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Notes from the field

Edwin Valenzuela Jr. (left) with his sister Leonela and Gary Snyder. Edwin and Leonela must navigate around intractable socioeconomic barriers and the steep, craggy hillsides that surround them.

Scaling the high walls of poverty in Peru

By Gary Snyder

In a lot of ways, Edwin Valenzuela Jr. is just like most other six-year-olds. He's rambunctious and creative, with an irrepressible spirit worthy of his favorite superhero, Spider-Man. He admires his dad, loves his mom and three sisters, and can't wait to start first grade next year.

What makes Edwin different from most kids growing up in the U.S. is that he was born into unrelenting poverty, greeted by a set of formidable barriers, any one of which would be difficult for most of us to overcome. Barriers like the absence of a physically safe environment in which to live, play, and learn. Like vulnerability to disease brought on by unsanitary sewage disposal and a lack of access to potable drinking water, or a poor diet that invites malnutrition. And like living in a makeshift house with hard cardboard walls splotched with mold.

If you'd like to donate funds to provide learning resources for the new library in San Isidro Labrador, please give here. If you'd like to donate educational materials, please contact Hannah Welch.

I saw Edwin Jr.'s world up close this summer when I lived with the Valenzuela family for a couple of days during a visit to Peru with Dartmouth colleagues and students. Within just a week, members of the Medical School community accomplished a great deal. Two medical students began work on a leadership training program and on examining the barriers to receiving government health insurance [see "Student notes from the field" section below]. Geisel established a new educational partnership with the University of San Marcos, the oldest university in the Americas, and reinforced our ongoing student and faculty exchanges with the medical school at Cayetano Heredia University and with the Cayetano Heredia National Hospital. Leaders of the Medical School toured the Ministry of Health's new outpost clinics in impoverished areas and facilitated a discussion between Peruvian mental health leaders and Geisel's renowned faculty experts in mental health recovery.

These are all important activities that improve lives, but for me, nothing compared to the opportunity to spend some time with the Valenzuela family. To break bread with them at breakfast, laugh with them through my broken Spanish and Quechua, learn with them as we reviewed math homework and their encyclopedia about Peru, and to end the day with them sleeping under the same roof.

Lending a hand in Peru

Find out more about the efforts of the Geisel community in Peru.
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Those who work in global health know that statistics can provide a meaningful—even essential—framework, albeit one that often fails to capture the full story. The data and conditions surrounding the Villa Maria del Triunfo District's San Isidro Labrador community—where the Valenzuelas reside—are daunting. The vast majority of residents live in poverty or extreme poverty. Twenty percent consume unsafe water. More than half of the adults have not completed basic primary education. The overcrowded homes lack security. At the Valenzuela casa, for example, seven people sleep in one small room with a door that wouldn't close.

What strengths and dreams could possibly be found in such a hardscrabble place? What chance might Edwin Jr. have in life? Where's the "preferential option for the poor?" Has it disappeared, just like the visibility of these so-called shantytown "squatter" communities on the steep hillsides, where the higher up the mountain you live, the poorer you are, and the more invisible you become to the Peruvian government and its basic safety net of services?

He was born into unrelenting poverty, greeted by a set of formidable barriers, any one of which would be difficult for most of us to overcome.

Spending time and being part of the Valenzuela family—even for a short while—confirmed the stark realities and the cold statistics. But it also revealed strengths within both the family and the communities living in these hillside pueblo jovenes (young towns)—strengths that don't reveal themselves until you see them personally on the ground. For example, the remarkable work ethic of Edwin Sr., who rose each day at 4:30 a.m. so he could begin his two-hour journey to a construction job, work 12 physically demanding hours for minimal pay, then ride a bus and other transport two hours back, arriving at home around 9 p.m., just in time to have a late dinner of pasta in broth, hug his family and share the day's events, and retire with his wife, Ruth, four children, and sometimes their niece to a room with only three twin beds. Then wake up and do it all over again, six days a week.

The library began taking shape in June. At right, Ana Hernandez of Visionarios discusses educational plans for students with Geisel Dean Chip Souba and first-year medical student Paula Piedrahita. Below, by September, with the floors and walls formed and the roof installed, the library's physical construction neared completion, much to the delight of the children and parents in the community.

