William and Mary
David Aday
David Aday

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Professor, Sociology and Community Studies

Newbies step up

April 2, 2014 by

The MANOS students had reason for concerns about language proficiency and depth for the annual project trip.  Two of our most talented and experienced teammates would not make the trip.  Lester Chavez ’14 (8 trips) and Kristina Ripley ’15 (2 trips), both native Spanish speakers and both deeply knowledgeable about our research, methods, and theory, were missed for their talents — and for their companionship. MANOS students with “advanced” speaking abilities were asked to step up and to step into more active roles in focus group interviews and community meetings.  Johnathan (“J$”) Maza ’15 (5 trips) and Kristin Giordano ’14 (5 trips), in particular, assumed lead speaking roles and made especially significant contributions to team efforts.  Chrissy Sherman ’14 (8 trips), Brooke (aka “Bruce”) Huffman ’15 (4 trips), Roni Nagle ’15 (4 trips), Tommy (“Mad Dog”) Northrup ’16 (3 trips), Ambika Babbar ’14 (3 trips), Steph (aka “Baywatch”) Wraith ’15 (4 trips), Emily Mahoney ’15 (2 trips), and Zander (aka “TZ”) Pelligrino ’15 (4 trips) pushed themselves to engage more actively as speakers and translators, and the result was that we had more language abilities in play than in any previous project work.  (My opinion; my teammates past and present may or may not agree.)  And, our newest team members, especially Quetzabel (“Q”) Benavides ’16 (2nd trip), Michelle Betancourt ’17 (1), both native Spanish speakers, moved seamlessly into very demanding roles in both interviewing and facilitating community meetings. Sarah (aka “SB”) Martin ’17 (1 trip) and “Quesa” Diya Uthappa ’17 (1) waded into the mix to provide both sound note-taking (in Spanish) and comments and questions in the course of meetings and interviews. In all, it was a very strong showing.

J$ Maza struggled against his comfort zone to meet team needs for communications — not just proficient Spanish but engaged, deliberative, inviting exchange that brought participants fully into important and consequential conversations.  Reminiscent of James Bond’s provisioner, our very own “Q” was a marvel of invention and innovation, particularly adept with the turn of phrase and metaphor — and remarkably steady in facilitating the participation and inclusion of Chaguite residents.

What to say of this intrepid, rowdy bunch of public health and participatory development research wonks?  They are not easily discouraged; they don’t whine; they bend to the work at hand; they rise above the challenges; and they stay focused on systematic knowledge and respectful partnering to promote change.  There was not much drama in this year’s work.  Given the challenges of logistics, the demands of the work, the difficulty of living with 18 or so other people 24-hours per day, and the complexity of the issues we attempt to understand and manage, that says a hell of a lot!  Somehow, Baywatch and her assembly of collaborators managed to set up and operate daily clinics in multiple locations, only one of which is intended for use as a medical clinic.  The daily setup and striking, by all accounts, were seamless.  FOMO Sherman was everywhere, responding to the needs of the work even before the rest of us knew that there were needs.  Kristin Giordano proved herself again to be a “thoughtful watcher,” keenly aware of details in exchanges, unfailing in her attention to human and cultural matters — even as she took on significant responsibilities as a lead speaker.  We have been fortunate throughout the project to have at least one team member whose deep concerns for respectful partnering, whose cultural awareness and sensitivity shine a bright light on what we say and do as guests in another country and community.  Kristin has been superb in this role.

As always, there is more to say:  ”Dog bites man.”  ”Mountain bruises car.”  ”Earthquake compounds travel difficulties.”  These might have been (and still might be) headlines for blog posts.  The countless contributions of every member of the team deserve to be spotlighted, but fortunately for all of us, we don’t do this for recognition.  The satisfaction comes from learning and from careful, methodical efforts to test the value of what we learn in advancing authentic partnerships for change.

Chaguite, Cuje, Clinic

March 24, 2014 by

We have worried about the value of our annual clinic since we first opened the doors in 2007.  We intended NOT to be a duffle-bag medicine project—arriving with U.S.-based notions about what our patients might need and dropping off short-dated medicines in small quantities.  Eight years later, we’re still trying to find ways to make our clinical efforts smarter, better founded, more integrated with local medical and health efforts, truer to the needs of our partners.  We are encouraged by this year’s meeting with Dr. Blanco.  We hope that our evolving relationship with the Totogalpa clinic will allow us to be more strategic and more attuned to needs defined by those who have responsibility for providing health care on a continuing basis.

