Contents:Readings • Case Study • Student Engineers’ Reflections • Letter to Students The preparation of this module and others in the “Preparing for Engineering Communication in Intercultural and International Situations” was supported by a generous grant from the Engineering Information Foundation. We are grateful for their belief that today’s engineering students need information that will prepare them to deal with international collaborations. This module was collaboratively prepared by Linda Driskill with help from several people who chose not to list their names. Several students also contributed to the readings in the module. You will find their contributions vivid and valuable.

READINGS

Community-based Approaches for Health Projects in Resource-Constrained Settings The projects are undertaken in rural areas of the developing world, where technology and other resources, including human resources, are constrained. Students most often work in rural, agrarian communities. Few undergraduate students today come from truly rural backgrounds, and fewer still have had coursework in how to interact with people in traditionally-structured societies. This module introduces community-based approaches, concepts, and issues in rural development for low-resource countries. The module on participatory approaches complements this one. Here, the key objectives are to Explain approaches to the ecology of disease (a blend of traditional epidemiology and the cultural and biological elements of ordinary ecology) that recognize multiple factors Introduce the concept of social medicine, using participatory action research as a case study Suggest some steps for the implementation of community-health projects in a resource-constrained setting.

Global Health and Social Medicine Those who work in low-resource settings in the developing world need to recognize the global nature of many diseases that increase the disease burden for rural populations. In 1997, the Institute of Medicine defined global health as “Health problems, issues and concerns that transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions.” Throughout prehistory and history, humans have always taken their pathogens along with them on their migrations and expansions. Some typical examples include infectious diseases like Yellow Fever and malaria, water-borne diseases such as cholera (the 7th pandemic began in the early 1980s.), and the HIV-AIDS “pandemic,” which is a global constellation of interconnected regional epidemics. So, global health is about linkages: common problems and common solutions best addressed by cooperative actions such as the Millennium Development Goals. By 2015 all 189 United Nations member states have pledged to: Eradicate extreme poverty and hunger Achieve universal primary education Promote gender equality/empower women Reduce child mortality Improve maternal health Combat HIV/AIDS, malaria and other diseases Ensure environmental sustainability Develop a global partnership for development Eradicate extreme poverty and hunger Achieve universal primary education Promote gender equality/empower women Reduce child mortality Improve maternal health Combat HIV/AIDS, malaria and other diseases Ensure environmental sustainability Develop a global partnership for development See: Millenium Goals Site Not everyone who is exposed to an infectious agent or an environmental contaminant will have an adverse health event such as becoming infected or developing a disabling condition. Likewise, among those who do become infected or debilitated, the symptoms and severity may vary greatly due to many factors. Some important variables include: sex age occupation nutritional status risk-taking and health-seeking behaviors innate immunity (inherited) education (inherited) availabililty of health care (inherited) passive (mother-to-child)or acquired (previous exposure and vaccination) immunity and even “structured risks” such as government policies which can increase risk for certain individuals or populations.Social medicine is an interdisciplinary field that seeks to better understand the cultural, economic, and political contexts that impact health, disease and the practice of biomedicine. Social medicine considers many factors, trying to understand the reciprocal influences of biology, environment and behavior. It also aspires to foster grassroots awareness at the community level and health policies at the governmental levels that can lead to healthier societies. Finally, it is important to realize that both global health and social medicine are about linkages. Economic development is always linked to health, for example: Technology can improve quality-of-life and measures such as average life expectancy Environmental degradation—and sometimes even improvements like reforestation—can increase infectious diseases For technology to be a solution to health problems, it must: Be culturally and environmentally appropriate Ensure access at the community level Be sustainable Be effectively integrated Epidemiology is the study of the determinants and distribution of disease. Figure 2 models approaches that recognize multiple factors as an “epidemiological triangle,” showing the epidemiological triangle for an infectious disease, malaria

To the classical "epidemiology triangle" of agent, host, and environment, people who are interested in medical problems should add "Treatment availability" to their analysis of "Environment." "Education level" might also be added to the human "Host" list because a person's level of education may be the key to what preventive actions and other decisions that will affect activity patterns and nutrition.

