In Service Training Report

I recently had an Inservice Training, and for it I had to write a report about my site - background, health conditions and priorities - after writing it I realized that it might help explain to those of you reading my blog a bit more about my site, how I spend my time in it and what kind of work I do and am trying to do. All place names have been replaced with a series of X's due to security concerns. Enjoy!



I. Background
The Commune Rural of XXXXXX is located on the extreme southern edge of the Middle Atlas, with the majority of its population located at and around the base of an extinct volcano, L’Rais. The commune was created by government decree in 1992 and is situated on the extreme northeastern edge of the province of Khenifra, and is bordered by the communes of XXXXXX. The ancient souk town of Itzer, is the administrative headquarters of the region and is where most government services are to be found for the surrounding communes, including: postal service, medical, police and caidat.
The commune itself is composed of roughly 15 douars, with the population predominantly found in three clusters. The first, and primary cluster of douars is located along Rural Route 503, constructed in 1946 by the French, which traverses the commune and serves as the primary transportation artery, which culminates in Fez, roughly 3 hours travel by public transportation. The principal douars which one encounters along RR 503 are, in order of location west to east: XXXX (560 people ), XXXXX (492 people) and XXXX (463 people). In addition to those douars located adjacent to the road are those scattered between XXXX and XXXXX, each located roughly one to three kilometers from RR 503: XXXX (164 people) and XXXXX (an artificial government conglomeration of three separate small douars which share a Moshe but little else) (190 people). The second cluster is located along a dirt road that branches off from the main road just prior to the Commune building in XXXX and is composed of: XXXX (298 people), XXXXX (157 people) and XXXXX (476 people). The third and final cluster is found along a road that branches off approximately four kilometers past XXXX traveling eastwards along RR 503 and is located at the edge of a plateau. It is composed of three douars: XXXX (413 people), XXXXX (560) and XXXX (471 people). The total population of the commune is believed to be 4,244 in approximately 700 homes, spread out over roughly 3000 Sq. Km.
Geographically the majority of the commune is pre-Saharan scrub plain interspersed with two large agricultural areas and the remnants of a once extensive forest ecosystem which has been logged into the aforementioned scrub plain. The soil of the commune is largely volcanic, and while well suited for agriculture is also exceptionally rocky. The agriculturally productive area of the commune is restricted to two areas, those sections watered by the spring La Rais and those at the edge of the plateau composed of those douars in the third population cluster. The spring La Rais is a viable source year round, with a late summer flow of 10.16 M3/S, this spring currently served the agricultural needs of all of the douars in the first population cluster – extending 10 kilometers from source – and has traditionally served those douars that compose the second population cluster, but due to an extended period of periodic droughts in the region, beginning around 1980, the water flow has steadily, if slowly decreased. The second agricultural area is at the edge of the plateau on which the Middle Atlas Range is located, and benefits from a sudden and extreme elevation drop of at places up to 80 meters which results in numerous seasonal and year round springs – estimated at between one and two dozen. As such while the remainder of XXXX often appears arid and lunar in the summer months, those areas at the edge of the Plateau are graced by natural grasslands and extensive non-irrigated stands of trees as well as extensive fields of crops not cultivated in other areas of the commune.
The primary economic activities of the commune are agricultural in nature, including subsistence and cash crop farming as well as the raising of domesticated animals, for local consumption. The primary cash crop of XXXX, as in the entire region of Midelt, is the apple. While landownership is somewhat restricted, with a handful of large farms producing the majority of the apples, small holders also contribute a significant amount to local production. Generally the farm practices are fairly modern, with a majority of producers, though not all, utilizing drip irrigation, large scale refrigeration facilities and with some limited use of nylon orchard covers. All and all though, while apples have provided a significant influx of financial liquidity into the local community – which manifests itself in the near universal presence of Pour Flush Latrines within the commune – with the increasing aridity of the region apples are likely not long to remain a reliable crop.
Ethnographically the population of XXXX is mixed, with roughly equal portions claiming Arabic or Berber origins. The question of ethnic origin though is not reflected in language use within the commune where nearly 80% of the population is proficient in Arabic and where no more then 40% routinely use Tamazight, either inside or outside of the home. A trend exacerbated by the prevalent ignorance of the children of Berber parents of the Tamazight language. The tribal structure of the commune itself is complicated with seemingly every village claiming a separate tribal identification. The name of the commune itself is derived from the name of a local tribe, Ait Ben Yacoub, a group which itself is not the most numerous group within the commune and while it historically dominated the area is now mostly found in the douars of XXXX, XXXX and in the mountains between the commune and the town of Giegou (province of Boulman) where they are found more extensively. A further example of the tribal variety is the village of XXXX, a converted Ksar, and primarily Arabic village, whose inhabitants have lived in the region for at least one hundred and fifty years but whose ancestors originally migrated from the region around Meknes, where they had migrated from the Draa Valley in the sixteenth century. This tribal variety is found not only between douars, but also within them. For example the douar of XXXX is composed of no less then five groups: the Harritine, Sahrwein, Ait Cherouchen, Cherfa and the Ait Ben Yacoub – who are themselves divided into three-sub clans: the Ait Lahcen, the Ait Makha and the Ait Omar. Suffice it to say that this ethnic diversity poses difficulties for the formation of inter-ethnic and tribal cooperation outside of traditional religious forums – such as the village mosque, which in some douars such as XXXX is not itself free from strive (from the middle of July until the end of October the Mosque has had four separate Fiqhs).