Our community-based approach inclines us to learn as much as possible from those who live in the communities we intend to serve with health care efforts. Our work in Chaguite has provided us with systematic information and increasing understanding of the health and health care needs of residents of that community.  We know better than to generalize these understandings to residents of the remaining communities that comprise Cuje—the micro-region served by our annual clinic.  We envisioned a Cuje-level Comite de Salud (CdS; Health Committee) that would comprise representatives of residents of each of the communities.  We imagined collecting information from brigadistas in each of the communities and we hoped that we might, through snowball sampling and sociometric techniques, identify such a group as a start for consulting with residents about ways to make our clinic more responsive.

In pursuit of that goal, we reprised our satellite-sites approach to the annual clinic this year.  The objective was to take each day’s clinic as close as possible to the geographic center of the remote communities of Cuje.  Working from those locations, we would dispatch team researchers to conduct interviews with the communities’ brigadistas and with members of randomly selected households to identify community residents who might be (1) interested in participating in discussions about improving the clinic services; (2) trusted to represent residents’ beliefs and needs.  After the first day’s efforts, student researchers reported that there is something wrong with the questions we’re asking or with the respondent-selection process.  Respondents usually were able to identify their community’s brigadistas or other leaders, but they routinely reported that these people did not represent their interests, did not understand their needs, and did not work with them or on their behalf.  We tweaked the questions and the general strategy and tried again the next day.  The results were unchanged.

None of the students on the current MANOS team participated in the first round of interviews in Chaguite.  We were asking very similar questions then—and we got answers very similar to what we are hearing this year in other communities.  That seems nearly impossible to believe now and, seen from our now customary view of collaboration in Chaguite, these other communities seem desperately (1) unfamiliar (because they are) and (2) lacking in social infrastructure (which they may be).  I have the benefit of historical perspective.  I recall residents of Chaguite who were able to identify two or three key leaders (some of whom were brigadistas) — and I remember the same residents saying that they do not work with these leaders and that these leaders do not represent their interests.  I remember the leaders saying that they try to hold community meetings but that residents will not attend and will not collaborate in projects with potential value for the whole community.

This year’s effort to “sample” our way into some rough understanding of the other communities and their social infrastructures was a well-intended effort to find a short-cut for gaining information from residents throughout Cuje.  We want to hear their voices as we think about how our clinic can be more than duffle-bag medicine.  At this moment, it does not appear that there is a short-cut, no substitute for the years of work in the community, on the ground, in the homes, working with good social science methods to learn, using the resulting information and knowledge to build relationships.

Dr. John Showalter (M.D., Knoxville, TN) played a significant role in our follow-up conversation with Dr. Blanco (Totogalpa Clinic Director).  His understanding of our approach and shared frustration with the apparent limited value of our annual clinical efforts were crucial to the discussion.  Speaking medical professional to medical professional, Dr. Showalter was able to convince Dr. Blanco of our determination to be more than another itinerant bunch with good intentions.  We will do all we can to build on this step forward.

Dr. Showalter joined us at the end of the week in two additional meetings, one at a medical school in Managua and the second at the American Nicaraguan Foundation (more on that in a later post).  Through inquiries by Kristina Ripley, we have been in contact with a professor of medicine at this university.  We toured the medical school, talked briefly about our projects in Cuje, and learned about our host’s interests in extending health services to the under-served in Managua.  Dr. Showalter inquired about good strategies for short-term, annual clinical projects and about sources of medicines that would be appropriate for the Cuje population.  His participation in the discussions clearly elevated the seriousness with which are efforts are regarded by this local medical professional.

Baby steps—but they seem to be in a good direction.  We don’t know yet how to make our clinic more responsive and more responsible.  We’ll add more research on brigade and short-term, international clinical approaches to our work for the remainder of the semester and it will top the list of topics for next fall’s seminar.

It’s Not Linear; 2/28/14

March 24, 2014 by

In November 0f 2009, I wrote that SHC was becoming MANOS and that the timing seemed more than incidental.  (And, it happened even before Chrissy Sherman joined the team.)  It seemed clear to me then that the project was evolving from the “service learning” group of 2006 and was finding its way.  The new name, Medical Aid Nicaragua: Outreach Scholarship, was in part a proclamation of  vision: to learn, to research, to engage with, to be mindful of presumptions about what we’re doing and how it may be received by those with whom we intend to partner.

