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Establishing a community of practice of researchers, practitioners, policy-makers and communities to… Spiegel, Jerry M; Breilh, Jaime; Beltran, Efrain; Parra, Jorge; Solis, Fernanda; Yassi, Annalee; Rojas, Alejandro; Orrego, Elena; Henry, Bonnie; Bowie, William R; Pearce, Laurie; Gaibor, Juan; Velasquez, Patricio; Concepcion, Miriam; Parkes, Margot Nov 8, 2011

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RESEARCH ARTICLE Open AccessEstablishing a community of practice ofresearchers, practitioners, policy-makers andcommunities to sustainably manageenvironmental health risks in EcuadorJerry M Spiegel1*, Jaime Breilh2,3, Efrain Beltran4,5, Jorge Parra6, Fernanda Solis2,6, Annalee Yassi1, Alejandro Rojas7,Elena Orrego1,7, Bonnie Henry1,8, William R Bowie9, Laurie Pearce10, Juan Gaibor11, Patricio Velasquez5,Miriam Concepcion12, Margot Parkes13,1AbstractBackground: The Sustainably Managing Environmental Health Risk in Ecuador project was launched in 2004 as apartnership linking a large Canadian university with leading Cuban and Mexican institutes to strengthen thecapacities of four Ecuadorian universities for leading community-based learning and research in areas as diverse aspesticide poisoning, dengue control, water and sanitation, and disaster preparedness.Methods: In implementing curriculum and complementary innovations through application of an ecosystemapproach to health, our interdisciplinary international team focused on the question: “Can strengthening ofinstitutional capacities to support a community of practice of researchers, practitioners, policy-makers andcommunities produce positive health outcomes and improved capacities to sustainably translate knowledge?” Toassess progress in achieving desired outcomes, we review results associated with the logic framework analysis usedto guide the project, focusing on how a community of practice network has strengthened implementation,including follow-up tracking of program trainees and presentation of two specific case studies.Results: By 2009, train-the-trainer project initiation involved 27 participatory action research Master’s theses in 15communities where 1200 community learners participated in the implementation of associated interventions. Thisled to establishment of innovative Ecuadorian-led master’s and doctoral programs, and a Population HealthObservatory on Collective Health, Environment and Society for the Andean region based at the Universidad AndinaSimon Bolivar. Building on this network, numerous initiatives were begun, such as an internationally fundedresearch project to strengthen dengue control in the coastal community of Machala, and establishment of a localcommunity eco-health centre focusing on determinants of health near Cuenca.Discussion: Strengthening capabilities for producing and applying knowledge through direct engagement withaffected populations and decision-makers provides a fertile basis for consolidating capacities to act on a largerscale. This can facilitate the capturing of benefits from the “top down” (in consolidating institutional commitments)and the “bottom up” (to achieve local results).Conclusions: Alliances of academic and non-academic partners from the South and North provide a promisingorientation for learning together about ways of addressing negative trends of development. Assessing the impactsand sustainability of such processes, however, requires longer term monitoring of results and related challenges.* Correspondence: jerry.spiegel@ubc.ca1University of British Columbia (UBC) – Global Health Research Program,School of Population and Public Health, Vancouver, British Columbia, CanadaFull list of author information is available at the end of the articleSpiegel et al. BMC International Health and Human Rights 2011, 11(Suppl 2):S5http://www.biomedcentral.com/1472-698X/11/S2/S5© 2011 Spiegel et al; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.BackgroundIn 2004, the Sustainably Managing EnvironmentalHealth Risks in Ecuador (Ecuador Eco-Health) projectwas launched in response to concerns that deterioratingecological and social conditions in this low-income SouthAmerican country were aggravating the threats to healthbeing experienced by vulnerable populations during aperiod of intensifying global integration [1]. Amid thewidespread poverty and disparities present in Ecuador,attention focused on the systemic circumstances thatcould be affecting health, such as the contamination ofland, air and water by intensive application of agro-toxins[2] or poorly controlled mining activities [3], as well asby deteriorating living conditions and inadequate waterand sanitation in both urban and rural settings [4]. Withfunding from the Canadian International DevelopmentAgency (CIDA)’s University Partnerships in Cooperationand Development program, an ambitious multi-facetedproject was launched to strengthen capacities for design-ing, conducting and evaluating interventions to contri-bute to sustainable solutions. The focus was ondeveloping knowledge, skills and attitudes for conductingrigorously designed action research projects, building onthe potential of international collaborations to supportthis [5-7].The project originated from 4 distinct global trendsthat intensified in the 1980s and 1990s:i) Increasing disparities and negative consequences ofdevelopment resulting from economic globalization [8];ii) Recognition of the complexity of factors in socialand ecological systems that contribute to human healthoutcomes [9];iii) Introspection into the role of the university, espe-cially the ability to effectively address community concerns[10]; andiv) Insights into the limits of traditional forms ofpedagogy and the power of interactive learning [11].Chronic underfunding of public universities in the atmo-sphere of fiscal restraint that predominated in this era wasa further global pressure of consequence [12] as theseinstitutions concurrently grappled with new demands toaddress intensifying social and environmental concernsamid great unevenness in the capabilities to do so. InEcuador, this was complicated by the challenge of intercul-turality (an estimated 25-30% of the population identify asindigenous) as well as existing low investment in thehealth and education sectors. To address such challenges,models of collaboration between universities in low andhigh income countries that emphasize local leadership andownership are receiving growing attention [13,14], espe-cially as an alternative to training approaches that