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Documenting outputs, outcomes and learning from Ecohealth projects : dengue; final report

Documenting outputs, outcomes and learning
from Ecohealth Projects:
Final report
Héctor Gómez Dantés MD. M.Sc.
Medical Doctor, Epidemiologist
Organizacional Affiliation: Independent Consultant
May 30, 2007
Documenting Outputs, outcomes and learning from Ecohealth Projects: Dengue
Executive summary………………………………………………………………………………………….2
Dengue as a global health problem………………………………………………………………………….3
Epidemiological context……………………………………………………………………………………..4
IDRC Ecohealth approach and dengue control in selected countries………………………………………..6
Argentina and Uruguay……………………………………………………………………………..9
Guatemala and Mexico…………………………………………………………………………….11
General context ……………………………………………………………………………………………..16
Awakening of consciousness (creating awareness)…………………………………………………………18
Level of integration of IDRC´s Ecohealth approach and its methodological pillars………………………..20
Community participation…………………………………………………………………………...22
Quality of outputs and their relevance to researchers and practitioners
from the health and environment sectors
Knowledge generation……………………………………………………………………………....26
Social capital strengthening and knock-on or domino effects……………………………………....26
Capacity building for the team ……………………………………..................................................26
Outcomes of projects related to human health, environment and development
Human health outcomes………………………………………………………………………….....27
Environment outcomes……………………………………………………………………………...28
Development outcomes……………………………………...…………………………....................28
General gaps and challenges observed…………………………...…………………………..........................28
How are Ecohealth approaches different from other approaches
to communicable diseases prevention and control? …………...…………………………...............................29
Lessons, insights, knowledge with respect to social and ecological determinants of disease
transmission, prevention and control strategies, and coping capacity
of communities concerning the diseases. …………...…………………………...............................................31
Local relevance and utilization of research results…………...…………………………..................................32
Outstanding contributions of projects to showcase the achievements
and potential of ecohealth approaches.…………...…………………………...................................................33
Annex: List of participants and publications………………………………………………………………….35
Executive summary
Dengue has become a major public health threat in the Americas. Traditional approaches to
dengue prevention and control have been inherited from the vertical control programs that
targeted the vector as the core of the control strategy. Failures to efficiently reduce vector
densities have forced the development of interventions with innovative approaches where
community involvement has been pursued with limited impact in the control of the overall
spectrum of breeding sites in the household and peridomestic surroundings.
IDRC launched an initiative to prevent and control dengue based on the principles of
transdisciplinarity, community participation, equity and gender directed towards a better
understanding of health determinants and improvement of population health through sustainable
environmental changes. Dengue infection in urban Latin American and Caribbean countries was
approached by 8 proposals funded in Cuba (2), Mexico, Guatemala, Colombia, Brazil, Argentina
and Uruguay. A review of the technical proposals plus additional documents produced during the
implementation of the projects was the base of the analysis presented. Sites visits to Cuba,
Argentina and Uruguay allowed for a more direct contact with the research teams and interviews
with local stakeholders.
The document presents a brief epidemiologic panorama of dengue and highlights the growing
trend of the disease in the region. It basically discusses the successful integration of different
scientific disciplines (social and biological) and their methodological approaches to the better
understanding of a deteriorated environment and its influence in health (dengue in particular). It
discusses how every research proposal generated a community based intervention targeting
dengue determinants and the implementation of educational and behavioural strategies to modify
the environment where vector’s breeding sites proliferate. The different ecological, social and
cultural scenarios of the areas studied illustrate the complexity of the determinants of dengue
transmission and the challenges for its control. The majority of the projects were successful in
mobilizing local community members and different stakeholders, generating effective
communication strategies to address local health needs and dengue control. The impact on
disease and entomological risks reduction requires further evaluation since even with very low
breeding indexes transmission may occur as detected in Cuba. The interaction with different
institutions (health, environmental, education) governmental agencies (water, waste management,
urban planning, municipal authorities, etc.) and non-governmental stakeholders, are a necessary
ingredient to produce long lasting effects and scale-up of the local interventions.
IDRC`s initiative is weighed against traditional prevention and control approaches that include
community participation as a component to the overall strategy. The knowledge produced and the
impact of the interventions at a local level are described as successful experiences but gaps and
problems are identified. If local experiences were successful in terms of mobilizing resources,
issues on sustainability and scale-up of interventions are addressed.
Documenting Outputs, outcomes and learning from Ecohealth Projects: Dengue
It takes a lot more than technical information
to construct pathways for the solutions of problems.
Oliveira e Valla , 2001
Dengue as a global health problem
Dengue is not a new disease in the Americas and vector control strategies in the past were at the
verge of eradicating the vector from our continent. Many of the countries now involved with
IDRC were free of the vector creating the false idea that any control strategy should achieve
similar changes. It is precisely the change in the environment that makes vector control a more
challenging activity today than it was in the past.
The current distribution of the vector in the Americas is below that which the vector can
reach, especially with the deterioration of social and economic conditions in the region. While
global warming is posited? as an important influence in the establishment of the vector in other
latitudes, Aedes aegypti has already demonstrated its ability to reach Philadelphia or Montevideo
in the past, and its capacity to transmit yellow fever or dengue in the present. Aedes aegypti is a
domestic vector, breeds inside houses and yards in artificial containers of different nature,
capacity and purpose. The vector’s behaviour make it a tricky target for existing vector control
technologies since larvicides have low coverage in terms of the large pool of breeding sites
present in any urban environment; insecticides are short in reach regarding the effective
penetration into the vector’s resting places and short lived in terms of the mortality of adult
mosquitoes produced when sprayed. Aside from these technical problems, there is no public
health program with enough human resources to tackle all households in urban centers where
Aedes aegypti represents a health risk (short response capacity).
Population movements (migration, tourism, etc) are important vehicles for spreading the
serotypes and strains, while routes of international trade provide natural paths for vector
dispersion, therefore no country is immune to the risks of dengue disease transmission in a global
economy. Dengue is not a disease of poverty because it affects wealthy neighbourhoods as well,
it should be considered rather an expression of a threaten environment. Protection is not an
individual responsibility but a collective concern since there is no vaccine nor effective treatment,
and control technologies have only a limited impact. On the other hand, peoples’ behavior
towards the domestic environment is creating new risks linked to the fast urbanization process in
the region that challenges municipal responses to satisfy basic sanitary infrastructure needs.
Today cities are better communicated by more and faster means of transport creating urban
networks where risks are easily spread from a local setting to an international scenario.
Traditional approaches to disease prevention and control of dengue have been inherited
from the vertical oriented programs that targeted the vector as their primary, and in some
instances, their only objective. Conventional vector oriented programs maintain the use of
larvicides and insecticides supported by breeding sites elimination as the core of the control
strategy. Failures to efficiently reduce vector densities have forced the development of
interventions with innovative approaches where community involvement has been pursued with
limited impact in the control of the overall spectrum of breeding sites in the household and peri-
domestic surroundings.
Dengue is not a health priority to the communities affected since their social, economic and
environmental realities are more compelling and urgent than those put forward by a disease that
on individual basis, is usually inadvertent, mild, solved by self medication or rarely requires the
use of health services. For the public health authorities, dengue control is approached as a
community responsibility and is not understood as a problem that demands resources and
financing from different governmental agencies and municipal actors besides the health sector.
Practical, technical and conceptual drawbacks have emerged in recent years demanding new
or more integrative approaches to the control of dengue because the determinants of transmission
encompass more than biological factors of the disease where most of the technical arguments for
control have concentrated. Strategies on dengue control have been dominated by biomedical
paradigms leaving aside the social, economic, cultural and environmental determinants of the
disease. The core essence of the Ecohealth approach is to understand dengue as a sanitary
problem linked to social, economic and environmental determinants that create the breeding
conditions of the vector and dissemination factors of the infection, amplifying its biological lethal
The objective of the present report is to give an overview of the outcomes, outputs and
challenges faced by the Ecohealth approach regarding the control of dengue in the Latin
American and Caribbean region.
Epidemiological context
Dengue has steadily established itself as the most important vector-borne disease in the Americas
and threatens the health of millions of people living in urban, suburban and rural environments.
Dengue emerges as a public health challenge due to its clinical behavior where a simple infection
transmitted by the mosquito bite can rapidly advance in some cases to a severe hemorrhagic
syndrome that can lead to the death of the individual infected. Its incapacitating nature and the
severity of clinical features expressed in an epidemic fashion is always a medical emergency to
every health care system because of the increasing number of cases demanding treatment and the
need to reduce vector densities responsible for the transmission. Clinical and public health
services have proved to be unable to control this disease since there are no vaccines available to
prevent transmission, no effective medical treatments that avert the development of severe signs
and symptoms, and no sustainable control measures against the vector that guarantee the
protection of affected communities.
The Americas is living a period of intensive dengue transmission with half a million cases
of dengue fever and almost 15,000 cases of severe hemorrhagic dengue occurring on average per
year in the region. The geographical expansion in Latin America has only left Uruguay and
Chile free of dengue transmission although the vector is already present in territories once
thought to be free of the risk. During the period 2000 to 2006 the peak of transmission occurred
During the preparation of this report a suspected case of dengue was reported in Montevideo but was not
confirmed by laboratory testing.
in 2002 with more than one million cases reported in the region, most of them reported by Brazil
(Table 1). The co-circulation of the four serotypes in the region is not homogenous but constant
introductions from one country to another due to population movements and trade increases the
risk of severe dengue infection. Differences in the magnitude of transmission reported are
modulated by several factors linked to the surveillance system and the laboratory capabilities in
each country. Table 1. Dengue cases in selected countries, 2000-2006
Country 2000 2001 2002 2003 2004 2005 2006
Argentina 1,700 11 214 135 3,284 34 181
Brazil 231,471 413,067 780,644 341,902 112,928 203,789 346,550
Colombia 22,775 55,437 76,996 52,588 27,523 30,475 36,741
Cuba 138 11,432 3,011 0 0 75 ?
Guatemala 9.006 4,516 7,599 6,750 6,352 6,341 2,863
Mexico 21,715 6,210 9,844 5,010 8,202 16,862 27,287
Americas 400,519 652,212 1,015,420 517,617 267,050 427,627 539,993
Source: PAHO, Feb, 2007
If Brazil concentrates a large proportion of cases, dengue incidence (per 100,000) puts Colombia
in a competing situation (table 2). Cuba had an important epidemic in 2001 and local reports
indicated that a large epidemic during 2006 affected most of the island. PAHO has not reported
this last event and should be requested to inform the magnitude of the epidemic due its
epidemiological importance.
Table 2. Dengue incidence in selected countries, 2000-2006
Country 2000 2001 2002 2003 2004 2005 2006
Argentina 4.6 0.03 0.6 0.4 8.7 0.1 0.5
Brazil 136.1 239.4 452.4 198.1 65.4 118.1 200.8
Colombia 53.8 272.7 210.3 258.7 135.4 149.9 180.7
Cuba 1.2 101.6 26.7 0 0 0.7 ?
Guatemala 79.1 38.6 65.0 57.8 54.3 54.3 24.5
Mexico 21.9 6.2 9.8 5.0 8.2 16.8 27.2
Source: PAHO, Feb, 2007
Rates per 100,000
The dengue hemorrhagic statistics put Colombia in a leading position with around one third of
the cases reported by that country (Table 3). Differences in diagnostic capabilities in the rest of
the region may explain the likely sub-notification of severe cases in many countries.
Table 3. Dengue Hemorrhagic fever cases in selected countries, 2000-2006
Country 2000 2001 2002 2003 2004 2005 2006
Argentina 0 0 0 0 0 0 0
Brazil 59 679 145 713 77 433 628
Colombia 1,819 6,563 27 4,878 2,815 4,306 5,379
Cuba 0 69 12 0 0 0 ?
Guatemala 42 4 47 22 39 32 4
Mexico 50 191 1,429 1,419 1,959 4,255 4,477
Americas 5,667 15,500 14,374 10,994 9,810 14,557 14,429
Source: PAHO, Feb, 2007
IDRC Ecohealth approach and dengue control in selected countries
The International Development Research Centre (IDRC) launched an initiative based on the
principles of transdisciplinarity, community participation, equity and gender directed towards a
better understanding of health determinants and improvement of population health through
sustainable environmental changes. Dengue infection in urban Latin American and Caribbean
countries was approached by 8 proposals funded.
Dengue control in Fortaleza, Brasil (100999); team leader: Andrea Caprara
Dengue control in Colombia (100999); team leader: Gabriel Carrasquilla Gutiérrez
Ecosystem Approach to the Sustainable Prevention and Control of Dengue (Cuba) - Phase II
(101545); team leader: Mariano Bonet
An Integrated and Participatory Dengue Surveillance System (Cuba, 101091-004); team
leader: Cristina Diaz
Ecosystem Approaches to Dengue Prevention in Argentina and Uruguay (101814); team
leaders: Nicolas Schweigmann and Cesar Basso
Dengue in the border of Guatemala and Mexico (Guatemala, 101091-003); team leaders:
Ricardo Lujan and Juan Arredondo
The countries involved in IDRC´s proposals concentrated at least 59% of the cases of
classical dengue occurring in the region from 2000 to 2006, percentage that increased to 86% of
the total cases during epidemic years. These countries also notified 12% to 73% of the
hemorrhagic fever cases in the region depending on the year of transmission. Although local in
nature, the experiences brought by the research proposals in these countries can be useful to other
countries in the region. The IDRC initiative sums the outcomes of each individual country with
the additional value acquired from the interaction of two settings: the border in Mexico-
Guatemala and the travelling corridor between Buenos Aires, Colonia and Montevideo.
The general approach of each research team to the application of the methodological
pillars in IDRC´s Ecohealth initiative can be summarized in a general framework where contexts
were identified, targets selected and baseline, process and impact indicators designed to evaluate
the impact and products of each intervention.
