WHEN Saleh looks up from the morning’s work of weeding his tomato plants only one building breaks the rocky horizon. It is the Sultan’s Palace, four storeys high, sitting squarely on the edge of a bare plateau overlooking the wadi. Water from the river is cleverly channelled from side to side of the wadi as it cuts a winding path into the mountains. Only here, in tiny squares dividing the strip of green, is farming possible. The water irrigates the land. And the river is used for washing and drinking— by the villagers as well as their goats and camels.
Water means life for Saleh’s village. But it can also mean death. Three years ago Saleh’s baby daughter Samah died because of diarrhoea. The source? Probably dirty water. ‘We used to think that water was just water,’ explains Saleh ‘and we drank it straight from the wadi. So every village lower down the wadi used to drink the diseases of the villages higher up.’ Today Saleh would know how to save his daughter’s life.
The Sultan has gone. He fled with the British in 1967. But his palace still dominates the life of the surrounding villages — it is the local health centre. And here, in less than a month, Saleh learnt to diagnose and treat diarrhoea, as well as malaria — the other big killer — and several infectious diseases. He can give first aid and knows when to refer someone for hospital treatment. But his training as one of Yemen’s first ‘health guides’ had another objective: ‘They taught us straight away that a health guide must not only cure disease, but even more important. most learn how to fight the causes of ill health.’
At first meeting Saleh seems shy. He is small, almost frail with his bag of medicines slung awkwardly from his shoulder by its long strap and clutched in front with both hands. He wears traditional dress: .a grubby headscarf, a cloth or fouta tied at the waist and sandals the colour of the earth. Catch him laughing and you see teeth coloured slightly green from chewing qat — a mild narcotic and one of the villages main cash crops.
Saleh still works as a farmer. He’s not paid for being a health guide — a radical step in the Yemen’s project — although the status, and sometimes the gifts, that he gets for curing a sick child are an obvious reward.
Marib, like every other village, has a People’s Defence Committee — designed as the foundation stone of Yemen’s revolutionary structure — and Saleh was elected Secretary for Health. Relationships within the party hierarchy seem easy going. I visited the village with the Deputy Minister of Health. Once the business was over, he took off his trousers, tied a fouta around his waist and settled down with half a dozen health guides to a qat-chewing session. Consultation— at every level— has been central to the project.
The ambitiousness of the Yemen’s approach to primary health care lies in its simplicity. The theory is well established. you don’t need expensive doctors and hospitals to tackle sickness and disease. Most ill health can be dealt with on the spot by economically trained and equipped village health workers. But an important question remains. How much of a doctor is the health worker meant to be? He or she obviously won’t need the thirteen years’ schooling plus at least seven years specialised education. that Western-trained doctors get. Most countries reckon on six months. But Saleh, and forty other health guides in Yemen’s pilot project, got 30 days.
It hasn’t all been easy. To begin with the villagers laughed at Saleh. ‘He’s mad’, they said, ‘does he think he’s a doctor after four weeks training?’ His first success with emergency cases must have seemed miraculous. Mohammed Saif, a baby boy, had a high fever. ‘In my father’s time,’ remembers Saleh ‘we believed there was no way to help babies when they were ill. The child was left to the mercy of God.’ But this time Saleh diagnoses malaria — too far advanced for the pills he carries, but still in time to get the baby to the health centre for an injection. A life is saved, Saleh’s reputation improves, and the project takes a step forward.
The aim of the project has been to strip the curative aspects of primary health care to the barest minimum. Saleh can save lives with his satchel full of medicines — dispensing chloroquine tablets for malaria and rehydration salts for diarrhoea — but he doesn’t give injections or sport a white coat and stethoscope. His success relies on three things: effective treatment of a few simple diseases that can win the confidence of villagers; reliable back-up from the rest of the health service so that when he can’t cope there is someone available who can; and good local organisation to carry out schemes like latrine building or rubbish burning aimed at eliminating the causes of ill health.
But Saleh faces another problem. The Minister’s visit provides a clue. So does a walk through the village. There were no women to meet the Minister. And in the village they cover their faces or hurry indoors when you pass. Women have legal equality in the Yemen. Polygamy has been abolished, as have arranged marriages. But centuries of strict Islamic tradition linger on — especially in remote villages like Marib. This means that men such as Saleh tend to get elected as health guides because of their traditional claim to authority, even though tradition also means that they can have little personal contact with women other than their wives. The critical area of maternal and child health — identifying difficult pregnancies, delivering babies, advising on contraception and child care — is beyond the practical reach of male health guides. Saleh does what he can to work with the giddha, or traditional birth attendant — usually the woman in the village with most experience of childbirth — and the Ministry of Health offers basic training for them too. But improving health means changing relationships. And that will take time.
Already Saleh’s new job has changed his life, and the life of the village. He will tell you that once he had an ambition to be a doctor, but his family was too poor to send him to school But now, as a health guide, he can say, ‘I know my environment, I know my neighbours, and I know the sickness that troubles us here. Even a doctor could not do my job.’