I witnessed parents who deeply care for their children and want to somehow create a better life for them, even if there appears no way out of their socioeconomic straits. The Valenzuelas see the promise in their oldest child, Lucy, who loves math and science but doesn't have anyone at home or in the community with the skills or time to help tutor her through the tough spots. I was impressed with these children who respect their elders, watch out for each other, share what they have, and show an amazing patience and positive outlook in the midst of harsh circumstances. The interdependency of neighborhood families reflects a cohesive vitality.

The Valenzuelas were wonderful hosts, with a welcoming spirit. I arrived a stranger but left an extended family member.

The Little Library on a Hill
Another strength of the Valenzuelas and other residents of this community perched precariously in the area called Arenal Alto (sandy ground on high) is their openness to joining with outsiders to improve conditions and build capacity for change. The group doing the most impressive work there is Visionarios Peru, a nongovernmental organization with roots going back to the Peruvian branch of Partners in Health, the organization cofounded by former Dartmouth President Jim Kim.

Visionarios led the first broad community assessment of living conditions and needs in Arenal Alto, assisted by Dartmouth medical students, during the summer of 2012. The research revealed a significant need for a community library—a safe, well-built place where children could learn and study, tutors could help them with homework, and programs could keep kids busy after school and away from other riskier activities. During a 2012 visit to San Isidro Labrador, Geisel Dean Chip Souba committed to raising the private funds to cover the costs of construction, and the biblioteca (library) will be finished and ready for its first patrons in early 2014. Visionarios is coordinating the construction on site and developing the educational programs, assisted by Peru's Ministry of Education.

Pictured inside the library are (L-R): Estefani Valenzuela Gutierrez, Edwin Valenzuela Jr, Leonela Valenzuela, Natalia Ramos Valenzuela, and Lucy Valenzuela.

So what difference can these global partnerships—or even a little library on a hill—really make? Why should we care what happens in San Isidro Labrador, or to the Valenzuela family?

Health equity work can make a great difference, wherever it's taking place, be it improving lives in Peru or Dar es Salaam, Tanzania, with migrant workers on Vermont dairy farms, or within American Indian communities. These partnerships provide Geisel students invaluable experiences within diverse learning contexts. They come face to face with conditions they've only read about, better appreciate the vital role of culturally appropriate care, and start to see how abstract health policies meet reality in the field. If Dartmouth is to be successful sending physician-leaders out into the world to tackle complex problems, these experiences help students develop the compassion, deep holistic thinking, and creative problem-solving ability to achieve that lofty goal. Plus, this work provides special opportunities with partner universities for collaborative research in areas like health-care delivery science and infectious disease.

What strengths and dreams could possibly be found in such a hardscrabble place?

Creating a little library on a big hill in the poorest part of Lima does more than build a better, sustainable future for struggling families there. It also sends an even bigger message: that we're all in this together.

Bells, Spider-Man and a Six-Year-Old's Future
Walking down the steep, dusty, loose-rock paths from the Valenzuela's home, I could hear church bells ringing somewhere far below in Villa Maria del Triunfo. Perhaps because of the many jarring disparities all around me in San Isidro Labrador, the sound had a different meaning that day, one that reminded me of the English poet John Donne's timeless reflection about the interconnectedness of our planet:

Gary Snyder is the associate VP for health affairs communications at the Dartmouth Geisel School of Medicine. He also helps with the development of Geisel's global health work, including the building of "the little library on the hill." He's the author of the chapter, "Global health communications and social marketing," for the McGraw-Hill book Understanding Global Health, being published this fall.

"No man is an island, entire of itself ... Any man's death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee."

Through Donne's lens, if a woman dies of TB in Africa, we all die. If a father struggles with addiction and homelessness in rural Vermont, we all struggle. And if Edwin Valenzuela Jr. is defeated by insurmountable conditions, we're all defeated.

The Valenzuelas gather for a breakfast of anise tea and a single thin piece of processed ham on a small bun. The walls of the kitchen are a form of hard cardboard.

We must lean on, learn from, and help each other, and be particularly vigilant of those who struggle on the margins. That's the Dartmouth and Geisel ethos. Indeed, no man is an island.

