The Dissertation for a PhD degree in Global Health of Dr. Eddy Pérez-Then written in 2009, serving to transform the reality of the community that lives in the Bateyes of the Dominican Republic.
The present study was designed to contribute to the application of human security principles in vulnerable populations, using “The Bateyes” (sugar mill camps) from the Dominican Republic (DR) as a case study. Following the “Robin Hood” principle of using resources allocated for the identification and treatment of human immunodeficiency virus (HIV) as a base from which to build infrastructure for other health and human security needs, this project sought to reduce inequalities and promote equal rights in a vulnerable population living in isolated rural areas of the DR. The impact of a human security model versus non-intervention (standard of care) was examined longitudinally in relationship to the outcomes (prevention of morbid events such as HIV, tuberculosis, diarrhea, dengue, malaria, and model impact on breastfeeding and vaccines rates). The project was implemented in three phases: baseline assessments, implementation of a “human security” model over a six month period, and evaluation of the interventions at six and twelve months after the initiation of the intervention. Qualitative evaluation methods were used to complement quantitative assessments. An economic analysis was also conducted to evaluate the costs of the intervention and potential sources of economic benefits. Overall, at baseline, the owners of the houses from Batey A (Case) were more likely to respond incorrectly than the residents of Batey B (Control) questions about knowledge, attitudes and practices, for the most prevalent infectious diseases of the southwestern area of the Dominican Republic. To control for baseline differences between the study groups, a Knowledge, Attitudes and Practices (KAP) score system was created. The KAP score system showed that the people living in Batey A had a higher percentage of right answers than residents of Batey B, six months after the intervention. These findings, however, were not observed at the 12 month follow-up visit, suggesting that future studies using the human security intervention model may need to be maintained for more than 6 months, to promote sustainability. Economic analysis revealed that the total cost-savings of the Program to the Ministry of Health and society overall to be US$252,399. In addition, at the follow-up visits, morbidity and mortality rates of the study population were lower than the rates reported in a recent Demographic Health Survey conducted in the Southwestern Bateyes of the DR. The qualitative interviews allowed for the identification of community perceptions of the model, as well as the necessity for an interdisciplinary approach, including structural interventions (i.e. water pump, construction of latrines, etc) and monitoring community security-related issues through household monthly visits. The use of HIV resources demonstrated that the money allocated for HIV prevention could be utilized, not only to reduce the burden of disease, but also to invest in health systems and services. Applied to other settings, the design and outcomes of this study could have a beneficial impact on refugee and undocumented populations in other countries under the impact of the structural violence observed in the Bateyes of the DR.