchange and coordination among these teams. The interdisciplinary approach is evident in the research teams' current exploration of the construction of identity among migrant women. In this project, being carried out with special funding from a Danish organization, researchers are considering the experiences and lessons learned in all La Casa programs.
In its work, La Casa has sought to balance efforts to help women address short-term needs and concerns with strategies that will empower generations of women and men to improve their lives. The provision of health care is one tool for current and future empowerment, and it is inextricably linked with other efforts to improve women's lives.
The Centro de Informacion y Desarrollo de la Mujer (CIDEM) is a nonprofit organization that conducts a variety of activities with women, primarily in El Alto. This case study focuses on CIDEM's reproductive health project based in the Kumar Warmi Clinic.
Kumar Warmi, which is Aymara for 'healthy woman,' has as its primary objective the provision of education and services that allow women to share in knowledge, responsibility, and decision-making about reproductive health and to participate in the design of health policies and projects. Kumar Warmi's work promotes the fulfillment of basic rights to reproductive health in two ways: by educating and empowering women, and by changing the structures and practices of health care provision.
CIDEM's approach to health care is unique in that it is based on a well-defined gender perspective that permeates the project's concepts, goals, methods and relationships. The approach includes an emphasis on continued education and growth, based on respect for differences; an integrated approach to education and service delivery; and a focus on interpersonal relationships.
Another unique aspect of CIDEM's program is that it breaks free of the traditional health service delivery paradigm. CIDEM recognizes health as an entity much more complex than medical service and something necessarily linked to education, human rights and personal empowerment. In addition, CIDEM's approach transforms conventional interpersonal relationships so that the doctor is no longer the sole active subject who monopolizes medical knowledge, and the client is no longer the timid beneficiary of the doctor's attention.
For this case study, we interviewed key participants in the project and women who attended the clinic. We also organized a focus group discussion with leaders of women's groups, who are members of the Kumar Warmi Health Committee. The committee has served as an advocate for local women's organizations for more than a decade. Another source of information was CIDEM reports and project plans. The following members of CIDEM spoke with us: Ximena Machicao, CIDEM director and sociologist; Mery Marka, member of the health education team; Justina Prado, clinic nurse; and Mar?Antonieta de Sald?, gynecologist-obstetrician at Kumar Warmi Clinic. We talked with the following participants who came to the clinic for care: Cirila, Cristina, Marina, Rosemary and Wendy. The following Health Committee members participated in a group discussion: Judith Ascarrunz, Natividad Condori, Emilia Guitierrez, Antonia Mari??nd Celia Perez. The clinic visits and interviews were conducted in February 1996. We held two follow-up meetings with CIDEM staff members to discuss drafts of this study.
The Kumar Warmi project is located in El Alto, a new city near La Paz that began to grow rapidly about 20 years ago. El Alto's population has expanded at the rate of 8 to 10 percent annually during the past five years, reaching its current total of approximately 450,000 residents. Aside from its anarchic growth, El Alto's notable characteristics include its cold climate, extremely high altitude of 4,000 meters, and lack of basic social services. The majority of El Alto's population is poor, and many families are migrants from the altiplano, who reproduce aspects of rural life within their new urban habitat. The coexistence of migrants from diverse geographic areas and ethnic and linguistic groups contributes to a complex social environment.
The distressing health situation of women in El Alto has been described in many studies. Major health problems include maternal mortality, sexually transmitted diseases, and complications from early pregnancies and unsafe abortions. According to recent figures from El Alto, 2 percent of women first became pregnant between ages 12 to 14, 43 percent between ages 15 to 19, and 40 percent between ages 20 to 24 (CIDEM 1995b). Thus, almost half (45 percent) of the women were teenage mothers; this has affected their standard of living, in many cases forcing them to leave school, work in poorly paying positions and engage in dependent relationships.
Another factor that contributes to the health problems of El Alto is the lack of access to health care. The survey, Women and Children in El Alto, (Basaure et al., 1990), found that 60 percent of women interviewed said they did not seek any medical care when they were sick, 43 percent said they did see a doctor, and 4 percent said they saw a traditional healer. Among women giving birth, 56 percent of women surveyed said they gave birth at home with only family to help, 21 percent gave birth in hospitals or health centers, and 10 percent were attended by midwives. Women of rural origin were least likely to seek medical services in cases of illness or childbirth.
Family planning and contraception are important issues in reproductive health. CIDEM found that 78 percent of El Alto women over age 15 said they had not used any modern method of contraception, while only 5 percent said they were currently using contraception. Sixty-one percent of women did not receive prenatal care, while 39 percent did (CIDEM 1995b).
The obstacles that prevent women from seeking professional health care include economic barriers and negative perceptions of the doctor-client relationship, which are different facets of the central problem of inequality and discrimination. A lengthy study in El Alto (Schuler et al., 1994) focused on reasons for women's non-participation in health care services and found "style" of health care service delivery is partly responsible. "A principal strategy for fostering this growth in demand [for reproductive health care] should continue to be an emphasis on improving the quality of medical services and encouraging providers to be more sensitive to cultural differences. The style of interaction between service provider and client, while always important, seems to be particularly important in this society." (Schuler et al., 1994: 219).
The reproductive health practices of women in El Alto are linked to their economic participation in multiple ways. CIDEM's three-year plan notes that "due to the impact of the economic crisis provoked by structural adjustment policies, women have diversified their wage-earning activities and have increased their work hours" (CIDEM 1995: 2). Women's form of economic participation is influenced by the degree of (or lack of) compatibility between family responsibilities and earning opportunities. Thus, the number and age of a woman's children restrict or make possible her access to different economic activities. Testimonies by women workers, published in Schuler's study, illustrate this. "With a baby, I could not go to the market to sell," said one woman. "At the market, the people I sell to want to be attended to quickly. They don't want to listen to a baby crying, and the baby does not let you work." Another woman said: "I suffered. ... I used to cry all the time when I had to go to work with both babies. You can't work -- you have to carry around a big load of goods and you have to carry two babies. And it was worse when it rained" (1994:213).
At the same time, the heavy burden of women's domestic and wage work limits their access to health care and fertility control services. Cirila, a young woman who came to Kumar Warmi for legal advice, told us, "I have four children and I have to work. There simply isn't time to go to the clinic, even though there is one right near my house."
When it began activities in El Alto in 1985, CIDEM defined its central goals as educating women about health care, educating women about their rights and supporting women's organizations. At that time, there was an extreme dearth of medical services in El Alto and not a single clinic for women. Many El Alto residents were afraid of clinics run by doctors, who had little knowledge of their cultural practices and beliefs. Poor, indigenous women often perceived that doctors did not respect them as clients.
In response to local residents' repeated requests for health services, CIDEM founded the Kumar Warmi Clinic in 1986 to offer integrated services addressing biological, legal, psychological and sociocultural aspects of women's health, with a complementary focus on traditional medicine, designed to recognize and reinforce the positive practices of women participants.
"The Kumar Warmi clinic grew out of a proposal advanced by the leaders of several women's organizations with which we worked," says CIDEM director Ximena Machicao. "They pointed out the desperate lack of services, and we responded by becoming the first clinic in El Alto oriented to women. We conceived Kumar Warmi as an integrated health clinic, with humane services and alternative methods, but more than anything, as a place for learning about health and about women's rights. The promotion of interpersonal bonds and the creation of women's support groups have been central components of the education program." CIDEM teams have always included Aymara speakers, who help promote greater confidence and understanding among clinic participants.
