What started as an annual trip to provide medical help to poor people in the Dominican Republic has evolved into something bigger and better. SOMOS—William and Mary's Student Organization for Medical Outreach and Sustainability—now includes a more scientific focus, a substantial ethnographic research component and two 3-credit-hour preparatory seminars tailored to the needs of each class.
The base mission of providing medical aid to the residents of Paraiso hasn't been diminished by the program's growth. Rather, project team members hope that the more holistic approach to the community's health will help to provide both better and more sustainable improvements in health and health care, as the SOMOS team works to identify the causes of disease as well as operating a medical clinic.
SOMOS is born
SOMOS had its genesis in a 2005 medical mission trip put together by Jason Starr '06 and Diego Vicente '05. A group of William and Mary students and a single physician spent a week in the Dominican Republic diagnosing illnesses and handing out medicines.
"It was very grassroots, kind of like we were flying by the seat of our pants," said Matt Harrington '05, a three-time trip participant currently enrolled in medical school at the University of Virginia. "And in fact we found out afterwards we had no permits to bring the medicines in, and it was just by luck that the Dominican border guards didn't search our bags and take away all of that medicine."
After the first trip, the group was struck by the extent of medical problems in the developing nation, and revisited their concept. Starr began to look for ways to expand the trip and searched for an academic sponsor to teach a related seminar course.
"Having an academic aspect to the trip had always been an interest of mine, and particularly because we were trying to make the trip a little more than just going down there on a feel-good mission for a week," Starr said. Enter David Aday, special assistant to the provost and professor of sociology and American studies.
After reading about the trip in a student publication, Aday contacted Starr and casually offered to help the group in any way he could.
"Of course I let him know immediately that there was something very big he could do for us," said Starr. "And I never dreamed that his involvement would turn out to be what it is. I think it's really remarkable that you can feel like you change the course of a professor's research, that he was engaged enough in what you were doing to make that a part of his own life, and I think Dr. Aday definitely did that."
Aday's areas of inquiry include the sociology of crime. He studies communities to trace the framework of extra-governmental arrangements in a community and how such community structures can be used to address problems posed by crime and violence. Community-based assets can be just as effective in promoting health care as they are in reducing crime and victimization.
"The medical mission really hit a responsive chord in me," said Aday. "It wasn't about domestic violence or drug and alcohol abuse, but it was fundamentally about how do communities get stronger, how do communities solve their own problems and how do communities optimize their resources so that they can find solutions for the longer term? And that was the question that--without being able to articulate it--I had been asking for more than a decade."
With Aday's help, the group created a 1-credit course to prepare for the trip. They wanted to be able to approach the problems of the community scientifically and help the residents make practical, real changes in their lives. Aday agreed to focus the seminar on community and volunteering, particularly on the nature of relationships between communities and outsiders.
Aday's SOMOS seminar is different every semester it's taught. Some of the students have taken the class three times, while others are joining the group for the first time. Their backgrounds and skills range from pre-meds with extensive health-care experience to Spanish-fluent students in Hispanic Studies to public policy and sociology majors with little Spanish and no clinical aspirations at all.
The class makeup varies widely each year, so Aday tailors each session and semester to fit the knowledge base and capabilities of the current class and the needs of the project. Disparities in age, academic background and previous trip experiences encourage highly cooperative learning, with more senior students helping along the others, and necessitating an approach Aday calls "inquiry-based teaching and learning."
"The key to the approach is to start by asking, 'What do we need to know?'," Aday explains. "Not what do we want to teach, but what do students need to know in order to do whatever it is that's important to you in this project?"
Growth, and more growth
The class has evolved as it has expanded, from a fall-semester seminar into a full-year experience, with the option for two 3-credit seminars. Aday jumped at the chance to include ethnographic research methods. A process characterized by careful observation, finely tuned interviewing methods and efforts to understand as closely as possible from the lived experiences of people within a community and culture, ethnographic research methods are introduced to a small number of undergraduates, but rarely to those outside majors in anthropology or sociology. And, there is very little opportunity for undergraduates to engage in hands-on field research grounded in the method..
"I happened to work with a couple of really extraordinary ethnographers, who took me into the field and helped me to learn interviewing and observing methods, but I have to tell you, I don't think that was the best training I got in ethnography," said Aday. "I happened to graduate at the time when the Vietnam War was going on, and rather than being drafted I enlisted in the field of Army intelligence. The training I got in surveillance and interrogation was far better than the training I got later in the academy."
Aday applied his interviewing and field observation skills to his own ethnographic research and passes on the techniques to the students in the SOMOS seminars. And when the SOMOS class left for the Dominican Republic, their professor was on the plane, too.
Observing while dispensing
His first year in Paraiso, Aday and the students added ethnographic research to staffing the medical clinic as they observied community members passing through the clinic's pharmacy.
"It was an ideal place for me to do some systematic observation, because every patient that came through the clinic also came to the pharmacy," said Aday. "From the perspective of community development, the clinic is our offering to the community as a first step towards establishing reciprocal relationships."