Table 4. Framework of Ecohealth Dengue Control Proposals
Context Targets Baseline
data Evaluation
Indicators Impact
and results
Social and economic Identification of health
needs, social and living
Housing, public health
and sanitary
Stakeholders level of
involvement Adoption of results
Policy making
Cultural and
risk perceptions,
health attitudes,
roles of community
Knowledge, attitudes
and practices
Behavioral change
Risk maps
Breeding sites
(types, density,
Risk and Disease
In general terms, most of the proposals coincide in the identification of three contexts
(socioeconomic, cultural/educational and ecological) linked to the urban environment and its
influence in the health of populations. For each context, a set of targets were selected for detailed
characterization. In the social context, the target was to identify and describe the problems and
social dynamics of each intervention area, collecting baseline data for a detailed description of
the housing conditions as well as the public and sanitary infrastructure. The sequence of events
lead to the recognition of the main actors (stakeholders) that could participate and create positive
contributions to the project. The expected results in the social context were the adoption of the
products that varied from the strengthening of local capabilities for dengue control to its impact
in policy making.
In the cultural context the target was the definition and analysis of the determinants of
behavior regarding risk perceptions, health attitudes, roles of community members and key actors
and identification of health needs. A vast range of social methodological tools (qualitative
studies) were used to explore knowledge, attitudes and practices towards health and the
environment of the different actors in the community. Once understood or interpreted, a wide
range of behavioral interventions were designed to improve health issues (dengue control)
through interventions directed to the healthy management of the environment (impact).
The ecological context demanded a detailed characterization of the social, cultural and
physical environment and was scrutinized and mapped through the use of innovative
computerized technologies where the entomological potential (breeding risks) was graphically
portrayed. Entomological surveys in almost every project were used to measure the levels of
change in behavior of individuals or the magnitude of participation of the communities involved.
The results from each intervention were measured in terms of vector’s densities, disease rates
(limited), environment changes, water management or overall health improvements.
The next section presents a brief description of the main contents of the work developed
by each proposal and is complemented with additional information (methodological and
technical) displayed in Tables 5 to 7. The presentation of data varies since the projects are in
different stages of development. Projects in Brazil and Colombia are in a “diagnostic” or baseline
stage; those in Argentina and Uruguay are in the final stage of summarizing results while projects
in Mexico and Guatemala are finished or in a follow-up stage (Cuba).
The results presented in this evaluation were basically obtained from the review of the
different proposals to IDRC and the technical reports forwarded by the research teams on a
periodical basis. Direct interviews were held with research team members in Cuba, Montevideo
and Buenos Aires. Field visits to the study sites were performed and allow the interview with
several members of the community members and technical staff like local public health
authorities, health promoters, students, vector control personnel, different stakeholders, etc.
Personal interview was held with principal investigator in Mexico but no field visit was
performed since interview was held in another city and state where the investigator was living.
Different educational and technical materials were provided by research teams and some data on
the capacity building generated by the projects was also provided. Email communications were
also performed with the research teams to clarify and provide additional data.
Dengue control in Fortaleza, Brazil
A descriptive study bridging anthropology, entomology and policy research was done in 2
middle-high socioeconomic areas and 4 low socioeconomic sections of 2 urban neighborhoods in
Fortaleza. The project produced baseline data based through ethnographic studies that helped
understand people’s living conditions in relation to the vector’s environment. Entomological and
epidemiological data were linked to climate variables. Social studies reflected around water
management, specially related to patterns of water storage associated to climate issues like
droughts in the region. Psychodrama was used as a tool for social mobilization, creating a
scenario where people could build their capacity to act appropriately (change behavior) in
community and health problems. This behavioral intervention is intended be tested in further
stages of the research if funding is available.
Basic outcomes: detailed analysis of health perceptions and dengue related attitudes. Water
management in conditions where drought is a seasonal problem creates an interesting setting for
dengue risks.
Dengue control in Colombia
The project was developed in two middle size cities (Girardot and Melgar) in the Department of
Tolima that are interconnected to the capital city by local weekend and seasonal tourism
(“floating” population in recreational houses coexisting with migration of poor populations in
search of employment opportunities). Social, entomological and health risk surveys were
performed in order to create baseline data for future interventions. Detailed information regarding
environmental variables and breeding sites were reported. Dengue is not recognized as a problem
by the population even though dengue is present and high vector densities were found. Among
the relevant issues reported is the “therapeutic itinerary” as an operative category that serves to
describe trajectories of individuals seeking competent solutions (pool of options) to their health
problems based on subjective assessment of disease severity, perception of risk and available
resources in the environment used accordingly to the diversity of meanings attached to dengue.
Water management is well thought-out and organized by needs (individual or collective) and by
social status but not around vector related activities.
Basic outcomes: a detail survey on Aedes aegypti risk factors. A comprehensive analysis of
water management, environmental determinants and breeding risks in the areas studied.
Dengue control in Cuba
An Integrated and Participatory Dengue Surveillance System, EL Cotorro, Cuba :
The project was developed in El Cotorro, a suburban area with mixed rural and urban
socioeconomic characteristics, bordering the city of Havana. The work was centered in the
development of an active surveillance system to monitor vector densities and set up the early
detection of dengue cases supported by the active participation of the community. Community
groups were formed (Grupos Vecinales) and they were in charge of monitoring the environmental
risks in the community, promote the solutions within their capabilities and establish contact with
other social organizations (Consejo Popular de Salud) when solutions were out of their reach.
Community members developed and were responsible for the collection of health and
environmental indicators and discussed them with the team established in the district health unit.
An interesting management of environmental risks was developed in which open public spaces
where breeding sites represented environmental or health hazards were transformed into small
parks, family orchards or recreational yards. Strong entomological surveillance and serological
data allowed the design of computerized risk maps in a geographical information system.
Detailed information (environmental, social, demographic, entomological and epidemiological
data) was gathered and risks maps were produced to guide work on the risk areas identified. The
methodological and practical approaches of this project were later adapted and introduced in an
urban environment in Centro Havana.
Basic outcomes: A labor intensive clinical and entomological surveillance system with GIS
support. Scale-up of the intervention to municipal level and provided important inputs to the
national agenda on vector control program. Small but effective impact on environmental changes
by changing public spaces with high breeding risks into recreational parks, clean public gardens
and individually own orchards.
Ecosystem Approach to the Sustainable Prevention and Control of Dengue in Centro Havana,
Centro Havana is a high density populated urban area in the capital city with serious sanitary
infrastructure deficiencies and restricted access to potable water. Overcrowding and irregular
water service (available by night) and inadequate waste collection services are some distinctive
features. This district was previously targeted for an urban renovation project years after the
economic crisis in the 1990´s (Período especial) so work in this area was facilitated by the solid
organization of social groups in the area. Based on the experiences in El Cotorro, the project in
Centro Havana adopted methodological and practical experiences on dengue surveillance and
control. The core of the project was to change ways families dealt with water collection and
storage and introduced a surveillance system that gathered entomological and environmental risk
information supported by epidemiological and clinical data of potential dengue cases as an early
risk detection system. Integration and flow of data from the 3 subsystems (entomological
/environmental/ epidemiological) allowed the deployment of opportune actions in the risk areas
identified. The area changed from a high to a medium risk categorization during the period of the
intervention and reports by team members indicate that during the 2006 epidemic this area was
among the last to enter the epidemic and among the first to be free of the transmission.
Basic outcomes: A less labor intensive clinical and entomological surveillance system with GIS
support. Scale-up of the intervention to municipal level and provided important inputs to the
national agenda on vector control program.
Ecosystem Approaches to Dengue Prevention in Argentina and Uruguay
The special condition of these two countries in relation to the absence of dengue and Aedes
aegypti in Montevideo and the presence of the vector but no local transmission of dengue in
Buenos Aires, created particular challenges to the research teams in both countries. The first
challenge was to create individual proposals that dealt with the potential local problem in face of
the regional risks. The second challenge was to create an environmental risk assessment system
based on entomological data in two different scenarios, one where the vector exists and the other
where it doesn’t. This created an additional challenge in terms of motivating health awareness
when you target a disease that is not present or when people have no previous experience with it
but represents a serious health threat to the community.
Buenos Aires
The research study took place in four different neighborhoods with different socioeconomic
status (2 low /poor Barrio Charrua y Loma de Rosa and 2 middle class, Villa Pueyrredón and
Olivos in Vicente López district), the basis for implementing a participatory approach was to
contact local health promoters and alfabetizadoras’ or literacy workers (religious group) and
work with local schools in those neighborhoods to involve children and their families.
Entomological data was collected in all areas connecting the study sites (transectas). Climate
variables and geographical information systems allowed the creation of aerial maps and views of
the entomological and environmental data. Feedback to the community was performed through
local newspapers, stands in fairs and public spaces. Schools participated in a very outstanding
manner with a long term commitment. From the pilot intervention in two schools, the whole
district with more than 10 schools adopted the formative strategy and created a program on health
and the environment focused on dengue control that was implemented in every school and their
communities. The recent dengue epidemic in Paraguay created unusual interest in the activities
developed by the project and some members of the research team (entomologist, municipal
primary health authority, health promotion leader) were requested by the government authorities
to incorporate the experiences into an action plan against the threat of dengue in the country.
Basic outcomes: An entomological surveillance system with GIS support. Educational
intervention was systematized by educational authorities with important impact on students,
teachers and community members. Intervention provided important inputs to the national agenda
on vector control program.
A similar proposal was generated in Uruguay with 2 areas selected (1 working class
neighborhood and 1 middle class) in Montevideo and Colonia (tourist center), where
entomological surveillance of the areas was done with children in the schools involved along
with larger entomological studies (transect (lines connecting study areas) and graveyards). Urban
developers and architects contributed with innovative approaches in computer technologies to
understand local breeding sites ecology. Climate specialists contributed with data that enabled a
better understanding of vector biology in the area. Geographic information systems incorporated
social, demographic, entomological and environmental variables to generate a Follow up
Observatory and an Early Warning System, still in process. The schools elaborated fine
educational materials with different levels of complexity or detailed information according to the
target audiences. Information was produced after theoretical and practical sessions that included
knowledge and attitude surveys as well as entomological investigations and laboratory work.
Promotional material was designed accordingly to keep the environment free of the mosquito.
The level of awareness that governmental areas have about the results of the project is very
important since the research team (based on academic institutions) has direct contact with health
and social institutions. The recent report of a case of dengue in the country has given credibility
and responsibility to the results of the project.
Basic outcomes: An entomological surveillance system with GIS support. An Early Warning
System is still to be provided. Interesting input from architects and urban planners in the
understanding of the domestic environmental conditions. Educational intervention had an
important impact on students, teachers and community members. Intervention materials and
products were used to design the national agenda on vector control program.
Dengue in the border of Guatemala and Mexico:
An interesting opportunity was created by combining a geographical area with intensive
population movements, endemic dengue transmission, painful living conditions and a
deteriorated social environment. Both proposals approached two water related problems (dengue
and diarrhea) from the perspective of an environmental problem. While not directly linked in the
field, the individual proposals can also be seen as complementary from a regional perspective.
The areas selected in both countries have similar problems with respect to reliable water supply
and poor water quality. Residual waters are not treated therefore contaminating surface and
groundwater sources. Wells are not supervised by municipal authorities and are in close
proximity to latrines and septic tanks.
Two small towns in the southern border with Guatemala (Huixtla and Ciudad Hidalgo) were
selected in the study. One is in the border with the natural social conditions of a poor bordering
town and the other is a few kilometers away. Dengue and diarrheal diseases were approach from
an environmental perspective in terms of water management and household hygiene. Several
transversal surveys were performed during the study to measure impact. Health promotion groups
were formed (Monitores comunitarios) that were basically women who organized workshops and
meetings with community members that were mobilized to control breeding sites and elaborate
educational material that would promote behavioral changes related to water management and
hygiene in the household. Ten ‘ideal practices’ were promoted to tackle each health problem (5
by 5). For dengue the practices were to cover containers, weekly cleaning of big water storage
containers, daily change of water in animal drinking pots, weekly change of water in flower pots,
keep tires under roof, clean the patio and the roof of the house. For diarrheal control the easy
practices were boiling, filtrating, chlorinate drinking water, washing hands, protect and cover
drinking water, waste disposal and clean the bathroom. Entomological, water quality analysis and
epidemiological data supported the results of the intervention. Health municipal authorities in
Huixtla were deeply involved because the intervention supported a local initiative of a healthy
city with strong political support.
Significant reductions in entomological risks of dengue transmission were observed as a
result of community-based interventions, but unfortunately no impact was observed in
diarrheogenic risk factors (i.e., fecal coliforms in drinking water). Nevertheless, such ‘failure’
could be in part due to the fact that bottled drinking water was fecally contaminated before, and
residents were not compelled to boil it because they thought that such water was clean. Also,
because prevention of diarheogenic risk factors had to be carried out on a daily basis, as opposed
to dengue vector prevention activities, suggested on a weekly basis, poor resident hygienic habits
could add to fecal contamination of drinking water.
Basic outcomes: Combination of the intervention to address diarrhea and dengue control. Design
of feasible, relevant health practices at the household level. Use of innovative entomological
indexes and evaluation of entomological results.
Two small size cities (Tecun Uman and Coatepeque) in the border with Mexico were selected for
the study. Coatepeque has excellent municipal organization and health services actively involved
in community affairs while Tecun Uman lives the opposite situation. Both health problems
(dengue and diarrhea) were approached in a similar (methodological) fashion than the project in
Mexico and the entomological component was even supported by the Mexican team. Since the
sources of risk factors for dengue and diarrheal disease are similar, the approach was to promote
the rational and proper use of water and disposal of waste at home, community and municipal
levels. Two transversal surveys (baseline and final) were done in one area as intervention and the
other as control. Community monitoring groups (volunteers) were trained to monitor Aedes
aegypti breeding sites, cases of disease, household water quality and water management at home.
