Rebuilding shattered lives

Karen Anderson (center) and community health promoter Amanda Caceres, during a mural painting event for an EPES-led anti-violence campaign in Santiago’s El Bosque neighborhood

[Fall 2010]

When an earthquake struck in Chile, HSPH alum Karen Anderson and the community health group she founded were the first on the scene—and they’re still there.

At 3:34 a.m. on February 27, 2010, an 8.8 magnitude earthquake hit Chile, killing more than 500 people, destroying tens of thousands of homes, and unleashing a tsunami that further devastated the southern coast.

Five days later, traveling damaged roads on an emergency government pass, Karen Anderson—a 1999 graduate of the Harvard School of Public Health and the founder of a longtime community public health organization called EPES (Educación Popular en Salud)—helped drive a borrowed truck loaded with supplies and its own fuel to the southern town of Concepción, in the region that had sustained the worst damage. The group was headed for EPES’ community center, in one of Concepción’s poorest neighborhoods.

The town looked like a war zone. Apartment buildings had been toppled, houses and stores smashed. With an 18-hour curfew and military checkpoints in place, the streets were eerily deserted. Panicked over aftershocks and exaggerated reports of looting, people were barricading themselves in their neighborhoods. Bridges were down, roads torn up and littered with debris.

The church next door was a mess of broken glass and fallen walls. But miraculously, the building that housed EPES’ vibrant center—a bright yellow two-story edifice with a kitchen and plenty of meeting space, a gazebo, and a playground—had sustained no structural damage. And while nearby stores and health clinics had been looted in the first couple days after the earthquake for milk and water and other supplies, no one had touched the EPES building—likely out of gratitude and respect that had grown over the years. It quickly became a distribution center for supplies, as well as lodging for EPES staff and people from relief organizations who had no place else to stay.

Sowing Trust 
With 28 years of experience in the shantytowns of Santiago (its headquarters) and Concepción, EPES was uniquely poised to take a leadership role when the disaster struck.  The organization has evolved into a precious resource for organizing communities around health as a human right, training thousands of poor people in how to analyze and collectively solve problems ranging from rat-infested illegal dumps and cholera to substandard housing and domestic violence.

When the earthquake struck, EPES was already on the ground, ready for action. As Anderson puts it, “We didn’t have to parachute in from somewhere else.” Indeed, she says, EPES approached the earthquake relief effort as it does all its projects: as a long-term grassroots community organizing effort, an opportunity to identify and train leaders who would participate in the rebuilding.

“This catastrophe overturned many of our assumptions and also brought us, as EPES, back to our roots,” observes Lautaro López, a physician who directs the Concepción center and who has been with EPES for more than 20 years. Though Haiti’s January 12 earthquake near that nation’s capital took a far larger human toll, with more than 230,000 dead, Chile is one of the seismologically most active countries in the world. “In southern Chile, we carry earthquakes in our blood,” López says. “It wasn’t the buckling of the earth, the power of the sea, that most surprised us. It was the initial absence of the state, the void and the chaos.”

Zuñilda Barrales (pictured), who lives with her 105-year-old grandmother, was forced by the earthquake from her home on Chile’s coast into an emergency camp in Villa Bosquemar, in Penco.

“In some ways,” he adds, “it feels like a return to our origins: working in a shantytown—in this case, a new one, created not by a land takeover but by a natural disaster—empowering women, creating leadership in health to support the greater goal of adequate housing, autonomy, dignity.”

Some relief organizations initially focused solely on providing emergency aid, Anderson recalls. But in their rush to help, they neglected to consult the people who needed the aid or to create a system of distribution that ensured supplies went to those in the most urgent distress.

Anderson and EPES took a different tack. López borrowed an emergency generator from the municipality—he had cultivated the right contacts to do so—to pump water from the water line on EPES’ property. With damaged roads and downed bridges preventing EPES staff from leaving their homes, he then enlisted people from the neighborhood to distribute the water to the hundreds of people who began lining up in the mornings with buckets. The neighbors themselves figured out an equitable and transparent distribution system, which involved giving everyone numbered tickets. With EPES’s help, they also distributed thousands of flyers alerting people that the water had to be boiled for drinking. (After several days, another nonprofit donated a water purifier.)

In the nearby coastal town of Penco, where residents had already been struggling to earn a living from the sea, fishing boats lay ruined on the streets. Hundreds of people had lost their livelihoods, their homes, and all their possessions. One of the first things López and EPES staff did there was to furnish an emergency wooden shelter built by the government with chairs and a table—and a tea kettle—so people could meet there to tell their stories about the earthquake, figure out their needs, and organize for the long-term work of rebuilding. EPES was starting the way it always does: by listening.

“They were people who were thrown together,” says Anderson, who attended the early meetings. “They came from three different communities that were washed away. At the meetings, they all ended up sobbing. They told stories of losing everything. Then they’d go down to the beach and see people scavenging and taking their belongings. There was just this huge heartache. But they seemed transformed as they got involved in the planning. Lautaro was there on the weekends, eating empanadas and talking with them, and going house to house and asking them what they needed.”