II. Methodology
If I had been asked to write this report after residing in XXXXX for only a short period, a week, a month, three months, then I would have written questions – put together a form, and gone door to door blundering through awkward conversations with absolute strangers in a language I don’t understand – speaking in a way that those I asked wouldn’t have understood either. Rather then that tact, I took a conversational, dialogue based evaluative method – one where I knew what kind of things I wanted to learn, one that held those desires in the back of my mind at all times, but one that also restrained me from asking those questions, until the time was right. So that even if I was learning things about the commune, about the health of the community, it didn’t seem like I was interviewing every one I spoke with, because I was foremost building connections, relationships and sometimes friendships – friendships that would make asking those awkward questions about health and health practices seem less awkward and more like the concerns of a friend, a neighbor.
Coupled with a conversational, relationship based interview style I have always kept my eyes open – so that I learned as much from simple observation through the sharing of a single communal village space as from interview and discussion. So that while my methodology may not be quantitatively rigorous it is qualitatively rich, dripping with experience and knowledge – knowledge much deeper and more truthful then plain statistics on a page. Because, while now I could get those statistics if I had a need to – for grant or government project – they would not have given me in the past any kind of worthwhile view into the life experience of the inhabitants of Ait Ben Yacoub, and the gathering of those statistics would likely have served to separate me farther into the category known as “Aromi” and I would remain, and always would remain known, not as “Jed”, but as the “American”.