Formats were developed with the community members. Healthy practices at the household level
were promoted (5 by 5 see Mexico section) and were supported by a massive communication
strategy (radio, posters, songs, press releases and fairs). Community monitors (volunteers) were
trained as Environmental Health Promoters. Entomological data was collected regularly and an
increase in household control activities and a decrease in vector densities were documented.
Basic outcomes: Combination of the intervention to address diarrhea and dengue control. Design
of feasible, relevant health practices at the household level.
The following tables (5 to 7) summarize and give an overview of the different
components of the research proposals. They describe the composition of the research teams and
the interaction with different stakeholders; the basic traits of their methodological approaches in
terms of the quantitative (surveys) or qualitative techniques used to approach the problem; the
support from the health infrastructure (laboratory and surveillance) and control programs
(entomological); and the main environmental determinants. Finally, they highlight the issues
regarding water management and breeding site determinants.
Table 5. Ecohealth strategies by country
Project Project
Leadership Transdisciplinary
Composition Multisectorial (participatory)
Stakeholders Gender issues Institutionalization,
Urbanization, community dynamics,
policy response and Dengue control
in Fortaleza, Brazil (Andrea Caprara)
Medical Doctor
Public health specialists,
nutrition, anthropology,
pedagogue, nursery
Collaboration with local community centers,
schools, NGOs. Women´s role in domestic
settings , household hygiene
and health risk
Diagnosis stage. Intervention institutionally
based (Municipal Control Programme)
Dengue Control in Colombia
(Gabriel Carrasquilla)
Epidemiologist Anthropology, public
health specialists, health
promotion, entomology
Community Action Boards
Municipality and Vector Transmitted
Disease Program
Network of health promoters paid by
municipal authorities,
Not reported Municipality and Vector Transmitted
Disease Program ,
(4 days of disposable items collection
Economic sanctions for breeding sites
legally allowed but not reinforced.
Ecosystem Approach to the
sustainable prevention and control of
dengue, El Cotorro, La Havana
2003-2005 (Cristina Diaz)
Social Scientist
educational specialist,
psychology, statistics,
Municipal primary health care unit, Popular
Health Councils, Neighborhood groups,
sanitary workers of the health and popular
councils, Statistics Information System,
Vector Control Program (Unit of
surveillance and Antivectorial Fight),
Environmental Sanitation
17 vecinal groups created but
composition changed with
Easily transferred to the health sector.
Institutionally based: integrated to health
Integrated participatory dengue
surveillance system
(Mariano Bonet)
Sociology, Social
workers, entomology,
Cuban Women Federation and Defense
Committee more involved
Municipal primary health care unit, Popular
Health Councils, (neighborhood groups,
Vector Control Program (Unit of
surveillance and Antivectorial Fight)
Team members, domestic
properties: tires vs aquatic
Easily transferred to the health sector.
Institutionally based: integrated to health
Ecosystem approaches to dengue
prevention in Argentina, 2005
(Nicolás Schweigmann)
Sociology, Veterinary,
anthropology, biology,
health promotion, social
Social clubs, pension centers, community
centers, health centers, schools,
educational sector, health authorities,
literacy workers, Parent’s committee,
religious groups, Bolivian consulate, radio
and newspapers, Barrio Assembly
Use of spaces
School based with promoters
and amplifiers of gender
Fast adoption by educational districts,
governmental agencies due to threat of
dengue epidemic
Vecinal and institutional acceptance due to
epidemiological situation
Ecosystem approaches to dengue
prevention in Uruguay, 2005
(César Basso)
Entomologist Social scientists, climate
specialists, architecture,
urban development,
Schools, municipal authorities, health
sector Age related, older groups
fixed domestic functions with
Fast adoption of procedures even before
the creation of the Early Alert model and
Follow up Observatory
Dengue in the border of Guatemala
(Ricardo Luján)
Epidemiologist Health promotion,
entomologist, social
city majors, community resources,
municipal authorities, Ecoclubs, schools,
etc., Primary Environmental Urban Health
Women roles in the
household (weak) Educational and communication material
used at different levels, useful for other
Dengue in the border of México
(Juan Arredondo)
Health personnel,
entomologist, social
Municipal level involved, community groups
formed, community leaders and local
resources, community volunteers
(monitores comunitarios)
Women roles in the
household, intervention
practices according to each
Strong links to the municipal level
Table 6. Intervention sites, methodological approach and technical support
Project Level of
intervention Baseline, process
and impact indicators Surveillance and
laboratory support Enthomology
Urbanization, community dynamics,
policy response and Dengue control in
Fortaleza, Brazil (2005)
(Andrea Caprara)
Poor sub-urban and middle
high areas Qualitative (ethnographic, in depth
observations, unstructured interviews,
participant observation, life stories, focus
Quantitative data entomological information
All household water
containers in the study area
were inspected , and larvae
were collected and classified
in the FNS (Health National
Foundation) laboratory
Every activity performed by the Aedes
Control Program in the Study Area has
been registered. (Approximately 1500
control program workers perform home
visits within the Dengue Fever control
program in the town of Fortaleza).
Dengue Control in Colombia
(Gabriel Carrasquilla)
Two middle size cities, “tierra
caliente” middle & low
income neighborhoods
Qualitative (ethnographic, focus groups
RAP, in depth interviews) direct social
Quantitative data (cross sectional survey
risk factors for dengue and entomological
None Strong entomological methods,
biological control (fishes in tanks)
Ecosystem Approach to the
sustainable prevention and control of
dengue, Cotorro, La Havana
2003-2005 (Cristina Diaz)
Rural and urban areas in
Low population density
1,131 hab /Km2
Transversal survey, risk factors for
infestation; KAP surveys
Indicators developed with the community
Strong health care
infrastructure, detection of
cases, serology and clinical
Active surveillance of vector densities;
Categorization of breeding sites, no
Strong vector control program
Integrated participatory dengue
surveillance system, Central Havana
(Mariano Bonet)
Urban environment with high
population density (43,600
hab /Km2)
Environment, entomological, clinical,
epidemiological and community indicators;
KAP´s (pre and post)
Key informant interviews
Strong health care
infrastructure, detection of
cases, serology and clinical
Active surveillance of vector densities;
Case control study determinants of
Use of commercial insecticides (area of
Ecosystem approaches to dengue
prevention in Argentina, 2005
(Nicolás Schweigmann)
Urban areas; middle and
lower class neighborhoods
(poor Bolivian community)
Workshops, interviews, social practices,
ethnographic methods, participant
observation, semistructured surveys and
field observation
Not incorporated Important support, ovitramps, breeding
sites identification; municipal vector
control personnel involved
Ecosystem approaches to dengue
prevention in Uruguay
(César Basso)
4 Urban settings in working
and middle class
neighborhoods in Montevideo
and Colonia
Workshops, interviews, social practices,
ethnographic methods, participant
Not incorporated. Ovitramps, entomologic surveys,
biological control (copepods) supported
by climate expertise and urban design
Dengue in the border of Guatemala
(Ricardo Luján)
Two middle size cities in the
Transversal surveys no stratifcation
KAP´s, in depth interviews, focus groups.
Baseline data
Water quality: total and fecal
coliforms and chlorine
residues in water, Dengue
cases reported
typology of breeding sites (disposable
and controllable) House Condition Index
Dengue in the border of México 2002-
(Juan Arredondo)
Two middle size cities in the
border 4 transversal surveys (cross over),
baseline, 2 mid-lines and final line,
stratified; RAP´s and KAP´s, in depth
interviews, focal groups, house trials
Water quality: total and fecal
coliforns and chlorine
residues in water, Dengue
cases reported
Detail surveys, typology of breeding
sites (disposable and controllable)
House Condition Index, Entomological
and diarrheogenic risk Indices
Table 7. Ecological, water management and breeding sites determinants
Project Environmental
Variables Water
management Breeding sites determinants Political milieu that
influences dengue control
Urbanization, community
dynamics, policy response and
Dengue control in Fortaleza,
Brazil (Andrea Caprara)
Rainy season, temperature,
humidity, domestic environment,
water provision and basic sanitation
Irregular piped water distribution.
Inadequate system of water distribution
at household level;
Cultural ties and practices due to
The most productive breeding sites are
inadequate containers such as pots, tanks,
drums, wells at household level. The
presence of these containers is due to
inadequate water management
Seasonality (droughts)
None detected
Dengue Control in Colombia
(Gabriel Carrasquilla)
Touristic areas, weekend places,
Girardot 138,000, Melgar with
28,596. Intra- domiciliary water
supply, sewage, garbage,
precipitation, solar brightness,
evaporation, mean temps, humidity,
influenced by rainfall
Cleaning low tanks weekly too much,
clean deposits vs fishes or chemicals
Water supply is suspended on weekends
for tourism
Tourism is a determinant of water
HI >30% BI= 49; Larvae and adult forms
surveys, indexes, control activities, low tanks
are most important based on pupae,
responsibility on vector personnel,
government, recycling of disposable
containers (useful)
Decentralization of health
services and priority setting
Ecosystem Approach to the
sustainable prevention and
control of dengue, Cotorro, La
2003-2005 (Cristina Diaz)
No climate data or vegetation, The
rubber and steel industries in the
proximity could influence the
breeding sites and control
Deficient water infrastructure,
physicochemical and microbiologial
study of water (nitrates, pH, fecal
Stratification of risk, alternative biological
methods (copepods, Bacillus thuringiensis,
Bactivec), problems identified are outside
domestic setting (solares, pets, abandoned
houses, vertederos)
Vertical oriented
Strong official support
Integrated participatory dengue
surveillance system
(Mariano Bonet)
Infrastructural: blocked drainage,
construction debris, water leaks,
vacant lots, flooded basements,
tanks in poor conditions.
Environmental indicators at
household level
Evaluation of pesticides impact in air and
water Breeding sites are low tanks (38%), barrels
(14%) cisterns (3.4%), 55% intradomiciliary
not protected.
Conditions of breeding sites explored, mostly
useful containers
Vertical oriented
Strong official support
Ecosystem approaches to
dengue prevention in Argentina,
(Nicolás Schweigmann)
Temperature, rainfall, humidity,
vegetation, basic sanitation, Water containers management Seasonality, high densities in all areas,
Ovitramps Legitimacy of governmental
agencies after economic
Ecosystem approaches to
dengue prevention in Uruguay
(César Basso)
Climate variables, breeding sites
ecology of domestic setting Water containers management Domestic utensils and use in the house. Social oriented government
Strong legitimacy of
educational agencies
Dengue in the border of
Guatemala 2002-2004
(Ricardo Luján)
Temperature, rainfall, humidity,
vegetation, water pollution Water use, management of solid waste
disposal Entomologica indexes
Waste disposal, housing conditions To be defined
Dengue in the border of México
(Juan Arredondo)
Temperature, rainfall, humidity,
vegetation, basic sanitation,
water pollution,
Water use, quality, management of solid
waste disposal, intervention with untadita
in water storage containers and water
replacement/turning/elimination of non-
water storing containers
Indicators of impact housing conditions,
compliance of residents with agua segura
initiative, evaluation of intervention on
entomological and diarrheal agents
Lack of involvement of local
health authorities at the
The following section gives an overall view of the main traits of the projects in terms of their
social and epidemiological context to understand the variety of conditions where dengue
flourishes. It also highlights the main challenge faced by all projects in terms of creating a new
kind of awareness towards dengue control due to the fact that most study sites have been exposed
to dengue in the past and control strategies have created the general perception that dengue
control is a responsibility of governmental agencies. It also addresses the issue of sustainability
as a major challenge since community participation initiatives are labor intensive, geographically
concentrated, directed towards selective groups depending on the intervention strategy and long
term enterprises.
General context
Among the significant issues that should be highlighted in this initiative are the ecological
diversity of the sites represented, the varied social and economic contexts of the areas studied and
the epidemiologic momentum of the places selected. In terms of their social, political and
economic circumstances, the countries and cities selected also provide an interesting spectrum of
environments that model dengue transmission and modulate the impact of the preventive
responses implemented. While on individual basis each reality provides motivating results on its
own, the incorporation of the results on a group basis allows for further interpretation and
understanding of the global phenomena in the region.
The sites represent urban as well as suburban environments where Aedes aegypti
flourishes without ecological restrains (Montevideo is the exception) and provide different
challenges to vector control strategies since populations profile, density, housing conditions and
public infrastructure differs from one area to another. In Cuba we have an extremely high-density
populated area as Centro Havana and a suburban neighbourhood outside la Havana, less densely
populated and with rural traits, as El Cotorro. In Fortaleza we deal with a heavily populated
suburban neighbourhood within an important urban centre while in Colombia we deal with two
medium size cities that have intensive communication with a capital city. In the case of Mexico
and Guatemala as well as Montevideo and Buenos Aires, the proposals incorporate the bordering
relationships between two countries and the influence one area has over the other. In the case of
Mexico and Guatemala, the study sites were small urban towns not densely populated. Particular
issues arise since the cultural and ethnical ties between Guatemala and Mexican populations are
very similar (Maya origin). In Buenos Aires the areas were basically urban. One of the urban
settings selected (Barrio Charrúa) is highly populated area and with people coming from Bolivia
and Paraguay. In the case of Montevideo, the areas are urban moderately populated even in the
case of the poor urban areas.
With regards to dissemination factors such as population movements and economic forces
like tourism the proposals offered interesting data. In Cuba, stability of people living in the study
communities is greater than those living in Fortaleza where intensive migration from the rural
areas is a predominant trait. In Mexico and Guatemala, intensive migration between the areas is
the common denominator because of their cultural ties but important differences exist in terms of
receptor and expulsion dynamics. Temporal and seasonal migration links the study areas in
Colombia, while in Uruguay and Argentina population movements involve a major regional
pattern that engages high risk areas like Paraguay.