In a post dated March 11, 2010, I noted that we would begin this year to focus our community efforts in Chaguite.  We estimated that there are about 40 houses in this community and by the end of the 2010 March trip, we were close to completing interviews in all of the homes.  From the same trip, I described meeting with a local “brigidista.”  His name is Ysidro and it’s clear that he works very hard to care for his family and still finds time to serve in a volunteer capacity that involves “looking after” the health and health care needs of the community.

And so it is 2014, and we keep coming back—now routinely three times each year, in some fashion:  Small teams in January (like the one this year that facilitated community meetings with representatives of our newest partners from the Engineers Without Borders chapter at Cal Poly – Pomona);  the full team each March; and a team of three to eight students in the summers.  The work proceeds—slowly, deliberately, sometimes seemingly as much sideways as forward, but always as fully as possible in step with community partners.  Chrissy Sherman ’14 has traveled to do research in the community eight times, as has Lester Chavez ’14.  Other experienced team members have traveled from three to seven times each and, through that dedication, have developed understandings, appreciations, and real friendships within the community.

We now know the residents of the households in Chaguite, which number about 50.  We have mapped the region, the households, the health problems and assets. We seem to be realizing the vision in our name—and we continue to worry about our presence, our role, our relationships, and our partnership. Through repeated interviews in all households in the community, we have come to know residents and we have learned about their health and healthcare concerns, needs, and priorities.  We learned about the leaders and about interpersonal networks – those groups of people who communicate with one another and collaborate on occasion.  In our earliest interviews, we were struck by the paucity of communications and collaboration even as residents were able to identify “leaders.”  Residents told us that they did not work with leaders and that leaders did not work with them or understand their concerns and needs.  Through Social Networks Analysis (SNA), we identified “organic” networks of communication, groups of residents who do talk together and we encouraged them to meet together and with us to help us to understand the health and healthcare priorities.  They were modest in number, scope, and inclusiveness.

The social networks analysis (SNA) techniques enabled us to calculate measures of “network density” (the proportion of interpersonal connections reported as a proportion of the total possible connections for the respondents).  It is an imperfect method and an imperfect indicator, but SNA measures of network density provide an empirical and quantitative way to gauge communications and collaboration within communities.  In general, there is inadequate research to allow us to estimate what levels of density are “normal” or “typical,” but at a minimum, we can take measures at different points in time and compare these to observe change.  Our first round of research provided a network density estimate of less than two percent – that is, of all the dyadic (two-person) relationships that might exist in the community, less than two percent were reported as existing.

We have been working with these organic groups (which we began calling “regional groups”) for several years now and through communications within and across these groups, have worked with residents to create and authorize a five-year plan to improve health and healthcare.  Through these groups, we have partnered with the community to advance a project with Engineers Without Borders (EWB). We strongly suspect that our next round of SNA research will reveal significant changes in the level of estimated network density.  We believe, further, that network density is crucial to the development of effective social infrastructure – the organizing of resources, activities, and tasks needed for communities to collaborate to build sustainable solutions to shared problems.  We won’t know until we do a second round of systematic research, but it appears that levels of communication and collaboration have increased markedly over the last four years as we have encouraged engagement through the organic networks and participation through these in regular community meetings.  (We’ll be sure to report our findings to Chrissy Sherman no matter where her FOMO efforts may take her next.)

This year, we undertook interviews in households that have not been represented regularly (or at all) in regional group meetings or community meetings.  We are trying to understand how we might make engagement in community-level efforts to improve health more inviting, more accessible.  We were accompanied by community members from the respective regional groups in our hope to engage residents more fully in our research efforts.  The residents were more inclined to chastise those we visited than we preferred and we encouraged a point of view that emphasizes the value for all in increasing participation—particularly in the developing project to provide access to water for everyone in the community.

In a final note:  Chrissy Sherman once drove for approximately 3 seconds in Nicaragua.

