Oral Health Campaign

In April 2010, the Chijnaya Foundation, in collaboration with the Peruvian American Dental Association (PADA), inaugurated a sustainable oral health program with a special five-day clinic in Chijnaya, to be followed by monthly services at the community’s health post. Our goal is to create a pilot project that can demonstrate the possibility of achieving improved oral health in poor remote Andean communities.

The effort is a response to community members’ repeated requests for dental services and well documented need. In 2008, a group of graduate students from Loma Linda University’s School of Public Health conducted a dental health education and prevention program in Chijnaya and noted a high prevalence of cavities when they offered fluoridation to children.

A subsequent needs assessment (February, 2010), involving examination of 244 Chijnayans, provided epidemiological data demonstrating extensive need for dental treatment, particularly for caries control, extractions, root canal treatment, and prosthodontics.

With a new mobile dental unit and patient chair, purchased with a generous grant from a U.S. family foundation, representatives from PADA, the Chijnaya Foundation, and the Chijnaya community, along with four Puno area dentists, provided services to 305 patients during the inaugural April 2010 clinic. For a small contribution, patients were provided extensive oral health education, with an emphasis on the importance of regular toothbrushing, as well as the following services: oral examinations, fillings for caries, extractions, deep cleanings, pulpotomies for children, and fluoridation for youngsters aged 6-12.

The Peruvian American Dental Association provided supplies, equipment, and professional expertise while the Chijnaya Foundation managed the logistics and special funding.The Chijnaya Foundation and PADA will continue this collaboration, along with our four associated Puno area dentists, dental students from the University of th e Altiplano (Puno), and the Puno Lions Club. Currently, the Chijnaya Foundation offers clinical services monthly in Chijnaya. In the near future, we hope to provide oral health education and treatment services in other communities that work with the Chijnaya Foundation. With the help of PADA, we are also developing plans to provide badly needed more specialized services, such as fitting dentures for middle-aged and older patients who are missing many or most of their teeth.

The oral health team (left to right): Dra. Carmen Sanchez Herencia (dentist from Juliaca), Lic. David Cajo (Chijnaya Foundation Board member and Field Representative), Bruno Callata Tapia (mayor of Chijnaya), Zenovia Paricela Huancollo (volunteer community health promoter), Dr. Ann Stromberg (Chijnaya Foundation Board member and health specialist), Vicentina Alta Turpo (nurse at Chijnaya health post), Dr. Carlos Barriales Acosta (dentist from Puno), Dr. Juan Carlos Franco Barriga (dentist from Puno), Dra. Maria del Carmen Aragon Quispe (dentist from Juliaca), Dr. Oscar Trigoso (Founding President of the Peruvian American Dental Association). Not pictured: the photographer Silvia Trigoso, M.P.H, (PADA public health specialist), and other supporting members of the Chijnaya community including Jose Araca, Secretary, and Ismael Cayra, Chinaya Health Committee member.

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Clean water -- The "Suma Quta" Project

The Suma Quta (“Beautiful Lake”) Project

Today, many rural communities’ traditional livelihoods in the Lake Titicaca basin are threatened by water scarcity and pollution from mines, urban settlements, and solid waste. Most people today in the lake basin show awareness about pollution and the lake’s much-diminished fisheries, but until this project was initiated, no information about water quality and conservation had been available to the public.

The Suma Quta (pronounced "Sue-muh koh-tuh") Project began in 2009 and combines the efforts of numerous Peru- and U.S.-based nonprofits and universities, as well as regional government agencies in Puno, Peru, in developing public information about water quality and appropriate technologies and best practices for communities that have water sources that are risky or dangerous for human consumption.

Some examples are the following:

▪ Since 2009, The Chijnaya Foundation and the Puno-based nongovernmental action group Suma Marka have worked with Global Water Watch in building Peru’s first comprehensive community-based water monitoring program. Now, 58 monitors--mostly local community leaders and college students at the local National University of the Altiplano-- have been trained in 2 or 3 day long courses to do physico-chemical and bacteriological water monitoring using portable kits and incubators built from Styrofoam boxes, 15 watt light bulbs, and thermometers. The information gathered monthly by monitors at a dozen stations around the lake basin is available to the public, and is meant to provide local activists with data that shows where the nature and location of pollution entering surface waters. This is a critical step in being able to press regional and federal agencies to remediate polluted sites and stop new pollution from entering rivers and the lake.

