Research

B-team arrives; clinics underway

March 5, 2013 by David Aday

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 David Aday

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 David Aday

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 David Aday

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.

Progress

January 7, 2013 by David Aday

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!).