Sustainable Health Clinic in Rural Honduras

DukeEngage Proposal

Honduras EWB Project

June 5 – August 2, 2009

Sustainable Health Clinic in Rural Honduras

Sponsoring faculty: David Schaad (Civil and Environmental Engineering and Duke Global Health Institute), Linda Lee (Clinical Research Training Program, Duke University Medical Center) and Dennis Clements (Duke Children's Primary Care, Duke Global Health Institute, and Center for Latin American and Caribbean Studies)

Proposal prepared by: Varun Gokarn, Neel Vadoothker, Stephanie

Chang, Anna Brown, Ga-Young Joung and Rebecca Stein

Host organization: Heifer International, the Honduran Ministry of Health, and COMIPRONIL (a women’s economic cooperative)

Funding partner: Rotary International

Program Location: Las Mercedes, Honduras

Projected Dates: June 5th – August 2nd (tentatively)

Proposed number

of students: 10-12 students

Project Description

Since 1994, the Duke University Medical Center has fielded eleven medical outreach teams to rural Honduras through an interdisciplinary course titled “Exploring Medicine in Other Cultures.” The teams have included students, alumni, faculty and staff in a variety of clinical and nonclinical programs in the Medical and Nursing Schools. The Exploring Medicines clinics have provided limited short-term outpatient clinical care and health education to several small, isolated mountain communities near the town of La Esperanza in the Honduran department of Intibuca. Relationships with the village of Las Mercedes and neighboring communities have been strengthened through partnership with Heifer Project International, an organization which aids impoverished rural communities through gifts of livestock and education in sustainable agriculture.

According to a census conducted in August 2008 by Heifer and the Honduran Ministry of Health, 66.8% of the families in Las Mercedes, Rio Colorado, Belen, Cedros, Comunidad del Liquidambar, and Manazapa earn less than 5,000 Lempira (Lps) a year. This equates to an annual income of $270, or less than a dollar a day. Because of extreme poverty, the subsistence farmers of the region rarely seek medical care except in emergency cases. The closest hospital is in the larger town of La Esperanza, which is a 12-hour journey by foot or two hour truck ride; however, such transportation is limited, relatively costly, and inaccessible to most villagers. Some medical attention is also available in a small clinic in Rio Grande, a rural community between Las Mercedes and La Esperanza, but patients often face a three to four hour wait in addition to traveling time. The inconveniences and expenses associated with even basic care have deterred many from seeking treatment for non-emergency illnesses, such as open wounds, chronic disease, and malnutrition. Thus, the free clinics offered by the Exploring Medicines teams have attracted a high turnout from all of the communities during the ten days they run each year.

Although the annual outreach model has functioned satisfactorily in the past, a permanent clinic staffed by a full-time nurse will ensure that the region's villagers have access to care throughout the year. Such an establishment will also develop Duke's existing relationship with the communities and offer a platform for well-established outreach opportunities to students within the undergraduate, medical, and nursing schools at Duke. To this end, Dr. Dennis Clements, chief of Children's Primary Care at the DUMC and director of the Exploring Medicine program, has gained support from the Honduran Ministry of Health to build a government-sponsored clinic in Las Mercedes. A $10,000 commitment from the Duke Chapel congregation and funding from local Rotary International clubs will cover most project costs for a simple cinderblock building with a concrete floor and running water. During the 2007-2008 school year, Dr. Clements and Dr. Linda Lee invited the Duke chapter of Engineers Without Borders to join the effort, recognizing its overlap with the EWB-Duke mission. In August 2008, five students from EWB-Duke traveled to Las Mercedes to conduct a site assessment for the proposed clinic. They collected topographical surveying data of the designated site, identified a source of water, priced building materials in La Esperanza, and obtained population statistics of the region.

