Introduction to San Jose Project

 

Program Philosophy
Project History
Key Faculty Personnel
Feeding Program Philosophy
Free Med Philosophy
Brief Project Summaries

Cookstoves
Water Filters
Latrines
Pilas
Piped Water Projects
Fish Farms
Fluoride Program
Microfinance
Scholarships
Student Education
Health Education
Parteras/Health Volunteers
First Aid Kits
Child Health Initiative

 

Program Philosophy (Why we do things the way we do)

We have partnered with one community to improve the long term health of that community in a sustainable manner. When an individual is sick, we believe curative medicine is essential to offer. However, curative medicine does not improve the health of a community, and is not sustainable for long term community health. Therefore, we work with the community to identify the main contributors to ill health and create interventions to combat the causes of ill health. Many of the causes of ill health are not addressed by curative medicine. This requires stepping beyond our comfort zone and getting into disciplines such as water and sanitation, nutrition, agriculture, banking and education. We attempt to make interventions in a small, low cost manner in an effort to increase long term sustainability from the community perspective. We anticipate sustainable changes will take a generation to realize. The community and our Program do our best to work in a collaborative manner. We are very aware that the Hondurans are very intelligent and hard working. They also better understand their problems than we ever will. We are very cognizant of our many mistakes, but we continue to learn from our mistakes and make small, steady improvements in our interventions. We also accept that communities and their needs/problems change over time, so constant adaptation is required.

If one looks at the time line of the human race, it is only in the last 100-150 years when significant advances in personal health and wealth have occurred for a small percentage of the human population. This 150 years is a tiny spot on the 10,000+ years of humanity. Although we from the developed world like to think of our ways as superior, we have only enjoyed our ease of life for a very brief time. We are not better, just fortunate (possibly) to be born in a country that has advanced a bit faster than less developed countries. Our goal for our work in Honduras is to accelerate the development process to improve health outcomes for all in a sustainable manner. We do not believe our society is the best long term answer for humanity and we hope that through the collaboration of our two cultures, we can find a sustainable solution that is good for the Hondurans and for the planet.


Project History

In 2002, the Department of Family Medicine of the University of Rochester School of Medicine decided to extend their collaboration with the under-served to people in the developing world. Given we are a residency training program first, we needed to choose a location that was easy to get to and not cost prohibitive. Additionally, we needed support on the ground in Honduras. Shoulder to Shoulder was looking for institutional partners so the collaboration was born. Our first trip to Honduras occurred in October 2003. The first 2-3 trips were more curative medicine-based as we searched for a Honduran community to partner with. In 2005, we chose the community of San Jose San Marcos de la Sierra in the Departmento (State) of Intibuca. More information is available here.


 

Key Faculty Personnel

  • Douglas Stockman, MD. Director, Global and Refugee Health Program. The direction and the philosophy of the Global Health Program is primarily due to Doug's vision. All other key players in the Program adapt and expand that philosophy as we constantly improve. He has the most experience overseas and has gone on every trip to Honduras since 2003.

  • Barbara Gawinski, PhD. Associate Director, Global and Refugee Health Program. Barbara is responsible for ensuring residents meet all GH requirements, Scholarship and educational programs, collaboration with our main donor – the Unitarian Church of Rochester, and for the emotional side of the experience.

  • Stephen Schultz, MD. Residency Director. Steve was instrumental in creating the GH program and is highly committed to the success of the Program. He and his staff control when the trips to Honduras occur and which residents go on which trip.

  • Lindsay Phillips, MD. She is a family doctor who works at East Ridge Family Medicine and is an enthusiastic and key member of our Global Health Program. She created and manages a number of our successful projects including: micro-finance, maternal child health and First Aid kits. She also collaborates with Barbara G. with educational activities, Scholarships, and the interface with the Unitarian Church. Given her love of hiking and her enthusiasm, she also maintains on the ground relations with the distant community of las Delicias.