Persistence and Partnering. 2/27/14

March 21, 2014 by

The MANOS advance team (Johnathan Maza ’15; 5th project trip); Stephanie Wraith ’15, fourth project trip; Sarah Martin ’17, 1st project trip; and me, 8th project trip) met with Dr. Benito Blanco, Medical Director of the MINSA clinic in Totogalpa, Nicaragua.  We summarized our medical and community efforts over the past seven years in Cuje (micro-region) and the community of Chaguite.  Dr. Blanco expressed appreciation for these efforts—and some mild aggravation about the lack of coordination of our efforts with his office.  He noted that our clinic has been helpful but could be more effective through such coordination.  We agree—and we are encouraged by his perspective.  We’ve been urging that point of view since 2007.  There are several plausible explanations for and possibly contributing factors to the lack of effective partnering to date.  It is likely, for example, that for the first several years the local medical professionals saw no reason to believe that we would keep coming.  There was a different clinic director when we began.  He’s now the mayor of the municipality of Totogalpa.  And, when we began, the region was in a deep drought and even the most meager of resources had dried up.  At that time, we found the clinic woefully under-staffed and with the most minimal medicines and equipment.  There was a “siege” kind of feeling about the operation and the clinic staff seemed more than satisfied for us to do anything—without much consideration of strategic advantages.

The entire region has seen remarkable improvements over the last several years:  more rain, resurgence of flora and fauna following the transformation of the ecology through clear-cutting of the evergreen forests, a relatively stable government, and increased presence and investment of national and international NGOs.  Like the clinic, the mayor’s office, where we met with the Sub-mayor and the General Secretary of Community Cabinets, the facilities were in good repair and had an air of organizational efficiency that clearly was absent when we visited earlier.

It seems likely that these things have contributed most to the current moment for engagements:  (1) Success by Dr. Blanco and his colleagues and staff in gaining and using resources to achieve organizational and professional goals; (2) the increase in NGO presence in the area, leading to a sense of need and possibility for strategic arrangements; and (3) our persistence in returning to the area.

We do not quibble with Dr. Blanco’s view that more can be done through better collaboration. That, essentially, is our mantra.

We met also with officials in the mayor’s office.  We heard a similar message and we embraced that with equal enthusiasm.  We deserve and take no credit for their (seemingly) increased enthusiasm to partner—other than our persistent effort to learn from them how we can best work with them to partner with communities to improve health and health care.  Readiness to partner involves more than one potential participant.  And, in the current era of volunteering, service, service learning, engaged scholarship, action research, and participatory development, it seems necessary to establish proper creds in order to expect authentic discussions about the role that might be played by outsiders.

B-team arrives; clinics underway

March 5, 2013 by

B-team arrived on schedule, and as predicted, silliness ensued. It is a measure of their engagement that the later arrivers could not wait for a full briefing on the A-team’s accomplishments. The promise of a full disclosure at the team meeting (around 11pm) was not sufficient to defer questions (bordering on inquisition). I savor this moment, which is filled with anticipation and boundless energy. Tomorrow will be given mostly to counting and sorting pills and the tedium of logistics.

Yardley Albarracin ’13 (and veteran of half-a-dozen trips or more) needed to confirm details for some of our remote clinic sites – and wanted the opportunity to get the newest team members into Cuje before the first clinic day. We learned more than in previous years about local “mountain-to-hollow” shouting conventions and team members saved more than a few torturous trail steps by executing (probably poorly) those conventions. For me, this was the first trip back to El Mojon (uno y dos) in more than five years. In the first years of the project, the field research teams attempted to map the micro-region without the assistance of 4-wheel drive – or vehicles of any sort. That meant walking from the clinic outpost in Las Menas to eight communities spread across 50 square miles on three mountain tops. It was good to remember some of the places in the Mojons and to see them while still being able to draw.

The first of the week’s clinics was in Mojon Dos in a recently constructed cinder-block “community building.” Team members had purchased plastic tables and borrowed plastic chairs from our hotel in Ocatol to furnish the single room open space. Dr. Roger Martinez, back with us for the seventh year and veteran of approximately 10 trips, arrived from Managua on Sunday and was at his post, as usual, in the clinic. Dr. John Showalter, internal medicine doc from Knoxville, TN, returned for the third year as a volunteer medical provider and was joined by Dr. Robbie Duerr, orthopedic resident from the University of Pittsburgh). With the support of the director of the residency program (Dr. Mark Sangimino), Dr. Duerr will provide medical consultations and do broad assessment of the prospects for a partnership with the University of Pittsburg residency program that could result in significant expansion of medical resources for the micro-region. For some years now, we have been aware of the muscular-skeletal issues that we see among residents. We have been frustrated by our inability to do more than provide very, very modest pain relief. There may be extraordinary prospects for the future.

