December 2013. Introduction of the Simple Field Test in the South Atlantic Autonomous Region (RAAS, Región Autónoma Atlántico Sur)
The two provinces on the Atlantic Coast, the RAAS and its northern neighbor the RAAN (Región Autónoma Atlántico Norte) occupy approximately 50% of the land area of Nicaragua, but contain only 12% of the population. Culturally, geographically and to some extent politically the regions are quite distinct from the rest of the country. While the western half of the country is ethnically homogeneous with more than 90% mestizo (Spanish/Indian descent), there are six distinct ethnic groups on the Atlantic coast, three indigenous, two of African descent, and mestizo. Five languages are spoken, though the official language is Spanish. The three indigenous groups of the region, Miskito, Rama and Mayagna have a considerable degree of political autonomy which must be carefully respected when working in the area.
Geographically the Atlantic Coast is isolated from the rest of Nicaragua; there is only one all-weather road from the west coast, to Puerto Cabezas, the capital of the RAAN. Surface travel to Bluefields, the capital of the RAAS must be completed with almost 100 km by boat on the Río Escondido after the road from Managua ends at the town of El Rama. There is airline service from Managua to Bluefields and Corn Island but once on the coast of the RAAS all travel between communities is by water.
This isolation makes delivery of health services in the RAAS extremely difficult. To make it possible the SILAIS RAAS attends only the seven coastal municipalities (see the map above). Even in this limited area long distances separate the communities; the most remote municipality, La Cruz del Río Grande, is 325 km from Bluefields, an entire day's travel by launch.
Of the western municipalities, El Ayote, El Rama, Muelle de los Bueyes and Nueva Guinea are provided health services by SILAIS Chontales and Paiwas by SILAIS Matagalpa.
TASCA spent three days in Bluefields at the end of January 2011 at the invitation of the Director of SILAIS RAAS. Even with this background we knew that we had much to learn, particularly about sanitation and the supply of drinking water.
In Bluefields, there is a water system that supplies untreated water from two machine-drilled wells and a poorly functioning desalinization plant. This system covers less than 12% of the population; otherwise there are 30 hand-dug wells which are regularly chlorinated by ENACAL, and many private wells. Corn Island and the town of El Cruz de Río Grande have piped water systems but the great majority of the population get their water from hand-dug wells, creeks, rivers and rainwater. There is a program underway for construction of piped water systems in several of the other municipalities; the system in Laguna de Perlas was near completion in 2011.
None of the communities of the RAAS, including Bluefields, have sewage systems, just septic tanks and latrines, so keeping the water in the wells clean is extremely difficult but not impossible with regular manual chlorination.
South Atlantic Autonomous Region (RAAS) Click map to display a larger version.
MINSA dock, Bluefields, with launches (pangas), the major mode of transportation between the communities of the RAAS.
Public well with rope pump, Bluefields
Testing of water quality other than measurement of chlorine by SILAIS RAAS and ENACAL is extremely limited. Any testing of water samples is done by flying samples to Managua or occasionally (and very expensively) by submitting samples to a laboratory in the Bluefields Indian & Caribbean University (BICU).
So both management and field staff of SILAIS RAAS were very eager to discover whether the use of the Simple Field Test would meet their needs for water testing. Our presentation of the method was well received and was followed by extensive discussion of how the test should be employed.
Given the differences in infrastructure between the RAAS and the other Departments that were already using the SFT it was clear that new procedures for training of hygiene promoters in use of the test and for carrying out testing would have to be used in the RAAS. First, they would want to use the test for urban water supplies as well as rural since the was no current water testing capability. With regard to training, the procedure in other Departments had been to gather all the hygiene promoters who would be using the test in a central location for 2 days of orientation and hands-on training. This would not work in the RAAS, given the difficulties of transportation. The solution was to establish a chain of training; TASCA would train key personnel in Bluefields who would later travel to individually train the hygiene promoters in the different municipalities. In turn these promoters would train the staff in the key communities of each municipality.
The work began immediately with training of three of the principal hygienists of the SILAIS. Each collected and processed several water samples and from the results next day it was clear to them that the test worked very well and that the training had been successful.
The Director of the SILAIS formally requested that TASCA provide the apparatus and materials to begin the program; these were shipped in April 2011 and the first test results were reported in August. These confirmed that water quality in the RAAS was indeed very poor, with only 20% of water sources tested free of fecal contamination. Testing through 2012 has showed a significant increase in water quality and we expect that this will continue.