The first phase (2004-2008) of our Ecuador Eco-Health initiative focused on implementing a “train the trainer” perspective through a nationally accredited “Master’s in Health with an Eco-system Focus”. Explicit criteria were applied at different levels to support this orientation:
i) Selection of participating institutions was designed to include a university with well-established academic traditions (U of Cuenca, founded in 1867) and 2 relatively new universities that lacked strong research capacities, but where serious problems persisted: intensive resource extraction and poverty (Technical U of Machala, founded in 1969); indigenous rural populations and poverty (U of Bolivar, founded in 1977).
ii) Selection of students was based on criteria that explicitly weighed academic disciplinary aptitudes alongside capacity for undertaking community-based interventions and knowledge translation, as well as cultural diversity, producing a first group of 30 students who were interdisciplinary, interregional, and intercultural with 5 indigenous community leaders. Additionally, 5 of the 10 selected by each university had to have university faculty positions and the promise of continued faculty positions after completion of their program. The expectation was that these latter 15 individuals would play a key role in maintaining appropriate Eco-health programs at each of the universities.
iii) Criteria for thesis research were explicitly adopted to include not only 1) rigorous and clear methodology, but to insist that there be 2) clear research and impact objectives; as well as 3) focus on relationships between human health, ecosystem health, and community wellbeing; 4) significant community participation; and 5) collaborative relationships with other students, key stakeholders, and the community.
An innovative curriculum to support interactive community-based learning for the first cohort of the Master’s Program was developed and implemented by the international team led by co-authors JS and AY and established Ecuadorian researchers in the area led by co-author JB, with the coordination of co-author MP. To reinforce the role played by local university thesis directors, who were only becoming acquainted with a new action research orientation amid their other obligations, a dedicated team to support thesis preparation was established and coordinated by co-author EO. As a result, 27 participatory action research Master’s theses were successfully completed in 15 communities by 2009, involving over 1200 community learners. Through this collective experience, reflections on inadequacies of current theoretical and methodological approaches fuelled a focus on the social determination of health, observable in distinct contexts, and not the excessive examination of isolated determinants.
From a “top-down” perspective, this experience served as a crucible for establishing new training programs led by Ecuadorian universities with international reinforcement. A second Master’s program cohort was initiated by the University of Cuenca (led by co-author JP) in 2009. When the Ecuadorian academic director for the inaugural Master’s program (co-author JB) was appointed director of the health area of University Andina Simon Bolivar (UASB) in 2008, the consortium expanded to support the launch the following year of an innovative Doctoral program on “Collective Health, Environment and Society” to provide a strong foundation for the emerging national network. The Universities of Bolivar (co-author JG, a professor who is a Master’s graduate and current UASB PhD student) and Machala (co-author PV, a professor who is a UBC PhD graduate with support of the Ecuador Eco-Health program) meanwhile are preparing certificate courses to be operated in 2011 to build capacity in priority areas for their context, and workshops with active practitioners are being conducted in areas such as disaster preparedness in collaboration with co-author LP.
Also in 2009, an innovative way to link directly with policy-makers was begun through a direct alliance between the UASB PhD program and the Organismo Andino de Salud
, now led by the former Ecuadorian Minister of Health, which represents Andean Region governments affiliated with the Pan American Health Organization. The “Observatorio Regional de Salud Colectiva, Ambiente y Sociedad” [Regional Observatory on Collective Health, Environment and Society] (led by co-author JB with participation of members of the international team as a part of the group of professors delivering the PhD program modules including co-authors JS, AY, AR and other international experts) identifies priority research areas capable of macro and meta level analyses of evidence related to health concerns and policies at a national and sub-continent / regional level [19
]. These are directly linked with the PhD initiative that itself has an Andean (i.e. multi-country) charter – providing a strong policy-relevant orientation for the 18 action-research doctoral investigations that are now underway.
From a “bottom-up” perspective, locally established action research projects have laid foundations for larger scale applications engaging broader arrays of policy makers and funding agencies to enable further knowledge translation and innovation. Some examples of local initiatives that led to sustained impact include the following: In the urban community of Machala, three feasibility projects were undertaken as Master’s theses to strengthen community based dengue prevention and control, through direct involvement of school children, health promoters and community members as well as the pursuit of alternatives to heavy pesticides use. Building on this foundation (established with assistance from co-authors WB, BH and AY), a 3 year trial applying a comprehensive integrated surveillance program was launched in 2010 with funding from the WHO Tropical Disease Research Program (TDR) and IDRC, notably with the 3 Principal Investigators being i) a Master’s program graduate who heads the province’s Vector Disease Control program (co-author EB); ii) the PhD program director (co-author JB); and iii) the UBC-based Ecuador Eco-Health project director (lead author JS), with active involvement of Canadian and Ecuadorian graduate students. The provincial Ministry of Health is directly involved and committed to province-wide scaling up once results are evaluated with an active participation of local school boards, health units and community organizations.
In the rural setting of San Jose de Balzay, a community heavily involved in the artisanal production of clay tiles and roofing materials, lead poisoning (from glaze used in the production process) was diagnosed and alternative materials and work practices incorporated to alleviate this problem as the result of a student thesis in the first master’s cohort. By working with local community organizations and an active national Non-Governmental Organization, Acción Ecológica, the University of Cuenca, in partnership with the UASB and UBC launched (in December 2010) a new form of “eco-health centre” (Clinica Ambiental del Sur) based on the linking of prevention at a population level with primary care clinical attention in underserviced areas. It is noteworthy that as new initiatives are being undertaken, opportunities are being increasingly created for women researchers who have been previously under-represented in the ranks of the leadership. For example, direction of the Clinica initiative as well as the second cohort of the Masters program was assumed by a young female PhD trainee (co-author FS) in 2010.
A further action research program addressing food security, food sovereignty and health equity has been initiated, with submissions for international peer-reviewed funding in early 2011, by co-authors JS, AR and JB, along with other members of the authorship team together with additional community and policy-maker partners–with funding for 5 years approved to begin in late 2011. To reinforce concentration on practical applications of knowledge, this group includes the national Ministry of Health, the Ministry of Agriculture (reinforced by the hiring of a Master’s program graduate as national director of the irrigation program), the Ecuadorian section of the development bank Banco del Sur which is interested in providing credit for more sustainable and equitable forms of agriculture, the national organization of small-scale indigenous and non-indigenous farmers (FENOCIN), and peasant coastal producers involved in domestic and export-oriented production (UROCAL).
Innovative methods to teach and learn constitute an integral part of the Ecuador Eco-Health initiative through the team’s explicit pursuit of a strategy emphasizing participation through the formation of a community of learners combined with problem-based learning centered on contributing to beneficial community impacts. Knowledge sharing has fundamentally taken place within the dynamics of difference (three or more cultures, half a dozen disciplines, distinct paradigms, three languages, and the great diversity of the Ecuadorian regions). This approach was vividly evident in repeated showings on national television of a video on the benefits of pursuing a more integrated intercultural approach to childbirth in indigenous communities based on the Master’s thesis of an indigenous nurse with the national Department of Indigenous Health. This initiative seeks to incorporate both traditional and modern practices to improve maternal health. With UBC partners, this team is actively pursuing international funding for a network of communities and government agencies that will make timely technical assistance possible through innovative use of communication technologies alongside improved local mobile infrastructure.
The results to date from the Ecuador Eco-health project indicate that action research oriented to health equity is quite feasible if there is a commitment from both the “top down” and the “bottom up”, engaging local policy makers and practitioners in the research process, and then broadening the partnerships to consider scaling up. The effectiveness of these efforts in terms of health outcome will continue to be studied in the coming years.