Establishing a Sustainable Partnership Through Short-Term Global Field Experiences: The University of Florida and Canton el Limón Collaboration

Student and faculty interest in addressing issues of global health has shown a remarkable increase in recent years.¹ International experiences among medical students have increased such that 27.5% of U.S. and Canadian medical students reported participation in a global health elective in 2008.² Medical, nursing, and public health schools have all attempted to meet this interest by providing short-term courses in developing countries. Limited by cost and time constraints, however, many of these short-term international health trips are fraught with challenges. Labeled as “medical tourism,”³ these trips are often critiqued on the basis of (1) self-serving interests, without meeting community needs; (2) raising expectations that cannot be met; (3) providing temporary fixes ineffective in addressing root causes of health problems; (4) imposing burdens on local health facilities; or (5) failing to follow standards of health-care delivery, such as continuity or sustainable care.¹ Too often, quantity of patients treated takes precedence over quality of care, with little effort to transfer skills to the local health workers to maintain a sustainable change in the community.⁴

The University of Florida (UF) has created a spring break course within the College of Public Health and Health Professions in El Salvador, with an aim to overcome these challenges faced by short-term international medical trips. The goals of this course are to provide students with the opportunity to gain public health field experience and knowledge, and work toward improving health for the local people, while building a sustainable relationship between UF and the local community. This article is intended to provide a framework to help guide other public health or medical school trips that wish to achieve similar goals.

Our model for an international spring break, health-focused course emphasizes multidisciplinary and multisector partnerships with a primary goal of sustainability. Our initial two-year UF-El Salvador collaboration is an example of this approach. From joint public health and anthropological perspectives, we actively engaged with the community at a local, regional, and national level, initiating sustainable changes that can be continued in our absence.

BACKGROUND

The country of El Salvador fought a violent and lengthy civil war from 1980 until 1992. The war in El Salvador, along with the wars in Guatemala and Nicaragua, is considered to be “among the most severe conflicts in the 1980s and 1990s.”⁵ The origins of the war were partly the result of 50 years of undeviating military rule⁶ and inequalities that the country faced.⁷ In 1992, an exemplary peace declaration was signed that initiated the transition to peace in the country. The transition process included the transformation of the insurgent group into an established political party along with the dissolution of the national police and national security forces. The latter were transformed into the National Civil Police, which was intended to be under the control of the executive branch of government.⁶ Unfortunately, the socioeconomic conditions of the poor and the concentration of power by the elite—some of the factors that contributed to the war—have remained unchanged.⁸

In our intervention, we focused on the area of Morazán, given that it is currently the poorest department of El Salvador and historically was where political turmoil was the most concentrated during the 12 years of civil war.⁹ Furthermore, the people of Morazán were also victims of several massacres by the military, including the massacre in El Mozote, where more than 1,000 people lost their lives in 1981. The turmoil in Morazán was the result of the strong presence and hold of the revolutionary group Farabundo Marti para la Liberacion Nacional (FMLN) that launched its first military offensive from Morazán in 1981.¹⁰ This offensive turned Morazán into the “geographical rear guard of the insurgency, its northern part serving as a guerilla stronghold.”⁹ The continued presence of the FMLN, therefore, shaped the way people live and also the current politics that affect health care and access to resources between the ruling party and the local governments of Torola, which are governed by the FMLN.

El Salvador, as a whole, has experienced extreme health and social disparities among its citizens. Approximately 36% of the population is below the poverty line and it has a Gini Index of 52.5;¹¹ this was also observed when the students were able to compare the opulent parts of San Salvador with the community of El Limón, which lacked running water, electricity, and sanitation services.

PROGRAM DESCRIPTION

Our program began in 2007 as a spring break course option for public health students at UF. During this first trip, the students and faculty endeavored on a public health assessment in Morazán. The assessment was accomplished through visits to and meetings with the national hospital “Rosales,” National University officials, the U.S. Agency for International Development (USAID) offices in the U.S. Embassy, and different clinics of northern Morazán. Based on the group's experiences and assessment, El Limón was chosen as the focus of future collaborations.

Prior to each trip, students engage in research and discussions to become familiar with El Salvador. To maximize the program's impact, each year the subsequent group traveling to El Salvador develops its work plan based on the final reports of the previous teams. In 2008, the students were divided into two groups: an intervention group to work primarily in the community of El Limón and an epidemiology group to work with the Perquín Health Center. The students also gathered donations of clothing, toys, dental, and medical supplies to distribute.

