By Courtney Cavaliere

Introduction

The island of Ometepe within southern Nicaragua is inhabited by approximately 35,000 people—and it is equipped with one 24-hour hospital. The island’s hospital, the Moyogalpa Health Center, contains 25 beds and is attended by a total of 5 doctors, only one of whom is available for 24-hour in-patient care. Poverty is so extreme on the island that citizens often have trouble affording bus fare to the hospital, where they are offered free medical services through Nicaragua’s Ministry of Health.

It is here that a new kind of relief organization, Natural Doctors International (NDI), developed its successful pilot program. NDI established a site in Ometepe in 2005, and for the past few years the organization has encouraged naturopathic physicians (NDs) and other alternative healthcare practitioners and students to volunteer their services for the island’s underserved population.¹

The Development of NDI

NDI was established with the goal of enabling NDs and other alternative healthcare providers to participate in international relief medicine—much as the program Doctors Without Borders provides for conventional medicine practitioners. NDI has established a permanent presence on Ometepe and is involved in multiple sustainable services and programs for the local community, serving as a model for other volunteer networks interested in global justice and medical assistance.

The organization was co-founded in 2003 by Tabatha Parker, ND, Laurent Chaix, ND, and Michael Owen, ND.² These 3 co-founders established NDI after discovering that there were few opportunities for the naturopathic profession to participate in international relief efforts. The founders were passionately committed to developing and implementing NDI within the legal framework of any foreign country hosting an NDI site. Further, they wanted participants of NDI to live and work closely within the local community, rather than stay in resort areas or fancy hotels and have limited outside engagement with citizens, as is the case with some international relief programs.

The founders chose Nicaragua as the location for the first NDI site based on their previous travels to the country and the pre-established contacts they had made in the area. Nicaragua was also selected due to its extreme poverty and deficits of healthcare.

“Nicaragua is the second poorest country in the Western hemisphere,” explained Dr. Parker, who continues to live in Nicaragua and serves as NDI’s executive director (oral communication, May 15, 2008). “There’s a lot of need there.”

According to the World Bank, Haiti is the only country in Latin America with an economy worse than Nicaragua’s.³ Although some economic progress has been attained in recent years, including a reduction in the scale and severity of poverty in Nicaragua, it is still estimated that 46% of the population lives below the poverty line. The World Health Organization (WHO) indicates that communicable diseases such as malaria, tuberculosis, and HIV/AIDS are prevalent or increasing in some areas of Nicaragua, while noncommunicable diseases such as cardiovascular disease, cancer, and diabetes result in high morbidity and mortality.⁴ Nearly 22% of children from the most disadvantaged quartile of urban Nicaragua suffer from malnutrition.

Dr. Parker and her colleagues collaborated with Nicaragua’s Ministry of Health in developing NDI.¹ They set up a 3-year contract with Nicaragua’s government, which recognizes NDs as licensed practitioners and allows them to legally work within the country through NDI.

Volunteering with NDI

NDI offers 1-year volunteer opportunities for state licensed NDs. These long-term volunteers treat patients through a clinic NDI has established within the hospital, generally averaging between 15 to 20 free patient consults each day. (Between 50 and 150 people typically visit the hospital every day.) These volunteers further assist the hospital staff when needed. They also take part in community projects, consult with some patients outside the hospital, and occasionally produce and package herbal therapies for NDI’s pharmacy. Three NDs have completed long-term rotations on the island, and a fourth ND is currently volunteering long-term with NDI.

Tania Neubauer, ND, worked with NDI as a long-term volunteer from January of 2007 through March of 2008. “My practice was full to bursting—from the minute I arrived, I had to struggle between trying to help more people, faster, and how many people I would turn away,” she said (e-mail, May 5, 2008). “I’d see a lot of what you see in primary care in the United States—lots of respiratory infections, lots of skin conditions, lots of urinary tract infections, digestive problems, diabetes, hypertension—and of course, things that you don’t see quite as commonly here, like parasites and malnourished children.”

