At eight in the morning on Wednesday, March 18, Milagro Calderón shouldered her big backpack, black with with blue stripes, and put on a tan baseball cap. She grabbed her purple umbrella and left her house in the canton of Candelaria, heading toward the small village of La Cuchilla in the municipality of Comalapa in Chalatenango, El Salvador. Calderón walked for about 20 minutes along a dusty road, under a rising sun that, even in these early morning hours, was already sweltering. When she arrived at a house with brick walls and a tile roof, and after saying hello, Milita—as she is known to the community here—delivered the same message she had been repeating to people over and over for the previous few days.
“Good morning. How are you doing, compadre?” she asked.
“Very well, Milita,” responded a dark-skinned man in his 60s.
“I’m here to talk to you a little bit about this new illness, about the coronavirus. I’m here to ask if you would want to help out a little and join our efforts.”
Milita is the promotora de salud, or community health advocate, for the canton of Candelaria. According to the Salvadoran Ministry of Health, advocates are 'the basic element of the national healthcare system'—the first level of care for many communities. But this is a matter of perspective. What the state considers to be the first level of care can often be the final (or only) link in the chain of health services available in rural areas. During the current coronavirus emergency, or during any other health emergency, health advocates are the only government health services present in many remote communities.
According to a 2017 report from the Salvadoran Ministry of Health, there are 3,285 health advocates in El Salvador, and they serve roughly 2.4 million people (38.2 percent of the population). The Ministry provides advocates with basic medical supplies like blood pressure monitors, cotton swabs, bandages, scales, thermometers, backpacks and lab coats. Advocates are responsible for preventing maternal and newborn deaths, alerting communities when there are outbreaks of infectious diseases such as dengue fever or diarrhea, and vaccinating dogs and cats to prevent rabies.
Working in the rural areas of the country, health advocates have to contend with people who might not believe in the existence of a new illness, or who are living in fear because of the misinformation circulating on social media. “There are people who don’t believe [in the coronavirus] and tell me that it’s being made up by the government,” says Calderón. “Others are scared because of what they’ve seen on social media—they think airplanes are going to pass over and fumigate their communities with chemicals. My work is not to cause alarm, but to insist on the importance of prevention and to ask them to stay informed through the oficial channels, and to not believe everything they see on social media.”
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Candelaria sits atop a string of mostly deforested hills. It is one of the four cantons that make up Comalapa, which has 628 residents and is about 92 kilometers north of San Salvador. The canton has a school that educates students through ninth grade, a community health advocate, and a bus that runs up and down the dirt road two or three times a day. It’s about five kilometers from the canton to the main street of the municipality. This time of year, that’s five kilometers of dust, but when the rainy season comes, it will be five kilometers of mud.
“When someone has an appointment at six or seven in the morning at the hospital in Chalatenango [the closest hospital to Candelaria], they have to get up at one in the morning to go and catch the bus,” says Calderón. “I don’t think these folks are sleeping, because they also have to get ready to leave.”
In El Salvador—a small country where nothing is very far away—places can be remote in other ways. The municipality has a health clinic, but because of the distance, or because of local customs, some residents of the Candelaria’s three small caseríos (Candelaria, La Cuchilla, and El Pilón) prefer to seek help from community healers.
“Today things are looking up. Yesterday everything was sad. He had a sore throat,” explains Tania, the mother of Víctor Manuel, a two-year-old child who lives in La Cuchilla.
“At the clinic,” Milita tells her, “they've set up an area for people who have the flu. Don’t stay at home; you need to take him in for a consultation.”
“I won’t go [to the clinic]—they’ll just shame me,” Tania said. “And I know a señor who gave him a little branch, a few leaves from I don’t remember what, but they were rough, and some guaro [cane liquor]. He gave him three pacifiers, and now he’s had a few hard sleeps. Now you can see he's gotten better,' insists Tania.
“Don’t go doing that,” Milita tells her. “When the boy has diarrhea or the flu, you have to take him to the health clinic. If he gets the flu, you need to avoid exposing him to the woodsmoke in the kitchen, and if he gets a fever, you need to take him to the clinic. You must not let a healer give things to the child.”
Tania and her son live on the side of the dusty dirt road. When the wind blows across the hills, or when a motorcycle or other vehicle enters or leaves the canton, the clouds of dust waft into her house. “It's really hard, with these respiratory problems, especially with people who live on the side of the road, because they are always being exposed to the dust,' says Calderón.
“And what have you heard about the coronavirus?” asks Milita.
“It’s a new illness, and some people who go out to play are getting it,” says Tania.
“Look, we’re out here talking with folks about this so that they don’t get alarmed. If you don’t have anything you need to do, it's best to just stay home. Do you know how this disease is spread?”
“Through hugs or kisses.”
“If you notice symptoms like fever or a dry cough, you need to go to the health clinic. You and your son need to wash your hands really well with soap and water, even if you don’t have hand sanitizer. The house must be kept really clean. If you can, clean things up with a little bleach,' recommends Milita.
Calderón walks to the back of the small dark courtyard to inspect the cement wash basin. Then she takes a notebook out of her purse and records Victor Manuel’s weight.
“Look, the water in the basin needs changing. Right now we have a suspected case of dengue in Candelaria and we need to be careful not to create breeding ponds for mosquitoes. I’m saying you should wash the basin because we already have dengue, zika, and chikungunya. And now the coronavirus is coming. Imagínese. What are we going to do if we don't eliminate the mosquitos? I’m also going to leave you with these little packets of vitamins and electrolytes, because the child’s weight indicates he’s on the cusp of being malnourished.”
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After attending to Víctor Manuel, on the morning of March 18, Calderón continued walking the dusty streets of La Cuchilla. She took an elderly woman’s blood pressure, gave an injection to a teenage mother, consulted with a pregnant woman. In each of these visits she repeated the same basic advice for preventing coronavirus, always dedicating a good portion of her time to dispelling misinformation that circulates through social networks.
“We shouldn’t believe what people on social media are saying—about airplanes flying over and fumigating. Others have said that the government is going to give away free phone data [because of the crisis] and this isn’t true either. We shouldn’t go around believing everything that’s published, we must only listen to what the president [Nayib Bukele] says,' recommended Milita.
Don Colato, an 85-year-old man, father of 15 children, listened attentively. He was one of those worried about the possibility that, one day, planes would appear in the sky fumigating against the coronavirus, spraying who-knows-what substance. “I pray to God that this shall not come to pass.”
But now that Don Carlato has been told that reports of aerial fumigation are false, there’s something else that still troubles him: 'Is it true that those who die from this disease are burned?”
Pandemic or no pandemic, the work of community health advocates involves breaking down myths, clarifying facts and information, and closing the kind of distance not measured simply in kilometers between the capital and the country, between the city and the canton.
Here, everything arrives late, in a slow, diffuse way—including the coronavirus. And through the hills and swirls of dust, Milita walks from home to home, doing what she can to remedy this marginalization.
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On the night of March 21, during a national radio and television broadcast, President Bukele declared a 30-day national quarantine. Will this measure affect the work of rural health advocates? At least in Candelaria, the campesinos have not stopped their daily agricultural and artisan work (making hammocks and nets). 'We are going to continue monitoring pregnant women and refer any suspicious cases [to the health clinic],' said Milita on Monday, March 23, before lying down to sleep—and then waking up and heading out for another day on the road.
*Translated by Max Granger