During those meetings, residents decided that parents and children urgently required trauma counseling. With Chile’s cold, rainy winter approaching—the southern hemisphere’s winter occurs during the northern hemisphere’s summer months—they also needed to winterize the 53 makeshift wooden shelters, which authorities conceded would be in place for three to five years. “We were no strangers to Penco,” López says. “We knew the fishermen, their trade unions, their food stalls, and the restaurants along the beach. We identified local leaders, mediated among them, helped them survey and inventory their situation.”

EPES’s subsequent winter health campaign included providing materials and working with local leaders and volunteers to repair roofs and insulate ceilings and walls; leading emotional support workshops for women; and training volunteers to deliver first aid and treat acute respiratory infections. EPES also partnered with the Oregon-based humanitarian aid organization Mercy Corps to conduct trauma counseling for children.

In other words, people trusted Anderson and EPES at a moment in their lives when all that was familiar collapsed. According to Julia Paley, assistant professor of anthropology at the University of Michigan, that hard-won trust was crucial to the emergency efforts.

“The kind of work EPES does endures over decades because the people involved have been profoundly transformed in the process,” says Paley, who spent a decade studying health groups trained by EPES for her book Marketing Democracy: Power and Social Movements in Post-Dictatorship Chile. “They no longer consider their health issues to be individual problems, but rather understand them to be the product of broad-based inequality faced by many people. It is this long-term commitment to the formation of grassroots leaders and organizations that has allowed EPES to create an immediate and profound response to the earthquake.” 

Roots in Social Justice 
Karen Anderson’s commitment to public health as a social justice issue has its roots in her childhood in Owatonna, Minnesota, where her parents were Lutherans concerned with peace and justice issues. Her father, the late Franklin C. Anderson, a physician, co-founded in 1948 The Owatonna Clinic, a community health clinic now part of the Mayo Health System and well known for its commitment to providing quality preventive, primary, and specialty care.

After graduating from St. Olaf’s College with a nursing degree, she moved to New York City in the late 1970s to work with exiles from Chilean leader Augusto Pinochet’s military dictatorship, which was established after the violent overthrow of the democratically elected Marxist president, Salvador Allende.

“I was outraged by the role of the U.S. in the overthrow of Allende,” Anderson says. “And I was devastated by the brutality of the military dictatorship. I felt like everything I grew up believing in made no sense if I were not willing to do something, however small or modest, to respond.”

In 1981, at age 25, she moved to Chile, volunteering at a clinic that worked with families of “the disappeared”—the more than 1,000 people detained and presumably killed by Pinochet security forces—and becoming deeply involved with the nation’s broad-based movement for justice and democracy. A year later, Anderson co-founded EPES as a project of the Evangelical Lutheran Church in Chile (IELCH) to train community health promoters in the poorest sections of Santiago and Concepción. She shared leadership of the group with Canadian public health physician Christina Mills, and with two Chilean women, social worker Maria Eugenia Calvin and health educator Rosario Castillo. Initial funding came from several international Lutheran organizations. Today, major funders include Action for Health in the Americas, Mercy Corps, and the Evangelical Lutheran Church in America Global Mission, of which Anderson is an employee. On the current 14-member staff, Anderson is the only non-Chilean.

Inspired by Jonathan Mann 
Anderson earned her master’s degree in international public health from HSPH in 1999. What drew her to the School was the inspiring example of Jonathan Mann, a world-renowned researcher and champion of human rights. Mann had led the World Health Organization’s Global Program on AIDS from 1986 to 1990. He joined the School’s faculty in 1990 as professor of epidemiology and international health. In 1993, he became the founding director of the François-Xavier Bagnoud Center for Health and Human Rights. Mann died in a plane crash in 1998.

“He was such a visionary about what was making people vulnerable,” Anderson says. “That whole idea that you need information and adequate social services, but also a positive social environment. And that it’s discrimination and exclusion which make people vulnerable.” Around 1992, a friend arranged for Anderson to meet with Mann while Anderson was in the States. “I talked to him about the work we were doing around HIV and AIDS prevention,” she says. “He talked to me about the School. There was a long line of students waiting to see him. But we talked for about 45 minutes. He was a total inspiration.”

Poverty, Health, and Power  
Anderson’s mission at EPES was to help people learn how to use their talents and knowledge to take action to improve their lives. “Poverty and health are linked to power,” Anderson says. “People listen to communities that get organized and can raise a voice.”  Using this method in a shantytown in Concepción, a team of community health promoters trained by EPES discovered that the rats that were biting children thrived in poor living conditions that included illegal dumps, dirty latrines, and an overflowing sewage system. With the help of EPES facilitators, the health promoters and dozens of other volunteers organized an anti-rat campaign, distributing tens of thousands of educational flyers and holding a press conference at one of the illegal dumps. The press conference resulted in local authorities donating rat poison, offering trucks to clean up the illegal dumps and, for the first time, visiting the community to discuss the rat problem.