  • Lina Vega, DDS. Lina is a general dentist in Rochester and runs our Dental program. She provides curative and restorative activities when in Honduras, and manages our fluoride rinse program.

  • Laurie Stannard, FNP, DNP. Laurie is a nurse practitioner at Highland Family Medicine. She is an active participant who travels to Honduras on a regular basis and manages many programs when on-site.


 

Why we do not have a feeding program or feed local people while we are in Honduras

Feeding programs create dependency. The people being given free food become dependent and at some level, entitled, to free food. It reduces a person's drive to expand their food production capacity. Our program also becomes dependent on donors to support a feeding program long term. Except in starvation situations, it is much better to help people find methods to increase their own food production and become self sufficient. People in the served communities have been dealing with food security issues for thousands of years. We believe it is much better to invest 20-40 years in improving food security in a sustainable manner that does not breed dependence. If you see a hungry person in front of you when you are here and give them a meal, yes you have helped them for that meal. But there are hundreds of millions of other people around the world who are just as hungry. What happens to that person you fed, when in 2 weeks you are back at home and not giving them free food. They and the millions of others are out there just as hungry, but you can more easily ignore their plight while you are home. Some argue that by giving a handout, you are treating yourself; your own guilt about you having and others not having. Does that help the poor person long term?


 

Why we charge for medications

Someone has to pay for the medicines. If the Honduran government will not provide medicines, then either donors or the recipients of medicines must pay. We use the revolving drug fund approach to keep costs to a bare minimum that is affordable for most local people. It makes them responsible for the appropriate use of the medicines. It also avoids dependence on outside agencies. This increases long term sustainability. People generally value anything they have to work hard for or pay for, more than free handouts. A number of S2S programs have run into financial difficulties because of providing free medicines. We have also found that when medicines are provided for free, the majority of patients presenting to the clinic are not actually sick. They are making up symptoms in order to obtain free medicines. Sometimes this practice has become so bad that dispensed medicines are found in local markets for sale. Another common scenario is when a person states they do not have enough money for a specific medicine (such as an antibiotic), then they pull out additional money to buy soap or shampoo. Infrequently, we will provide essential medicines for a very poor person, but it needs to happen rarely.

We often perceive almost everyone in the project area as very poor – and they are from our reference point. However, when local people are asked to identify the real poor in their communities, they identify 1-2 out of 100 families.


 

Brief Project Summaries

The following is a brief introduction to many of our interventions. Many of these introductions have links to more detailed reports. The purpose of the brief introduction is to rapidly orient others to the activities of our Program. It provides a general overview. The detailed reports can be used by trip participants to manage specific programs when they are at the Project site. The detailed reports are created by prior trip participants who were in charge of a specific project. 

 

Cookstoves

The traditional cookstove in Southwest Honduras consists of a flat metal plate placed on some rocks over an open fire. The flat metal plate is ideal for cooking tortillas, but the open design makes the kitchen very smoky, increases the risk of burns and is wasteful of firewood. We have modified existing stove designs to meet the needs of our community and then taught local people how to make the improved cookstoves. Although there are more efficient designs out there, the one we have chosen is easily made with local materials and easily repaired by the homeowner.

The technology of designing and then building a cookstove is easy. The hard part, as always, is the people. We have created a specific approach that has worked well for our group. Given local people do not have much money, we subsidize the cost of the purchased parts ($45-$50) and request they use their labor and local resources.

For each cookstove, the following applies

  • Recipient must complete 2 days of communal labor (about $6 equivalent for local pay rate)

  • Recipient must pay L100 ($5) for stove parts

  • Recipient must attend a Charla (class) where they learn how to build a cookstove

  • Recipient must provide all locally needed materials: build the table for the stove, provide the mud, rock, and metal can.

  • We provide the plancha (metal plate), ree-bar to support the plancha, 6 feet of chimney, 3 mud bricks, and a small bit of cement to seal the roof perforation.

When the above conditions are met, a foreman we pay ($5) helps build the stove and ensure the stove meets our minimum standards.