Upon arrival, we first met with the director of the Perquín Health Center, who educated us about the health conditions in Morazán and communicated the community's expectations to us. We were also educated about the New Model Health Plan, a new initiative being tested by the Ministry of Health (MOH) but yet to be administered in El Limón. The New Model Health Plan started in November 2006 as a pilot program with hopes of making it a national strategy by 2009. The program places more emphasis on prevention, such as implementing behavior change, than on treatment. The program maintains separate health files for each family, which allows better record-keeping for follow-up on noted issues and conditions. Health teams are sent to the homes to identify root causes of health problems, such as the lack of potable water, and reasons why people do not travel to the clinics (e.g., poor road conditions or arthritis). The main barrier that the MOH faces is a lack of human resources.

Upon learning about the New Model Health Plan and the need for its implementation in El Limón, we paired with the Torola Health Clinic to conduct the surveys and health assessments in this community. The Torola medical team taught us how to conduct the health assessments and surveys as well as how to distribute Puriagua, a chlorination agent used to purify drinking water. After the Torola medical team trained us, we split into two groups, each group with a medical doctor, to assess the rest of the community. In total, our team visited 21 of 26 houses. We believe that by adapting our work plan during our visit based on new findings, we were better able to benefit the community of El Limón.

Water purification is a major issue in El Limón, as there is no local source of potable water. Instead, the residents obtain their water from small surrounding water sources, many of which are at least a 15--minute walk from their houses. Our intervention group mapped the location of the nearby water sources using a global positioning system (GPS) unit.

During this period, the epidemiologic team met with the director of the Perquín Health Center to learn about the center's current epidemiologic methods and how we might help improve them. On their last day, the epidemiologic team gave an educational lecture to the 26 regional directors of clinics in Morazán, with the purpose of updating the directors on their epidemiologic principles. Additionally, the team committed to future involvement with the clinic in the form of correspondence via e-mail and plans for future visits.

To finalize our visit, we met with the Vice Minister of Health in San Salvador to explain the purpose of our project and to form future collaborations in assisting the community of El Limón. By bringing this remote village to his attention, particularly the problems with access to clean water, we hope to have made a positive impact that will lead to improved health in this and other communities in the more remote regions of the country.

STUDENT OUTCOMES

The students gained practical experience on how to perform public health assessments of communities, as well as firsthand exposure to international public health issues. They were immersed in socioeconomic conditions they had never before experienced, which armed them with immediate and personal knowledge of the situation of underserved populations of the world. For example, students were mainly surprised to learn of the lack of water resources in the community as well as how inaccessible the community was to surrounding areas. This new insight into the conditions of extreme poverty was a revelation for many students, changing their perspectives on public health and, for some, even shifting their future career choices.

Learning how to collaborate and network with the different stakeholders was another important accomplishment. Students met with USAID officers based in San Salvador, members and faculty of the public health college from the National University, nongovernmental organizations (NGOs), community leaders from Morazán, the mayors of the towns visited, and the Vice Minister of Health. These visits gave them the opportunity to compare each stakeholder's roles and responsibilities, while helping them understand why it is important to include all relevant interest groups of a community when starting a health program or intervention.

COMMUNITY OUTCOMES

Much like the students, the people with whom the students worked and collaborated also benefited from the experience. In Perquín, a sustainable research collaboration has formed between the Perquín Health Department and UF. The collaboration involves education initiatives including training of physicians in Morazán and the continued communication between the director of health for Perquín and the Department of Epidemiology at UF. In addition, UF and the Perquín Health Center have worked together to obtain resources that the clinic needs.

One of the most significant outcomes the -communities experienced was the building and strengthening of relationships among Torola, Perquín, and El Limón. Despite the political boundaries, we managed to open the lines of communication between the communities and subsequently introduce Torola health workers to El Limón. The community members of El Limón stated that this was the first time the health-care workers had visited the community to provide health care and evaluations, a major breakthrough for the community members who had not left El Limón for more than 10 years due to physical limitations. We are hopeful that the health workers will continue to assess El Limón.

SUSTAINABILITY

One of the unique features of our spring break course is the explicit effort to initiate and maintain sustainable change in the local community—a feature often neglected by other international programs.¹ Most importantly, our course is designed to return annually to the same community, so that our commitment is reinforced by our continued presence and mutual collaboration. However, we seek to avoid a paternalistic approach, where the community waits for our next visit without playing an active role in addressing their health issues. This will be achieved by empowering the community to be the owners of the project and to be held accountable, together with us, in maintaining the collaboration between UF and El Limón, and building upon the progress initiated by succeeding generations of students. Additionally, a student government group has been established to facilitate fundraising and education of other students about the program.