According to Dr. Parker, the organization is attempting to initiate an additional long-term NDI volunteer opportunity, which might allow year-long rotations for acupuncturists in the near future.

NDI also provides short-term volunteer opportunities by hosting a global service learning course titled “Natural Medicine in Global Health.” Affectionately referred to as “medical brigades,” these courses offer a unique combination of cultural immersion and global health training—both in the clinic and the classroom. These brigades typically consist of 10 participants, who spend 10 days in Nicaragua. Participants live with Nicaraguan families during their stay, and they pay these families a fee for room and board, which provides enormous financial assistance for those families. Brigade members assist NDI’s long-term ND volunteers by providing services in the hospital and community clinics and by assisting in community projects. They participate in farming activities to gain a better understanding of the lifestyle and environmental conditions faced by local citizens. They also attend classes taught by NDI personnel regarding global justice issues, such as the effects of trade agreements and various international policies on the citizens of developing nations, the economic, educational and health disparities between poor and prosperous countries, etc.

“These brigades are a combination of activism and medical education,” said Benjamin Woodard, one of the brigade facilitators and faculty members of NDI, as well as director of StillRiver Health LLC in Boulder, Colorado (oral communication, April 29, 2008). “They’re exhausting but profoundly inspiring for everyone involved.” Woodard makes arrangements for the brigades and also accompanies brigades to Ometepe to teach in NDI’s clinic facilities and classes.

Former National College of Natural Medicine (NCNM) student Missy Pannone participated in a brigade in August of 2006 and was so inspired by her experience that she remained with NDI for 6 more months after the brigade ended. “We in the United States are blessed with great education and so many resources. More people in the United States need to do what [Dr. Parker] is doing,” said Pannone (oral communication, May 1, 2008). “The work she is doing down there is just awe-inspiring. She is on the front line, making amazing things happen.”

Since its inception, NDI has hosted 12 medical brigades. Woodard stated that he has begun booking brigades nearly a year in advance, due to steadily growing interest in NDI participation. Several naturopathic schools have organized student groups as brigades. Alternative and conventional medicine practitioners have also participated in brigades, and persons with no medical background are also welcome.

“Everyone comes with something they can offer,” Woodard stated, explaining that this could include administrative skills, language skills, medical expertise, etc. “We try to find a place for anyone who has an interest.”

Funding and Support of NDI

The tuition of the global health course participants helps to fund NDI’s programs and services.⁵ Many groups conduct fundraising to help cover costs, as well as to bring donated herbal and nutraceutical products to the island. Donated botanical, supplement, and pharmaceutical products are widely used by NDI volunteers and staff in their clinical practice.

“A lot of donations come from the students just going out and talking to people,” said Dr. Parker. “When groups come down, we never quite know what we’re going to get. We have to be pretty flexible.”

Companies and individuals have also contributed greatly to NDI’s mission through donations. Dr. Parker mentioned that the dietary supplement manufacturer Standard Process (Palmyra, WI), for instance, once donated $22,000-worth of products. NDI has also received important donations of homeopathic medicines and mother tinctures (solutions of botanicals in alcohol and/or distilled water for use in homeopathic remedies) from various companies via charitable donation.

“About halfway through my time [volunteering with NDI] we got a tremendous donation of many gallons of bulk tinctures from Oregon’s Wild Harvest and Heron Botanicals, which really improved my ability to practice herbal medicine,” said Dr. Neubauer. “We also had a very extensive homeopathic pharmacy, and last year we got a donation of hundreds of homeopathic mother tinctures, which is great—the clinic will be able to replenish its stock permanently without being reliant on future purchases or donations. We could never keep enough vitamins in stock—there is an immense need.”