Each aspect of the clinic's operation is staffed by a rotating schedule of students. Some students register patients coming in, taking blood pressures and medical histories. Bilingual students translate for the medical providers who don't speak Spanish; others staff the pharmacy; and still others are in the field doing research with Aday. Each day the groups switch.
Aday takes a group into the field every day of the clinic to conduct interviews with the residents. The students wear scrubs to create an immediate connection with the clinic, Aday explained. The groups go to different parts of the barrios, gathering data about health needs, bathing, waste disposal, food and nutrition and lifestyles. With observations from the clinic and data from interviews in the community, Aday and the students began looking for their first big project to tackle. It soon became clear that many of the town's health issues stemmed from a single cause--water. Or, rather, the lack of clean water.
Water you wouldn't want to drink.
SOMOS already had begun collecting ethnographic information about health practices and complaints specifically related to water use. Access to clean water is a constant problem in Paraiso, Aday said. Some households in Paraiso receive municipal reservoir water through a system called the tuberia, but tuberia water is salty, contaminated, and delivered unreliably, forcing even the few residents connected to the tuberia to buy all of their drinking water. Aday estimates that average families of Paraiso, with four to six members, consume five to seven gallons of drinking water a week, while international health standards suggest that a family of four ought to be consuming thirty to forty gallons.
The water concerns drove a change in research focus. In previous years, the interviewing process was more exploratory and descriptive, but this year's water-focused data gathering necessitated a highly structured interview protocol, with each question worked in fine detail, then finessed carefully into Spanish.
"These are people with dignity and pride, and they're smart," said Aday. "If you ask them stupid questions, or questions that seem insulting, then you're gonna get answers in kind." Aday teaches ethnographic observation techniques in his pre-trip class. He maintains that the best way to learn observation techniques is by experience--and by observation.
"The first year we asked the question, 'Do you wash your hands before you prepare food?' And I know a good proportion of people thought, 'What kind of a heathen do you think I am? Of course I wash my hands!'" said Aday. However, he observed a decided lack of hand washing before food preparation. "They don't have hand sanitizers, they don't have Handi Wipes, and they're not going to waste the drinking water they're paying for. So the truth is they wipe down their hands and go about their business. Sometimes there's the socially expected answer, and the real answer."
After returning to William and Mary, the class analyzed the data and agreed that the first long-term SOMOS intervention project should address the collection and storage of safe, potable, easily accessible water.
Last summer, program participant Jim Donecker was awarded a Mellon grant to study groundwater contamination in the Dominican Republic. He and other students, some working on a grant Aday procured; others with funding from the College's Roy R. Charles Center, spent the summer studying water, particularly in the canata, a flood control canal running through the community of Villa Mella. The students spent six weeks collecting water samples and water flow data, and interviewed residents regarding their experiences with and opinions about the canal. Their research is supplementing the data from the January trips, and adding an epidemiological layer to the group's knowledge of the community. That work has been advanced further this summer with eight different students doing research in the community with differing sources of funding, one from a Mellon grant, several from a grant Aday received from the Reves Center, others supported by Monroe funds, and one supported by a national Laura W. Bush UNESCO grant. These students conducted field research focused on community networks and leadership, and Aday joined them for a week in July to lead on-site data analyses and to plan for the final phase of the summer work.
During the spring 2008 semester, the class analyzed the January 2008 data, and developed a preliminary plan for the summer water project research. Aday speculates that the class will probably end up partnering with just one of the barrios due to resource limitations, and in the hope of demonstrating that collaboration with SOMOS will result in practical and sustainable solutions to critical community problems. One student's father, a private sector water specialist who has worked for a number of World Bank projects, visited the group during its January trip. He has been helping Aday and the students with planning. Current project proposals tend towards microeconomic strategies of rainwater harvesting.
"It'll take all summer," said Aday, "because first you have to understand the formal and informal leadership and authority arrangements in the community, the municipality and the nation. Then, you've got to get buy-in from the residents, then you've got to figure out who will help lead it, then you've got to identify and form relationships with government officials who may not help, but certainly can hinder. There are inevitable political conflicts to deal with, and in the mean time, we'll be trying to figure out how to get funds to actually invest in the startup of this kind of microeconomic project."
Aday plans to continue working with SOMOS on basic and applied community action research focused on improved community health. At the same time, he has been working with a second student project, Students for Healthy Communities (SHC), that has similar goals in the Cuje district of Nicaragua. Aday has travelled with SHC student team members to the Nicaraguan community for the past two years. As with SOMOS, they establish and operate a week-long medical clinic and conduct ethnographic research to understand the community, its resources, and its health problems and needs. The goal with both is to partner with communities, undertaking one project at a time. Each project must be regarded as important and necessary by community residents and leaders, well-executed and eventually self-sustaining. The ongoing research is critical to Aday's developing regulatory theory of community agency.
"We're just undergraduate students, a faculty member and some medical providers," said Aday. "Clearly, there are limits to what we can accomplish. A critical part of these projects from my point of view is the use of knowledge to solve real-world problems, and the demonstration of the power of knowledge."