Senior Week

March 4, 2013 by

It’s 8:30 pm. The advance team has been busy since eight this morning, when we left the hostel. Chrissy Sherman has arranged the agenda, which includes visits to Chaguite homes to ensure that they know about the clinic and the community meeting that is scheduled for Monday; visits to the homes of brigadistas (community health representatives) in Buena Vista and Quebrada Grande to ensure that they know the day and location of the clinics for their communities; and a meeting with the newly selected mayor’s representatives in Chaguite. The team is reviewing and clarifying field notes. With two speakers and two recorders/observers, the notes are thorough and team members quiz each other about what was said and who said it, one conversation at a time. When we return to campus, these transcribed notes will be examined more closely to extract data to describe ongoing activities and emerging infrastructure.

The “B team” (the remaining students, three doctors, and our friend for life Freddy (professional driver and cultural guide) will arrive around 10pm. There will be embarrassing displays of affection and general silliness, which will give way to debates about whether the “updates” and “progress reports” should be done tonight or could wait until tomorrow. We’ll stay up too late and get up too early and tomorrow will be filled with logistics, pill counting, sorting, and bagging, and more logistics.

This year will be no easier for senior team members, who will try not to notice that these are their crowning moments and culmination – and I will be no more adept at expressing my appreciation for all that they have done to build forward from the work of those who preceded them.

Another newbie meets Cuje

March 4, 2013 by

Introducing a new team member to the region and community is always interesting. It is one thing to communicate the approach, the core concepts and theory, the methods, and the accumulated understandings from six years of work in Cuje and Chaquite. It is quite another to describe the look, feel, and only partially grasped character of a place and the people who live here. We are in Nicaragua again, preparing for our seventh annual project work: a free medical clinic, this year with three physicians and community-based participatory research to advance our ongoing partnership with the community to improve health and health care. Kristina Ripley is fluent in Spanish, went to high school in Managua, and is participating in the MANOS project for the first time now. Like many who preceded her, she is uncertain after the first day – about how this compares to what she imagined; about how to make sense of the work we’ve done and that we’re prepared to do this year; and about her role in a project that calls on diverse skills, challenges preconceptions, and requires navigation of hairpin turns (literally and figuratively). And all of this in spite of her personal familiarity with Nicaragua.

Those of us who are returning (Stephanie Wraith ’15; Yardley Albarracin ’13; and Chrissy Sherman ’14 – the advance team sent ahead to prepare for the week’s work) are accustomed to the sights and sounds and meet friends as we travel through the community to arrange meetings, check on clinic sites, and announce the schedule for the coming week. Even in this seventh year, I find the first day unsettling. We see changes that we hope local residents find encouraging, but the persisting devastation caused by first-world exploitation of the region is not easier to accept. More than 60 years ago, American corporations led the way in clear-cutting this region of Nicaragua, transforming lush evergreen forest to high mountain desert. The companies promised re-forestation but planted scrub varieties that would not survive – and if they had, the resulting trees would have been stunted and of no economic or productive value. Our trip up the mountain road at midday is dusty; the few cattle are underfed with bony haunches and sharply defined ribs. Terraced fields look hopelessly under-nourished, dry, brittle. The faces of those who walk the miles of road up and down the mountain are determined. The trip down the mountain in late afternoon is a dirt storm. Those who are still walking scramble for protection, covering noses, mouths, small children and babies.
Our friends in Chaguite greet us warmly and tell us of the work that has progressed since we were here in January. In the coming days, we will learn in detail about the water project that is being advanced through a partnership with universities from Managua. We spoke briefly with some of these partners in Managua before leaving yesterday. Residents are eager for the resources that will come through this arrangement, but it’s clear also that the work will result in only partial realization of the goals of the first stage of the 5 year plan. Much of our work this week will focus on understanding how the residents believe we can collaborate to build from what currently is anticipated to what, together, we have envisioned as the first objective.