The Use of Herbal Medicine by NDI

In addition to donated supplies, NDI also purchases some tinctures, salves, bulk teas, and other ingredients from 2 organic Nicaraguan farms—Isnaya and Cecalli. NDI volunteers and staff occasionally make some of their own medicines, and they use some local Nicaraguan botanicals as well. According to Woodard, one of the latest brigades harvested turmeric (Curcuma longa, Zingiberaceae) from an organic farm as part of its educational experience. This turmeric was then tinctured for patients’ use, since NDI did not have the processing equipment available to encapsulate it.

“We use a tremendous amount of herbs,” said Woodard. “This is a paradigm in which patients often prefer natural medicine to allopathy. Not once have I had a patient who was uneasy or tentative about taking herbs.”

Dr. Neubauer, likewise, noted that she prescribed natural medicine for probably 80% of her patients. “One of the biggest differences [between working as an ND in the United States and Nicaragua] is that natural medicine is part of everyday life in Nicaragua,” she explained. “Most people still grow up knowing some of the plants around them and how to use them as medicine. It’s not an exotic, strange thing as it still is in the United States. The vast majority of people are very interested in natural medicine and very happy to use it . . . Also, there’s a significant percentage of people—it seems to be much higher than in the United States—that only want natural medicine and that never want to use another pharmaceutical again, so they are completely thrilled to have access to an ND.”

A graduate student at Virginia Polytechnic Institute and State University conducted a survey in 2007 of 100 Ometepe inhabitants, as well as 20 semi-structured interviews, to determine the community’s perceptions of NDI and its use of naturopathic medicine.⁶ The student, Andrew Allen Duncan, found that all surveyed Nicaraguans considered natural and herbal medicine to be a legitimate form of therapy, and responses to the interviews indicated that natural medicine was generally viewed more positively than conventional pharmaceuticals. Moreover, 99% of all respondents claimed to believe that natural medicines were a part of their culture.

According to Woodard, many local Nicaraguans traditionally use botanical therapies that NDI physicians have incorporated into their own practice. Locally used medicinal plants include Cassia grandis (Fabaceae) for anemia; guava (Psidium guajava, Myrtaceae) for dysentery, diarrhea, and parasites; calendula (Calendula officinalis, Asteraceae) and Tecoma stans (Bignoniaceae) for skin disorders; eucalyptus (Eucalyptus globulus, Myrtaceae), mint (Mentha spp., Lamiaceae), and aloe (Aloe spp., Liliaceae) for respiratory complaints or skin conditions; and Artemisia vulgaris (Asteraceae) for parasites or scabies. Dr. Neubauer would sometimes prescribe a cough syrup made from the local plant juanislama (Lippia spp., Verbenaceae), and she said that she frequently used a plant called jiñocuabo (Bursera simaruba, Burseraceae) to treat urinary tract infections, skin disorders, and respiratory infections.

“One challenge we often encounter is incorporating folk use of botanicals sustainably into clinical use,” said Woodard. “We have to ensure that the herbs, their use, and delivery all truly work. When herbal medicine is one of your first lines, you better have faith in it!”

In addition to their widespread acceptability and general sustainability, herbal medicines are also typically a first choice among NDI physicians because they are considered more effective than many available pharmaceuticals. Woodard explained that drug resistance is a huge problem of “social justice medicine.” Whereas citizens of economically developed countries generally have access to a multitude of pharmaceuticals, communities in developing countries usually only have access to a few. These few pharmaceuticals are then overused for a variety of conditions, and patients are often placed on previously ineffective treatment protocols when alternatives are not available.

“We now are seeing more than 80% resistance to amoxicillin, a first-line broad-spectrum antibiotic, in uncomplicated urinary tract infections, simply because of overuse,” Woodared explained, noting that this and other drugs cease to be effective, as patients’ bodies grow accustomed to the medications.

Dr. Parker noted that many patients in developing countries also present with multiple complaints during consults. “One of the great things about herbal medicine is that you can really tailor and customize a treatment for someone,” she said. “It allows us to be more flexible in our treatments.”