▪ In June 2011, on the basis of tests that showed dangerous levels of e Coli in the water supply of the rural community of Parina, one of our certified water monitors, Ricardo Quispe, convinced his village government to provide materials and labor to clean up a water source. Working with a visiting Masters in Public Health student from Loma Linda University, community members in Parina built a system that has doubled their water supply and reduced exposure to the pathogens from the spring head. The community now has set its sights on remediating a neighboring well. Seeing how much can be achieved through community-municipality-civic collaboration, neighboring villages are keen to copy this model.

▪ In summer and fall of 2011, Suma Marka and The Chijnaya Foundation teamed with the Engineers without Borders chapter at the University of California (EWB-UCB) to initiate a pilot project in constructing filters for wells in the region that have dangerous levels of toxic arsenic in the water. The filters are simple, inexpensive, and can be made by local technicians with basic training. They use perforated ceramic pots filled with layers of broken brick, polyester cloth, fine and course sand, charcoal, and rusty iron scraps. This simple design has proven effective in other parts of the world where arsenic is similarly a significant problem. To carry out the project, the Suma Quta partners entered into an agreement with the Puno Directorate of Public Health (DIRESA) to create a public-private effort that matches community surveys and filter development with outreach and monitoring by DIRESA’s rural doctors and nurses. The EWB-UCB has made a five-year commitment to the project, with stated goals of working with regional health authorities to scale up arsenic sampling in wells in Puno and filter availability for families whose wells exceed health standards.

▪ In 2012, there are plans to undertake a feasibility study for a small factory that could make ceramic household water filters with colloidal silver paint (a “Potters-for-Peace” innovation used around the world). This filter has low unit cost and has been proven effective in removing bacteria and parasites from contaminated water. A Pomona College senior is preparing to supervise the study in conjunction with leadership from Suma Marka in Puno.

NEEDS of the Suma Quta network include operating expenses for full-time coordinators in Puno, equipment for Total Suspended Solids sampling and metals analysis, equipment and laboratory support for mass arsenic sampling and analysis, equipment for limnological biosampling, GIS training and software licensing for our Peru partners, and a zodiac for deep-water sampling, especially near intake pipes for municipal water systems.

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Arsenic remediation in rural wells

Arsenic exposure is recognized by the World Health Organization and agencies such as the U.S. EPA as a significant threat to human health. Long-term exposure to arsenic via drinking-water causes cancer of the skin, lungs, urinary bladder, and kidney, as well as other skin changes such as pigmentation changes and thickening (hyperkeratosis). The problem of arsenic in drinking water is not unique to Peru, but it is relatively understudied. The state of groundwater is of particular concern in this area because many rural communities are drawing increasingly on wells for drinking water as growing informal urban settlements contaminate streams and rivers. Our tests of wells indicate that as many as 30 percent of wells in the area may have unsafe levels of arsenic, and some range as high as 500 parts per billion. The World Health Organization's maximum contaminant level for human consumption is 10 parts per billion.

This project aims to enable rural families located in these arsenic “hot spots” in Puno to acquire a simple arsenic filtration device for water used for cooking or drinking. In June 2011, a group of volunteers from the Chijnaya Foundation, the Puno-based nonprofit Suma Marka, the University of California-Berkeley Chapter of Engineers without Borders, and Regional Health Directorate (better known by its Spanish acronym, DIRESA) constructed the first pilot filters for this effort utilizing porous iron scraps from machine shops in Puno, wood charcoal, washed sand, polyester fiber, and bits of brick. The filters were installed in June and July 2011 in health posts in two localities with elevated arsenic, with the goal of field-testing the filters and taking monthly data on arsenic removal rates and filtration flows

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The project will begin in Carancas, Peru (pop. 2,500) and Paucarcolla (pop. 1,200). If successful, the pilot phase of the project may also extend to Bolivia through the Terra Foundation, where well tests in similar geology have indicated elevated arsenic there as well. We estimate that there may be 100,000 or more people in the basin with elevated arsenic in water; this pilot project would serve approximately 400-500 households; full buy-in from the DIRESA with a microenterprise in filter construction could reasonably cover all households in the basin at risk.

The training will be followed up with monitoring through a twelve month period by local health authorities and the staff of Suma Marka, who will consult recipients’ about whether they are using the filters, test filtered water to ensure proper functioning of the filters, and ensure that technicians are building filters according to specifications.

Health Promotion and Special Campaigns

In Chijnaya basic preventive and primary health care is provided by the nurse assigned to the community’s Health Post by Peru’s Ministry of Health (MOH). More complex medical problems are referred to the Health Center in Pucara, some 6 kilometers away, staffed by a physician, midwife, nurse, and, occasionally, a dentist.