Population movements are also visible in terms of tourism and every country faces this
economic force with different intensity. Cuba has recently opened its economy to the tourist
industry and this particular situation has provoked a change in the environment since
commodities for tourists are now easily available with an as yet unmeasured impact in the
number of increasing non-recyclable containers and potential breeding sites. The southern border
of Mexico with Guatemala has population movements local in nature but with international
implications since this is the port of entry for many South and almost all Central American
people moving towards the United States. Tourism between Buenos Aires and Montevideo is the
major risk factor for the dissemination of the vector and the infection among these two countries
that also faced the introduction of the virus from other neighbouring countries like Paraguay and
Brazil. Tourism is also a fundamental activity in the areas selected in Colombia but the risk that
arises is more local than regional. The political implications of these issues are managed in
various ways by each country.
The ways in which every country organizes its social response to health problems is also
an important trait to understand the potential impact of the Ecohealth approach initiative
proposed by IDRC. The political organization in each of the countries is extremely important to
measure or understand the scaling up capability of each project and how evidence based
decisions are taken in different social environments.
Without pretending to describe the social and political organization in each country, it is
important to gaze at least at some examples to understand the impact the projects may have in
different political and social environments. For example, Cuba has been a historical model of
effective public health education and how traditional vector control programs have been working
in the region. The sophisticated and labour intensive discipline of the program has kept dengue
transmission under control although important outbreaks and epidemics have occurred in recent
years. Reasons for outbreaks in Santiago (1997), Havana (2000, 2001, 2002 and 2006) can be
tracked down to the influence of tourism and the environmental and social deterioration due to
the economic crisis in the 1990´s. Previous epidemics have become sanitary disasters in the
island and therefore the government has responded with an outstanding surveillance
infrastructure to monitor vector densities and early detection of dengue cases. Along with this
sanitary infrastructure and technical resources, Cuban society relies on the effective mobilization
of local social units like the Revolutionary Defence Committees (CDR), Popular Health
Committees (CPS) and Revolutionary Women Federation (FMR) to deal with the basic needs of
the population. Even in such organized social structures, enhanced community participation,
generated by the project, proved to be invaluable to the overall dengue control program in
Havana city.
On the other hand, Buenos Aires has been living with Aedes aegypti since 1986. The
serious economic crisis in 2001 brought down many social programs and community resources.
A recent dengue epidemic in Paraguay has imported cases of dengue in several sectors of the city
with positive vector densities. The risk of an epidemic is real so government officials, interacting
with the group in charge of the project, have requested that the experience gained by the public
health services involved in the project be adopted by local authorities. In the case of Montevideo,
Uruguay, where no Aedes aegypti has been found, the government is deeply concern on the future
development of the metropolitan area of the capital city. Since urban planners recognize the risk
of dengue as a logical consequence of the city’s growth, the threat of an introduction of dengue
derived from Argentina or the recent epidemic in Paraguay, has created an unprecedented interest
in the results of the project. In Colombia, different responses are expected since the process of
decentralization of health services and political initiatives provides certain autonomy to the
municipal governments putting individual agendas in dispute of resources. This situation is
expressed through different kinds of support or receptivity towards the range of health initiatives
present in the Colombian scene. The scaling up potential of these experiences in a setting like
Mexico is similar to Colombia. Local authorities can develop individual agendas based on
existing available resources and political commitments. An example is that of Huixtla which.
implemented a healthy city initiative that was not extended to the neighbouring city.
In terms of their epidemiological backgrounds each area provides a priceless setting to
test the principles of Ecohealth approach to dengue prevention and control since transmission
patterns are historically different. Cuba has been able to sustain a vigorous control over Aedes
aegypti and dengue transmission until last year when an important epidemic affected most of the
island (personal communication with senior dengue researchers in the country). Neither PAHO
nor Cuba have made a statement regarding this situation which certainly arises serious concerns
to all countries in the region since Cuba has the most proactive and meticulous vector control
program in the Americas. Mexico and Guatemala have had dengue since the early 80´s and
suffered epidemics as a region basically linked to intensive migration within the area. In the case
of Brazil, endemic dengue distinguishes the city of Fortaleza and the areas selected in the study,
while in Colombia dengue transmission is also a trait in the two cities selected. In the case of
Buenos Aires and Montevideo, this region represents the most actual epidemiologic moment
since Buenos Aires is infested with Aedes aegypti but has no local transmission although
migration from Paraguay has introduced several imported cases to the metropolitan basin.
Montevideo, on the other hand, has no Aedes aegypti in the metropolitan area but is surrounded
by foci in different areas in the country. Uruguay reported one native case in March but was not
confirmed. In epidemiological terms, the areas studied included countries with occasional but
explosive epidemics, mixed with highly endemic cities that have intensive transmission and
dengue hemorrhagic cases all the way down to a city with no Aedes aegypti but a high risk of
introduction and transmission.
Awakening of consciousness (creating awareness)
An interesting phenomenon arises from the integration of data and the results gathered through
qualitative research methodologies in every site. The projects all faced different challenges in
order to make the community understand the relevance of management of the environment and
its links to dengue control as a product of a healthy environment. The situation is not so difficult
when the communities already have experienced dengue and family members or neighbors have
been affected by the disease. Their relationship with the disease and the risk it represents is
completely different form those communities in Buenos Aires and Montevideo that haven’t been
exposed to the disease and their only knowledge is through mass media information. No matter
how common or unknown the disease may be in the area selected, one of the principal targets of
all proposals was to create a new type of awareness around this particular public health problem.
Dengue is not a new disease in the region but it certainly represents a new risk for many
countries. The research teams in countries where dengue has been endemic for a couple of
decades (Mexico, Guatemala, Colombia, Brazil) in those who suffered occasional but epidemic
transmission (Cuba) or those who have imported dengue cases or nothing at all (Argentina and
Uruguay) designed their preventive strategy based on the their previous experience either
successful like in Cuba, or not, like Mexico or Guatemala.
In this case, we can assume that a new paradigm in dengue control is being established by
IDRC´s Ecohealth approach by conceptualizing dengue as a problem linked to the environment
and not as an individual vector-borne disease that needs to be tackled with specific technical
resources. In the IDRC´s initiative, the emphasis is put on the environment and the factors that
are identified as a threat to healthy environments. The innovative forms in which every project
addressed the challenge created new insights to the solution of the problem. By linking dengue to
the environment, they understood that the magnitude of the efforts require for control are bigger
and permanent. When dengue is seen in the traditional framework, efforts and strategies are
smaller, shorter in time and occasional in periodicity.
The proposals funded by IDRC worked on the basis of building up the community
awareness of risk to the health of the community when the environment deteriorates. Mosquitoes
are identified as a nuisance, their breeding sites as a risk and disease as a consequence. Dengue
and breeding sites control were built into the umbrella of health and a cleaner urban environment,
a topic that also requires a fresh approach to the set of cultural, popular and social beliefs around
the disease and its determinants.
The approach to dengue control had to be adapted to new circumstances even in cases like
Cuba, where the control program can be considered highly successful in terms of the low level of
vector densities reached all year round and all over the country. Adoption of new strategies in
Cuba and elsewhere were required because the standard response of the community to epidemics
is based on an emergency scenario where the institutions and social organizations mobilized
every human resources available in the area to tackle the breeding sites. The proposals funded by
IDRC faced the indelible fact, imbedded in the community, that the vector control personnel is
responsible for checking the domestic and peri-domestic containers; applying larvicides in tanks
and cisterns as well as insecticides inside and outside the houses on a regular basis. In the past,
and under the principle of reaching effective control of dengue transmission, this strategy
partially worked in Cuba and not so successfully in other countries in the region. In order to
modify the social relationship with this disease, the model proposed by IDRC´s projects worked
on the basis of health risks and the environment where dengue and Aedes aegypti appeared as a
risk, not as the prominent and independent problem. As one member of the team in Havana city
stated: We need to work on risks not on problemsif we need to spray insecticides then
prevention failed…This situation is particularly true to community members involved in the
projects in Buenos Aires and Montevideo since they have not experienced dengue in their
community and therefore mobilization can only be generated if awareness of risk is in place.
Community participation health projects face an indelible reality that threatens their fundamental
nature since participation germinates as a voluntary action based on the recognition of a problem
that requires continuity of actions for overcoming the problem encountered. Finding the
ingredients necessary to generate a continuous action is especially critical when changes in
behavior are expected to modify the environment where the problem arises. Sustainability
provides an additional difficulty to community participation projects because it searches not only
for continuity of actions but seeks an evolving scheme of actions nourished by the results of
previous experience.
It has been an attribute of the projects financed by IDRC to foster the sustainability of
prevention and control actions and the variable ways it has been accomplished. While most of the
proposals emphasized the impact on behavioral changes of individuals, families and groups, there
was also a more subtle mention of changes in the behavior of institutions (health, education,
municipal authorities, etc.). A fundamental partner in all of the projects was the role of
institutional agencies linked to health and environmental issues but changes were also required in
these stakeholders in order improve the continuity of the project.
In the context of Latin American countries, the perceived legitimacy of the government
institutions by civil society is fundamental in order to understand and guarantee the sustainability
of programs. While most of the projects worked along with different state institutions, none of
them was really based on them primarily because the communities have their own appreciation
and assessment of those institutions at the local level. In Cuba there was a strong link with health
institutions and municipal authorities and their participation is unquestionable when taking
decisions regarding the welfare of the communities. In Buenos Aires the recent economic and
social crisis has left the credibility of institutions on a very low level that needs to be recovered.
The project nevertheless was very well supported since it was guided by academic institutions
linked to governmental agencies. In Uruguay one of the reasons the scaling up of the project may
be so successful was the respect people have of the different governmental institutions which
were involved on a bottom-up as well as a top-down relationship with the project. The projects in
Colombia, Brazil, Guatemala and southern Mexico all have several degrees of collaboration with
governmental institutions and everyone mentioned the high level of commitment necessary in
order to bring the projects to a useful end.
Along with the co-responsibility with governmental institutions, it is necessary to stress
that practices, especially those dealing with dengue control, can only be changed and sustained
when they are supported by efficient municipal infrastructure. All projects worked on developing
a methodology that could bring the necessary managerial capabilities to the members of the
communities so as to empower them with skills for the identification of problems and solutions.
Some solutions were within their reach while others required an active participation of public
agencies responsible of certain key areas (water provision, waste management, education, etc.)
1. What is the level of integration of IDRC´s Ecohealth approach and its methodological
pillars in the individual projects supported?
The organization of the teams within each country also provided interesting inputs. The
composition of each team was created according to the needs and epidemiological context of
each project. Nevertheless, the research teams mixed social and biomedical strengths that proved
incredibly useful to the Ecohealth approach. Leadership of the projects had a balance in terms of
the academic background of the principal investigators and team leaders. It also shows a balance
in gender, not in the leadership of the projects but in the composition of the teams. Most of the
balance may be shaped by the inclusion of social and medical sciences where women have a
more important participation. In the end, it is the input from every scientific discipline and the
perspective of men and women in the projects that nourished the proposals, strategies and
approaches of Ecohealth projects. An important effect was how the contributions by each
discipline were impregnated with the principles and theoretical inputs of the others. It was
common to see “biological” and “social” oriented members of the team supporting each other’s
work in the field.
The Ecohealth proposals embraced new technologies and specialists into the groups.
Computer generated maps and geographic information systems (GIS) were practically
incorporated by every proposal. Risk maps, where population, vector densities, social and
environmental variables are interrelated, appear as innovative tools that could be very useful in
the operative level. Urban developers and architects in Montevideo provided new insights and
computer technologies to better understand the ecology of local breeding sites. Climate
specialists in Argentina and Uruguay also incorporated important analytical variables in the study
of entomological settings, obtaining a more integrated vision and understanding of vector
biology. Medical epidemiologists participated in areas where dengue has been a serious health
problem in the community.
Entomology had a distinctive participation in all projects providing baseline data,
identifying risk areas and measuring potential impact of interventions. The use of traditional
entomological indexes and incorporation of new ones (productivity and House Condition
indexes) represented a challenge to the projects as a whole. Although most of the projects
explored from a social perspective the usefulness of certain containers in the domestic setting,
there seems to be a need to unify the criteria, typology and the way breeding sites are measured
or categorized, especially when this data is expected to reflect changes in the behaviour promoted
by the interventions. An important issue that arises from the Ecohealth approach is that
containers should be seen not only from the water management perspective but also from the
solid waste or environmental deterioration perspective.
Social sciences were represented by diverse disciplines (sociology, anthropology,
pedagogy, social work, health promotion, gender specialists, etc). Their invaluable input to the
understanding of health problems and community relationships is unquestionable. In depth
interviews, focus groups techniques, key informant interviews, KAP surveys, observational
studies etc., have all provided important information to understand needs, knowledge, behaviours
and attitudes towards the environment and health problems. It has been through the interaction
with social scientists and their proposals that communication channels have been established and
all activities surrounding the community participation been organized. Much of the success of the
projects in terms of community involvement and sustainability has been produced by the
analytical inputs that social scientists have brought to the field of health prevention.
All the projects were very successful in the integration of the research teams although
understanding of roles, responsibilities and functions within the teams were not easily achieved
given that differences in methodological approaches and understanding of scientific principles
between disciplines required in depth discussions. More time than “what could be expected” was
spent in those discussions but it was necessary. It was even argued that specific time for this type
of interaction should be scheduled in every project before it is launched in the field.
An important attribute of the research teams’ composition was that the majority of team
members had previous and intensive exposure to fieldwork in community projects albeit not
necessarily health or dengue related.