Challenges of Providing Medical Aid in a Developing Country

Working in a foreign culture and developing country does present various challenges. Woodard pointed out that Nicaraguan citizens often have deeply-seated cultural beliefs that must be taken into account when prescribing treatments. For instance, many Nicaraguans believe in the concept of aire—the belief that illness can result from abrupt temperature changes.

Dr. Parker explained that a Nicaraguan who has returned from working in the hot fields will often not cool off by taking a cold shower (it is believed that this abrupt temperature change could result in sickness), but he or she might instead drink hot coffee. Similarly, certain medicines are considered “hot” and “cold.” Pills, for instance, are considered “hot.” A person with symptoms of a cold might therefore scoff at the idea of taking a pill as a treatment, as humoral medicine theory suggests that a pill could cause their symptoms to worsen. For this reason, teas and tinctures are sometimes considered better treatment options than conventional pharmaceuticals.

“You have to be respectful of that and learn how to speak their language,” said Dr. Parker. “Having this conversation and being open is very important, because otherwise you could be giving all of this advice that isn’t going to be followed.”

Witnessing the poverty and suffering of patients is also a huge challenge for volunteers of NDI. For this reason, members of brigades attend group processing sessions, which are designed to help participants understand and cope with what they observe in the clinic and in the community.

“Bearing witness to this much suffering is really a lot to handle,” explained Woodard. “We try to provide as much emotional support as we can.”

Woodard described one of his own experiences on the island, in which he was introduced to a woman with Parkinson’s disease who had not eaten for 4 days due to the seeming hopelessness of her condition. Another patient was diagnosed with kidney stones but could not afford a trip to the mainland for necessary treatment.

NDI’s Community Projects

Because health is connected with so many environmental, economic, educational and other factors, NDI has implemented and is leading several community projects in addition to its medical services.⁷ For instance, NDI has been developing a program to educate local farmers about safety measures to use when harvesting tobacco. Over 15 women and children were admitted to the hospital with nicotine poisoning in 2007 from picking wet tobacco, an illness known as “green tobacco sickness” that can resemble intoxication from organophosphate pesticides.

As one of her community projects, Dr. Neubauer worked with a group of community health workers (CHWs) on Ometepe: “The best way to multiply your work is to train CHWs to take care of their communities. The CHWs in many cases are more culturally appropriate and better aware of what the most important needs are than any visiting foreign doctor can ever be, no matter how long the doctor stays in the community. The CHWs on Ometepe were particularly interested in natural medicine.” Woodard noted that many CHWs and traditional healers of Ometepe are women and that midwives, in particular, typically hold much of the botanical medicinal knowledge within the community.

Dr. Neubauer explained that the education of CHWs is particularly important since local communities have begun to lose this knowledge. “Nicaragua, like many places in the world, is experiencing a cultural rupture—many elder healers are not training anyone new to take on their work because it is too hard to make a living taking care of your impoverished neighbors in exchange for a few eggs or vegetables. On the island where I lived, almost every family had members abroad sending money home from their job as a dishwasher, construction worker, etc. Which does the world need more—an intact healing tradition or another dishwasher?”

Duncan’s 2007 survey results also indicate that herbal traditions in Ometepe have been declining in recent years.⁶ Although the vast majority of respondents claimed that herbal medicine was part of their culture, some interviewees qualified that herbal use was primarily a part of their cultural past. Some explained that the influx of pharmaceuticals into Nicaragua and their use by local doctors has helped to facilitate this decline in herbal knowledge and practice. Twenty-one survey respondents claimed that pharmaceuticals had replaced the use of natural medicine, although many more (67) indicated that this had not yet occurred. NDI’s education of CHW’s, in addition to the organization’s own naturopathic services, could assist in reviving or reinforcing widespread use and popularity of natural medicine in Ometepe.