Community Health The primary source for this part is BL Norton et al. (2002) and citations therein, “Community Capacity,” in DiClemente et al. (2002): Emerging Theories in Health Promotion Practice and Research (San Francisco: Jossey-Bass Publishers). The community is the most important level for implementation of health projects. A community can be defined as “a group of people who have common characteristics” such as location, ethnicity, age, occupation, common-interests, self-identity, etc. Persons living in complex, heterogeneous developed societies often belong to multiple (and sometimes overlapping) communities. In rural areas of developing countries, a person is most often a member of a distinct, delimited, homogeneous group with common residence, typically an extended family- or kin- grouping. For developed countries, community health has been defined as “the health status of a defined group of people and the actions and conditions—both public and private—employed to promote, protect and preserve health.” While this definition is equally valid for the developing world, practitioners in the lesser-developed countries usually call it “primary health care.” Another important consideration is that the definition of the “self” usually varies between those living in complex, technology-based societies and those in low-resource, subsistence or non-wage economies. While each person is the product of enculturation and many socializing influences during his or oher growth and development, two general orientations are recognized: Individualistic societies Collectivist societies. Some authorities estimate that as high as 70% of the global population lives in collectivist societies where the self is defined more communally. Other facets of human psychology also impact self-identity as well, such as self-focus and group-identity (ingroup-defined self, publicly-defined self, privately-defined self). Despite the complexities of personal psychology and social anthropology, those working among rural communities should be aware of these differences. The following lists offer some attributes of persons who have grown up in individualist or collectivist societies.

Individualist Societies: Attributes Social unit is the person Cultivate own judgment and opinions Behaviors determined by personal goals Emphasis on self-reliance, competence, independence, separation Achievement through competition Relatively little concern for group or family Personal freedom Private property excesses

Collectivist Societies: Attributes Self is embedded in the group as the primary social unit Behaviors determined by group goals Social cohesion, consensus-seeking Membership by ascription (being assigned rather than earned) Family integrity and in-group “health” paramount Generalized reciprocity, duty, fatalism, dependency Shared ownership Defiance to out-group “authority” (even those on “humanitarian” missions)

Theories and Models for Community-Based Health Interventions Obviously, scientific theories and models are conceived within the cultural orientations of advanced societies. There science, since its beginning, has been dominated by individualistic approaches and explanations of human behavior. However, over the past two decades current public-health professionals have relied less on individualistic models and have made more efforts to develop theories and models that account for the social and contextual influences on human behavior. These emerging “community” models have come from the social sciences and have been developed by those interested in social medicine, or what is often called “behavioral health” or “behavioral medicine.” There are several reasons for this fresh look and reorientation, for example, The complex etiology (study of causation) of health problems New recognition of the complex interplay between humans and their environments (both ecological and social) Acknowledgement of the limits to using individually-oriented strategies for behavioral change, especially when applied to health problems in more collectivistic-oriented societies such as much of the work in global health. However, community-based models of behavior are not easy to apply.

Challenges for newly emerging, community models Complexity—When one works at the broad social and contextual level, the issues are complex, therefore the constructs will be complex, addressing multiple determinants Design & analysis—This results in a critical challenge: to better craft research design and analysis methods that are capable of determining program efficacy Theory selection—Choosing a theoretical orientation for an intervention is complicated Multilateral nature—Since sociocontextual approaches are multidisciplinary and multi-layered, probably no single theory will explain all the variables and contexts Metrics & measurement—One must develop reliable and valid assessment techniques Cultural differences—Each cultural context requires fitting the application to the setting. It is important to be flexible and adaptive; the cultural equivalence and relevance of constructs must be considered