The organization grew. Over time, its health workers took up some of the country’s most pressing health care issues: domestic violence, HIV protection and awareness, tobacco control, early detection of breast cancer, and environmental health.

EPES’s efforts in Santiago to improve breast cancer diagnosis give a sense of how the organization creates change from the ground up. In 2000, a group of women in one neighborhood who had been trained as a health team by EPES decided to inform themselves about breast cancer—the second leading cause of cancer death among women in Chile. When they learned that women with large tumors were waiting up to 10 months for mammograms, they visited primary care clinics, where they discovered that nurses made referrals for mammograms only after cancer had already been detected. They also learned that the nearest hospital didn’t have a mammogram machine and that the machine at a second hospital was available only half-time. They subsequently discovered that the municipal health system had outsourced mammograms to a high-priced private company whose tests were so unreliable that the doctors who had ordered them were rejecting the results.

The women mounted a public education campaign, using posters—art, music, and theater are an EPES trademark, part of its emphasis on culture—and pamphlets to raise awareness about early detection of breast cancer. They gathered 3,000 signatures for a petition for more mammogram machines and presented two ministers of health with statistics showing the urgent need for more tests. As a result, the mammography service at one hospital was extended to full-time and, with support from local authorities, a machine was purchased for the other hospital.  

Breaking Taboos
Similarly, in 1990, a team of shantytown women trained by EPES developed a public awareness campaign around what was then a taboo subject: women and AIDS. The team learned that women had plenty of information about the transmission and prevention of HIV infection, but lacked the economic resources and social power to implement prevention strategies, such as buying condoms and insisting on their partners’ use of them during sexual intercourse. The EPES team also discovered that few health clinics provided HIV prevention services, including counseling, testing, and free condoms. Eventually, the team requested—and was granted—a meeting with the Health Ministry, where they presented members of the National AIDS Commission with their research results and their ideas about how programs for poor people should be run. Two years later, EPES formed a local health network to coordinate efforts in HIV/AIDS prevention.

This summer, EPES launched a campaign in the El Bosque district of Santiago to improve access to services for women with HIV/AIDS and to raise public awareness about domestic violence. The campaign grew out of research conducted by EPES as part of a study in Chile, Argentina, Brazil, and Uruguay, funded by the United Nations Development Fund for Women, that found a link between HIV/AIDS and violence against women. For the campaign, EPES teamed up with three public health clinics, four municipal programs, and a half-dozen self-help and community groups. The initiative will include painted murals in public places, educational workshops, and door-to-door distribution of pamphlets. There will also be training sessions for municipal and public health service workers on violence prevention and counseling.  

Women: The Engines of Change 
As these examples show, in EPES initiatives, women are typically the engines for change. While men often show up initially for training sessions, women have stuck with EPES year after year, many of them emboldened to finish high school and go on to college, bringing their daughters and even their granddaughters into the organization. After the February earthquake, these veteran EPES women were the ones who collected truckloads of emergency supplies, drove through the night to deliver them to Concepción, and ran neighborhood training sessions in first aid.

“EPES started in our lives during a very difficult time in Chile,” says Soledad Puebla, an EPES trainee who finished high school and then college and delivered aid to Concepción. “We were afraid. We formed health groups, we became leaders. I discovered myself as a person, a woman. I discovered my intelligence.”

“In poor communities, women are the movers and shakers,” Anderson says. “They’re the ones who influence health. They’re the ones taking care of everybody.”

The HSPH Connection 
Once in Boston, Anderson experienced HSPH as “a chance to step back after so many years on the front lines to learn from world-class scholars, to debate and learn from incredibly talented fellow students, to study and review the literature on a wide range of topics.” Her time here also planted an idea: to return to Chile after her time at HSPH and to eventually start and direct a training school in popular education—which she did, in 2009. The first EPES International Training Course, which was funded by the Evangelical Lutheran Church in America and included fellows from eight countries, was held at the community health center in Concepción the month before the earthquake. The next training course, which will be held in January 2011, will share the approach that EPES developed in responding to the earthquake and provide an opportunity to spend time with community organizations participating in the grassroots reconstruction and rebuilding efforts. The course is directed toward public health students and professionals, educators, church and global mission workers, and activists.

Does Anderson have any advice for young people who want to work in community public health? “Get involved with social movements and global organizations,” she says. “There is no magic bullet for the problems facing the poor and marginalized. The answers involve complex social, political, and economic changes and long-term work.”

Yet however complex those answers are, they can be found on the ground, in the communities of poor and marginalized people—the place where leaders can emerge. Karen Anderson and EPES found those leaders during their early years under the Pinochet regime. They found them again when the February earthquake shattered their worlds.

Sara Rimer is a Boston-based journalist and author. Photos by Stephanie Mitchell.