Dr. Parker noted that NDI also sponsored a baseball team on the island as another community project, at the suggestion of local community members. According to Dr. Parker, this receptivity to community input and constant interaction within the community, in addition to NDI’s medical assistance, has encouraged citizens of Ometepe to embrace the organization.

“We’ve been really welcomed by the community, and part of the reason, I believe, is that we really work with the community and deal with the needs that they bring up,” said Dr. Parker. “We really try to bring the community into being active participants in the growth of NDI.”

All respondents to Duncan’s survey who had previously received treatment from NDI claimed to consider NDI staff as part of the community.⁶ The vast majority claimed that NDI often or always includes the community in making decisions and defining local problems, and they further professed a belief that NDI would be open to suggestions or criticisms. Almost every respondent of the survey indicated that foreign assistance is necessary to good healthcare in their community. Duncan concluded—based upon NDI’s services, its sensitivity to global justice issues, and its overwhelming support within the Nicaraguan community—that NDI represents a model organization for providing such aid.

NDI Efforts in Mexico

Although the site in Ometepe is the only currently active NDI site, the organization hopes to have a second site operational by the end of 2008 or early 2009. Jacqui McGrath, ND, has been working with the Mexican Ministry of Health to establish an NDI site in Bacalar, Mexico. Whereas the NDI site in Nicaragua functions within Ometepe’s Moyogalpa Health Center, Dr. McGrath plans to establish an autonomous clinic in a rural location of Bacalar among some of the area’s poorest citizens, many of whom have difficulties traveling to currently available health centers.

Dr. McGrath decided to initiate her own NDI site after participating in the “Natural Medicine in Global Health” course in Ometepe. “I love NDI’s philosophy of mutual respect and consideration for the culture and for the government, in addition to providing long-term health for people and communities,” she said (oral communication, May 30, 2008). “It’s not just about giving consults. There is a respect for the governments’ laws and the traditions of the local people to create projects and programs to help community health as well as individual health.”

Dr. McGrath has been laying the groundwork for the NDI site in Mexico for the past few years. She has been working with a local foundation to get the NDI site registered as a Mexican nonprofit, and she recently performed a year of social service work in order to obtain a license to practice medicine in Mexico. During this time, she has begun to familiarize herself with the needs of the local community, so that she can develop NDI projects particular to this region.

The anticipated NDI site in Mexico will follow the same basic model as the site in Nicaragua, offering courses in global health/medical brigades and relying to some extent on donated supplies. The educational component of the site will be complementary to the classes and teachings given in Nicaragua, although much of the information will focus on Mexico. Certain differences between the two locations and cultures, however, may impact the way that the Mexican site is developed. For instance, farming is not a common practice in Bacalar, so brigade participants might spend a day with building crews or concrete workers to better understand the local living conditions, instead of the Nicaraguan NDI experience of working in the fields for a day. It is also possible that patients in the Mexican NDI clinic might pay a small fee for consultations, when they can, since this might be considered more appropriate within the local culture than the free services of the Nicaraguan clinic.

Dr. McGrath expressed that she hopes to use a great deal of herbal medicine in her practice, particularly since many local patients prefer natural therapies. However, she said that Bacalar currently seems to lack some of the herbal resources of Nicaragua. While the NDI site in Nicaragua is able to rely on 2 local suppliers of quality herbal tinctures and creams to help supplement the clinic’s donated herbal products, Dr. McGrath noted that there are currently no similar suppliers in her area of Mexico. Dr. McGrath said that she has only just begun to learn about the area’s medicinal flora, and she hopes to begin communicating with local herbalists and traditional healers to increase her own knowledge of local medicinal plants.

Like the site in Ometepe, the site in Mexico will take part in various community projects. “I would like to work on rescuing the traditional knowledge in this area,” said Dr. McGrath. “Traditional Mayan knowledge is still here, but it’s tenuous. There aren’t a lot of midwives or bonesetters in training.”