The advance team will be busy tomorrow and Saturday as we prepare for the arrival of the full team on Saturday. There are more newbies in that crew, and undoubtedly, they will add to the store of insights, questions, and puzzlement.

SOMOS/DASV 13: The Spirit is Willing

January 16, 2013 by

I wish I could bottle it – that synergy that comes from hard work, dedication, diverse training and skills; that instantiation of hope that is the project week for SOMOS and DASV. DASV: Dominican Aid Society of Virginia, a small non-profit with five officers and volunteer medical professionals who give graciously their time and talents. And, SOMOS: Student Organization for Medical Outreach and Sustainability, now in its ninth year of promoting improved health and health care through community engagement and a model of participatory development in Paraiso, Dominican Republic. The spirit is magical. I’m old enough now to say that without blushing, and I say it because it’s true.

Pharmacists and pharmacy students brought acumen to the completion of the clinic’s medical services. Their work reflected attention to detail and pure thoughtfulness that is largely unknown to the residents of this peri-urban and marginalized community. It was obvious in their orderliness and in their exchanges with patients. Julie Jeong (Pharm.D.), Nellie Jafari (Pharm. M.S.), and Tim Pierce and Elizaveta Budko (pharmacy students) demonstrated both professionalism and just plain kindness. And they contributed to the magic with observations flavored by diverse perspectives (Korean, Uzbek, and others).

Nurse Practitioner Margo Potts and nursing students Marie Vu and Marc Bein and a crack team of physicians provided patient consultations and care that was culturally sensitive and discerning beyond the resources of the clinic. Margo is a member of the DASV board and a returning provider for the clinic. In addition, she supervised Marc Bein in a community-based project that will significantly advance efforts to identify patients with chronic illnesses, including hypertension. Our goal is to provide continuous care for those in the community with chronic illnesses, and Margo’s and Marc’s field study provides a strong beginning point for both identification and for understanding possibilities for effective management.

Luke Neillans (’05; MD, Howard University) and Matt Harrington (’05; MD, University of Virginia) were among the small group of students who founded what we know today as SOMOS. Dubbed B.J. and Hawkeye (from MASH fame) for their quick wits, seeming irreverence, and skillful medical practices, Luke and Matt reflect much of what has been true about this undertaking from the beginning: deep commitment; a critical perspective; lively suspicion about good intentions; and a strong sense of adventure, ready to test what is possible in righting inequities. Aye Otubu (MD, Howard University School of Medicine) and Mal Azmi (MD, soon to join the faculty at VCU School of Medicine) joined the team, added to the caring medical professionalism, and brought joy and the power of diverse experiences to the medical team. The clinic and medical staff were led as ever by the quintessential community outreach doctor, Mark Ryan, ’96; MD, Virginia Commonwealth University. Mark’s goodness and his determination to provide quality health care to un-served and underserved people pervade the clinic and reach beyond clinic walls to raise the hopes of residents and project team members alike.

In SOMOS, we promote leadership through practices and processes more than through people and positions. We expect much of each other, we’re slow to blame and we’re quick to take responsibility in an effort that many would guess to be impossible—or at least, improbable. Undergraduate students engaging in knowledge-based, participatory community development that is grounded in systematic social science theory and research: really? Sustaining and advancing a project across generations of students, recruiting and selecting peers to learn, embrace and carry forward a nuanced model that hinges on community ownership: plausible? It’s still too soon to say for sure, but the evidence certainly is accumulating. Three seniors were selected to facilitate the leadership activities this year, and they were remarkable: Jo Weeks (4th year; 6th trip); Amalhyn Shek (3rd year; 5th trip); and Lindsay Schliefer (with an “i,” Schliefer; 3rd year; 3rd trip). They modeled the practices that we hope to see manifested in the community: inclusive decision making, reciprocity, networked communication, and flexible and accountable organizing.