Challenges

  • Cookstoves are not sustainable at this time. Most local people do not have the $45 to build on their own. Through other interventions, we are attempting to improve their financial reserves so replacing broken parts becomes possible. The plancha (flat metal plate) is the most costly part and does wear out after a few years. They cost about $25. When a replacement is needed, we charge $15 at this time.

  • Some people elect to enlarge the hole where the wood is fed into the fire. This increased the heat output of the stove and allows larger wood to be inserted. The downside is that the efficiency goes down and more wood needs to be collected.

Cookstove details


 

Water filters

We introduced a modified Potters for Peace (PfP) filter into the area around 2008. See this link for more details. Another filter we have introduced, but is more costly, is the slow sand filter. We charge $2 for the PfP filter that costs $18. The local population does not have the financial ability at this time to pay the full price. As of 2013, we are considering increasing the price. Given the PfP filter does not filter water quickly, many families request 2 filters. We have not done this yet, but we may consider using a tiered cost structure. An example might be L60 ($3) for the first filter and L200 ($10) for the second filter.

Education about cleaning and using the Potters for Peace filter

  • We place the valve on the bucket for the owner.

  • Review small amount of chlorine in water inside the plastic bucket and swirl around until all inner surfaces are coated. Drain the chlorine water out of the valve.

  • From then on, the outer surface of the clay pot and the inner surface of the bucket should not be touched, unless retreated. If algae grows on the surface of the clay pot, it can be gently scrubbed off with a boiled brush or rag, ensuring the hand does not touch the surface.

  • The outer surface of the clay pot should never be set on any surface or contamination will occur.

  • Chlorine and chlorinated water should never be placed onto the clay pot surface. This will disabled the silver emulsion layer that is bacteriostatic.

  • Review the fragility of the filter. They may want to tie the bucket down so it is not knocked over during daily use.

Potters for Peace filter details

Slow sand filter details


 

Latrines

When we arrived in the San Jose area, most homes did not have latrines. People relieved themselves outside, around the house. This can increase disease transmission, both fecal-oral and fecal cutaneous (such as hookworm). Interest in latrines was initially low, but gradually community members started to accept the benefit of reduced exposure to bodily waste. We discussed various latrine designs: particularly the Ventilated Improved Pit (VIP) latrine and the composting latrine. People were adverse to the concept of emptying the composting latrine so we focused on the pit latrine. A third option that is most desirable for people with adequate year-round water is a flush latrine. Water is poured into a simple latrine bowel to flush the latrine. Although the flush latrine has many benefits, a significant proportion of local people that have installed flush latrines through a government-sponsored program, do not have the water to operate the latrine. Therefore, they must still relieve themselves around the house.

For each latrine, the following applies

  • Recipient must complete 2 days of communal labor (about $6 equivalent for local pay rate).

  • Recipient must dig the 3 meter (~10 foot) deep hole.

  • Recipient must attend a charla (class) on how to build a latrine

  • Recipient must provide all local materials and labor.

  • We provide all outside materials

We do not charge money for latrines at this time. Digging the hole can take many days of back-breaking labor. We felt that was payment enough. Additionally, latrines can last for many years.

Latrine details


 

Pilas

A pila is a cement tank that is the Swiss army knife of a Honduran's kitchen. It is a water storage tank, the kitchen sink, a place to prepare food and do laundry, and even a place to give a baby a bath. Although we have always worried about the water storage aspect as a place to grow bacteria, we have given in to the necessity of the pila in the lives of rural Hondurans and encourage people to filter any water coming from the pila before consuming. Pilas can be built with cement block or locally gathered rocks combined with cement or concrete. We have chosen to support the lower cost approach of using rock and concrete. Each pila costs about $100 to build. The Hondurans are very skilled at building a pila, so our main assistance is monetary. Fortunately, pilas can last for many, many years so sustainability is not a big issue. Given the significant cost, we are slowly supporting pila construction.