Other projects that Dr. McGrath hopes to pursue include a garden project, an educational program on nutrition, and a project concerning garbage disposal. She would also like for the site to participate in local efforts for creating jobs, as poverty is the root cause of many local health, environmental, and other problems in the area.

Future Goals of NDI

NDI may eventually open additional sites in more countries. “We’re looking for people who are passionate about doing this and interested in following this model,” said Dr. Parker. Since countries have different regulations and licensing requirements for medical practitioners, the ability to open new NDI sites and the speed at which such sites could be developed may depend largely on the types of opportunities available through foreign governments.

Dr. Parker has also been working to obtain non-governmental organization (NGO) status for NDI with the United Nations. According to Dr. Parker, NGO status would give NDI access to large organizations involved in global policy work, which she argued is important since few natural medicine organizations and associations are presently involved in this arena. The WHO has stated that more NGOs, as well as national and international professional organizations, should take on the mission of expanding the appropriate role of and access to traditional natural medicine in developing countries.⁸

While the organization continues to expand its reach through new sites and networking opportunities, its mission has been spreading even more rapidly through the enhanced knowledge and perspectives of volunteers and brigade participants. According to Dr. Parker, the living conditions and poverty that students and volunteers witness during their time with NDI may be difficult to observe, but the experience as a whole can be extremely uplifting and motivating.

“The developing world is an extreme,” she said. “It can be very empowering if you learn how to incorporate your experience there in a positive way.” She stressed that participants are encouraged to integrate their experiences with NDI into their own lives and communities at home.

“I’m more committed than ever to being a doctor working for global justice,” said Dr. Neubauer of her own experience with NDI. “More doctors need to be speaking out about the health effects of international policies that are condemning many people to lives of poverty and suffering . . . Doctors have a unique and respected voice—we should be using some of the authority vested in our profession to push for the big changes at the global level, in addition to ‘being the change we wish to see’ in our daily practice with our patients.”

References

1. Parker T. Going global: Natural Doctors International. Naturopathy Digest. January 2006.
2. Alumni Career Spotlight: Tabatha Parker, ND. Association of Accredited Naturopathic Medical Colleges Web site. Available at: http://www.aanmc.org/careers/ alumni-leaders-in-the-field/tabatha-parker.php. Accessed April 21, 2008.
3. Nicaragua Country Brief. The World Bank Web site. Available at: http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES /LACEXT/NICARA-GUAEXTN /0,,contentMDK:20214837~pagePK:141137~piPK:141127~theSitePK:258689,00.html. Accessed August 11, 2008.
4. Nicaragua Country Cooperation Strategy at a Glance. World Health Organization Web site. Available at: http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_nic_en.pdf. Accessed August 11, 2008.
5. Clinical Service. Natural Doctors International Web site. Available at: www.ndimed.org. Accessed April 21, 2008.
6. Duncan AA. A participatory evaluation of a development NGO in Nicaragua [thesis]. Blacksburg, VA: Virginia Polytechnic Institute and State University; 2007.
7. Projects. Natural Doctors International Web site. Available at: www.ndimed.org. Accessed April 21, 2008.
8. World Health Organization Traditional Medicine Strategy, 2002-2005. Geneva: World Health Organization, 2002. >

Funding NDI as Free Clinics for Underserved Populations


By Jillian Stansbury, ND

In April of 2007, I flew from Portland, Oregon, down to Nicaragua to find out how the young dynamo Dr. Tabatha Parker and her colleagues were able to set up a successful, free alternative medicine clinic for the Nicaraguan people in a remarkably short amount of time. I had been in clinical practice for 20 years and found it hard enough to stay afloat financially with paying patients—how could one offer naturopathic medical services at no cost and still eat? Now that my children were grown, I too had aspirations to turn my attention to the world and all its ills. I had flown down to volunteer with Natural Doctors International (NDI), as well as to learn from these young doctors. And learn I did—way more than I had anticipated.

