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In the past six years, the war torn economy of Nicaragua has steadily deteriorated as the last government committed itself to the rules of 'structural adjustment' imposed by the World Bank and the International Monetary Fund. These rules insist that the country's debt to the World Bank is paid back and this is done by cutting back drastically on government spending on health and education. As well as that a large portion of the international aid which the country receives is used to service the debt, thus reducing the amount of aid spent on eradicating poverty.HEALTH CARE IN NICARAGUAHealth and education services are being privatised and in a country where there is officially 60% unemployment, (unofficial figures are as high as 80%), the possibility of paying for medicines and health care is very limited indeed. Many rural health clinics have closed or are so badly staffed that they cannot meet the needs of the community and more often than not the clinic pharmacy does not have t ähe most basic equipment or medicines can amount to more than two weeks wages. If you can't get the money you go without treatment. As a consequence of such poverty the health of the community suffers enormously particularly the very young and the very old. This situation is made worse by having to live with bad housing, unclean water supplies, malnutrition and the spread of infectious diseases. The grassroots organizations in Nicaragua have worked hard at developing and educating a network of community health promoters in the urban and rural areas. Their role is to promote primary health care projects such as building houses, building latrines, wells to pump clean water and community education programmes to promote health and hygiene. Some communities have trained their promoters in first aid, dispensing basic medicines for children with diarrhoea and other chronic health problems related to poverty. These projects are by and large funded by foreign donations and the labour æ is donated voluntarily.NATURAL MEDICINE - ACUPUNCTURE The use of natural medicine has always been a very strong tradition in Nicaragua and other Latin American countries. People know and use local plants and herbs to cure many common illnesses. They also use massage and other forms of natural therapies to treat people in the community. The community organisations have done a lot to develop training manuals which are accessible to people working in the grassroots organisations who may not previously have had any opportunities to avail of formal education. In this context Acupuncture has become very popular as an accessible health care therapy both in terms of cost effectiveness and its low cost to the community at large. Acupuncture originated and developed in China and other parts of Asia over the last 5,000 years. While acupuncture has been adapted to meet the health care needs of modern industrialised societies of the Western world relatively recently, it has emerged and èdeveloped in a predominately rural and pre-modern society treating contagious diseases and health problems which prevail in countries where primary health care facilities have not had the chance to develop. Acupuncture was first brought to Nicaragua by Mexican and Cuban doctors who worked with the Sand’nista Ministry for health during the 1980's, and later by a group of Japanese acupuncturists. Training was given to doctors, nurses and physiotherapists who worked in the government health programme. In the 1990's the focus of training changed as government health care was privatised, and community groups sought to provide training for their health promoters who then could provide an affordable service to the community. This is a community based initiative and as such its approach to acupuncture training has been shaped very much by the particular community groups involved, funds and resources, the individual heath promoters coming forward for training and the trainers. One style of ã training given by a Japanese run project in the Pacific region of Nicaragua took on individual students as apprentices who then continued to work as assistant acupuncturists under the supervision of Japanese workers. Another approach used in Condega in the North of Nicaragua involved a combination of theoretical training during an intensive 9 month course along with supervised clinical training . A group of 22 health promoters where chosen by 3 local community groups both urban and rural. These groups included the local organization of farm-workers (women's section), UNAG; a parish church group (Catholic Church); the national network for community health promoters (Cecall). Each of these groups worked in partnership to provide the facilities to run the training, including food and accommodation for the students who travelled from rural communities, photocopying, facilities for educational materials, and facilities to run a training clinic in the local town. The trainers (1 yCuban and 1 Irish) were funded by Irish aid agencies who also funded the development of educational materials in the Spanish language. Other local trainers included a doctor who gave classes in physiology and anatomy and a herbalist who gave classes in the identification and medical uses of local plants and herbs, and the construction of a community herbs garden. These classes happened alongside the training in the theory and practice of acupressure massage and acupuncture. The group was very diverse ranging in age from 15 years to 72 years and previous formal education ranged from 3rd class in primary school to third level, but the majority had not been to secondary school. There were 18 women and 4 men. The methodology used was participatory and experiential inspired by popular education techniques widely used in grassroots organisations in Nicaragua. Out of this came Ethe need to write a manual of acupuncture specifically tailored to the educational and health needs of the region of Central America keeping in mind the training standard agreed by the WHO. This work is in progress. The need for training is ongoing and it is hoped that a second phase of training will take place to advance the skills further. At present some of the health promoters using acupuncture in their communities do so on a voluntary basis, doing house calls thus minimising the resources needed in terms of setting a clinic. Others offer a service from a community clinic run by a local parish group and a third group are involved a network of acupuncture and natural medicine clinics in the surrounding rural area. The most common ailments treated are headaches, high blood pressure, insomnia and nervous coplaints, di Egestive problems such as gastritis, abdominal pain and ulcers, diarrhoea and constipation, back-ache-ache and arthritis, chronic cough, tonsillitis, asthma, thyroid and gynaecological problems, kidney and urinary problems, anaemia and problems related to malnutrition. Many of the health problems encountered are stress related due to the strain of dealing with an ever deepening level of poverty and the aftermath of war, Most families have had someone belonging to them die in the war during the 70's and 80's and many have been left disabled. With less and less health care provided by the state, small communities are empowering themselves by taking responsibility for their own health needs. However, the need for funding and resources and sufficient training is a growing one. By Margaret Brehony and Mercedes Varona