 

Microfinance

It has been said that in absolute poverty, there can be no health. Given a significant proportion of the population we work with lives on less than $2 a day, we started a micro-loan program that is right-sized for our population (i.e. very small loans). We realize that unless we can bring new cash into the area, everyone will remain poor. The long term hope is that small businesses we help start will grow enough to hire local people and have “wealth” diffuse to others in the community. Reducing poverty is essential to long term sustainability of many of our interventions such as cookstoves and water filters. Unless a person has enough financial reserves to replace worn out parts, our interventions have not achieved sustainability. Loans start out at $25-$50 for a new applicant and go up to about $150 for a person who has successfully paid back prior loans and their business is going well. We employ a revolving approach to loan funding. When a loan recipient does not pay back a loan on time, we grant less new loans because there is less money available for loaning. Prior to getting a loan, an interested person must attend a business class on basic concepts. They then create a loan application and this request for a loan is reviewed and granted or denied based on the business plan and a general appreciation for the character of the person. As of November 2013, we have started using local people to help determine the chance of success for repayment for specific individuals.

Common local businesses include: gathering fruit locally and transporting to a city to sell; making tamales or bread that is sold at markets and social events; creating small bodegos; and raising chickens or pigs. We charge 2% interest every 6 months and expect loans to be repaid in 6 months. Women are much more likely to repay a loan than men. The only long term defaulters on loans to date for our program are men.

Microfinance details


 

Scholarships

When we first started working in the San Jose area, primary school enrollment was very high but only about 5 students in the San Jose area attended middle school. The main barriers were cost, and for some students the 1.5+ hour walk to the nearest middle school. Our main donor, the Unitarian Church of Rochester, saw this situation as a need and offered to fund children to attend middle school. Both our group and the Church believe that improved education is a long term investment that has a high potential to combat poverty. Additionally, the more education a woman has, the better the health of her family. The Church funds about 3-10 students per grade from 7th through 10th grade. We found that many of the students coming out of the San Jose schools were ill prepared for middle school so we identified a tutor to help our students get up to speed. As of November 2013, two women are in 11th grade and have a good chance of finding jobs that will support them and possibly allow money to be sent back to the family of origin.

Scholarship details


Student education

 

 


Health education

 

 


Parteras/health volunteer education

 

 

First aid kits


 


 

Piped water projects

When San Jose residents were asked what the biggest problem facing their community was, they responded: “access to water”. It is not uncommon for inhabitants to spend 1-3 hours a day hauling water up mountainsides for domestic use. We have worked with local people to identify naturally occurring springs with adequate water flow even in the dry season to be harvested and piped to local homes that are below the water source. As of November 2013, we have helped 5 communities install piped water systems and are working on a new piped water system in Delicias-Coyolar. We provide the technical know how and raw materials. The people who will benefit from the piped water project do all the work. This often involves digging kilometers of trench using a pick ax and shovel, carrying heavy loads to their distant community, and finally, learning how to and then assembling the piped water system.

Piped water project details


 

Fluoride program

Children who use a simple fluoride rinse twice a week have less cavities and less pain from existing cavities. We have introduce a twice-weekly fluoride rinse in area school. We purchase and bring packets of fluoride to Honduras and have educated teachers on correct mixing and application of the fluoride rinse. We are exploring ways to improve delivery, particularly when children are on extended vacation.

 

 

 


Child Health Initiative

 


 

Fish farms

Inadequate quantity and quality of food is felt to be a significant contributor to under-nutrition in the San Jose area. One simple intervention we started was the creation of family-level fish farms. The general concept is quite simple. A home owner digs a hole in soil that can hold water. Water from a local spring is brought through pipes to the hole. Tilapia fry are introduced into the water-filled hole. In about 6 months, Tipalia are harvested for both the family's needs and sometimes for sale. At locations where the soil can hold water and there is a nearby year round water source, fish farms have been very successful. The fish farms can pay for themselves and provide food for the table. Given the paucity of water available from local springs, fish farms have limited penetration, but the intervention is great where applicable.

Fish farm details

 

Detailed Project Information