I learned about global medicine, social justice, structured poverty, and much more. I was impressed by the knowledge of Dr. Parker, and of her recent National College of Natural Medicine graduate intern Dr. Tania Neubauer, regarding the international political issues that continue to keep multitudes of people in impoverished circumstances. They knew the presidents, the years, the trade agreements, and the foreign policies that contributed to the plight of the Nicaraguans and many others. I grew to fully realize the deep goal of NDI and the difference between NDI and those organizations doing “medical tourism” (i.e., sending doctors to hand out band-aids, stay at the nicest hotel in town, and then fly home, after which the drugs they brought with them quickly run out, the underlying issues are left largely unaddressed, and the diagnosed conditions receive no follow-up treatment or management).

NDI was operating on a whole different level—just like alternative medicine—establishing a permanent presence within the community and dealing directly with the underlying causes of ailments, including the environment, the poverty, and the politics, to do more than just treat the symptoms. As the creation of better health requires better quality water, foods, wages, and workload, NDI also is sponsoring water, agriculture, sustainability, and living wage efforts.

The heat body-slammed us as I exited the airport with Dr. Parker, and it never lightened from then on. We took a taxi to the ferry and a ferry to the island of Ometepe, and we walked from there in search of a hotel. The hospital on the island is small and basic. NDI operates independently in one wing alongside the conventional medical services that include small obstetrical, pediatric, and in-patient suites. NDI’s waiting room was filled with women fanning themselves or wiping sweat from their faces with handkerchiefs. The elderly often exhibit complaints related to lifetimes of fairly brutal labor out in the fields under the blazing sun, such as various forms of arthritis and aches and pains. Fungal infections related to the unrelenting heat and humidity are common, as are cystitis and renal stones from lack of access to clean water and adequate hydration. Numerous children were scattered about, and babes in arm, and the occasional neighborhood chicken wandered in the open door to be quickly shooed out again. Fans run in the tiny consult rooms, though they certainly don’t make them comfortable, and patients file in and out all day long. Treatments include donated nutritional and herbal supplements, a few herbal tinctures that the doctors make themselves, as well as practical dietary and hygienic support and advice. As medicine supplies are extremely limited, individual supplement and herb bottles are opened and only half dispensed, with the intent of saving the remainder for the next patient. Patients are asked to bring back empty plastic bottles and containers for re-use and as a preventive measure against littering. As not everyone can afford the 10 cents to take the public bus to the hospital, the doctors also make rounds in outlying villages and provide patients with bus fare for follow-up visits when needed. Malaria is a public health issue in this region, so NDI also works with governmental agencies, farmers, and villagers on environmental issues that impact the spread of malaria.

The funding to provide these services is garnished largely from “brigades.” Students of alternative medicine rotate through the clinic paying a fee to NDI for their accommodations and training. Naturopathic, chiropractic, acupuncture and Tai Sophia Institute’s herbal medicine master’s degree students may travel as student brigades to Nicaragua, their tuition sustaining NDI and providing for its basic operating expenses. In addition to clinical experience, NDI provides classwork and facilitates discussions on global health politics, environment factors, and structural poverty that contribute to people’s health and healthcare resources. Students stay in private homes and work alongside the community in the agricultural fields to fully comprehend peoples’ lives, resources, work, and the living conditions that contribute to their health issues.

Future NDI sites expect to continue this method of funding to be able to offer free services to additional communities around the world. Although hosting brigades is successful and is keeping the Nicaraguan clinic afloat, finances are a continual challenge and struggle (as is the case for most nonprofit organizations). The all-volunteer board throws in its own money, is actively engaged in grant-seeking, and is presently developing other fund-raising venues. Tax-deductible donations can be mailed to Natural Doctors International, 1168 Butler Creek Road, Ashland, OR 97520.

Dr. Jillian Stansbury is a naturopathic physician and chair of the botanical medicine department at the National College of Natural Medicine in Portland, Oregon. She serves on NDI’s Board of Directors.