In the field

At Sagzy and surrounding villages in the mountains beyond Isfahan, the land reform has led to a rise in farm income. This increasing purchasing power is affecting old village attitudes of fatalism and resignation. In these villages there is a growing awareness that the people have in their hands the beginning of some power to transform the quality of their lives.

Some 20,000 people live in this intermountain area of scattered wheat fields, fodder corn and small fruit orchards. In 1966, through the village councils, they were called upon to offer voluntary contributions towards building a clinic. The response was excellent.

Quickly the farmers raised some 400,000 rials, the equivalent of $5,300. The response on the part of the farmers showed that they were aware of their plight and were eager to change it. They wanted, for example, to reduce the infant mortality rate so long a major problem among them.

Health Corps doctors, however, had saved children. That children might be saved from death was one of the prime motivating forces the decision to build the clinic and the strong voluntary financial response of the farmers. The clinic that soon went up, using for the most part voluntary village labor, conforms to a standard Health Corps specification. A large, single story structure, it includes a spacious waiting room, which doubles on occasion as a lecture and cinema hall.

From this waiting room doors open to an examination room in which the doctor sits, an injection room manned by a medical aid, and a well- stocked pharmacy, staffed by a medical aid. There are also public toilets. The Health Corps living quarters are in the same building. These include a kitchen, dining room, bathroom and bedrooms. Outside, a garage contains the vehicles used by the mobile teams on their village rounds.

In this set-up, the Health Corps team puts in a 12-month tour of field duty. They serve about 100 patients per day in Sagzy and the surrounding villages. While this is an impressive figure, the number of sick treated is not a very accurate measure of the effectiveness of the Health Corps. The prime task of the Health Corps is not to rush aid to the sick who previously had been unattended for centuries, but to deal with the root problems of rural health, create a healthier environment and stimulate a healthier way of living.

Habits are difficult to change, but they are even harder to change if the environment does not also change. Moreover, there must be a strong motivation if the change is to be voluntary.

The strategy of the Health Corps in action is to first gain the confidence of the villagers. This is most easily gained by treating the sick, easing pain and saving life. With confidence established in the Health Corps and in the effectiveness of modern medicine, the next step is guiding the villagers towards self-help efforts involving fundamental changes in the villages and the way of life. With only a handful of doctors, no scheme of medical care on a vast scale involving millions of people could hope to be effective without stimulating these efforts towards self-help.

In practice, these efforts prove most successful where the educational level is beginning to rise, and the change is easiest when income is also rising, and the people stand at the threshold of broadening possibilities. Experience in the field proves that for a program of developmental change, public health can only be one aspect of a coordinated effort in which health care both gives and receives support from simultaneous efforts to raise income and education.

At the Sagzy clinic, the physicians convinced the villagers that they needed a new water system. These were started in 10 villages in the area. Deep wells were dug, one of which was sunk 420 feet deep, and pipes laid to carry pure water to central outlets.

From this point, a number of new projects were soon underway, each concerned with purification of the water. Among the major targets of attention are toilets, waste disposal systems, bathing facilities, slaughterhouses and mortuaries. Today in this area, virtually every house has installed a new toilet and waste disposal system which is cheap, effective and hygienic. The bath houses have been converted from, the old immersion type pool, in which the water was heated but rarely changed, into a shower stall system permitting hygienic fresh water bathing. Improvements have been made in the quarters used for slaughtering animals, drying and treating the pelts, and in handling and burying the dead.

The population of the area has been inoculated against various diseases, notably smallpox, diphtheria, whooping cough, and tetanus. Action has been taken against trachoma, tuberculosis, ringworm and rickets.

Meanwhile at the clinic, a program of films, slides and lectures dealing with private and public hygiene went into action. Among the major points made was the necessity of washing hands before eating and after toilet, and using soap in doing so. The brushing of teeth was also stressed.

Dental care involves special problems. Toothbrushes are distributed, but the villagers must be motivated to use them daily. In this motivation, positive values are stressed along with the appeal to beauty and vanity. The cultural value of white teeth is emphasized through familiar lines of Persian poetry. Among these is the Old Iranian saying, "I want a child with a lock of golden hair and pearly teeth." The villagers do not yet have toothpaste smiles, but the message is getting across as toothpaste is now being sold in the village shops.