Bruce Pfirrmann (’13; 3rd trip), Rob Marty (’14; 2nd trip), Mel Alim (’14; 3rd trip), and Rebecca Silverstein (’14; 4th trip) helped to organize efforts in flood mitigation, including working with the community’s “boat committee” and Engineers Without Borders (EWB) committee. These fledgling efforts are maturing now and it seems very likely that we will succeed in facilitating a partnership involving the community, EWB, and SOMOS. Rebecca also was instrumental in facilitating the development of a community health committee and a partnership involving that committee, a local government clinic and health promotion program, and SOMOS. She worked with Jeff Rohde (’14; 4th trip), Christian Delgado (’14; 2nd trip), Melanie Rogers (’13; 3rd trip), Betsy Coco (’14; 1st trip), and Cathy Merritt (’15; 1st trip) to advance significantly a role for the community health committee in leading and coordinating efforts to bring resources and coherence to health services. Christian Delgado, Jeff Rohde, Amalhyn Shek, and Jo Weeks were particularly effective in helping to facilitate the community meetings and to guide them gently to outcomes that will advance community efforts.

In addition to the organizing efforts, SOMOS students undertook another round of data collection, this time in anticipation of testing hypotheses about the relationship between social network density, infrastructural development, and social change.

I will forever be awestruck by the way in which these remarkable students move seamlessly from theory to research to praxis to the depths of interpersonal sensitivity and caring—and on to the heights of just plain silliness. And all of it is necessary, essential to this improbable project. It is too soon, still, to know if we are succeeding, but here are some very promising indicators:

  1. The concluding community meeting was animated. More than lively, it was contentious. My experience and the accumulating research and theoretical literature suggest that residents of marginalized communities don’t waste time competing when they see little prospect for change and little possibility of accessing meaningful resources. Residents came to the meeting in significant numbers and they spoke directly, assertively, and comparatively about differing ideas for promoting change—and using resources.
  2. Residents are beginning to see the “logic” of the emerging infrastructure, comprising “regional” or “block groups,” focused committees (boat, EWB, health), and community meetings for making collective decisions. This logic was articulated eloquently and compellingly by the recently selected co-leader of the community health committee, identified here as “Pastora.” Her summation brought to a productive and hopeful conclusion a meeting that was teetering towards devolution. The beginning of the week brought resident reports of “traditional” understandings that reflect alienation: “No one works for the community.” “We must depend on the government to solve problems, and they won’t and don’t.” “Some people talk about doing things but they don’t do anything.” The ending meeting reflected the anxiety of seeing possibilities but worrying about particularism and favoritism. Pastora offered an alternative view—the view that SOMOS has championed from the first efforts: organized, collective efforts to solve shared problems through reciprocity and collaboration.

So, I’ve more than made up for the blog space left unfilled since last March. It’s too much to read, and I’m not sure I’d bother. But if you’re reading this, perhaps you did—and I appreciate it.


January 7, 2013 by

It may be that blogs have gone the way of postcards. Again, I have been a poor correspondent and note that I wrote last in March — during the annual MANOS project trip. The SOMOS advance team is in the Dominican Republic as I write; the full team arrives on Saturday. At the same time, a MANOS research team will be in Nicaragua.

Both projects have gone amazingly well — and dreadfully slowly. Participatory development is notoriously slow and not uncommonly painfully so. Some speak casually of “teaching a person to fish,” imagining that as a way of characterizing the work we do in Nicaragua and the Dominican Republic. It is nowhere nearly that easy (though I’ve had my share of difficulties in teaching people to fish as well!). We have a clear and specified approach to community capacity building. We promote organized and improvised collective actions that build infrastructures that solve collectively defined problems. That’s a mouthful and may seem needlessly jargon-laden. For those of us in SOMOS and MANOS it is a clear, precise, and theoretically and empirically grounded description of an approach and a set of methods and practices.

In the Dominican Republic, we are challenged to work with emerging arrangements to mitigate flooding. There is a “boat committee” that is working with us to find safe and effective ways to use a boat provided through the SOMOS-Esfuerzo partnership. There also is an “EWB committee” comprising local residents and SOMOS representatives. Working together, this committee submitted a proposal to Engineers Without Borders in hopes of undertaking a partnership that would provide broad scale relief from perennial flooding. The EWB representatives declined, noting that the scale of the proposed project was beyond their capacities. They invited further discussion and spoke very positively about the partnering approach reflected in the proposal. We learned that these representatives regard our work in the community as an ideal basis for EWB partnerships. We’re optimistic about limited projects with EWB going forward, and these will be discussed with community residents in the coming week.

