SHOULDER TO SHOULDER

Building Sustainable Partnerships Between U.S. and

Rural, DevelopingCommunities

Wayne WaitePresident, Shoulder to Shoulder, Inc.

Health Disparities: Life on less than $1 per person per day

• No running water• No latrine• 1 room for 6 people• Only 2 beds• No books in the house• Inadequate land to grow

enough food • Growth stunted children• Intestinal parasites, anemia

and vitamin deficiencies• Schooling ends at 3rd grade

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Problem of Poverty

• 4 hours on mountainous dirt road to the nearest “hospital”

• Malnutrition about 30% population• Income ~ $15 / month, skilled

carpenters earn $4 / day

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Intibuca, Honduras

• Honduras is the third poorest country in the Western Hemisphere. Intibuca is one of the poorest and most remote

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Her Bedroom

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Values and Needs

• Our mission is to serve the poor and to help them help themselves

• You can Volunteer

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Future Plans

• Expand the “model”• Expand Service to

Resource Poor • Provide Hope

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Levels of Poverty

Extreme Poverty: Household with an income less than $30 per month/person, without basic services (water, electricity, hygiene, sustainable production)

Relative Poverty: Households with a monthly income between $30 and $60 per person, and with at least one or two basic services

Not Poor: Household income above $60 per month person per

AMFI: Levels of Poverty per Municipality(percentages)

Municipios Extreme Poverty

Relative Poverty

Non poverty

Total

San Marcos73.4 6.3 20.3 100.0

Concepción 75.6 5.5 18.9 100.0

Colomoncagua 72.4 6.3 21.3 100.0

Camasca 69.9 5.3 24.8 100.0

Magdalena 68.5 7.4 24.1 100.0

Santa Lucía 69.4 5.5 25.1 100.0

Total 72.0 6.0 22.0 100.0

Prueba chi-cuadrado p= .734Fuente: Encuesta de hogares PNUD-FLACSO

Variables S. M. de

Sierra (%)

Concepción(%)

Camasca(%)

Colomoncagua.(%)

Magdalena(%)

Santa Lucia(%)

S. Antonio

(%)

Extreme Poverty

73.4 75.6 69.9 72.4 68.5 69.4 -----

Extreme Exclusion

72.6 69.9 54.2 60.0 60.8 63.9 ------

Infant undernourishment (0-5years old)

79.7 69.5 66.5 70.2 63.7 65.2 67.1

Pre-school 35.3 39.5 45.4 39.1 53.8 37.9 65.3

Elementary School

93.6 96.6 94.2 92.7 94.7 89.2 92.9

Jr. High/ Plan Basico

71 48.6 51.1 55.3 52.2 45.5 55.7

Diversified /Colegio

25.3 23.7 33.7 27.7 26.4 18.3 32.3

Childbirths by midwives

27.3 57.1 31 74.3 33.3 48.5 69.4

Water access by Pipe

31.8 78.5 84.2 81.6 70.1 82.3 77.4

Have bathrooms

58.6 87.3 81.5 70.4 60.6 51.3 66.5

Have electricity 29.3 33.5 60.2 54.8 65.3 57.2 74.6

Illiteracy 27.6 20 15.8 18.8 19.1 26.9 16.9

INDICATORS: AMFI – ASOCIACION DE LOS MUNICIPIOS FRONTERIZOS DE INTIBUCAJuly 2008

Health Disparities: Spending per capita United States vs Honduras

United States • GNP per capita= $32,000(10th

globally)

• % GDP per capita spent on health care = 15.4%

• Total $ on health/capita= $6,477

Honduras• GNP/capita= $740 (146th

globally)

• % GDP per capita spent on health care = 8.3%

• Total $ on health/capita= $61

Spending per capita for health in Honduras is <1% of that in the U.S.

Health Planning and Health Spending

TertiaryCare

SecondaryCare

Primary Care

HouseholdCare

Health Care Priorities Health Care Spending

Effects of Health Disparities: Under Five Child Mortality

• Under 5 mortality accounts for 50% of the global gap in mortality rates

• 10.9 million in the year 2000

• All but 200,000 from developing countries

Why Partnerships? Health professionals work in many ways to improve health in developing nations…

Build health infrastructure (e.g. a hospital)

Supplement Specialty Services shortages

Short term Medical Missions Community

Partnerships

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3 4

Model 3: Short Term Medical Missions

• This is the most appealing and most frequently selected model for doctors, nurses and dentists

• Key characteristics of this model: focused specialty care, addresses problems at that moment in time, suggested triage of chronic problems with limited or no follow-up

• Physician Service Opportunities Abroad. JAMA – Annual listing of opportunities to volunteer– The majority are short term medical mission opportunities

• Good for addressing acute needs, offering educational interventions, cross-cultural exposure, BUT…

Model 3: Short Term Medical Missions

• Limitations: – Long-term health status impact rare, except for

recurring visits by interventionalist educators– Difficult to empower community, incorporate them

into systematic improvement of their own health – “First, do no harm”… short-term missions can risk

making diagnoses/referrals that overwhelm local health infrastructure or dispense advice & medication that harm patients/communities if they are not working in close partnership with local leaders

Voices of the Poor

• 60,000 interviews of poor people

• 60 countries• Basic question: Who helps?