Community participation
Vertical approaches to disease prevention and control have failed to understand and value the role
community organizations (formal and informal) can have in the implementation of effective and
sustainable interventions. Public health programs still depend on a unilateral and hierarchical
relationship with community members and few programs now embrace and incorporate the
community in the design and implementation of their strategies (eg. HIV-AIDS).
In the case of dengue, the role of the community is fundamental to the success of any
strategy that deals with breeding sites control. It must first be stated that community involvement
was incorporated into the dengue vector control discourse when the impact of technical solutions
(insecticides and larvicides) was evidenced as poor if not short lasting. This situation came along
with the break down of many vertical control programs in the region, the deterioration of the
urban environments and the lack of funding for public health programs that demanded heavy
budgets but provided light results. This situation was also propelled by the political and economic
ideology that established that tackling the social needs of the population was no longer
responsibility of the government alone but of the individual. On the other hand, it must be
emphasized that technologies and financial resources available do not allow the implementation
of a prevention and control program directed towards the Aedes aegypti without the commitment
and direct participation of the communities affected, since most of the breeding sites are
“produced” inside the domestic setting. Without placing the whole responsibility on the
community or lessening the responsibility of municipal authorities in charge of the provision and
maintenance of the sanitary infrastructure (potable water, solid waste collection and sewage)
dengue has become a challenge for public health because solutions lie outside the medical arena.
Community involvement may have different expressions in intensity, magnitude or
coverage of the target population. While in some projects the participation may be more massive
but short lived in terms of the people involved, in others, the intensity of their involvement
although limited to some sectors of the community, can prove to be very effective in the long
term. For example, in a rigidly organized society as the Cuban, community participation is not an
easy task even when people respond to several official mobilizations with outstanding efficiency.
It is precisely this strict form of organization one of the reasons that gives the community a
chance to organize itself around local interests and problems and not only to respond to vertical
and national priorities. In this particular case, the community initiatives that arose from the
Neighbourhood Groups (Grupos Vecinales) used the organizations in place, as the Popular
Health Council, in order to meet their objectives. In the case of Mexico, the organization of
community groups (Monitores Comunitarios) and their working agenda in the community relies
on the continuity and involvement of the municipal health authority whose involvement was
extremely important. In Buenos Aires, the commitment of a district supervisor led to the
incorporation of the experiences of the two schools initially involved in the project into the
curricula of all the schools in his district. Not only did all the schools become involved, but a
systematisation of the educational and formative process of teachers and students was established
with a well organized program that included objectives, resources, budget, activities to be
performed, products expected from each activity, and an evaluation scheme with follow up of the
results. The teachers in this district also became multiplier agents of such experience in all
Buenos Aires educational districts. A similar experience was generated in Montevideo but at a
lower scale (fewer schools involved). In Colombia, the networks of health promoters have
motivated the interest of municipal authorities and of the Vector Transmitted Disease Program
which in a way guarantees their sustainability. In Guatemala the Environmental Health Promoters
and in Mexico the Community monitors are an example where selected groups can guarantee
important levels of commitment and action.
The success of each project in developing a sustainable participation of the community
has some basic traits. When health promotion groups are formed in the community an essential
ingredient is that their members are part of the community and reside in the same areas where the
project is developed. In Colombia it was a policy not to be broken. In some cases it is even
useful, if possible, that members of the research team also belong or lived in the community
where the intervention is being developed. This was the case of Vicente López in Buenos Aires
and Fortaleza, Brazil. This issue turns out to be important to the community but also to the health
promoter or those involved in the intervention. A finding in Barrio Charrúa in Buenos Aires
illustrates the issue when lack of involvement of the school teachers and the health center
personnel in the neighbourhood was identified. The qualitative studies identified an issue of
hidden “discrimination” towards the population that was composed mostly by migrants from
Bolivia; therefore, teachers and health center personnel thought they should not get involved with
problems that were not theirs. The results also showed that teachers and doctors look at the area
(the people) with disdain since they were send there as a “punishment” or in a “stand by”
position. Absenteeism and constant replacement of personnel were the rule. Commitment under
these circumstances is not feasible.
In sum, all the proposals fulfilled the principle of “belonging to the community” and are
now identified as Grupos Vecinales (Cuba), Monitores comunitarios (México), Red de
Promotores de Salud (Colombia), Alfabetizadoras (Argentina), Grupo de Señoras (Argentina),
teachers groups (Argentina and Uruguay), the Environmental Health Promoters (Guatemala) and
therefore it is natural to expect better results. The case of Haydeé in El Cotorro, la Havana, is
highly representative since her professional background is health promotion and she now
represents the 17 Community Groups (Grupos Vecinales) created to tackle the dengue
problematique in the area and also sits along with the President of the Popular Health Council of
that district during the regular meetings held to deal with local problems, not only dengue.
Another issue that goes along with the sense of belonging or identity profile, is the
continuous presence of members of the research team in the area. The way the projects achieved
this aspect is extremely variable and it starts from direct social observational studies on site
(Fortaleza). In Buenos Aires an information stand was put in the weekly fair in Barrio Charrúa
and in a popular crossroads in Villa Pueyrredón. These are labour intensive activities that slowly
opened community relationships to the members of the project. Vector control personnel also
worked as good envoys of the project since they are routinely walking through the area. Not all
personnel had good communication skills so they need to be trained to perform such an important
task. It is important to keep the same personnel in charge of the same areas so the community
recognizes them as the link to the project. In Cuba they say know your area first (conoce tu área
Communities should be understood in their social context since most have experienced
social crises that often broke social ties and trust within their members. Binding with the
community is difficult because of insecurity, violence, trust of migrant populations, rejection to
governmental proposals, etc. Security issues in any Latin-American city are a matter of concern
and it certainly awakens mistrust when project personnel sometimes request the inspection of the
domestic setting. Once the community identifies the members of the project this issue tends to
vanish. Nevertheless, many projects mentioned that constant replacement of personnel presents a
barrier to advance in the project’s objectives. Lack of bonds between the agents and the
population caused by turnover of vector control personnel was an important finding in Fortaleza.
On the other hand, permanence is valued. For example, after the epidemic in Paraguay hit the
media in Argentina, people in the medium class neighbourhood in Buenos Aires who were
indifferent to the research team at the beginning, open their houses and asked more questions to
the girls in charge of monitoring the ovitramps. The same issue arises when different
stakeholders (municipal health authorities) are removed by political agendas creating the need to
re-socialize the project with the new authorities. This was important in Guatemala and Mexico.
This raises the challenge to institutionalize the projects into the agenda of key stakeholders.
An attribute should be that community health projects use previous experiences in the
areas selected and build on those results and interventions. Examples in several projects prove to
be very beneficial. For example, in Centro Havana the team worked years before in a housing
renovation project in the area and was later involved in the dengue control proposal. In Mexico,
community groups participated in a more active manner because the cities selected had been the
target of other research initiatives related to dengue control. In Guatemala a previous large scale
communication intervention proved to be very effective in involving the population in the
monitoring of vector control activities. In Colombia, the Vector Control Program in the
municipality had already created a network of health promoters and campaigns directed to the
collection of disposable items along with aerial fumigation activities and biological control
initiatives (4 times per year). In Buenos Aires, the Primary Health Unit in the Vicente López
municipality had developed several projects related to cholera control, drug abuse and
reproductive health. It is desirable that experiences outside the health arena nourished
experiences like these. In Mexico, for example, women participating in a social program directed
to poverty reduction (Oportunidades) were the most participative (200 out of 360 in the
intervention area were from this program). Benefits from one area can support initiatives directed
towards health and the environment. On the other hand, it is important to interpret the role of
political organizations since communities recognized that they promise more than what they offer
and that their support is short lived. Participation in health projects can not be granted expecting
material goods.
Gender oriented aspects:
The socialization of roles in terms of health care, domestic activities, community responsibilities
is determined by cultural, educational and social issues. In the case of health it has been a matter
of concern that women are perceived as the ones responsible of taking care of the family needs.
The domestic setting is seen as a women’s space and men are seen as the providers. The
introduction of health as a reality related to environmental factors creates the need to modify the
gender roles since the domestic and community environment is a new space where collective
responsibilities need to be define and understood. As the projects faced the need to change
community’s perception that dengue control is a responsibility of government agencies alone, it
was also necessary to explore and identify how community members perceived and acted upon
the issues of health risks in public spaces.
A practical concern of all the projects was that most of the people interviewed were
women. There is a strong perception that domestic hygiene is an activity under the responsibility
of women even in physical activities like cleaning low tanks, like in Colombia. Some interesting
results were obtained from the qualitative studies. In Buenos Aires the teachers (basically
women) were identified as sources of potential bias in terms of gender definition since they could
reinforce and reproduce gender stereotypes if they are not conscious of their role as women and
educators. They teach who is in charge of places and roles in the domestic setting and therefore it
is important to create awareness of this particular situation so as to produce a change with the
children and their families. In Uruguay, the educational level and equalitarian attention women
and men received in education, sets a situation where gender issues are more age related since
domestic roles are fixed in women of older age groups. The economic crisis in Argentina in 2001
brought also a crisis in masculinity since women were more easily employed than men and
women had double working schedule creating a new situation regarding the differentiation of
roles in the domestic arena. In terms of the distribution of tasks within the household, the
composition of the Grupos Vecinales in Cuba changed with time and functions since the
detection of problems was basically defined by women and changed when solutions were
identified and more men were involved. In Buenos Aires the project gave women in a Religious
association (Caritas) the opportunity to participate and experience and interesting transformation.
Adult women learning how to read and write were involved in the design and production of
educational materials. This situation produced a dramatic change since they were put in a public
space where they previously had no place (illiterate, foreigners), and now they taught others their
experience and messages. In Mexico, most of the women participating in the project were
involved in a poverty reduction social program (Oportunidades) that gives women control over
the resources (money) provided by the program. This situation is empowering women in the
definition of priorities and how resources are managed from a new gender perspective.
Results from the other projects identified that certain breeding sites, cleaning activities
and domestic spaces were gender related and explored behavioral changes directed to this
particular finding. There is a trend to link women to tidiness and cleanliness in the house and
with prevention and health, which raises a quandary for researchers: if messages relate lack of
hygiene with the transmission of dengue, and imply that the environment of the houses is not
healthy, this may put into question the ability of the women to keep their home healthy and clean.
These examples illustrate findings of the projects that can be related to gender as an
important component of the proposals. It should be stressed that change in gender roles were not
systematically explored nor targeted in the interventions implemented.
This methodological pillar was not addressed directly by the proposals.
2. What is the quality of outputs generated by individual projects (in terms of knowledge
generation, social capital strengthening, and knock-on or domino effects, capacity building
for the team, publications, etc.) and their relevance to researchers and practitioners from
the health and environment sectors?
Knowledge generation
The nature of transdisciplinarity in all projects generated an innovative approach to the
understanding of health determinants through the incorporation of risk as the aim and the
environment as the target. The knowledge produced by the experiences in dengue control can be
adapted to tackle other health problems with similar benefits.
The projects developed a vast amount of educational materials (posters, videos, triptychs, games,
songs, handbooks, slide shows, etc), that were targeted to different audiences, focused in diverse
control strategies with different knowledge purposes and to encourage different levels of
commitment. Compilation of a complete set of this material would be extremely useful for other
researchers and communities if contents are adapted to local contexts. A good amount of
publications, technical and scientific, has been produced and knowledge generated is already
being presented in different forums (Annex).
Social capital strengthening and knock-on or domino effects
An outstanding result is how most of the projects were able or successful in generating awareness
and interest from different government agencies. The most benefited were municipal health
authorities in several sites, indistinctly of the epidemiological context in which the project was
developed. In Cuba as well as Uruguay (opposite dengue realities) the project outputs were
incorporated into local contingency plans and even scaled up to strengthen national dengue
control agendas.
The educational sector was an active stakeholder in Argentina and Uruguay that will
benefit from the experience by the systematization of the formative and educational process in
teachers and students. Teachers mentioned that projects like this one bring purpose to our
educational role.
The communities involved developed strengths and capabilities to face local problems
that will eventually improve their living conditions. In the case of Buenos Aires, for example, the
health promoters in Vicente Lòpez were in the process of creating a non governmental
organization that would enable them to get hold of financial support for different projects and
interventions in their communities. The Neighbourhood Groups in el Cotorro are working hand in
hand with the Popular Health Committee. The network of health promoters in Colombia is
collaborating with the local vector control program.
The work developed by all these groups is likely to create a domino effect in their
communities and further follow up may show how the Ecohealth approach can enlarge its
branches to other areas of concern of the communities involved.
Capacity building for the team
Interaction among different disciplines, academic centers, institutions and social key stakeholders
has created a nourished milieu where benefits multiply in terms of the local capacity built in
research centers and academic institutions. The technical infrastructure (laboratory, software
hardware, physical areas, equipments, etc) provided through IDRC´s funding is still in operation.
Teams are now recognized not only as an array of individuals specialized in a field but as an
experienced research team in the area. In most of the projects, the interventions were useful for
postgraduate thesis and training of local research teams. The overall experience demonstrates that
innovative research initiatives generate strengths that are not created by individual efforts. One
example that merits recognition is that of the health promoters in the poor urban area of Buenos
Aires, where they are organizing a non-governmental organization to search for funds useful for
other health issues in their neighborhood. The experience and capabilities developed in the
dengue control strategy was useful to understand and tackle other health needs in the community.
Follow-up of such enterprise will be necessary in order to measure the global impact of IDRC’s
initiative. In Guatemala, additional funds were obtained from a private foundation and the Lions
Club to pursue an intervention on diarrhea control supported by the research team.
3. What are the intended outcomes of projects related to human health, environment and
development? Have they been tracked? Are they being achieved and to what degree? How
did projects contribute to their achievement?