Further referral can be made from the Health Center to the Regional Hospital in Ayaviri, about 40 kilometers away. Many services, including transportation for patients, lab work, radiology, optometry, dentistry, and other specialties, are not available at Health Posts and Centers.

In response to needs identified by the community, the Chijnaya Foundation sponsors periodic health promotion campaigns to supplement the services provided by Chijnaya’s Health Post and the Health Center in Pucara. These campaigns are carried out in collaboration with other groups, such the Health Committee formed by residents of Chijnaya, personnel from the Health Center in Pucara, the Puno Lions Club, and the Global Health Department of Loma Linda University. Community residents who attend the special clinics contribute small fees ($1 or less) for the services provided. Our health promotion campaigns have included the following:

In 2007, four students from the Global Health Department of Loma Linda University’s School of Public Health, along with their professor, Ann Stromberg, offered a campaign focused on eye care. With special funding from a U.S. family foundation, we:

Provided education on eye care and prevention of eye problems, using small group discussions and an evening of community theater, music, and dance. Community members collaborated with the Loma Linda students in writing the script for scenes addressing aspects of eye care and did all of the acting as well as performances of dance, poetry, and song.
Screened all school children in Chijnaya and a neighboring community for problems with vision.
Hired a Quehua-speaking ophthalmologist and assistant from Cusco, for a six-day clinic, to examine the eyes and vision of children, youth, and adults. Some 430 residents received eye examinations.
Worked with the Puno Lions Club volunteers to provide corrective lenses for persons needing glasses.
Assessed contributing factors to eye problems, e.g., high altitude (13,000’) combined with outdoor work that increases exposure to UV rays; frequent exposure to wind and dirt; indoor smoke and particulate matter from cooking fires in unventilated kitchens
Promoted the wearing of hats and sunglasses to protect residents’ eyes from such risk factors and to prevent the early onset of cataracts and pterygium.
Provided funding for two people to have surgery for pterigium and cataract surgery for a small number of seniors from Chijnaya. Further follow-up for cataract surgery is still needed.
Provided two well-attended presentations on nutrition, by Peruvian nutritionist Neda Pomé , a member of the Loma Linda team.

Simultaneously with the 2007 eye care campaigns, several physicians offered their services as well as medications in a four-day clinic. Dr. Michael Rensink, a Chijnaya Foundation Board member, provided general medical care as well as services in his specialty, otolaryngology, to 100 patients. Physician members of the Puno Lions Club also participated in the clinic, offering general medical care as well as expertise in obstetrics-gynecology, to some 160 patients.

In 2008, four Global Health Department students from Loma Linda, along with Dr, Stromberg , collaborated with the Foundation in a health promotion campaign focused on oral health care and prevention of disease. The students:

Partnered with the elementary school principal and teachers to offer oral health education in all classrooms. Puppetry, posters, and role-playing were used to teach toothbrushing and the importance of diet for good dental health. All students practiced good brushing technique with the new toothbrushes that were provided.
Offered fluoridation to all children in K through 6 who had parental permission
Worked with community members to develop and present an evening of community theater, music, and dance, with theater scenes focusing on oral health.
Provided toothbrushes to adult members of the community and training to the Health Post nurse so that she can follow-up with regular fluoridation of children’s teeth
Provided a presentation by Loma Linda team member and nutritionist, Neda Pomé, on nutrition for dental health using locally available foods.
Assessed the extensive need for treatment of caries and other dental problems. As a result, in collaboration with the Peruvian American Dental Association, the Chijnaya Foundation subsequently developed an an Oral Health Program in Chijnaya in 2010.

The Chijnaya Foundation looks forward to collaborating in additional health promotion campaigns in Chijnaya and other communities. We welcome inquiries from health care providers who might wish to work with us in the future.

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Health Post and Staff

The support of the Chijnaya Foundation has been crucial in improving the facilities and staffing of the Chijnaya Health Post in a number of ways:

Initiating the rehabilitation of the interior of the health post
Installation of running water and a sink
Upgrading the electrical system, resurfacing the floor, and painting the walls.
Supporting the addition of walls in the formerly open patient waiting area so that community members have protection from rain, wind, and sun as they await medical attention.
Providing the Health Post in Chijnaya and the Health Center in Pucara with computers to improve staff members’ capacity to keep records and prepare reports.
Financing the construction of hygienic facilities for the health post, namely, a small building with a shower and two flushing toilets and provision of hand-washing facilities.
Advocating on behalf of the Chijnaya community with Ministry of Health and other governmental officials in Pucara, the location of the nearest MOH Health Center, for daily staffing of the Chijnaya Health Post by a nurse. The Chijnaya Health Post had been deactivated some year earlier. Through a concerted effort on the part of nurse Vicentina Alta Turpo, with assistance from the Foundation, bureaucratic obstacles were overcome, and the Health Post reinstated as the official MOH entity in 2010. As a result Vicentina attends patients five days a week at the Chijnaya Health Post.