The challenges in Nicaragua are, in some ways, even more enticing. Community infrastructure has matured rapidly, with regional groups meeting to discuss aspects of the Five Year Development Plan which was written and approved in collaboration with MANOS. Regional group leaders have cell phones now and the ability to communicate with one another and with MANOS team members to facilitate group-level efforts in anticipation of community meetings. Two significant parts of the Five Year Plan involve improving access to clean water for all households and improving nutrition. Those goals became the focus of a collaborative grant proposal involving the community, two Nicaraguan universities, and MANOS. The proposal was funded and provides for technical consulting (through Nicaraguan university engineers and their students) and materials needed to implement a water access project and gardens to improve nutrition. There have been problems in communication and in working out the roles of community members, university engineers, representatives of the mayor’s office, and MANOS team members. Our goal is to provide the support and technical advice that can optimize community residents’ knowledge and their sense of ownership of the project. Partnering is a much more difficult concept and practice than normally is understood.

We have an exceptional crew traveling to the Dominican Republic this year — again. As always, the medical/clinical team is led by Dr. Mark Ryan (’96) and a member of the very first group that traveled from W&M to the Dominican Republic to promote improved health and health care access. Joining him as physicians are two other founding team members, who were undergraduates on the first trip: Matt Harrington (’05), M.D. and Luke Neilans (’05), M.D. Other M.D.s joining the team this year are Mal Azmi (soon to be at VCU) and Aye Otubu, Howard University School of Medicine. Nurse Practitioner Margo Potts (returning medical provider) will be joined by Nursing/Nurse Practitioner students Marc Bein and Marie Vu. Pharmacy Doctorate (resident) Julie Jeong will be accompanied by PharmD students Nellie Jafari, Liz Budko, and Tim Pierce, all from the VCU School of Medicine.

And so, there is progress and we move ahead. Perhaps it is time to find a new venue for communications about SOMOS and MANOS. It is unclear whether there is an audience for the musings on this blog. Very soon, we expect to formally join forces with an international network of volunteers and community-based projects and organizations that span that globe. We are pursuing discussions with Omprakash leaders that would create a partnership through which SOMOS and MANOS would provide intellectual and academic content, consulting, and mentorship to the network. That arrangement might eventuate in certification arrangements for undergraduates and others who want to pursue international community engagement activities. It might, in time, produce online for-credit courses. Stay tuned (if you’re out there!).

Unfolding a five-year plan

March 19, 2012 by

There have been times when we worried that the individual level needs are too urgent, that our methodical efforts to identify promising community level strategies would take too long.  We have worked with occasional assurances that community residents appreciate our efforts to understand from their perspectives.  We were struck by how quickly residents endorsed our plans to work with smaller groups that we identified through social network analysis; encouraged by the fact that these groups quickly formed “cabinets” of officers; that they met in our absence.

We are back now, building on the research done by small research teams last summer and in January.  We meet in turn with the focus groups to talk about our specific suggestions for how to take on the persistent health concerns that were identified in the community meeting last March.  We are especially heartened to find all members of Group One present and engaged.  We have worried from the beginning that this group includes the most marginalized households in the community, and that they will be reticent to the point of losing out in community efforts.  Previous research has revealed that they are the least likely to get information that is distributed in the community; the least likely to attend community meetings.

We have noticed the building of trust relationships with us and with each other.  With each contact, they have become more forthcoming, more willing to talk, to smile.  We have brought a diagram to illustrate project possibilities and how they are interrelated.  The diagram attempts to suggest the possibility of solving problems of full latrines by a process that produces “humanure” for gardens, which in turn could help to improve nutrition.  They are amused and a little embarrassed by the discussion, but they see quickly the efficiency and promise of the possibilities.

We will continue, on occasion, to doubt our progress, to worry that we have not been sufficiently careful, that we have not understood, that we are missing important facts, relationships, or events and that our shortcomings will be the undoing of our best efforts.  We meet with a focus group that is the polar opposite of Group One.  This one includes several CPCs (mayoral appointments; people who still struggle with daily existence, but who have more resources, by far, than those in Group One), and they seem to be saying that they are organized.  They seem to suggest that if we’ll just give them the resources that they can solve the problems.  In some ways this perspective is persuasive, but our earlier research makes clear that the resources would not be used in ways that would result in optimal benefit across the community.  Moreover, the continuing discussion makes clear that they value us for more than tangible “stuff.”  They are interested in the ideas we bring, including a new technology for human waste disposal, solar ovens, a strategy for improving access to water throughout the community.