Description of a Collaborative Health Improvement Program Between
San Jose San Marcos de la Sierra, Intibuca and
Department of Family Medicine – University of Rochester / Hombro a Hombro

History
In 2003, the Department of Family Medicine at the University of Rochester (Rochester, NY USA) decided to create a global health program. The goals were to improve the health in a sustainable manner of communities in developing countries and educate medical professionals and others about working with people of different cultures living in resource-poor environments.

The Department decided to partner with Shoulder to Shoulder (S2S, or Hombro a Hombro in Honduras). They had created a clinic in Southwest Honduras about 12 years previously and were looking to expand into others areas of Honduras. In combination with the Honduran Ministry of Health and S2S, we chose to work in the San Marcos area in the state of Intibuca. This is by some reports the poorest county in the poorest state in Honduras. After interviewing multiple communities in the county, we chose San Jose San Marcos de la Sierra.

San Jose is composed of seven villages populated by the aboriginal Lenca Indians. Realizing the San Jose residents are the experts on the problems adversely affecting their health, we spent much of the first two years listening to their advice and observations. Based on this original community assessment, we have collaboratively created solutions to their problems. The San Jose people rank-ordered their problems as follows.
  1. Water
  2. Nutrition
  3. Education
4. Health care
5. Poverty
Although the Department is most experienced in medical care, curative medicine will not fix many of the contributors to ill health as identified by the community. Given the real goal is improved health for the community, we expanded our operations beyond traditional “medicine” borders to achieve long term improvements in health. Dr. Stockman, the Director of the Global Health Program, has significant experience in rural improvement activities from 3 years in West Africa. Using his experience as a foundation, various interventions targeted at improving the health of the San Jose people are underway or will be in the future. A brief sampling of a few of the interventions are listed below.
Problem
Example Interventions
Water – limited access to water and water contaminated
  1. Piped water from natural springs to homes – where applicable. 3 piped water projects completed, two more in progress
  2. Ferro-cement water tanks and rain water collection – 4 built so far and each hold 4,500 gallons
  3. Purifying water – Both Potters-for-Peace and Slow Sand Filters being introduced (>150 homes already have filters).
  4. Latrines – Ventilated Improved Pit (VIP) Latrines being constructed (>25 built to date)
Nutrition - Inadequate calories for the amount of daily physical labor and inadequate micro-nutrients due to limited food choices
1. Reduce calorie expenditure getting water and firewood. By doing this, the limited amount of food available is adequate for the reduced calorie burn.

- Reduce time and calories spent getting water – see water projects above.
- Improved cookstoves – reduce wood use by 50% which reduces calorie burn by 50%. Because people do not have to collect so much firewood they save calories. Additional benefits are elimination of indoor smoke and reduced risk of burns to children.
2. Agricultural projects – Attempting to increase food availability by improving the local farming techniques through multiple interventions such as: drip irrigation, green manuring, terracing, improved fertilizer availability, diversify crops and cash crops, fish farming, expanded animal husbandry etc.
Education – High illiteracy rate and very few children can afford education beyond the 6th grade.
  1. Support local teachers who are high performers to ensure they stay in the area.
  2. Provide expanded teaching materials and school supplies for students and teachers alike
  3. Created a scholarship program to help support the best students who would otherwise not be able to attend school after 6th grade due to family poverty. We have selected 10 students for the first year to receive scholarships.
  4. Health education both in schools and as needed in communities.
Health Care – The nearest existing health center in 1-2 hrs walk away, often not open and limited medication availability
  1. Support a local woman, whom the community chose, to become a Community Health Worker (CHW). She has completed the two year program due to our support and treats patients when the Rochester personnel are not on site. We are training another local woman to become a second CHW.
  2. Created a Revolving Drug Fund to improve local access to much-needed medications.
  3. Attempting to build a small clinic to improve the services offered.
  4. Provide curative medical and dental health when on site.
  5. Introduced a fluoride rinse program in area schools with a 95% reduction in dental caries.
  6. Perform basic health education to schools and groups.
  7. Work with the local midwives to improve pregnancy outcomes and women's health in general.
  8. Started a folate distribution program for women.
Poverty – It is estimated that more than 50% of the population lives on less than $1 US per day. Most people are less than subsistence farmers and must do migrant farm work to stay alive.
  1. Started a micro-finance loan program. Two micro-loans have been granted with more applications coming in at a fast rate.
  2. Basic business education classes have been held to improve business knowledge for interested community members.
  3. Expanding an existing fertilizer cooperative so more local people can take advantage of low cost fertilizer.
  4. Organizing women who create local handicrafts and assisting in marketing
An important distinction between this program and many other NGO interventions must be high-lighted. The Rochester group realizes they are not the experts and San Jose is not their home. It is the San Jose people who must learn how to improve their own lives so they can become self sufficient. The Rochester group can offer some technical and financial assistance, but the San Jose people must direct interventions and must learn how to construct and maintain all interventions. For example, San Jose residents have been shown how to build improved cook stoves and VIP latrines. They are now self sufficient in their construction.
Basic Philosophy
  • Identify one community for long term partner
    • The community must be motivated, collaborative and have prior success
  • First listen to the community
    • They are the experts, not us, they know their problems
    • Next we explore collaboration
  • Combine the best of their and our talents to solve problems
    • Goal #1 is improved health for the community
    • Goal #2 is sustainability – sustainable changes may take a generation
  • Low cost, low tech with community doing most of the work
  • In time, expand activities outside initial target community with the help of the target community
Douglas Stockman, MD
Clinical Associate Professor, Department Family Medicine
Medical Director, Highland Family Medicine
Director, Global and Refugee Health
Department of Family Medicine, University of Rochester
Barbara Gawinski, PhD.
Associate Director, Global and Refugee Health
Department of Family Medicine, University of Rochester