Can Anyone Hear Us? Voices of the Poor – Deepa Narayan

Lessons from the Poor

“North Americans have big hearts but don’t use their heads when it comes to giving.” Daniel Castro, Honduras ~1993

• Existing local social structures provide the most effective assistance, but often lack resources.

• Government and NGOs are perceived as poor listeners and inconsistent in the efforts

The Shoulder to Shoulder Model

Strategic Approach

1. Partner with communities to develop solutions to health problems

2. Understand and address the key determinants of health

3. Pair dedicated health focused groups, e.g., Academic Health Centers, Universities, etc. with poor communities around the world.

Model 4: Build Community Partnerships

• Key characteristics of partnerships:– Long-term Commitment to

same community– Communities themselves are

the key participants– Communities select leaders

who make decisions– Problems and solutions are

identified by the community – Key Volunteers

The benefits of partnershipsThe Benefits of Partnerships• Community takes ownership• Addresses the social rather

than only the biological determinants of health

• Capability for addressing chronic issues

• More direct and efficient use of resources

• More gratifying for all partners

Partnering with the Local Community Board in Santa

Lucia• Community Health Boards

are independent entities• Broadly represent the Santa

Lucia and smaller surrounding communities

• Identify needs and solutions to community problems

• Work collaboratively with US counterparts to identify resources and expertise in both communities

US Academic Health Center Partners

• University of Cincinnati• University of North Carolina• Johns Hopkins School of Medicine• University of Rochester• University of Pittsburgh• Baylor College of Medicine• Brown College of Medicine• University of Kentucky• Morehouse College of Medicine• University of Wyoming, Casper Campus• Thundermist Health Center• University of Virginia

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How Shoulder to Shoulder Views the Determinants of Health

Determinants of Health Examples

EcologySanitation

Water QualityFood Quality & QuantityEnvironmental Stability

Faith Health Beliefs

Mother’s literacyHousehold income

Household care

Primary Health Care

Risk for diseases

Health and Disease

In a Community

Social Determinants

Physical Determinants

Cultural Determinants

Genetic Determinants

Health System Determinants

Primary Health Care

Household Care

Water Quality

Literacy- mother

Ecology

Food Quantity

and Quality

Sanitation

Environmental Stability

Household Income

Faith and Culture

Determinants of Health for the Individual

Health outcomes are improved by effecting the determinants of health

Addressing Determinants of Health

Shoulder to Shoulder addresses the determinants of healthin communities with 6 key strategies:

1. Health Center2. Social Networks: Yo Peudo Program3. Feeding Program4. Education/5. Dental Care 6. Water Purification Program

Expanding the Health Center Network

Evaluating access to community health resources

Access: The Distance Decay of Utilization

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

1 km 3 km 5 km 7 km 9 km 11 kmDistance

Uti

liza

tion

INTIBUCA

Santa Lucia

La Esperanza

Concepcion

Girls Project

• JA type program with High School girls

• Sew, small grocery stores, delivery services, etc

• Creates pride and self destiny concept

• Hope in hopelessness

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Effecting the Social Determinants: Improving the Self Esteem of Girls in Society

• Girls have decreased opportunities in rural Latino society, but remain the primary decision makers in their families regarding: – health care – education – sanitation – hygiene – nutrition

• The literacy rate of women in society closely correlates with health outcomes

Some Benefits of Raising Female Education and Literacy

• ↑ Education = ↓ Decreased Fertility rates– Castro MT, Stud Fam Plann. 1995 Jul-Aug;26(4):187-202 (26 country review)

• “Universal formal education appears to be the most effective weapon against maternal death.”

– Harrison KA, Maternal mortality in developing countries, Br J Obstet Gynaecol. 1989 Jan;96(1):1-3. (REVIEW)

• 1-yr ↑ in mother's education corresponds with a 7-9% ↓ in under-5s' mortality

– Cleland JG, Van Ginneken JK; Maternal education and child survival in developing countries. Soc Sci Med. 1988;27(12):1357-68.