The IDRC initiative is directed towards a better understanding of health determinants and
improvement of population health through sustainable environmental changes. The immediate
impacts of projects, given the short time frame of the proposals implementation, are more clearly
seen in areas different than health, although on a long-term basis they should also become
manifest in the health area.
Human health outcomes:
The projects were directly or indirectly involved in the measurement of health risks or disease
prevention. Those that measured direct health impacts were Cuba (dengue), Mexico and
Guatemala (dengue and diarrhea). The projects in Cuba were involved in the development of a
surveillance system designed for early detection of cases and environmental risks for breeding
sites. Low infestation rates in Cuba can hardly be replicated in other countries in the region, and
once the projects ended, Cuba actually suffered a dengue epidemic. This issue is a major
scientific and health concern because it shows that even with low entomological indexes
transmission of dengue may still occur. The laboratory-based surveillance system supported by
community members created risk maps, and actions were taken according to the findings. While
epidemiological data was collected and mapped, the impact of the early detection system was
mentioned as good since the areas in both projects (El Cotorro and Centro Havana) were the last
to detect transmission and the first to control it. While no data was presented since analysis is still
in progress, the low infestation rates in the areas may “guarantee” low transmission rates. The
impact of the intervention can also be registered since Centro Havana was previously classified
as a high risk area, and after the intervention it was classified as medium risk according to the
entomological, epidemiological and environmental indicators. An overall assessment of the
opportunity of the surveillance system requires a detail report by the Cuban team.
The results in Mexico and Guatemala offered some evidence of change in health risks for
dengue but not so for diarrhea, although no serological evidence was produced in the case of
dengue transmission. The 5 by 5 healthy practices directed towards breeding sites control and
water management were evaluated and measured. The healthy practices for breeding sites and
water containers control were easier to perform (once a week) than those related to diarrheal
control (daily). The frequency of the activities promoted may have an impact on the adoption of
behavior changes.
The projects in Melgar and Girardot (Colombia) and Fortaleza (Brazil) are in their
baseline and diagnostic stages where health risks were established but no interventions were
introduced as to evaluate their impact. On the other hand, the projects in Buenos Aires
(Argentina), and Colonia and Montevideo (Uruguay) represent a unique scenario to measure the
impact of the interventions since no local transmission has been detected even though imported
cases have occurred in Buenos Aires. The recent detection of one dengue case in Uruguay creates
an ideal scenario that needs intensive follow up. Since the monitoring of health risks
(entomological) is being performed and amplified by the epidemiological risk situation in
Paraguay, the chance to evaluate their impact in health outcomes is optimal.
Environment outcomes
All projects developed a particular approach to measure environmental risks for mosquito
breeding sites and with the exception of Colombia and Brazil, all intervention sites reported
different levels of change in the management of environmental risks. In Cuba some high risk
public spaces (vertideros) were transformed into parks, gardens, orchards or recreational spaces.
Though small in scale, they proved to be feasible through community involvement. In
Montevideo the cemeteries now use sand in flowerpots to prevent mosquito breeding sites,
reducing the risk in neighboring areas. The breeding sites cleaning campaign 4 days a year
established in Girardot, Colombia has improved the breeding environment in the area. Better
water container management was registered in all sites producing lower infestation rates in
several containers. Nevertheless, the recent experience in Cuba demonstrates that the reduction of
infestation to minimal levels still represents an important risk for disease transmission.
Development outcomes
A long term result not evaluated.
4. What are the general gaps and challenges observed?
The experiences in the projects all bring promising results to the field of health prevention and
control. Far from being conclusive they also raise some important challenges and point out gaps
that need to be tackled.
The “community” is not a social homogenous unit or necessarily receptive to collective
action. If we are to promote collective participation when social dynamics are torn down
(unplanned urbanization, migration, insecurity, gender issues, violence, drug abuse, etc.) the
rescue of “collectiveness” and the establishment of care networks could be important strategies.
Further interventions need to recognize those particularities in order to produce collective
If programs at the municipal level (potable water provision, garbage collection, waste
management, health promotion, etc) work independently, the scale up of the interventions is
definitely compromised. The experiences demonstrated that when the interventions were
considered of public interest by different social actors or stakeholders, the chances of
sustainability increased substantially. It is through this channel that community and government
agencies can promote alternative water supply systems and engage in the revitalization of public
spaces. When appropriate municipal infrastructure is not in place it hinders changes in practices
and attitudes. Municipal services need to be reoriented to allow community participation
initiatives. Sustainability of interventions requires permanence and continuity of partners.
Tourism is an important economic force in most of the project sites, in some cases it is a
matter of national economic security. Water management (distribution) in these areas is key to
the reproduction of environmental and health risks. Stakeholders in this sector should be
incorporated to protect the environment, diminish health risks and secure this economic activity
(virtuous circle).
Environmental risks are not produced but reproduced and amplified by the community.
The environmental deterioration registered by the projects in terms of waste management,
breeding sites multiplication, water storage practices and health risks has become a natural
consequence of the proliferation of non recyclable containers produced by the industry. We can
not expect that house dwellers improve their domestic environment without community or local
resources that keep breeding sites away. Community members have no tools to destroy or dispose
of massive numbers of containers that are produced outside, introduced massively but not
collected, without the direct participation of municipal authorities. On a long term basis,
industries should be involved and regulated to guarantee a cleaner environment.
A serious concern for all those involved in dengue control should be the definition of
transmission risks based on entomological indexes. All the projects used infestation indexes as
parameters to measure environmental risks and evaluate impact of interventions when performed.
The Cuban experience demonstrates that epidemics can occur when house or container indexes
are below 1%. An imperative component of any proposal on dengue control should incorporate
detection of cases in order to understand the level of efficacy required in terms of the low density
of containers or larval density. On the other hand, traditional indexes do not reflect changes in
behavior in a detailed fashion. While entomological surveys identify if containers were positive
or negative they do not always describe if they are covered, turned upside down or protected.
Impact of the interventions should also be established in terms of the effectiveness of such
control activities (frequency of activities, duration of control status, permanence of breeding sites,
productivity of breeding sites, etc).
5. How are Ecohealth approaches utilized in the individual projects different from other
approaches to communicable diseases prevention and control? How are they the same?
What is the added value? What is left out? What are the trade offs?
IDRC´s initiative demonstrated that disease prevention and control projects do not need to be
under the leadership of a medical professional to generate effective strategies and products. It was
also demonstrated that technical human resources (vector control personnel) under the
administration of health programs required training in their entomological as well as their
communication skills.
Health is not seen from the perspective of the disease but as a risk developed from the
environment. Vertical and disease oriented approaches focus on technical issues and define, and
set up actions directed to particular issues and according to establish priorities. In the case of
dengue the targets are the breeding sites and mosquitoes, not how or why breeding sites are
produced and reproduced. The promotion of behavioral changes is based on imperative
instructions (do this, this way and for this long). At the end the impact is limited, transitory and
demands constant reinforcement. From the population point of view dengue is not a problem,
therefore Ecohealth approaches work along the needs of the community, identifying priorities and
developing capabilities appropriate for dealing with other health issues, not specific targets.
Feedback, instead of reinforcement, creates awareness of their impact and promotes co-
Community members in the IDRC`s projects were involved in the identification and
understanding of their problems. These are not set according to global health policies that may or
may not be justified. The health promoters are trained in the evaluation methods, sharing
responsibilities and giving purpose to their actions. Indicators are designed to be accessible and
simple to monitor the process and the impact of their activities. An important difference with the
traditional control strategies is that communities take responsibility in monitoring environmental
risks, identify solutions according to their capabilities and develop strengths to contact key
stakeholders to solve problems out of their reach. While community participation projects
empower the members of a community, traditional programs managed by health authorities “keep
power” (technologies, educational tools, resources management) to themselves and under their
Educational materials are not produced massively and directed to an abstract audience; in
the Ecohealth approach, messages are designed according to cultural and educational
backgrounds and materials are adequate to age groups or audiences and produced with local
resources (slides, triptychs, posters, puzzles, videos, etc.). Systematization of the formative
processes and learned experiences can be extrapolated to other health issues. In traditional
programs, community personnel are trained in specialized areas or programs. Ecohealth approach
searches for self-reliance in the actions of the community while traditional programs need to
oversee (supervise) their progress.
Both approaches acknowledge that changes in attitudes and practices take time to become
established but traditional programs are not concerned with sustainability of interventions since
they are based on the continuity of actions and dependent on the flow of public funds. A
substantial difference is the nature of the traditional programs that are based on repetition of
actions not in reinforcement and feedback.
Traditional approaches to health prevention and control now place the responsibility
(blame) on individuals (diet, lack of exercise, smoking, reproductive risks, etc.) while the
Ecohealth approach searches for co-responsibility of all actors involved. Even in dengue control,
blame in traditional programs is “dumped” in the household and participation is seen as a
substitute for the lack of government investment and break down of vertical programs.
An important difference also arises from the perspective the problem is seen. While
traditional control programs view the problem from the vector perspective, the Ecohealth
approach understands that breeding sites are result of a complex interaction of factors that create
a deteriorated environment suitable for breeding risks. At the end, traditional programs are
organized as emergency responses delivered against the mosquito without any consideration of
the environment. They do not even critically assess the ecological impact of the insecticides used.
Ecohealth approach intends to modify the environment to diminish the health risk and looks for a
long term impact. None of the projects are in a position or time schedule to assess this issue.
6. What lessons, insights, knowledge follow from the various sets of projects with respect to
social and ecological determinants of disease transmission, prevention and control
strategies, and coping capacity of communities concerning the diseases?
It has been clearly established that community members have a well structured idea (knowledge)
about dengue as a disease but not regarding the mosquito as a vector of infection. The existence
of knowledge does not guarantee behavioral change. Even when the notion of risk is in place,
people still view government agencies as responsible for the control. An Ecosystem approach has
been useful to overcome knowledge barriers and establish bridges to better understand the risks
by linking the health problem to an environmental concern and a collective responsibility.
The problem of understanding and assimilating information may originate on the irregular
nature of communication campaigns, the way information is elaborated and transmitted to the
population, and the lack of a clear educational tasks. The projects’ efficacy in dengue education
and communication campaigns relied on previous identification of the community’s knowledge
and the messages adaptation according to the local reality. Not every action or campaign about a
health problem results in long-lasting, sustainable changes or impacts at a socio-cultural level. In
some cases campaigns must continue even when the threat is not present. This was certainly true
for the case of Montevideo and Buenos Aires since their reality in terms of dengue experience is
opposite to the one living by the other study sites. The challenge is to create risk communication
strategies to improve impact of projects.
The major challenge ahead is to build a framework for action directed towards improved water
management since negative repercussions of increasing access to water are a result of the survival
needs of the community not understood as vector related activities. If water gives people the
possibility to have a better standard of living, storage, accumulation or accessibility by whatever
means cannot be perceived as a disease niche or a health risk. This can also be true when related
to the cleaner environment since accumulation of things (usable or not) gives a certain kind of
status versus not having them. Traditional control programs avoid a wide spectrum of issues why
communities need to store water and where. Interventions (larvicides, insecticides and containers
collection campaigns) act against community’s beliefs and needs; therefore resistance is the
natural response.
Ecohealth approaches search for solutions by understanding cultural and educational
backgrounds involved in the management of the domestic environment. What needs to be
highlighted is the relation between responsibility in the control and the production of risks.
Massive introduction of a wide spectrum of non-recyclable recipients is not created by the
community members. Their choices of control are limited if those containers are not collected by
public solid waste agencies as they lead to a deteriorating environment. Traditional control
programs blame the community and make them responsible of controlling what is out of their
control. IDRC´s projects created a new set of conceptual, technical and practical tools that have
the potential to enhance the control strategies in the region. By promoting co-responsibility,
strengthening the interaction with different stakeholders, promoting responses according to
capabilities, educating individuals, families, communities as well as institutions, the Ecohealth
approach introduces conceptual innovations to community participation control schemes. By
identifying actions not only related to vector control but focusing on the modification of the
environment, Ecohealth projects look for a durable impact and not a transitory one.
7. Local relevance and utilization of research results: Who has and how have research
results been utilized?
The IDRC Ecohealth approach is in itself a relevant result that was used to understand and design
better prevention and control strategies directed to improve the environment and dengue situation
in the project areas selected. Most of the projects will produce scientific publications relevant to
the vector control community, governmental control programs and educational fields.
In this particular case, the project that took place in the suburban area of El Cotorro had
immediate relevance to public health researchers and the knowledge produced was adopted by
the team in Centro Havana project also financed by IDRC. While most of the methodology aimed
to establish a surveillance system, additional components were incorporated to the Centro Havana
project. The vector surveillance information system is labor intensive as well as the elaboration of
the risk maps (GIS). Maps were very detailed because of the amount of information collected. In
the end, the model was adapted to Centro Havana conditions, resources and personnel available.
Members of both projects (El Cotorro and Centro Havana) were involved in the design of an
emergency plan to guarantee the sustainability of dengue control in the island where all
governmental actors along with community organizations participate in a coordinated manner.
Much of the results from the projects were incorporated into such a plan.
Buenos Aires:
The project followed a desirable but rarely traditional route. Actually it proved to be one of the
biggest bets in IDRC funding policy. Like any other project, Argentina faced the threat of dengue
transmission because Aedes aegypti was already present in the metropolitan area. This was in
essence a real prevention project and is now being put to the test. Its relevance came from the
imminent risk of dengue transmission, and when the research was almost finished an epidemic in
Paraguay created an ideal scenario to put all what the project was working on into practice. First,
the entomological team is being recruited to perform a wider monitoring of vector densities in the
metropolitan area. Second, the Primary Health Care Unit in the municipality of Vicente López
(intervention area) was also invited to provide their experience in the project to organize the
health promotion and community participation components of the governmental program. Third,
activities in the two pilot schools of the project were later scaled up by the district supervisor to
all other schools in the district. Systematization of the experience was extremely important since
all the material, the program, the objectives, activities and evaluation materials were integrated
and organized in a very professional manner. This was how part of the research results were used
in the educational field. Another and most important way was that those teachers involved in the
development of the educational strategy became multiplier agents of the experience in the rest of
the school districts in Buenos Aires. In the end, it is expected that all the schools will benefit
from the information, knowledge and skills developed by the students and teachers in the two
pilot schools.