After three years of field experience, some 180 clinics similar to that in Sagzy have been built. The goal over the next five years has been set at bringing this number up to some 600, all paid for through the self-help projects of the people.

Another typical clinic is at Asgaran, on the opposite side of Isfahan, some 80 kilometers distant from Isfahan. This clinic with its two sub centers handles some 15 large villages. It also deals with about 100 patients per day.  Today the diseases are seasonal and follow the urban pattern, with most complaints being gastro-intestinal diseases and some incidence of rheumatism and winter pneumonia.

The major development at Asgaran, in addition to the clinic, is a sophisticated new water supply system. A deep well has been dug, a diesel pump installed, and a water tower built. Through the tower, the village uses 50,000 liters of water for daily domestic purposes. It is piped to 55 outlets in the village, including three new bathhouses of the modern type. There is no location in the village further than 50 meters from a water faucet. The cleanliness of the village has improved dramatically.

The stress in a village like Asgaran today is in changing habits and increasing general knowledge on health matters. This is aided and reinforced through the new school system and through the general rise in the economic level of the area.

In villages such as Sagzy and Asgaran, the Health Corps is coming to the end of its term. As a pioneer organization pushing along the frontier of rural medical care, these villages are already far behind the lines. A permanent Ministry of Health doctor, operating in a similar fashion to the medical member of the mobile team principle, can now be put in, releasing the Health Corps as shock troops for a new area. This in fact, is the pattern. The Health Corps, which could cover some 33 percent of Iran's rural areas, is targeted to extend medical care over 75 percent of rural areas of Iran within the next five years.

Already mobile teams are pushing into the outlying islands of the Persian Gulf, their mobility provided by the local hand-sewn sailing ships, the dhows, that ply the island commerce. It is a unique island service, with main centers on the larger islands and sub centers on the smaller. But the dhows this year will be replaced by fast motor launches which will permit better use of the doctor's time and provide a rapid water ambulance service. The Health Corps continues to improve the efficiency of its operations. Since its inception three years ago a total of seven groups involving some 4,504 have participated in the program; of this number, 2,958 are the medical aids, and 1,527 the medical group. 

A detailed account is as follows: 

1st Group: 132 medical; 296 medical aids

2nd Group: 146 medical; 289 medical aids

3rd Group: 89 medical; 173 medical aids

4th Group: 214 medical; 431 medical aids

5th Group: 183 medical; 311 medical aids

6th Group: 372 medical; 785 medical aids

7th Group: 391 medical; 693 medical aids


At the beginning, training was staggered, held in three four-month intervals over the year. But this led to hardship among the medical school graduates who didn't know whether or not they would be called upon and were unable to start anything until they were sure, sometimes leading to the waste of a year. Now induction and training is once in the year, permitting the graduates to know where they stand and to make the appropriate plans.

With the 8th Group, a new training plan will go into effect. Training will be extended to six months, and the total time in the field will be 18 months. In addition, medical aspects of the training will be continued in the field. University professors will tour the bases in aid of the program in an attempt to maintain the highest possible professional level of practice.

More specialists are being called in to staff key facilities in difficult areas. One such place is the base laboratory at Bandar Abbas, which is the only laboratory in the entire region. It includes a sampling room, a hematology lab, a parasitology lab, a bacteriology lab, and a laboratory for biochemical analysis. In addition to serving all the Health Corps mobile teams in the area, it is used by the local hospitals and private physicians as well.

Woman doctors are now also being introduced into the Health Corps. They will concentrate for the most part on child and maternal care. Increasing the strength the medical group. In addition, nurses, nurse aids and midwives are joining the Health Corps. 

One major result will be increased attention to family planning as an aspect of family health and welfare. Already some 600 Health Corps physicians have been trained in family-planning techniques as Iran prepares to mount an active program in the rural areas.

The vaccination program is being carried forward with a special project aimed at bringing measles under control by injecting the rural population with the new vaccine. The Health Corps is also aiding in regional pilot projects such as brucellosis control and bilharzias control.

As the Health Corps starts its fourth year of field operations it has become a more supple instrument to extend medical care to the rural areas, moving in where it is needed, and bringing to problem areas both greater experience and a wider variety of services. In action, the Health Corps has proved remarkably effective and this effectiveness through the experience gained continues to be improved.