To maintain our linkages in El Salvador, we have formed collaborations with a local NGO called Centro de Capacitación para la Democracia (CECADE), which serves as a link of communication with Torola and Perquín. By joining forces with this NGO, along with local physicians and members of the health department of Perquín, our commitment to the health of this community will be upheld year-round, and not just restricted to the short spring break visit. Not only do they continue the work we initiated, they have already begun to provide regular feedback from the community regarding the status of health and changes brought about by our efforts. Also, our faculty course director has managed to visit the community twice since spring break. Furthermore, our collaborations with the Peace Corps, community leaders, the Vice Minister of Health for El Salvador, and the National Hospital and University will strengthen our ties with El Salvador throughout the year, so efforts can be maintained even in our absence. We have even involved local business owners in helping with fundraising for the community by facilitating the sale of Salvadorian handicrafts in the U.S. All of these sustained interactions have ensured our commitment to the health of this community, and have contributed to the formation of a deep bond between the UF students and the people of El Limón. Perhaps the most significant indication of the depth of the relationship between the two parties is the use of the word hermanos, implying trust and respect by the community in reference to the UF students and faculty.

PRELIMINARY OUTCOMES

Although we have described an elaborate framework for a sustainable program, it may take years to assess the true effects and to determine its true sustainability. Once our impact has been felt for a few years, we plan to compare the current health of the community to the initial health based upon data reported by the MOH in Perquín. The MOH has shared key health indicators from the assessments done from our team and the Torola health workers (Personal communication, Dr. Erick Gomez, Medical Director, Unidad de Salud de Perquín, Morazán, El Salvador Ministry of Health, May 2008). One of the main health issues found was the high rate of dental caries and gum disease among both adults and children. Additionally, migraines, depression, arthritis, hypertension, and drug/alcohol abuse were health issues found among adults. The MOH reports that approximately half of the children in this community had signs of malnourishment defined as below normal growth based on age, height, and weight (Personal communication, Dr. Erick Gomez, Medical Director, Unidad de Salud de Perquín, Morazán, El Salvador Ministry of Health, March 2008, August 2009). Although many health issues were identified, community members only stated limited use of health-care resources.

It is our hope that repeated visits in upcoming years will continue to improve health-care access and to reinforce the behavioral changes we have recommended to the community. For example, the community is educated annually about the importance of dental care and adding Puriagua to their drinking water. Also, by repeatedly taking Torola health members to the community during our visits, we hope that they will make visits on their own and educate the community about more of their health-care options. However, as behavioral change can take years to achieve, we will not be able to assess these changes for a few more years. It is our hope to have future involvement of -engineering, pharmacy, medicine, and dentistry students in our program, which will help alleviate problems with health-care accessibility and, in particular, help reduce dental issues in the community.

Students and faculty returned to El Salvador and the community in 2009. Enthusiasm about the interventions and the value of working with the community has motivated students and professors from other health science disciplines to join the trips, most notably from pharmacy and medicine. The meetings the students and faculty had with MOH officials have also borne fruit: electricity and water supplies are now being brought to the community.

FUTURE DIRECTIONS

We plan to expand our efforts in future years by applying for additional funding to allow more frequent visits and larger intervention projects. For example, the community has recently expressed the desire to establish a small-scale farming initiative to increase the skill set and income of the village as a whole, which will also create a more substantial food supply and benefit the health of the community. In pursuing this goal, we hope to provide the tools to enable the community to improve its living conditions. We would also like to help the community gain easier access both in and out of their village.

To achieve these and other future goals, we plan to expand our participants to include an even more interdisciplinary cross-section of the UF community. We have invited students of engineering, medicine, pharmacy, and dentistry to join our program. Dental students have already expressed interest in attending next year's course, which is fortuitous as dental caries is one of the leading health problems of the community. Moreover, our faculty course director and a UF faculty member from the Pharmacy College recently visited the College of Pharmacy at the National University of El Salvador and met with the Vice Minister of Health to establish a collaboration to add pharmacy students to our efforts in El Limón and in the MOH regional clinic.

CONCLUSIONS

Despite the challenges faced by short-term international health trips, we believe that meaningful and sustainable health improvements can be achieved. Our program provides a model that can be replicated by other schools of public health. We believe the keys to a successful impact, even in short-duration courses, reside in the establishment of wide-scale partnerships with local and national stakeholders, maintaining these relationships through communication throughout the year, and annual returns to the same location. Furthermore, we value a broad interdisciplinary base, where students from multiple colleges within the university can contribute skills and ideas. By working with the community to identify and meet their needs, we are facilitating an exchange of knowledge and skills that will benefit both the students and the local people for years to come.

Cooking area of family home in Canton El Limón, Department of Morazán, El Salvador. Photo by Dr. Alba Amaya-Burns

Living, dining, and bedroom areas of a family home in Canton El Limón, Department of Morazán, El Salvador. Photo by Dr. Alba Amaya-Burns