Understood as a common project with Argentina, the project in Montevideo was exposed to the
same intensity of media information and awareness of the society as a whole. Nevertheless, the
project in Montevideo is still developing its most important products: the Early Warning System
and the Follow up Observatory. Governmental agencies are already asking the team leaders to
provide them with data and their experience but products are not ready yet. The material
developed by the schools will also be used to train other teachers and organize other schools in
the recognition of the problem within their communities. During the writing of this report, one
autochthonous case of dengue was reported in northern Uruguay. Predictions by the research
group were fulfilled, a sanitary emergency was established and the inputs from the project are
being used as part of the national contingency plan.
The final technical report of the research develop in Mexico is still in process and final results
have not been presented to different stakeholders in the area and at national level. Local
authorities have adopted the experience though it could be difficult to sustain if the municipal
health authority that participated is removed since she was a key person in the development of the
whole strategy of community organization. Socialization of the project is required when removal
of key actors is a regular situation.
The technical reports show a wide participation of different stakeholders in the institutional and
social level. The project served as an important input for academic training for social, biological
and even sanitary engineering postgraduates.
Colombia and Brazil
These projects are still in a developing stage although promising results may be expected from
both experiences. In Colombia at the end of the project a series of meetings were held with
municipal authorities in both areas where results were presented and adoption of several practical
control measures were discussed. Future evaluation of such interventions are targeted in a second
phase of the study if funds become available.
8. What are examples of outstanding contributions of projects (eg. Knowledge, strategies,
policies, health outcomes) that can be documented to showcase the achievements and
potential of ecohealth approaches?
The Ecohealth approach has brought appealing and innovative issues to the prevention and
control of public health problems and not only dengue as an isolated topic in the health agenda.
First of all, we are transcending the approach of a health problem and specific strategies by
engaging in the definition of healthy ecosystem where social, economic, cultural, biological
determinants of health are analyzed and reflected upon as a unity. To interweave different
elements that influence health and behavior, that are usually taken independently, gives a clearer
unity and meaning to the understanding of dengue reality. In this particular case, new
technologies (GIS) were incorporated and proved to be very useful in the understanding of
environmental risks, population dynamics and health hazards.
The diversity of ecological and social environments where the projects were developed
illustrate the complexity of dengue transmission determinants. The rural and densely populated
urban environments are settings where dengue flourishes and there is no single strategy that
addresses all the determinants of the mosquito breeding risks. Water provision and waste
management are important determinants of a clean environment and every proposal had
particularities that required consideration in order to design appropriate interventions.
Risk awareness define by a deteriorated environment was a key contribution to involve
the community in much favorable ways towards the control of vector breeding sites. Since
dengue is not perceived as a priority by the community, the goal of managing the environment
gave more sense to the activities proposed in the interventions.
An outstanding contribution from all the proposals was the identification of the axis of
water management-water storage-risk perception-and social conditions as a complex relationship
that needs to be translated into concrete actions that find coherent solutions to the social groups’
realities. In every case, the problems faced were related to water management (scarcity or
irregular provision, absence, abuse, misuse, etc.) and solid waste disposal that obliges members
of the community to undertake certain practices that will eventually lead to health risks and
environmental deterioration. This situation is analyzed not only from the individual perspective
but as a social problem where every member of the community has a role and a responsibility.
Far from just reducing the approach to the presence of breeding sites and practical ways to deal
with them, the projects analyzed their determinants (social, cultural, economic, etc.) in order to
tackle them more effectively.
Community participation is not seen as a substitute for governmental inefficacies but as a
necessary component for all effective interventions. The take home message is not to blame
authorities for what they stop doing but to try to solve what is on your hands. If the community
solves problems, identifies obligations, accomplishes what is requested then it is able to demand
action from other sectors of government. Co-responsibility with government agencies was an
important outcome from all projects since “a well organized community can demand solutions”
not just ask for them.
Most of the work concentrated in the identification of health problems, needs and also the
proposal of solutions to those problems identified. An interesting result was the changing
relationship with private and public spaces since both scenarios are now viewed as risk and where
responsibility is a collective not only an individual task. Creating this type of awareness towards
the environment as a group responsibility, generated the substrate for more interesting risk
communication strategy with different educational materials (posters, booklets, pamphlets, songs,
etc.), pertinent to different audiences, feasible for target populations, easily monitored by
community members and useful to public health agencies. The analytical and technical products
were also more appropriate to the needs of decision makers.
Annex 1.
Composition of research teams and activities developed
(Workshops, Congress, Publications, Thesis, etc.)
Research Teams
(* people interviewed)
Universidad de Buenos Aires
Nicolás Schweigmann (Fac. de Ciencias Exactas y Naturales)*
Andrea Rizzotti (Fac. Latinoamericana de Ciencias Sociales)*
Gabriela Castiglia (Municipalidad de Vicente López)*
Fabio Gribaudo (Municipalidad de Vicente López)*
Edgardo Marcos (Gobierno de la Ciudad de Buenos Aires)*
Pablo Dinghi (Docente investigador)
Sandra Gómez (Docente investigador)
Santiago Maldonado (Fac. de Ciencias Exactas y Naturales)
Pablo Maccione (Fac. de Ciencias Exactas y Naturales)
Natalia Calvo (Técnica de laboratorio y campo)
Paula Prunella (Técnica de laboratorio y campo)
Mónica Monti (Técnica de campo)
Claudia Serrano (Técnica de laboratorio y campo)
Nora Burroni (Becaria)*
Gabriela Freire (Becaria)*
Vanesa D´Onofrio (Becaria)*
Sara Oberlander (Becaria)
Héctor Schillaci (Becario)*
Universidad de la República
Fac. de Agronomía
César Basso, team leader*
Jorge Pereira*
Fac. de Humanidades y C. de la Educación
Sonnia Romero*
Fac. de Ciencias
María Martínez*
Mónica Gómez*
Walter Norbis
Mario Caffera *
Mario Bidegain
Karina Sans
Nancy Andreoni
Danilo Calliari
Maite Ponds
Nicolás Vidal
Fac. de Arquitectura
Ingrid Roche*
Sumila Detomasi*
Mariana Alberti,
Trilce Clérico,
Ma. Gabriela Detomasi,
Rodrigo Fernández,
Néstor López.
Center for Research in Malaria, Tapachula , Chiapas (CIP-INSP)
Juan Ignacio Arredondo-Jiménez, Principal Investigador*
José Genaro Ordóñez-González
Norma Edith Rivero
Kenia Mayela Valdez-Delgado
Teresa López Ordóñez
Margarita Pérez-Ramírez (†)
Joaquín Covarrubias
José Luis Espinoza
Raúl Monzón
Eleazar Pérez
Amílca Zúñiga
Municipal authority in Huixtla
Arhemy Durante
Universidade Estadual do Ceará (UECE)
Andrea Caprara, MD, PhD, Principal Investigator, Professor*
Alice Correia Pequeno Marinho, MSc,
José Wellington de Oliveira Lima, MD, PhD, Professor
Eddie William de Pinho Santana, PhD, Professor
Ethnographic researchers
Lucyla Oliveira Paes Landim Santana, MPH
Paola Gondim Calvasina, MPH
Fátima Maria de Sousa Sales, Nurse, Master of Public Health Student,
Fábio Angelo Lima Verde Araújo, Nutritionist, Master of Public Health Student
Ellen Rodrigues Lima, Pedagogue, Psychodramatist,
Luisilda Maria Dernier Martins Santana, Nutritionist, Master of Public Health Student
Mardênia Gomes Ferreira Vasconcelos, Nurse student
Amanda Nobre, Medical Student
Carolina Arcanjo Lino, Medical Student
Carlos Maximiliano Medical Student
Entomologic researhers
National Health Foundation
Carlos Alberto dos Santos Barbosa, Technician
Clodoaldo Olinda Fernandes, Technician
Fábio Gomes da Silva, Technician
Francisco Antônio Bezerra Araújo, Technician
Francisco Deusimar Girão de Carvalho, Technician
Raimundo Ferreira da Silva, Technician
Health Research and Study Centre: CEIS Fundación Santa Fé de Bogotá
Gabriel Carrasquilla,M.D., PhD, Principal Investigator*
Julian Quintero
Victor Olano
Universidad de los Andes Anthropology Department
Roberto Suárez
Catalina González
Juan Manuel Viatela
Jairo García
Instituto de Medicina Tropical “Pedro Kourí”
Prof. Gustavo Kourí *
Lic. Cristina Díaz, Principal Investigador*
Dr. Ángel Manuel Álvarez*
Lic. Yisel Torres*
Lic. Omar Fuentes*
Dra. Lázara Alfonso*
Lic. Zulema Menéndez*
Dra. Belkys Galindo
Lic. Ana Margarita de la Cruz*
Dra. María Guadalupe Guzmán
Dr. Osvaldo Castro
Lic. Dulce María Torres
Lic. Alicia Reyes
Téc. Ernesto García
Instituto Nacional de Higiene, Epidemiología y Microbiología.
Dr. Mariano Bonet, Principal Investigator*
Dr. C. Maricel García
Lic. María de los Ángeles Mariné
Lic. Liliam Cuéllar
Lic. Ana María Ibarra*
Dr. Ramón Suárez
Ing. Miriam Concepción*
Lic. Olivia Sardiñas
Téc. Giselle Arce
Unidad Municipal de Higiene y Epidemiología Cotorro.
Dra. María Eugenia Piquero*
Dra. Ida Valdés*
Lic. Ibian Castillo*
Lic. Beatriz Ramírez*
Téc. Rafael Valdés*
Téc. Aida Valero
Lic. Nereyda Noa
Dra. Mercedes Vázquez
Dra. Lilian Legrá
Téc. Juan Antonio García *
Téc. Manuel Porvén
Nutrition Institute for Central America and Panamá, INCAP
Dr. Ricardo Luján, Principal Investigator*
M.Sc. Olga Rebeca Torres
Licda. Christa Haeussler de Valverde
Dra. Zully Anabella Hernández-Ramírez
Ing. René Morales-Flores
Ing. Francis Gilroy Lewis
Ing. Ronald David Matías
Licda. Patricia Mercedes de León Toledo
Lic. Rudy Benedicto de León Calderón
Licda. Jaroslava Lemus
Lic. Jorge Arturo Matute Flores
Lic. Humberto Méndez
Lic. Héctor Sabel Gamero Figueroa
Licda. Claudia María Mérida Alemán
Licda. Evelyn Piedrasanta
Dr. Juan Fernando Hernández-Escobar
Workshops and Courses
Several actvities were developed during the design and implementation of the proposals that help generate more
precise documents. Workshops were also held to discuss advances and to analysze results which were very
usefull for the research teams. The list of events and products where researchers participated is taken from the
technical reports send to IDRC. Additional information was requested to complete each of these sections.
Taller Regional sobre Ecosalud, Dengue y Chagas en Centroamérica y el Caribe
Technical Review Panel & the Steering Committee for Ecosystemic approaches to Human Health in
Centroamerica and the Caribbean
2nd International Congress on Dengue and Yellow Fever (May 31st-June 3rd)
Socialización de Resultados con Actores Locales y Tomadores de Decisiones; Centro Internacional de
Investigaciones para el Desarrollo (IDRC) No. 102477-002
EcoSalud y Transdisciplinaridad y Participación Ciudadana con Enfoque de Género; Centro Internacional
de Investigaciones para el Desarrollo (IDRC) No. 102477-002
Conjunto de Discusión Académica INCAP/OPS, Guatemala – CIP/INSP, México; Centro Internacional de
Investigaciones para el Desarrollo (IDRC) No. 102477-002
“Enfoque de ecosistemas para la Prevención y Control del Dengue en América Latina y el Caribe:
Desafíos para la investigación. Ciudad Habana, Cuba. 4-5 de Junio/2004.
Curso Internacional de Dengue. Ciudad Habana, Cuba. Agosto/2003. Introducción al enfoque
ecosistémico en Salud Humana para la prevención de enfermedades transmitidas por vectores.
Scientific forums and Congress
Dissemination of the results of the research are important assets for the research teams since feedback
from other research groups is necessary. The list of events and products where researchers participated is
taken from the technical reports send to IDRC. Additional information was requested to complete each of
these sections.
II Congreso Internacional de Dengue y Fiebre Amarilla, La Habana, Cuba. 31 Mayo- 3Junio/2004.
Round table
An ecosystem approach to human health for the prevention of Dengue. Havana City. Cuba
Cristina Díaz, Angel M. Alvarez, Maricel García, Belkis Galindo, Ida Valdés, Yisel Torres
Basso C. & Schweigmann N. 2004. Ecosystem approach to the prevention and control of Aedes aegypti in
Uruguay and Argentina.
Experiences from the use of indicators for Dengue control and prevention
María de los Ángeles Mariné, Maricel García, Angel M. Alvarez (Cuba)
Determination of the chemical-physical main characteristics of the aquatic habitat of the Aedes aegypti in
the municipality of Cotorro, Olivia Sardiñas, Maricel García (Cuba)
Aquatic habitat and dengue vector ecosystem by Teresa Torres, Maricel García (Cuba)
Applying geographical information systems in health: integrated surveillance system for dengue
prevention in Cotorro, Lilliam Cuéllar, Beatriz Ramírez (Cuba)
Vigilancia Centinela en la atención primaria de salud para le prevención del dengue; Belkys Galindo,
Lázara Alfonso, Angel Manuel Alvarez (Cuba)
XI Congreso de Investigación en Salud Pública. Cuernavaca, Morelos /2004.