Yes, Edwin faces some great barriers. Along with the environmental, economic, and educational walls he must scale, he carries the weight of society's stigma of the poor. Next year he will attend first grade at San Martin, a simple public school on the side of another hill, made up of students from two demographics: poor and extremely poor. To some in Lima, he could remain just one of those faceless kids from the hillside slums. Or worse, he will be stereotyped as a squatter whose family "invaded" Lima from the Peruvian Sierra (high Andes), bringing emotional remnants from the origins of Peru's civil war. In truth, Edwin's mom and dad came to the city for the same reason migrants and refugees do everywhere: for a chance at a better life.

It may take a superhero effort to pull Edwin Valenzuela Jr. out of the web of poverty. But then again, he's already exhibited Spider-Man-like resilience and the agility to dodge life's obstacles tumbling quickly toward him. Maybe allies from the Justice League—taking the form of Visionarios, Dartmouth, or the World Bank—can lend Spidey ... er, I mean, Edwin ... a helping hand up and a decent shot at that better life. Ultimately, we all hear the bells toll.

Student notes from the field

Geisel medical students David Hernandez and Paula Piedrahita discuss community leadership and barriers to receiving government health insurance with Bernardina Córdova Velasquez, outside her home in San Isidro Labrador. Eda Palacios (far right) from the NGO Visionarios Peru, provides logistical support and helps connect the students to the community.

My experience in Peru during my first summer at Geisel was exceptional. I examined the barriers to obtaining or using health insurance issued by the government for vulnerable populations. It was a great experience because I was able to see the health-care system through the eyes of the people I served. Their frustrations and concerns have become mine, and I hope I was and will remain an agent of change in creating access to health care for vulnerable populations.

But more important than my academic reasons for being in Peru was a strong sense of social responsibility, which is what led me to medicine in the first place. My experience in Lima helped refuel my passion to serve people in need. Throughout my project, which involved interviews with several families in a very poor community in the Villa Maria del Triunfo District, I have had many people open up and reveal some of their greatest frustrations and concerns. I spoke to a woman who lost her husband and now is solely responsible for raising her three children on less than minimum wage, which in Peru is the equivalent of less than $300 a month. Another woman in her thirties looked decades older due to the great stress, both financial and emotional, in her life.

Although the American health-care system has many flaws, the health-care system in Peru shares many similar deficiencies as well. I think the knowledge that I've obtained from this global health experience will provide me with the skills to manage the health-care challenges of the future.

David Hernandez, second-year medical student at Geisel

Residents of the San Isidro Labrador, an impoverished community in Lima, Peru, with the first books to arrive for the new library.

This summer I spent seven amazing weeks in Lima, Peru. I created a survey aimed at understanding the needs for a community leadership program that will create advocates for health and economic development in Villa Maria del Triunfo, one of the poorest districts in metro Lima. The project's premise was based on a needs assessment survey carried out last year by Dartmouth students and Visionarios Peru. I conducted one-on-one interviews with current board members of the community as well as with potential leaders identified by community members. The long-term goal is to establish workshops that will help educate and empower leaders. Working with these communities and Visionarios Peru, with their combined experiences, was an ideal first experience with global health.

Outside of my main research project, I also joined Olga Saldana from Partners in Health, and Albert Mulley, director of the Dartmouth Center for Health Care Delivery Science, on home visits to speak with gestating women as part of a pilot study to identify the barriers for timely access to medical attention. I spent several days shadowing Raul Acosta, chief of emergency medicine at Cayetano Heredia National Hospital, in Lima. We saw how difficult it is for the emergency department to service such a large population, given its inadequate resources.

During my time in Peru it was obvious that there were many people from Dartmouth doing remarkable work, some of which overlaps and points to future collaborative endeavors. Working together toward common goals will allow us to make greater improvements in low-resource communities. The best advice I heard while in Peru came from a tour guide's recounting of an Incan expression about things that are done with love not lasting years or a lifetime, but lasting forever. While as individuals we can move rocks, the Incas knew that it took a labor of patience and love to move mountains. It is my hope that the communities in Villa Maria del Triunfo will be able to do just that.

Paula Piedrahita, first-year medical student at Geisel

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