In an expression of gratitude and support for the reactivated service, the Chijnaya community, without assistance from the Foundation, built a one-room house for Vicentina so she can spend the night in Chijnaya as needed. Normally she commutes from her home in Pucará to Chijnaya (about 6 kilometers) by motorcycle.
The improvements in the facilities and presence of Nurse Vicentina, as well as growing collaboration with the staff at the Health Center in Pucara, have been essential to the Foundation’s ability to offer the special health promotion campaigns and the Oral Health Program that have developed in recent years.

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Indoor air pollution and women’s health

Respiratory ailments caused by indoor air pollution plague many rural residents of Puno, where biomass in the form of dung and straw is still the main source of energy for households, accounting for 60 to 90 percent of cooking and heating. Women and young children are at greatest risk because their household responsibilities—principally cooking and child care– result in high exposure to pollutants from unventilated stoves and fireplaces. The smoke from hearths poses serious health hazards due to acute and chronic exposure to particulates (PM10), sulfure and nitrous oxides (SO2, NOX), carbon monoxide (CO), fluoride (coal), aldehydes and para amino hydrocarbons (PAH). The Chijnaya Foundation is currently conducting a pilot phase of a program promoting the installation of improved stoves. These stoves reduce exposure to indoor air pollution and can be built for approximately $90 per unit. The Foundation has made loans for improved stoves to over 300 households in the communities of Chijnaya, Tuni Requena, Tuni Grande, Llijillica, and Huancarani. Residents manufacture adobes and pair them with manufactured chimney materials purchased by the foundation and construct the stoves under the supervision of a visiting technician from the department capital of Puno. By funneling smoke and particulate matter out of enclosed areas and sealing off heat sources around the edges of cooking pots, the stoves should conserve fuel, heat efficiently, and reduce risk of burns from open flames.

Older open hearths expose households to high levels of particulate matter and toxins. Well-functioning improved stoves, when used consistently, improve respiratory health outlook of those who spend time significant time indoors when hearths are lit. This is especially important for the pulmonary and eye health of women and small children, who receive the most exposure while cooking and preparing food.

The Foundation's improved stoves project is evolving. An assessment of the project to date by Loma Linda University Global Health students and faculty found that families are uniformly enthusiastic about adopting the improved technology, recognizing its health benefits. Some early adopters of improved stoves, however, found that rust formed in their chimney pipes, and the Foundation is studying alternative designs using bricks and concrete for chimney construction. When this research is completed, the Foundation will be replacing the metal chimneys for families that experienced problems while implementing a superior design for households who build new stoves in the future.

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Agricultural and Community Water Management

Chijnaya, like many communities in the Altiplano, suffers from inadequate water supply. Villagers identified problems with their primary irrigation canal and with their potable water system.

In the 1980s, the community had been the beneficiary of a project which constructed an irrigation canal. But after only a couple years the canal fell into disuse and was abandoned. An initial survey of the canal with members of the community disclosed that the banks had been overgrown with vegetation and in some places there were cracks in the concrete lining of the canal. A joint decision was taken to make a more detailed assessment of what steps would be required to put the canal back into operation.

An initial assessment of the potable water system identified several areas which needed attention. One area of concern was the unprotected water sources and storage tank on the mountain sides above the community. Another area of concern was the condition of the water pipes and control valves which distributed water within the community.

The Chijnaya Foundation approached the Engineers Without Borders at Utah State University about providing assistance to the community to improve the potable water system and put the irrigation canal back in operation. The Engineers Without Borders team traveled to Chijnaya and worked with Chijnaya Foundation representatives and the community in preparing an assessment of the two water systems and recommendations for actions to be taken by the community.

As a result of the Chijnaya community's implementing the recommendations, vegetation has been removed from the canal banks and the concrete lining has been repaired. Water now flows in the canal and farmers are using it for the first time in more than twenty years.

The community has also implemented most of the recommendations for the potable water system. They have protected the water sources and storage tank which will help assure the community of a safe water supply.

These improvements have greatly increased the quantity and quality of water available to Chijnaya. The additional improvement needed in the management of the irrigation and potable water systems are being considered by the Chijnaya community leadership.

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