Social Ecology and Community Capacity While we do not have time to cover in detail specific models or theories and discuss their strengths and weaknesses, is it important to discuss briefly “social ecology” and “community capacity.” As we have emphasized, (1) recently public-health authorities have urged reorientation to emphasize and prioritize the community as the best setting for change (Institute of Medicine’s 1988 report, The Future of Public Health); and (2) health professionals working in rural, low-resource settings in the developing world must understand human adaptations (cultural and biological) within an “ecological framework.” Such an understanding emphasizes a systemic approach to the interactions and interdependence of people, their values and norms, their institutions, etc. all operating within the broader ecologic, social, and political environment (from local to global). As such the local community has been viewed as: An integrated ecosystem composed of assets and capabilities Not merely a collection of individuals or a geographical setting Something both concrete and intangible. Some attributes of communities include: A shared identity, history, symbols, and common values A sense of membership and belonging Common needs and a commitment to meet themWhen one works with many communities, it becomes very apparent that the capabilities, leadership, community spirit and initiative, and so on vary considerably due to the personal dynamics and the group’s social history. The term used today to summarize these attributes is community capacity. McLeroy defines the concept this way: “Characteristics of communities that affect their ability to identify, mobilize and address social and public health problems.” Community capacity, then, is based on the idea that the nature of social relationships within a community affects the ability of that community to redress health problems. While creating community capacity is often seen an important outcome (of an intervention) in and of itself, at the very least capacity building is essential for sustaining programs and health improvements: Infrastructure is created (facilities, tools, equipment) People are empowered (skills, confidence, educated) Community commitment is created. Infrastructure is created (facilities, tools, equipment) People are empowered (skills, confidence) Community commitment is created All of which can be applied to future health and social problems Understanding community capacity requires a cross-disciplinary approach. Researchers have yet to develop a consensus “metric,” i.e., some way to measure community capacity/competence. However, it is obvious that (a) community capacity consists of the human and material resources that are the building blocks for assets, (b) community assets can be recognized and mobilized to bring about change, and (c) community capacity is linked to quality-of-life. Students working in rural communities should be aware that community capacity integrates many facets: Skills and resources Nature of social relationships Structures and mechanisms for community dialogue Quality of leadership Extent of civic participation Value systemLearning culture

Building Community Capacity and Community Coalitions If community capacity is critical to health improvement, projects and interventions must address and assess it. Based largely on decades of United Nations work to develop tools for rural community development, collective “development wisdom” can be useful.First, communities can develop their own capacity to deal with their own problems and citizens may need to acquire skills for and through community capacity building. Second, a basic principle is that local people should participate fully in defining, adapting, and controlling the changes in their own community. Third, sustainability rests on self-initiated changes. For our purposes, “sustainability” can be defined as:he capacity to maintain service coverage at a level that will provide continuing control of a health problem (Claquin 1989 in Norton et al. 2002); and [Optimal] Improved community capacity/competence to conduct effective health promotion programs (Jackson et al 1994 in Norton et al. 2002).

Summary Projects and interventions implemented in low-resource settings like those found in rural communities in the Developing World must be based on social-medicine and multifactorial approaches. To be effective at the community level, health interventions must assess and address community capacity. These ingredients are essential for ethical project implementations: (1) commitment to genuine grassroots development using participatory methods; (2) stakeholder ownership; (3) community empowerment; and (4) a reasonable plan for access and sustainability. Intercultural communication and health care-related engineering projects are not formulaic. They must be carefully designed with the input of the community.

Example of How to Start a Health Project in Liberia, West Africa The purpose of this last section is to very briefly list the steps, and use the terminology introduced above, showing how the concepts are used in an actual field implementation designed to build community capacity. Set in a rural West African community, the project entailed conducting health assessments and implementing a community health program. Participatory methods are covered in a separate module (Module 6) and you should refer to that module for details on the methods, approaches and techniques. Essentially, PRA (participatory rural appraisals) and PAR (participatory action research) use a process in which outsiders and insiders work systematically together to explore, define, identify, and redress health concerns for the community. In this case study, five major steps were employed to undertake a community-health assessment and implement a sustainable, community health worker program.

Implementation Steps for a Community-Based Health Worker Program In this project, a field team from a regional hospital works in local communities. Step 1: Mobilize and sensitize the community Use PRA to conduct a rapid health assessment Gauge community capacity/motivation Request permission to return (2-3 visits at weekly intervals) Step 2: Organize a community-based health organization Help community create a health committee with subcommittees, set priorities, identify community health workers Step 3: Conduct a formal community health assessment about the following: Immunization/vaccination (extent of coverage) Water and sanitation / vector (disease source)-control Social worker / domestic issues / nutrition Traditional midwife / reproductive health Step 4: Train the community-selected community health workers and begin community projects 6-week training session Field team works with community-based health organization and the public works committee on disease control and education Step 5: Launch work by community health workers on fee-for-service (barter & labor) with periodic retraining Ongoing: Health professionals make periodic visits to the communities; A Project Officer oversees field teams for 10-20 communities

SUMMARY: When beginning health-related projects, remember to take a community-based approach. Health problems and are often based upon many factors and rooted deeply within a community. Health solutions are rarely formulaic and a cross disciplinary approach is often required. The keys to success lie in improving community capacity by building infrastructure, empowering the community, and focusing on sustainability.

