Ecuador: Listening to a Community and Building Partnerships

BY ADAM BECKMAN AND NORA MORGA-LEWY.
Photography by Adam Beckman and Nora Morga-Lewy.

SPGH article picture“Why are you working on HIV in Ecuador?

This question has challenged Yale undergraduates, MPH candidates, and Global Health Fellows who comprise the former Yale-Ecuador HIV Clinic Initiative. Each of us has lived for up to twelve weeks in a small Ecuadorian town, dedicated full-time to research projects, an education initiative, and a testing clinic – all focused on HIV. Given that less than 0.4% of Ecuadorians are HIV-positive, “Why HIV?” is an excellent question.[i] For the past fifteen months, our organization – now Student Partnerships for Global Health – has tried to respond. We have reevaluated the work our group does and why we do it, and have devoted ourselves to new community-based projects.

In 2010, Yale junior, Sam Vesuna (YC ’12), interned in Guayaquil, Ecuador. In the middle of the summer, he met a doctor who invited him to visit a government hospital three hours away. The two arrived in Manglaralto, a coastal village of 6,000 with dirt roads, a quiet beach, and small concrete houses. Towns like Valdivia, San Pedro, Olon, and a dozen others – most described by the World Health Organization as severely impoverished – surround Manglaralto. Every year, more than 20,000 townspeople flock to the modestly sized Manglaralto Hospital for care including immunizations, prenatal check ups, simple lab tests, and C-sections. The six doctors there see as many as ten patients an hour. Inspired by conversations with the hospital leadership about the need for an HIV testing and education program, Sam and the Hospital Director created a plan for Yale students to return the following summer to assist the laboratory with an HIV testing campaign. Six months later, Sam had connected with Fundación VIHDA, an NGO working to prevent vertical transmission in a region of Ecuador with disproportionately high rates of HIV,[ii] and recruited a small group of passionate students to found the Yale-Ecuador HIV Clinic Initiative.

For three summers, Yale students returned to this site and built on the initiative that Sam had launched. With Yale School of Public Health faculty advisors, each cohort of students collected data as part of collaborative research projects. For instance, Stewart Dandorf (YSPH ’12), Hilary Rogers (YC ’13, YSPH ’14), and Farrah Khan (YC ’13) published an evaluation of barrier to HIV testing at Manglaralto Hospital. Fabi Fernandez (YC ’15, YSPH ’16) and Hannah Mogul-Adlin (YC ‘14) conducted an ethnographic study of sex-work in Ecuador, looking at the effects of legalization on power dynamics and condom usage. Katherine McDaniel (YC ’14), Erinma Kalu (YC ’14, YSPH ’15), Adam Ford (YC ’13) and Lauren Mellor-Crummey (YC ’14) investigated the effects of machismo on perceptions of HIV. In addition to surveys and qualitative interviews, over spring break and summer trips, YEHCI members collaborated with Fundación VIHDA to assist Manglaralto Hospital in conducting over 2,300 HIV tests. Starting in 2011, YEHCI teams also formed relationships with three local schools and delivered short presentations about HIV and sexually transmitted diseases to over 6,000 people. Each year, the new student group had the advantage of being able to build on the work of past teams.

Our partners in Ecuador as well as students and faculty at Yale have, over the years, emphasized the many benefits that YEHCI offered to those involved. Manglaralto Hospital, Fundación VIHDA, Colegio Fiscal Técnico de Manglaralto, and other local partners have told us how they value growing multi-year partnerships with a group of students, rather than receiving volunteers one summer for a few weeks with little to no follow-up. While college students returning from global health field experiences often report, in hindsight, feeling underprepared,[iii] YEHCI participants benefited from many weeks of meeting with Yale students from previous trips to prepare research projects, discuss aspects of the local culture, and learn from the challenges that past students faced at the site. Faculty members at Yale, and other global health experts who advised us, valued the fact that each summer team was interdisciplinary, composed of a combination of freshman, sophomore, juniors, medical students, MPH candidates, and nursing students. For these reasons, YEHCI grew every year, and each fall more Yale students apply for the available spots.

Even with this positive feedback, the organization kept returning to a fundamental question: What is the purpose of our work? Some would argue that any global health field experience that does no harm and exposes students to new or surprising perspectives is worthwhile, especially if their time in low- or middle-income countries leads them to devote parts of their adult lives to underserved populations. Yet in meetings with Professors Richard Skolnik and Kaveh Khoshnood, two of our primary faculty advisors, we pushed ourselves to consider whether we were adding the most possible value in our work, including whether HIV was a top concern to the people in the community where we worked. We centered these conversations around data from our past projects, and carefully considered what it would mean for the “Yale-Ecuador HIV Clinic Initiative” to stop its work on HIV. While Professors Skolnik and Khoshnood encouraged us to continue the research projects we had already spent four months preparing, everyone in the room ultimately agreed we would also use our time in Manglaralto in the summer of 2013 to re-evaluate our projects with an eye to the future.

