Response: January 2014 Issue

The Courage to Speak

The Courage to Speak
Health promoter Sara Donoso points to beads representing the average size of breast lumps that can be detected by various screening methods

In a small room in downtown Concepción, Chile, Monica Maldonado, a self-assured woman in her 50s, recites a few lines of a poem: "1973 arrived with the Caudillo Vigueta against people unarmed. With their ideals they killed our happiness and destroyed our dreams."

The poem is the beginning of Ms. Maldonado's explanation of how during the perilous time of Augusto Pinochet's dictatorship the Chile-based nonprofit group Educación Popular en Salud [Popular Education for Health] empowered women and brought communities together with the aim of promoting health and educating women and children. Ms. Maldonado refers to herself and her fellow EPES members as "dreamers" and shows me pictures of the group. The pictures are poignant, reminiscent of self-conscious family photographs. Most of the faces are women.

Among the women in the photos is Karen Anderson, founder and current director of EPES's International Training Program. Ms. Anderson's presence in Chile in the mid-1980s was not by chance. She moved to New York in the late 1970s and worked there in the early 1980s with exiles of Pinochet's Chile. This led her to volunteer in Chile in 1981, working with families of "the disappeared" at a clinic, and to found EPES a year later as a project to train health promoters in Santiago and Concepción. The organization was founded as a project of the Evangelical Lutheran Church in Chile (IELCH) and became an independent nonprofit Chilean foundation in 2002, supported by a wide range of organizations, including United Methodist Women.

While EPES began as a health promotion project, it has its roots in social justice, women's empowerment and building communities. As Ms. Anderson said, "Poverty and health are linked to power." Echoing this sentiment, long-standing EPES health promoter Sonia Martinez described how her perspective on women's rights has changed: "We have learned to claim good health care. Before, the doctor was there, [but] he was untouchable because he was the professional. He was the man dressed in white. But [after] we raised our awareness to fight for our health and rights, then we stood differently in front of them. We stand for our health rights; we use the public health because we cannot afford private health care."

Health promoters such as Ms. Martinez, 66, are community members who undergo a rigorous training program provided by EPES. They are taught how to identify the health needs of their communities and how to advocate for improvements in health, social policy and justice. Ms. Martinez and others work in semi-autonomous teams. This bridge between formal health care and communities has been the pivot of EPES's success as it has opened channels of communication previously difficult to access.

One of EPES's early successes was a campaign to rid some of the poorest areas of Concepción and Santiago of rats that were biting children. The campaign was carried out by volunteers, health promoters and communities. EPES shared educational pamphlets and held a press conference at an illegal dump, one of the sources of the rat problem. Thereafter the local authority issued rat poison and used its trucks to help clean up the illegal dumps.

Dr. Lautaro Lopez is the director of the EPES center in Concepción and has been an EPES staff member since 1989. He explained that EPES leverages ideas and skills that originate within communities themselves. "What you learn working with the team in the community is beautiful," he said. "I feel much rewarded in terms of learning. I think that I have been able to give my contribution to the community. You help with the problems, you see the community as another actor, and that generates transformations beyond what anybody can think. To my judgment this is a very strong issue, how people are empowered and achieve objectives for their life and for their community."

EPES is ostensibly an organization for communities and families. Men do lend their voices and support to some of the EPES activities, but as the pictures show and the stories tell, it is women who play a leading role. Training women as health promoters gives them a voice. "They begin to speak," Dr. Lopez said. "They begin to communicate, and they begin to be visible in their communities … as health leaders in their families. Besides their struggle to improve their living conditions in their communities, there was the need to improve their status in their homes." He explained that some women health promoters have faced significant opposition from their partners for their work.

Sonia Garcia, 60, another health promoter, recalls this tension. "I always remember that when I started participating in the group my husband told me: 'You will participate in that group, and you will lose a husband,'" she said. "Then I responded: 'I will participate because out there I can find any husband,' and I continue participating in the group."

The EPES women are confident and outspoken. On the day I visit them in Santiago they're conducting a rally to raise awareness of breast cancer in an open-air market in the suburb of El Bosque. Gel-filled models demonstrated what tumors feel like, and younger and middle-aged women were handing out pink ribbons. The women walked up and down the main street of the market with bullhorns, calling out "Apechuga con tus pechugas"—a play on words loosely translated as "Take your breasts to heart." As they went, they were warmly greeted by sellers and customers, receiving embraces and kisses. Some called back to them. They spoke about issues many would consider taboo.

During its 30-year existence, EPES has evolved to address a wide range of issues that have threatened communities in Santiago and Concepción. This is illustrated by the events following a massive earthquake in Chile in February 2010. Five hundred and twenty-three people died, and 800,000 people were displaced. Sixty miles southeast of its epicenter in Concepción the offices of EPES stood unscathed. In less than a week EPES set up a distribution center for relief efforts and began the slow process of rebuilding property and communities. But it wasn't simply the good fortune of having well-built offices that led EPES to take such an active role in Concepción's disaster relief; EPES was able to rapidly mobilize a network of community members who could accurately identify what their communities needed and begin disaster relief from the ground up.

The town still struggles to recover from the earthquake and the tsunami that followed. Dr. Lopez described how EPES helped more than 1,700 children recover from the effects of the earthquake through trauma counseling, workshops where children worked on a "my earthquake/tsunami story" notebook.

The efforts of EPES have not gone unrecognized. In September 2012 EPES was awarded the prestigious Clarence H. Moore Award for Excellence for Voluntary Service. This was issued by the Pan American Health Organization and the Pan American Health and Education Foundation, and it recognizes the work of EPES in improving the lives and public health of the people of Chile.

EPES has facilitated radical improvement in women's status at both individual and community levels. Despite the obvious poverty in Concepción, there is optimism. The women sang the praises of the country's first female president, Michelle Bachelet, for supporting gender equality and health, but they were also unafraid to criticize and hold her accountable. This could have never happened under the Pinochet dictatorship. This courage to speak out may be one of EPES's greatest successes.

Nile Sprague is a photojournalist based in Mendocino, Calif. He visited EPES in Chile to see its work firsthand and co-wrote this piece with Séamus Maclennan, a New York-based freelance writer.

Posted or updated: 12/31/2013 11:00:00 PM