While teaching the Community Health Module, to midwives in Haiti, I came to appreciate the value of observation,  conversations and a walk about the area.  As part of the WHO curriculum, the students were asked to go on such a walk and find people to interview.  This method of learning about maternal health was compelling and life changing.

Road in the Marshal Islands 

I had started my midwifery career because I observed young children with fetal alcohol syndrome.  I noticed a problem in the community where I was working and could see that it took route in early pregnancy as well as in how women perceived themselves.  Within the context of Head Start, I saw maternal health as an integral part of the community.  But once I was a midwife I focused on clinical measurements with far less of a focus on the community.  Healthcare in the United States was rarely embedded in a specific community, reflective of its unique strengths and challenges.  Mothers were islands within a large healthcare system, disconnected from culture and community.

When I arrived in the Marshal Islands, I knew I would be meeting with the midwives and mothers. I quietly began this informal and enjoyable way of doing a maternal health assessment.  I do this now, without even thinking, everywhere I go.  Doing this, in Portland, led me to begin to see the Portland Harbor and it fossil fuel hub and their relationship to maternal health.  I began to see the world in relationship to how it cared for and protected mothers and babies.

The premise of these walks is that the well-being of mothers and babies, is directly connected to the resources available to them from the time of their own birth.

Children in the Marshal Islands at a morning assembly.  All children in the Marshal Islands receive a free k-12 education.

One of the first things I am interested in is the state of education in a community.  If all children and particularly girls are able to receive a free k-12 education with access to higher education, they are far more likely to avoid a child marriage, plan when they give birth and access health care.  They are more likely able to prevent abuse of themselves and their children and to be able to contribute to the community.  In the Marshal islands, all children receive a free k-8 education.  In high school, they go to regional boarding schools and have an opportunity for college.  Requiring uniforms, certain shoes and ribbons, may serve as a barrier to education.  Here uniforms are not a barrier to education.

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Here we see a coconut charcoal burner, a common source of fuel in the Marshal Islands.

Another thing I look at is the fuel that people use to cook their food.  How far they had to walk to get fuel and the impact that fuel has on their well- being, including air pollution.  In my community, we are often dependent on fossil fuels such as gas and oil and coal to cook our food.  This method of cooking our food, heating our homes and transportation has a desperate impact on our own health as well as the people in other places in the world.  Climate change and pollution impacts a small island like this, while they create a sustainable method of producing charcoal from cocoanut husks. In many countries, the few trees available in a community are cut for charcoal so that families can send their children to school or pay for healthcare.

Water capture system installed but the government. In the marshal islands, most drinking water must be captured
from rainfall.  Draught is one of the most serious problems facing a country with almost no fresh water sources.

Collecting water is one of the greatest challenges many women face around the world.  Young girls and women may walk hours a day to collect water from a pump.  Rain catchment, in the Marshal Islands, saves women hours of work each day and assures them a clean source of water.  This system prevents contamination of a water source by human or animal waste.  Because it is covered, it can not provide a breeding place for mosquitoes.  It is easy to see that water catchment, makes a significant impact on women's health.  

A community health station in the Marshal Islands.  Each atol has a community health clinic with a trained nurse who provides preventative and day to day care.  The nurse can communicate with the health department in the capitol and order medical transport, as needed.  This model provides the community basic healthcare, immunizations and first-aide.  This basic level of free community care assures the people on this island the security of health care.

How and where women and children receive healthcare, is critical to any community assessment.  Is the care easy to assess? Is it close by and are the clinics well supplied with necessary medications and supplies?  Can women access prenatal care, family planning and a safe birth?   Although the island had no skilled birth attendants, it had a certain level of health security.  All women could choose to fly to the capitol for their birth.

Access to food is a critical need of any community.  The people of the Marshal Islands, lived
for thousands of years in a culture of sustainability.  They gathered shell fish and fished and ate local coconuts and breadfruit.  World War II and the subsequent years, have destroyed much of their food security.  It is now estimated that 90 percent of their food is imported.  Locally grown and gathered food has been replaced by white rice, processed meat and sugar.  With this comes, higher levels of diabetes and high blood pressure.  There is evidence of stunting in children and a decreased life expectancy.  A culture's ability to produce their own food is critical to their well-being.

Catholic Church in the Marshal Islands

The role of religion in any community is an important part of a community's health.  Does true freedom religion exist?  Do religious leaders abuse their power and exploit the resources of the community?   Religion appears to be important in the Marshal Islands but I did not observe the abuses that we see both in my country and Haiti.  There was no evidence of a class based religious system.  I was never in a community in Haiti, where I did not observe some sort of abuse by priests which impacted women and children and almost universally remained unchallenged by NGO's.  In my country, fundamental branches of  many religions, negatively impact health outcomes of women in our country and around the world.   Women appeared to be able to use church spaces for community education and gatherings in this community.

Harms and Risks 

The Marshal Islands face many risks including climate change, over fishing by other countries and drought.  Because of the compact it has with the United States, they estimate that 1/3 of the country has left for the United States.  Residents of the Marshal islands do not need a Visa to enter the United States.  The outer islands are losing their populations and thus their culture.  Many people move to the crowded urban center on Majuro or to the US military base for work.  Rising seas, the loss of traditional foods and the on-going military relationship with world powers, puts the people of the Marshal Islands at risk. Despite a good education and healthcare system, the risks are still high.  Once in Hawaii and the mainland United States they face discrimination, cultural barriers and exploitation.   

The impact of dropping atom bombs on these small islands, can not be underestimated.  The United States works to avoid responsibility for the harm done to this island nation.  

Birth and Women's Health

I'll share my visit with the midwives in the next post.