– Repeatedly shown, even when controlled for SES, urban status– 50% explained by ↑ health care utilization, but 50% comes from other benefits

Effecting the Social Determinants: Improving the Self Esteem of Girls in Society

• 2001 US State Department Funding launched the program; 8 communities in the Santa Lucia area

• School Based Program– Teacher training for leadership development– How to develop and operate a business: small entrepreneurial

projects with goal of sustainability– Formation of Business Clubs run by the students– Scholarships to continue with secondary education available

• In 2009– Programs still active– Shoulder to Shoulder Scholarships permit continued Education– A new group of emerging leaders

Expanding the Yo Puedo Project: For the Future

• Start Yo Puedo Projects in rural communities across Honduras

• Provide community based training programs to reduce domestic violence

• Provide scholarships for girls to attend secondary school

• 400 Schools at $1340 per community

Teachers participating in Yo Puedo Projects

Scholarship Program

• High School, grades 7-10

• No tuition, but need supplies and food

• Most children at that age are expected to earn their food

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Nutrition: Realities in Honduras

• Under nutrition and malnutrition are common risk factors for disease and failure to finish school.

• In Honduras 1 in 3 children under 5 are undernourished and the rate is 2 in 3 in the rural areas.

Feeding Program

• Feed 1800 children per day• Children are expected to support

own food at age 8• With food, they can go to school• Mothers required to cook• About $20 year / child school days• Beans, rice, tortilla, veg oil meal

with Fluoride drink

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The Process

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Outdoor “kitchen” at the school

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Grinding the corn

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Tortillas

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Cooking the beans and rice

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• THE POOR NEED AN ADVOCATE!

• POVERTY IS URGENT!

Iron Deficiency Anemia• Iron deficiency anemia

affects 3.5 billion people worldwide. Replacing iron in young children increase school performance and growth through their entire education

Vitamin A Deficiency• Vitamin A deficiency affects

250 million children worldwide and leads to increase susceptibility to infectious diseases mortality, particularly from diarrhea and pneumonia.

• Correcting Vitamin A deficiency will reduce mortality in children under 6 by 23%

Expanding the Nutrition Program: Goals of Vitamin A Supplementation

• Reduce children deaths from pneumonia and diarrhea by 20% in all affiliates.

• Goals enhanced by the establishment of clinics and evidence based treatment protocols

• Cost: $4.12 per child

Infant and Maternal Mortality

• Infant mortality in Honduras is 32/1000 (vs 6.5/1000 in U.S.)

• Maternal mortality is 110/100,000 live births (vs. 7.5/100K in U.S.)

• Rates may be more than double in rural areas (Maternal Mort. Estimates: 350/100K in Intibuca)

• Only 56% of births are attended by skilled health staff but it is almost non-existent in many rural areas.

Happy camper (no shoes)

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Dental Clinics

• 5 Dental chairs with modern dentistry.

• Compressor, suction, sterilization, restorative dentistry

• Now have 2 full time Honduran Dentists and assistants

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Expanding Dental Care: Fluoridation Program

• Intervention: – Dental Clinic as part of the Health Center– Spear-headed by Drs. Tepee and Ranz– Full-time Dentist and dental assistant provide acute, preventative

and restorative dentistry

• Goal: – Implement fluoridation program

in the Schools in the Santa Lucia

area– Expand the program to the

other affiliate sites as part of

the feeding program

The Water Purification Program

• Intervention: Originally Introduced home-based water filters in the Santa Lucia communities– Miles Bolton, Cincinnati-based hydro-geologist developed a

filtering system that can be made from local materials for about $200 Lempira (~$11.50)

– Microbiological testing confirms filters render water pure and safe for drinking

• Current Goal:– Facilitate wider dissemination

of filters in homes in targeted

communities surrounding Santa

Lucia

Water purification

• Potters for Peace• Low-tech, low-cost

colloidal silver-enhanced ceramic water filter

• 99.98% effective• 1-3 Liters/Hour• $15.50 per pot

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Expanding the Organization

• New affiliates joining the group, and forming new community partnerships

• As a growing organization, need new oversight structures in the US and in Honduras to manage the expanding number of affiliates and the additional community health projects.– Development of Shoulder to Shoulder

International

Expanding the Shoulder to Shoulder Model: Affiliates Relating to the International Board

New Programs

Thundermist HealthCenter

Baylor University

UniversityOf Rochester

UniversityOf Pittsburgh

UniversityOf Cincinnati

STSInternational

STS International:

•Technical Expertise

•Development of Project objectives

•Project oversight in country

•Legal services

•Customs clearance

•Sharing of resources

•Grants

•Collaboration with other NGOs

STS Clinic in Santa Lucia

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Shoulder to Shoulder

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Our web page:www. Shouldertoshoulder.org

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