VIII Global Forum for Health. México DF, México. 15-20 de Noviembre/2004
Ecosystem Approaches to Dengue Prevention in Havana City. Cristina Díaz et al. (Cuba)
Participatory Dengue Prevention; Cristina Díaz et al. (Cuba)
Curso Internacional de Dengue. Ciudad Habana, Cuba. Agosto/2005.
Medicine and Health in the Tropics. Marsella, Francia. 11-15 Septiembre/2005.
An ecosystem approach to human health for dengue prevention at local level. Ángel M. Álvarez et al.
II Congreso Interamericano de Salud Ambiental. Ciudad Habana, Cuba. 19-23 Septiembre/2005.
Round Table
Experiencias con el enfoque ecosistémico para la prevención de dengue; Cristina Díaz, Maricel García,
María de los Ángeles Mariné, Miriam Concepción (Cuba)
IV Simposio Nacional y III Encuentro Internacional “Vigilancia en Salud 2005”. Ciudad Habana,
Cuba. 4 – 7 de Octubre del 2005.
Dimensión Ambiental en la Salud Humana y Calidad de Vida.; Liliam Cuellar, Beatriz Ramírez (Cuba)
Jornada Provincial de Vigilancia y Lucha Antivectorial. Cuba.
Round Table
Participación Comunitaria; Cristina Díaz, Yisel Torres, Ana Margarita de la Cruz (Cuba)
The list of events and products where researchers participated is taken from the technical reports send to IDRC.
Additional information was requested to complete each of these sections.
Chapters in books
Basso C., Romero S., Martínez M., Roche I., Gómez M., Detomasi S., Pereira J. 2005. Prevención y
control del vector del dengue, Aedes aegypti (L.), en Uruguay acudiendo a un enfoque ecosistemático. In:
Augusto LGS, Carneiro RM, Martins PH (eds). Abordagem ecossistêmica em saúde. Ensaios para o
controle de dengue. Recife: Universitária da UFPE; 2005. p. 175-85.
Scientific Articles
Calliari D., Sanz K., Martínez M., Cervetto G., Gómez M., Basso C. 2003. Comparison of the predation
rate of freshwater cyclopoid copepod species on larvae of the mosquito Culex pipiens. Medical and
Veterinary Entomology 17, 339-342.
Gómez Erache M., Sans K., Basso C. 2004. Recent data on freshwater Cyclopoids Copepoda from
Uruguay. Nauplius 11, 145-148.
Caprara A., de Oliverira Lima, JW., Correira PM., Godim Cp., Paez LL., Sommerfeld J., Living with
scarce water and dengue
Menéndez Z., et al A new record of Mesocyclops pehpeiensis Hu, 1943 (Copepoda: Cyclopoida) for
Cuba. Journal of Vector Ecology 30 (5), (2005)
Mariano Bonet , Jerry M. Spiegel, Ana Maria Ibarra, Gustavo Kouri, Alfredo Pintre Lic, Annalee Yassi,
An integrated ecosystem approach for sustainable prevention and control of dengue in Central Havana, in
Jerry Spiegel, Mariano Bonet, Ana-Maria Ibarra, Nino Pagliccia, Veronic Ouellette, Annalee Yassi Social
and environmental determinants of Aedes aegypti infestation in Central Havana: Results of a case-control
study nested in an integrated dengue surveillance program in Cuba; Tropical Medicine and International
Health, in press
Abstracts in Congress
Gómez-Erache M., Sans, K. Lacerot G. & Basso C. 2001. Relevamiento de especies de copépodos
(Crustacea) potencialmente predadores de larvas de Aedes aegypti (Diptera, Cullcidae) en la región sur del
Uruguay. In: Actas de la VI Jornadas de Zoología del Uruguay. Facultad de Ciencias. 17-21 de septiembre
de 2001. pp. 44.
Martínez M., Romero S., Roche I., Detomasi S., Gómez M., Pereira J. & Basso C. 2005. Implementación
de un Proyecto Universitario de Investigación de Aedes aegypti en Uruguay. In: IV Jornadas Regionales
sobre mosquitos. Tucumán, Argentina. 14 y 15 de septiembre de 2005. p. 5.
Publicación en Expert Rev. Vaccines 3 (5), (2004): Dengue, one of the great emerging health challenges
of the 21st Century. Meeting Report of the 2nd International Congress on Dengue and Yellow Fever,
Havana, Cuba. Guzmán M.G., Kourí G., Díaz C. et al
Posgraduate Thesis
Master in Environmental Health
Análisis de indicadores ambientales, entomológicos, y epidemiológicos en el municipio Centro Habana.
Autor: Iván Giró López (Cuba)
Comportamiento de indicadores de salud del ecosistema asociados al Aedes aegypti y al dengue en el
municipio Plaza de la Revolución. Autora: Isabel Machado Martínez
Análisis de los indicadores de un sistema de vigilancia integrado durante la etapa de aseguramiento de la
campaña contra el mosquito Aedes aegypti en el municipio Cerro. Autor: Carlos Vázquez González.
Análisis de los indicadores ambientales, entomológicos y epidemiológicos en el municipio Guanabacoa.
Autor: Misael Novoa Hernández
Comportamiento de indicadores del sistema de vigilancia para la prevención y control del dengue y el
mosquito Aedes aegypti. Municipio Cotorro.Autor Ramón Rodríguez Jiménez (Cuba)
Un enfoque ecosistémico de salud para la prevención del dengue en La Habana Vieja. Autora: María de
los A. Mariné (Cuba)
Sanitary Engineering (Guatemala)
Inga. Bárbara Rosario Cruz Cano, Calidad físico química del agua de las fuentes de agua y para consumo
Ing. Gilroy Francis Lewis, Desechos municipales sólidos – producción y caracterización domiciliar,
Ing. Ronald David Matías Palacios, Desechos municipales sólidos – producción y caracterización de la
Central de Mayoreo y mercados.
Ing. René Morales Flores, Planta de tratamiento de agua potable “La Nopalera” y redes de distribución.
Ing. José Ismael Véliz Padilla, Caracterización microbiológica de aguas subterráneas y pozos.
Inga. Isabel del Rosario Monzón Sevilla, Administración y manejo de sistemas de agua.
Ing. Mario Ruiz González, Cuenca hidrográfica del Río El Naranjo, Gestión Integrada de Recursos
... It involves strategies integrating the analysis of social, economic, cultural and environmental determinants. 5 These are essential to understand the best prevention and control options with the incorporation of trans-disciplinary strategies, along with the participation of affected communities. ...
Full-text available
Objective: To design and analyze the efficacy of an Ecohealth competency-based course on the prevention and control of vector-borne-diseases for specific stakeholders. Materials and methods: Multiple stakeholders and sectors of the region were consulted to identify Ecohealth group-specific competencies using an adjusted analysis matrix. Eight courses based on the competencies were implemented to train EA tutors. The effectiveness of the course was evaluated through the use of paired- t-tests by intervention group. Results: Strategic, tactical, academia and community stakeholder groups and their competencies were identified. An overall gain of 43 percentage points (p<0.001) was observed in terms of competencies score in trained tutors, which further trained 1 033 people. Conclusions: The identification of the stakeholders and their competencies proved to be useful to guide training courses to significantly improve the initial competencies and create a critical mass to further advance the EA in the region.
... The aim is to modify the environmental conditions, social contexts and other factors that favour the proliferation of vectors to diminish health risks, using participatory multi-stakeholder approaches for longer-term sustainability and impact. This contrasts with the more classical vector control programs organized as emergency responses delivered against vectors, with limited consideration given to the ecosystem or why disease emergence is occurring in the first place 15 . ...
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A world of healthy people living in healthy ecosystems has proven to be an elusive goal of the sustainable development agenda. Numerous science-based assessments agree on the fundamental interdependence between people's health, the economy, and the environment, and on the urgency for more determined and concerted action based on multi-sector participatory approaches at the global and local levels. For knowledge to be policy-relevant and capable of contributing to healthy and sustainable development, it must take into account the dynamic and complex interactions between ecological and social systems (systems thinking), and it must be linked to development actions. This in turn requires greater interaction and exchange between decision-makers, researchers and civil society (a multi-stakeholder participatory process); and the harnessing of different disciplines and of different kinds of knowledge (a transdisciplinary approach). Ecosystem approaches to human health (ecohealth) link these elements in an adaptable framework for research and action. This paper presents an overview of ecohealth research approaches applied to vector-borne diseases, with particular attention to multi-stakeholder participation given its prominence in the sustainable development policy discourse.
Full-text available
The predation rates of six copepod species: Acanthocyclops robustus G.O. Sars, Eucyclops neumani Pesta, Macrocyclops albidus Jurine, Mesocyclops longisetus Thibaud, Metacyclops grandis Kiefer and Metacyclops mendocinus Wierzejski (Copepoda: Cyclopidae) on mosquito larvae, Culex pipiens Linnaeus (Diptera: Culicidae) were assessed. Experiments consisted of 24-h incubations of one copepod and 10 larvae without extra food at 16 degrees C and 26 degrees C. Nine replicates were considered for each species and temperature. Predation rates (larvae per copepod per day) were: M. mendocinus (1.8), M. grandis (3.1), E. neumani (3.8), A. robustus (3.8), Ma. albidus (6.1) and Me. longisetus (7.0). There was a significant effect of both species and temperature on predation: all species experienced higher predation at 26 degrees C than at 16 degrees C, except for A. robustus whose predation rate was similar at both temperatures. These observations are consistent with previous results that point to Macrocyclops and Mesocyclops genera as important larval predators and suggest the need for field trials to evaluate the response of Ma. albidus and Me. longisetus under natural conditions in Uruguay.
Full-text available
In summary, the cyclopoid copepod fauna of Cuba includes species of Mesocyclops, which are all excellent candidates for the biological control of mosquito larvae. Because native species are already adapted to local environmental conditions, and also because of the convenience of avoiding the introduction of exotic fauna, it is normally a good practice to collect and study those native species. However, additional sampling will be necessary to verify whether M. pehpeiensis has established viable populations in Cuba.
Full-text available
To characterize the social and environmental risk factors associated with the presence of Aedes aegypti in order to improve community dengue control. A case-control study with 'cases' being households with entomologically confirmed A. aegypti infestation; personal interviews in Central Havana, a densely populated inner city area characterized by overcrowded housing and irregular water service. The participants were residents of 278 houses with infestation and 556 houses without infestation. Greater risk of infestation was associated with lack of preventive measures, such as no larvicide in the water tanks (OR = 2.21) and use of flower vases for religious practice (1.93), not being economically active (1.64), vulnerable populations with higher risks in households with older people (1.52) and households with children (1.94). Efforts to reduce infestations should continue to focus on water tank sanitation and improving housing conditions, but also engage community religious leaders to help promote safe practices. Vulnerable populations should be especially targeted by prevention activities. A surveillance programme can produce evidence to guide interventions.
The authors developed and evaluated a comprehensive participatory ecosystem health approach for preventing the transmission of dengue, the most prevalent vector-borne disease in Cuba and the Latin America-Caribbean region. The integrated surveillance system central to this initiative encompassed three main subsystems (environmental; entomological; clinical-epidemiologic), relying on extensive community involvement. The study was conducted in Central Havana, Cuba. Indicators from each subsystem were selected and mapped using a GIS procedure providing instant visualization by city block in the municipality. To elucidate the factors affecting control and prevention efforts, perceived needs and risks, as well as knowledge, attitudes, and behaviors related to dengue, were assessed. Specific factors associated with the presence of mosquito breeding sites and risks of dengue were examined in a case-control study.
Ecosystem approach to the prevention and control of Aedes aegypti in Uruguay and Argentina
  • C Basso
  • N Schweigmann
Basso C. & Schweigmann N. 2004. Ecosystem approach to the prevention and control of Aedes aegypti in Uruguay and Argentina.
Ciudad Habana, Cuba. 19-23 Septiembre Round Table Experiencias con el enfoque ecosistémico para la prevención de dengue
  • Ii Congreso Interamericano De Salud
  • Ambiental
II Congreso Interamericano de Salud Ambiental. Ciudad Habana, Cuba. 19-23 Septiembre/2005. Round Table Experiencias con el enfoque ecosistémico para la prevención de dengue; Cristina Díaz, Maricel García, María de los Ángeles Mariné, Miriam Concepción (Cuba)
Medicine and Health in the Tropics. Marsella, Francia. 11-15 Septiembre Poster An ecosystem approach to human health for dengue prevention at local level
Medicine and Health in the Tropics. Marsella, Francia. 11-15 Septiembre/2005. Poster An ecosystem approach to human health for dengue prevention at local level. Ángel M. Álvarez et al. (Cuba)
Administración y manejo de sistemas de agua
  • Inga Del Rosario Monzón
  • Sevilla
Inga. Isabel del Rosario Monzón Sevilla, Administración y manejo de sistemas de agua.
Misael Novoa Hernández Comportamiento de indicadores del sistema de vigilancia para la prevención y control del dengue y el mosquito Aedes aegypti. Municipio Cotorro
  • Autor
Autor: Misael Novoa Hernández Comportamiento de indicadores del sistema de vigilancia para la prevención y control del dengue y el mosquito Aedes aegypti. Municipio Cotorro.Autor Ramón Rodríguez Jiménez (Cuba) Un enfoque ecosistémico de salud para la prevención del dengue en La Habana Vieja. Autora: María de los A. Mariné (Cuba) Sanitary Engineering (Guatemala)