III. Findings
Birthing Practices
Learning about birthing practices, while always a difficult task for a male in Morocco, is exceptionally difficult in XXXX due to an incident that occurred five years ago. At that time a child died during the birthing process, which led to a crackdown by the local gendarmerie on Traditional Birth Attendants in the area, including both verbal and physical intimidation and continual harassment. The aim of this intervention on the part of the Gendarmes was to eliminate the use of Traditional Birth Attendants in the area – a task they seemingly succeeded at – and redirect all births to govement operated birthing centers in Zeida, Midelt, Azrou or Khenifra. I say they seemingly succeeded because no women that I have spoken to in the Commune will admit to using a Traditional Birth Attendant, and no women will admit to currently being a Traditional Birth Attendant, though after five months of continuous habitation in the village of XXXX my host mother admitted to in the past practicing Midwifery before Rheumatism and the crackdown on the part of the gendarmes forced her into retirement.
Family Planning
Family planning is widely practiced within the area, with the most common request in the Sbitar being for Birth Control Pills. In addition to the simple request for pills there is also proof of their use, with families averaging three children today, as compared to the past when seven to ten children was not unusual.
Diarhial Diseases & Sanitation
The most common ailment in XXXX, especially among children and infants, is diarrhea. This is related to both issues with water sources and a lack of sanitation within the home – most often due to a lack of soap within the home. The concept of diarrhea, while understood is often unclear and I am unsure if people separate the concept of diarrhea from regular bowel movements.
Water Sources
An ongoing and omni-present problem in XXXX is water; simply put there isn’t enough of it. The average well depth is between 30 to 50 meters and for large periods of this past summer ran dry. The Sbitar only received running water two weeks ago, and the vast majority of homes in all of the douars do not have running water. XXXX and XXXX each have a system of community fountains and both are in the process of upgrading their water systems using government loans and limited community fundraising – with a goal of providing running water to all of the houses in their communities. The remaining douars remain off of any sort of grid and rely on personal and community wells as well as a smattering of small community chateaus. In addition to community and personal wells, the springs around XXXX & XXXX and the spring La Rais provide water mainly for agriculture – a troubling finding when one considers the situation in XXXX. XXXX is located in a former Ksar. Where the majority of people make use of personal wells rather thean the abundant springs which surround it, these wells are often located less then ten meters, from both pit flush latrines and barns a situation that has resulted in the presence of Fecal Streptococal Bacteria in all wells that were tested during a Ministry of Health visit in late July.
Sexually Transmitted Infections
Sexually transmitted infections are not addressed in the Sbitar in XXX and people remain largely in the dark as to what they are, how they are transmitted and how to prevent their transmission. I have reason to believe it to be a large problem in the area though – due to the prevalence of STI’s in Boumia and the extent to which men travel to Boumia and the amount of time spent in the café culture of Zaida.
Nutrition
There is a lack of knowledge of the importance of micro-nutrients in diet, especially Iodine, Iron, Vitamin A and Vitamin D. This knowledge deficit is especially common in women, especially older, who have had little formal education and whose food landscape is being transformed by the increased industrialization of food production in Morocco.
Dental Hygiene
Is an area of central concern, as among a large portion of the adult population knowledge is near nonexistent and practice is nonexistent. This leads to a serious deficit in the children of the area who are not receiving instruction in the school or positive reinforcement at home in regard to dental care while their diets incorporate increasing amounts of processed and refined sugar into their diets.
Skin Diseases
Corresponding to the scarcity of water and lack of a hammam in XXXX, is the prevalence of skin diseases. In addition to those caused by hygiene and easily identified, there is a disease that leads to the appearance of extensive white spots across the body, La Birsa in Arabic, that I don’t’ believe to be either Vitiligo, Tinea versicolor or Pinta.
Sbitar Staff and Physical Condition
The Sbitar itself is staffed by one nurse, who specializes in children’s vaccination and minor injuries, all other medical issues are referred to the doctors in either XXX or Zeida. Since my arrival their have been no rural vaccination drives, though the doctor in XXX did visit the sbitar in XXX one day a week for three consecutive weeks for consultations. Medical waste is disposed of by simple trash fire, which do not reach a temperature at which sharps would be rendered harmless, though the medical waste once burned is disposed of in a rock field roughly 50 meters from all human habitations and rarely visited by anyone aside from sbitar staff.

IV. Health Priorities
The areas that I have identified as being in greatest need of work, as well as most realistic to work on, are as follows – in order of priority:
1) Assessing and addressing deficits in water supply and in
cleanliness of sources.
2) Improving sanitation facilities in schools.
3) Improving the physical health infrastructure of the local clinic, as well as working to bring knowledge, skills and attitudes from outside health organizations into the clinic to improve the health conditions of those in site more quickly then possible through government initiatives. For example: optics organizations, SIDA testing organizations, skin disease organizations. This also includes health education within the sbitar on vaccination days.

V. Conclusions
After six months in my site I am still learning about my site, still encountering obstacles and still making contacts. My time has been complicated by not speaking Arabic, which has impacted my ability to work with a large portion, if not majority, of my population. My work is also challenged by the lack of interest by organizations in doing any work not guaranteed funding from the start and by the lack of interest on the part of people in starting any new organization. While I understand this to be a common difficulty for a first volunteer, I find it no less frustrating knowing it to be a common difficulty. Due to the difficult nature of civil society within XXXX I will focus on what can be done utilizing outside resources, as relaying on resources and organizations within XXXX would at this point result in little but two years of headaches and afternoons spent twiddling my thumbs. Hopefully though I will be able to include more members of the community in my work as they begin to see tangible benefits from my time spent within XXXX, if not within my time then in that of my successor.