STUDENT COMMENTARIES

Deepa Panchang: Looking forward to New Projects Since we are constructing the Bernardino Health Clinic this May, our team will also be looking for a new project. I think that the tools we learned in this class will significantly help us in scaling up - to work with a larger community or possibly multiple communities, and work perhaps with more complex designs. Going into a new community, I hope to apply PRA techniques to get more community-produced, detailed information on lives and livelihoods and have a community committee come up with needs and possible solutions. I also better recognize now the importance of simply getting to know community members better and overcoming some of the cultural barriers before proceeding with a project. I think this would have really helped us in our past projects, some of which I question if and how they will be used. Having done a more detailed PRA beforehand would have perhaps motivated us to reconsider some of our plans before implementation. In going through with an introduction or explaining a process, I do see now the importance of initial brevity and interesting visual aids. Also, any type of aid that helps connect with adults and even children in the community – through games, songs, etc. – is also helpful and I’m going to brainstorm such items for our upcoming trip. And, it is obviously important to practice such process presentations before they are given – as we learned in class. I really think that it is only in truly knowing community members personally that an appropriate project can be designed, and all of these things will help. Our class discussions on holding community meetings were especially valuable. Asking the assembled community members to set ground rules for meeting etiquette is an excellent idea to ensure that things don’t get out of hand and that the agenda is covered. Posting the agenda at the beginning is also a useful idea. Having children perform skits related to the project could also be fun and interactive and get everyone involved. Translation during meetings can also be tricky, and personally I think the best technique is to have a “translator’s assistant” who can understand what is going on and translate to the rest of the group, without the translator having to interrupt the conversation each time. However, I do recognize that these techniques all vary with community characteristics and different procedures may work for different communities. Having separate meetings for women and men can also be a good technique for accommodating the varying roles they take and to make up for any possible inequality in representation. Because of my experience with the class, I think I will also have more impetus to discuss these issues with the team before and during the trips. It was great to be exposed to the various experiences of other EWB members, and I think this made us realize that intercultural communication is not formulaic – what works best may be different in each situation. Thus, the questions and ways of thinking about them are the important part, and flexibility is key. It is also useful to have a pot of ideas to draw upon for various situations, and developing this pot was one of the really useful parts of the class. One of the viewpoints expressed in the class that I feel will really stay with me was the final point about sustainability. While we can take multiple, thorough measures to ensure the sustainability of these projects, there are always issues we may not be able to overcome. These aren’t a cause for not beginning the project however, and until a perfect solution is developed, it is ok to depend on human initiative – to keep going back to the site. I felt that this point was grounded in realism and experience and made the case for personal motivation in this work despite questions that may sometimes seem unanswerable.

A Letter from Dr. Phil Dennis, Anthropology Professor, Texas Tech University to Engineers Without Borders Students at Rice University January 27, 2007 Hello!Congratulations on such dedication and interest in using your knowledge to improve life in the Third World! I've read your journals on the Web and am really impressed. You're questioning your own methods and approaches and looking for ways to accomplish even more. I'm glad to try to help with some ideas. I've actually worked quite a bit with engineers. For instance, some years ago I spent a month in the highlands of southern Peru with Dr. David Clements, an engineer from the Univ. of Nebraska, working on the social impact of a huge hydroelectric project on local indigenous communities. We were invited by another engineer, the Peruvian director of the project, whose son happened to be a student at Tech. Dave and I found it really interesting to put together engineering and anthropology points of view. Thus, a first recommendation is develop and maintain contact with local professionals in Nicaragua or El Salvador. They may have a different take on projects than local villagers, but their support will be crucial. It will also be important to figure out who gets along with whom in the engineering community in the host country. One can easily imagine a group of Japanese engineers coming to West Texas to help a local community, and not bothering to contact our Engineering College at Tech. Major foot in mouth.