The proposed DukeEngage program will involve ten to twelve undergraduates in the design and construction of a 600 square meter (5,400 square feet) sustainable health clinic in Las Mercedes. The clinic, envisioned to serve approximately 1,800 people within an 8-km radius, will dedicate particular attention to infant and maternal health in support of Honduran Ministry of Health objectives and the Millennium Development Goals. The clinic plans are in part a response to the solicitation from the Honduras Secretariat of Health as part of its Programa de Mejoramiento del Nivel de Salud en Honduras (PROMESALUDH), in Request for Proposal document PRE-1619-UECF-001-2008. This program of the Secretariat targets the reduction of maternal-infant mortality in four Departments of Honduras (Intibuca, Lempira, La Paz, and Copan).

The team will be working alongside locals, providing the opportunity for cultural immersion as well as community involvement. This will ensure that the communities feel invested in the clinic and are equipped with the knowledge of general maintenance after the team has left. As a finished product, the health clinic will draw strength from the University's present leadership in global health and civic engagement to satisfy an established need in rural communities with inadequate access to medical care.

This interdisciplinary community development project aims to attract highly motivated students with interests ranging from engineering, appropriate technology, and sustainable development to poverty, health, indigenous rights, the Spanish language, and Central American cultures. Aside from the opportunity to contextualize their classroom and extracurricular studies in a real-world setting, the Duke students who help realize this goal will gain valuable experience in project management, ethical analysis, and cross-cultural communication.

Project Components and Curricular Involvement

Structural Design

Students from the Pratt School of Engineering and Trinity College will design the clinic, water supply, and septic system inthe spring semester course CE 185 (Engineering Sustainable Design and Construction), taught by EWB advisor Dr. David Schaad. The clinic will be designed with the parameters and information collected by the site assessment trip in mind. Students will work in teams with a client group consisting of Heifer International (Tim and Gloria Wheeler), the Duke Global Health Institute (Dr. Dennis Clements and Dr. Linda Lee), and the community of Las Mercedes (Regino Hernandez and Juana Dominguez). They will submit the design documents for the clinic to the client group for revisions, changes, and modifications. It is anticipated that at least some of the students participating in the course will travel to Honduras to build the clinic and see the realization of their design ideas.

Clinic Construction

Students will be working alongside community members to create concrete masonry units out of cement and sand, lay PVC pipeline to bring water to the clinic, and set up a septic system for managing wastewater. Depending on need, they may also install a photovoltaic array to power a small refrigerator and electric lights and a smoke-diverting adaptation of a traditional stove in the kitchen. These projects will expose them to key concepts in fluid mechanics, waste management, and off-grid electricity systems.

Improved Cook Stoves

In most of the traditional wood-frame, tin-roofed homes, respiratory health is compromised by cookstoves which vent smoke indoors. Heifer has tried to introduce a modern stove equipped with a metal pipe that diverts the smoke outside the house, but the cost of materials and installation remains too high for widespread implementation. So far, only one house in Las Mercedes has this modern stove installed in their house. During the year, students in EWB plan to research and design a low-cost smoke diverting system that could be integrated with the existing stoves in the homes. Once in Las Mercedes, and provided there is time, they can test prototypes and educate the communities on how to replicate and improve the technology locally.

Enrichment Activities

In association with the Exploring Medicine Program, students participating in this DukeEngage experience will be invited during the 2009 spring semester to attend the seminar series INTERDIS 422C, which covers culture, language, history, medicine, and religion in Honduras. During the course of the year, students will be educated on development issues and the culture, history, and contemporary politics and economy of Honduras. This will include safety and cultural orientations.

Additionally, while in Honduras, students will take a 4-day break, mid-program, to travel to Copan, Honduras where they will tour the Mayan Ruins and visit the Chorti Indian Village. These experiences will provide exposure to the rich cultural heritage of Honduras. The Copan cultural exchange component will be directed by Ricardo Agurcia, archaeologist, President/Executive Director of the Copan Association, and Duke alumnus.

Logistics

Transportation

Students will depart the US and arrive in Tegucigalpa on Friday, June 5th. Representatives from Heifer International will meet the team at the airport and transport them by bus to La Esperanza (approximate drive time is 3 hours).