SPGH article picture 2

In the midst of conducting research, education, and testing projects this past summer, the eight summer team members devoted many hours to discussing with members of the community what our role should be going forward. In these conversations, we forced ourselves to keep the possibility on the table that we had no business returning to Manglaralto again; our primary concern was to understand the needs of this region and to determine, with our partners, whether we truly could add any value. When we conducted an informal needs assessment with a sample of sixty community members, the results showed that adolescent pregnancy, diabetes, and hypertension were the leading issues. Conversations with local government officials, doctors at the hospital, members of El Juvenil de Desarrollo (a group of local young adults), and widely respected community elders highlighted these same health concerns.

Although our time was limited, we tried to respond right away to what we were hearing. Led by Ariel Kirshenbaum (YC ’14) and Sophie Shimer (YC ’14), we worked with Colegio Fiscal Técnico de Manglaralto to facilitate classroom conversations about sexual relationships using a curriculum reviewed by the school’s administrators. This job required our extreme sensitivity to cultural differences, and a specialist at the World Bank advised us via Skype that we were approaching the issue in the right way. In addition, Isabel Beshar’s (YC ’14) research on risk perceptions of diabetes enabled us to learn more about NCDs in this area of Ecuador. Towards the end of the summer, we met a nurse at a non-profit clinic, Futuro Valdivia, who began discussing with us future projects about NCDs and malnutrition that would greatly benefit the people that her clinic serves.[iv]

When we returned to Yale, we built on this groundwork to found Student Partnerships for Global Health (SPGH). SPGH begins with an understanding that there are vast disparities in access to health care and health education throughout the world. While we as students are not trained physicians or public health experts, we are passionate about doing anything we can to reduce inequality and the burden of disease. Our aim is to learn about a community and ask: How can we use our skills and resources to address a public health problem in partnership with existing in-country organizations? With collaborative, interdisciplinary student teams, we use any skills we can offer (survey collection, data analysis, education) to assist in addressing a specific public health problem in each community with which we are working. The projects abroad are done with long-term commitments to our partners and future members of the Yale organization itself.

This mission will guide two teams this summer, one in Manglaralto, and the other in León, Nicaragua. The team returning to Manglaralto will carry out projects that have been designed directly with the staff at Futuro Valdivia and other partners. For example, José Gutierrez (YSN ‘16) will lead a project evaluating a program for two hundred malnourished children at Futuro Valdivia, supported by the Downs Fellowship.[v] The León team will work in collaboration with Universidad Nacional Autónoma de Nicaragua-León and the New Haven-León Sister City Project. Kimberly Vasquez (YSPH ’15) will lead the qualitative portion of an investigation about ARV adherence at a clinic of HIV-positive patients, also supported by the Downs Fellowship.[vi] Since October, members of SPGH have met several times per week and – in addition to arranging the details of the summer projects – have prepared by speaking with experts from AYUDA (a diabetes organization in Ecuador), the Ecuadorian Ministry of Health, the Pan American Health Organization, the Inter-American Development Bank, and more. Additionally, led by Rachel Wilkinson (YC ’16), members of the SPGH Campus Team this semester organized a weekly speaker series to hear from Yale faculty experts before the summer teams go into the field.

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Global health work confronts complex issues with limited resources and it involves collaboration with partners who are often thousands of miles away; requires cross-cultural sensitivity; and demands adaptability and resourcefulness for surprises in the field. This work is even harder for students, who are often further constrained by lack of experience, resources, on-site knowledge, and preparation time.[vii],[viii]

These were the challenges we grappled with as we asked ourselves the question, “Why HIV in Ecuador?” And over the last year and a half, we have strengthened and evolved our partnerships to develop the most rigorous, relevant projects we can. We believe that these interdisciplinary teams, working closely with in-country partners, Yale faculty mentors, and student support, are best equipped to make meaningful contributions to host communities.

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[i] (UNAIDS) UJPoHA. Global Report: UNAIDS Report on the Global AIDS Epidemic: 2010. 2010.

[ii] The NGO emphasized that three out of four people with HIV do not know their status, and the literature described Ecuador as a country at risk for a growing epidemic.

[iii]Hetherington, Erin, and Hatfield, Jennifer (2012) ““I really wanted to be able to contribute something”: understanding student motivations to create meaningful global health experiences.” Canadian Medical Education Journal 3:2, e107-e117.

[iv] The rest of the Summer 2013 team included: Maggie Wilson (YSPH ’14), Nicola Soekoe (YC ’16), Vishaal Prabhu (YC ’14), Adam Beckman (YC ’16), Julia Randall (University of Mass. Medical School ’16), and Rahela Aziz-Boze (University of Mass. Medical School ’16)

[v] José’s fellow team members include: Sarah Merchant (YC ’17), Lily Vanderbloemen (YC ’16), Stephanie Granada (YC ’15), and Suhana Sarkar (YSPH ’15).

[vi] Kimberly’s fellow team members include: Dan Michelson (YC ’17), Sarah McAlister (YC ’16), and Natalia Forbath (YC ’15).

[vii]Hetherington, Erin, and Hatfield, Jennifer (2012) ““I really wanted to be able to contribute something”: understanding student motivations to create meaningful global health experiences.” Canadian Medical Education Journal 3:2, e107-e117.

[viii] Hunt, Matthew, and Godard, Beatrice (2013) “Beyond procedural ethics: Foregrounding questions of justice in global health research ethics trainings for students.” Global Public Health: An International Journal for Research, Policy and Practice, 8:6, 713-724.

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