Rescuers vs. Consultants All technical aid people should be wary of the narcissistic rescuer mentality. "We know best for you because we come from a rich, well developed country." It's easy to resent rescuers, even when they happened to be right! In fact, local peoples have ways of life that represent long adaptations to local conditions. Try to find out what those successful adaptations are. A good place to start is with detailed ethnographies by anthropologists. A large ethnographic literature exists and is easily accessible, in any good library or more recently on the Web. For example, I have worked for more than 25 years with Miskitu people on the Atlantic Coast of Nicaragua. There are two classic ethnographies of the Miskitu people, one by Mary Helms and the other by Bernard Nietschmann. My own book-length ethnography was recently published as well. Anyone who wants to do technical projects with the Miskitu would be foolish not to take a look at these books and learn as much as possible from them, about the people you are trying to help. An alternative role to that of rescuer is that of technical consultant. Everyone needs a technical consultant from time to time: a physician, a builder, a computer geek, and yes-- even an engineer! You guys seem to be playing that role well. A good technical consultant doesn't disparage local customs. Instead, he or she responds to the felt needs of the community, regarding a problem to be solved or an improvement made. The PRA methods outlined in Module Six are an excellent way to find out what local felt needs are. A good technical consultant is modest, unpretentious and friendly, someone who brings needed expertise and shares it happily. You're following in the footsteps of the very first engineers, those Sumerian experts who built the earliest cities in the world.

Living with Other People In reading your journals, I question the practice of staying in hotels and driving out to visit the communities to be benefited. The unspoken message is, I wouldn't live here, or want to share more time than is necessary to get these improvements made. It would help to be more like anthropologists: live among local people, even for brief stays. Use your local contacts to find host families willing to put you up for a few days while you're working on the project. They should be reimbursed for food and other expenses, but they should also be the sort of people who want to have young guests. You should be willing to sleep on the same kind of bed local people use, eat the same food, and use the same toilet and bathing facility. This involves giving up some of your comfort zone. It is also an adventure and will give you neat experiences to remember the rest of your lives. When you have a host family, they take responsibility for feeding and taking care of you. They are the ones who can show you what life in the local community is like—where to eat and sleep and poop, and to relax after the day's work is done. They will also look after your physical and psychological well being. They will want you to have a good experience and do their best to help it happen. You will stop being so much an outsider, and more like a fellow human being, although one from a different country. Put some time and effort into finding good host families. Also, keep a journal and write in it for an hour each day. Record your experiences, your feelings, your surprises and pleasures and disappointments. This journal will be your record of having this experience, and you should re-read it before planning other projects.

Conducting Local Meetings One specific problem mentioned in our meeting, and in your journals, is how to avoid blowups and loss of control in village meetings. This can certainly be disconcerting, and even frightening. The only way to understand the internal dynamics of a community is to live there and do fieldwork. This means that as outsiders you can't possibly understand what's going on in a new place. It's easy to imagine foreigners appearing with new, valuable resources (bridges, wells). Controversy then erupts over who will obtain these resources or benefit from them. You can't possibly understand the divisions within a community. You need more background to do that. Therefore, you must depend on respected local leaders to conduct the meeting. It must be their responsibility when things go awry, not yours. Local leaders have a vested interest in making sure things do go well. The less of an outsider you become, by living even briefly with local families, the better you will understand the local social structure. If you return to a community over the years, to continue working on projects, you will eventually gain a pretty good understanding of how the community works. This will only happen if you share local peoples' lives, stay in touch, and write and reflect about your experiences.

Gender Issues An incident was mentioned in which a man took a shovel out of the hand of a young EWB woman engineer. It was disconcerting and unpleasant, although apparently nothing more came of it. Some anthropology sorts of reflections may help put it in perspective. First, you can't change local gender roles yourself, although you may not approve of local practices. Local people themselves will change them, when and if they want to. However, you can make and respect your own gender roles, and demonstrate them to the community. For example, women EWB engineers can work hand in hand with men engineers, digging a ditch or a foundation. The demonstration effect will be interesting to observe. Second, be careful about thinking you understand local gender roles with only superficial experience in the community. Ask local women how they understand gender roles, and what they think of them. You may get some surprising responses. It's interesting to note that gender roles have been changing rapidly in countries like Nicaragua, which has had a woman president, a woman governor of the Atlantic Coast where I work, and a woman rectora (president) of the Atlantic Coast University. Equal opportunities for women seem to be a widely held goal. See what you can learn about gender issues in your host community, and if gender roles seem to be changing. Write about it in your journal! Finally, the problems you have had really seem to be very minor ones. Congratulate yourselves on putting your engineering expertise to such good use, and keep up the good work!

Phil Dennis

Reflection or Discussion Opportunity Select the student’s commentary or Dr. Dennis’s letter and discuss it, or discuss both. What other additional issues from the reading can you apply to their comments? How does the selection of a health-related project introduce new considerations that might not be involved in other engineering projects?

THere are no exercises associated with this module.END