Orientation

They will spend their orientation weekend in La Esperanza and will lodge at the Hotel Mina or a similar residence. Hotel Mina was where the EWB site assessment team stayed in August 2008. During this weekend, students will become acclimated to the culture, travel to the local market, and experience Honduran dishes at local eateries. Personnel from Heifer will assist the team in purchasing local ingredients for meals for the following week.

Food and Lodging

On Monday morning (June 8th), Heifer will transport students to Las Mercedes (about an hour drive from La Esperanza), where they will stay and work throughout the week. While in Las Mercedes, students will live in a community center next to the local school, giving students opportunity to interact with the communities they are serving. This is where the nursing and medical students have stayed every April as part of the "Exploring Medicine in Other Cultures" for the past several years. Juana Dominguez, the wife of the current leader of Las Mercedes, (and others) will prepare 3 meals a day for the team using the purchased food. On Friday the 11th, the team will return to La Esperanza using local transportation (regional buses) and will again lodge at Hotel Mina. Over the weekend, they will purchase food and bottled water for the following week and return to Las Mercedes via local transportation on Monday. This pattern will be repeated for the duration of the DukeEngage experience except for the mid-program break in Copan. The weekends in La Esperanza will allow students time to relax, take a shower (possibly hot one), plan ahead for the following week, and purchase building materials and food for the following week. Internet cafes and long distance phone calls will be available in La Esperanza on a weekly basis.

Supervision and Coordination

An on-site coordinator who is proficient in Spanish and/or engineering will be hired to help manage the project. This person will be working with full-time staff from Heifer International and the community leaders of Las Mercedes to provide an enriching, engaging, and fulfilling experience for all parties involved.

Funding for Clinic Construction

Most building materials will be purchased with funds provided by the Duke Chapel and Rotary International. This project aligns with Rotary International’s 2008-2009 theme, Make Dreams Real for the World’s Children; Rotary’s cooperative relationship with the United Nations Population Fund; and the 1999 Rotary International Statement on Population Growth and Development. Additionally, Mike Waters, the Rotary Club President of the Research Triangle Park, has made the Rotary leaders in District 7710 (the local district) aware of this project. They will all be partnering to submit for Rotary Matching grants later in the year.

Risk Management

Risks are inherent to any community development project in a rural area. As previously stated, Las Mercedes is about a one hour drive from the hospital in La Esperanza and three or more hours from Tegucigalpa, which has a large hospital and an international airport. These travel distances pose a legitimate concern to the welfare of the team, but are risks that will be mitigated through use of a satellite phone, frequent reminders about safe working practices, vaccinations against endemic diseases, and other safety precautions to ensure the security of the team. While the political climate is fairly stable, and crime, terrorism, and violence are not major concerns, students will be advised to only explore the area in groups of two or more to prevent any compromising situations. As in many other developing countries, the regional transportation infrastructure is not ideal. However, the road to La Esperanza is paved, and all roads out of La Esperanza consist of graded gravel. The regional bus traffic is frequent and relatively dependable.

Conclusion

There is significant momentum and support behind this community development project from the Honduran communities, Duke organizations, and international agencies involved. This is an excellent opportunity for undergraduate students from diverse educational backgrounds to engage in experiential service learning, deep cultural immersion, and translation of an original building design into a finished product. A working collaboration with the Duke Medical Center, Heifer International, Engineers Without Borders, Rotary International, and the Duke Global Health Institute, this project will improve the accessibility, quality, and sustainability of health care in impoverished rural communities in great need of year-round medical attention.

Contacts

Faculty Sponsor

David Schaad, , (919) 660-5174, Dept. of CEE, 126 Hudson Hall

Students from Site Assessment Trip

Stephanie Chang, , 2011

Ga-Young Joung, , 2011

Anna Brown, , 2011

Varun Gokarn, , 2009

Neel Vadoothker, , 2009

Heifer International

Tim Wheeler,

Global Health Institute

Dr. Dennis Clements,

Dr. Linda Lee,