haveserved to encourage migration away from low and middleincome country settings.The researchWhile our initiative itself focused on more systematicpursuit of action research investigations that incorpo-rated transdisciplinarity, participation, equity andsustainability (i.e. the framework and methodologiesassociated with an “ecosystem approach to humanhealth” promoted by Canada’s International Develop-ment Research Centre [IDRC]) [15], the creation of anational network with international links was, in and ofitself, conceived to be an intervention. A central researchquestion was thus embedded in the undertaking: “Canstrengthening institutional capacities to support a com-munity of practice of researchers, practitioners, policy-makers and communities produce sustainable healthoutcomes and capacities to effectively translate knowl-edge?” This in fact reflected an orientation supportingthe creation of such international networks to encouragethe application of eco-health approaches [16]. We soughtto explicitly concentrate on a national scale, but with thesupport of international partners.We proceeded with the understanding that Commu-nities of Practice (CoP) are groups of people who share aconcern, a set of problems, or a passion about a topic, andwho deepen their knowledge and expertise in this area byinteracting on an ongoing basis [17]. A systematic reviewon the use of CoPs in business and healthcare observedthat while specific structures of groups varied greatly, theyshare four characteristics: social interaction among mem-bers, knowledge sharing, knowledge creation, and identitybuilding [18]. This orientation to capacity-building wasitself embraced as integral to the academic programs atthe core of the “Ecuador Eco-Health” initiative.A comprehensive Logic Framework Analysis was devel-oped to guide activities, specifying outputs (such asestablished programs and their curricula, numbers ofgraduates etc.), outcomes (institutional strengtheningindicators such as accredited programs, qualified faculty,obtained funding for new collaborative research projects)and impacts (improvements in human and ecologicalhealth achieved, with particular attention to healthequity). Recognizing the innovative character of the inter-vention, explicit focus was applied to observe whethersynergies could be established to reinforce processes andstructures capable of effectively and sustainably achievingdesired outcomes and impacts.What was at stake, in this regard, over the initial sixyears of the initiative (2004-2010) has principally been atesting of the feasibility of consolidating institutionalentities capable of knowledge translation to improvehealth equity. To monitor progress, documentation ofprocesses, activities and participants (including commu-nity and policy-makers) has been consistently main-tained, including follow-ups of graduates and the actionSpiegel et al. BMC International Health and Human Rights 2011, 11(Suppl 2):S5http://www.biomedcentral.com/1472-698X/11/S2/S5Page 2 of 7research projects (by co-author EO) at 6 month intervals.In addition to providing a summary of this experience,we present two case studies to more vividly illustrate theinteractive benefits enabled by a community of practice,along with a discussion of challenges that have been andcontinue to be part of this process.Results and outcomesThe first phase (2004-2008) of our Ecuador Eco-Healthinitiative focused on implementing a “train the trainer”perspective through a nationally accredited “Master’s inHealth with an Eco-system Focus”. Explicit criteria wereapplied at different levels to support this orientation:i) Selection of participating institutions was designed toinclude a university with well-established academic tradi-tions (U of Cuenca, founded in 1867) and 2 relativelynew universities that lacked strong research capacities,but where serious problems persisted: intensive resourceextraction and poverty (Technical U of Machala, foundedin 1969); indigenous rural populations and poverty (U ofBolivar, founded in 1977).ii) Selection of students was based on criteria thatexplicitly weighed academic disciplinary aptitudes along-side capacity for undertaking community-based interven-tions and knowledge translation, as well as culturaldiversity, producing a first group of 30 students whowere interdisciplinary, interregional, and interculturalwith 5 indigenous community leaders. Additionally, 5 ofthe 10 selected by each university had to have universityfaculty positions and the promise of continued facultypositions after completion of their program. The expecta-tion was that these latter 15 individuals would play a keyrole in maintaining appropriate Eco-health programs ateach of the universities.iii) Criteria for thesis research were explicitly adopted toinclude not only 1) rigorous and clear methodology, but toinsist that there be 2) clear research and impact objectives;as well as 3) focus on relationships between human health,ecosystem health, and community wellbeing; 4) significantcommunity participation; and 5) collaborative relation-ships with other students, key stakeholders, and thecommunity.An innovative curriculum to support interactivecommunity-based learning for the first cohort of theMaster’s Program was developed and implemented bythe international team led by co-authors JS and AYand established Ecuadorian researchers in the area ledby co-author JB, with the coordination of co-authorMP. To reinforce the role played by local universitythesis directors, who were only becoming acquaintedwith a new action research orientation amid theirother obligations, a dedicated team to support thesispreparation was established and coordinated by co-author EO. As a result, 27 participatory action researchMaster’s theses were successfully completed in 15communities by 2009, involving over 1200 communitylearners. Through this collective experience, reflectionson inadequacies of current theoretical and methodolo-gical approaches fuelled a focus on the social determi-nation of health, observable in distinct contexts, andnot the excessive examination of isolated determinants.From a “top-down” perspective, this experience servedas a crucible for establishing new training programs ledby Ecuadorian universities with international reinforce-ment. A second Master’s program cohort was initiated bythe University of Cuenca (led by co-author JP) in 2009.When the Ecuadorian academic director for the inaugu-ral Master’s program (co-author JB) was appointed direc-tor of the health area of University Andina Simon Bolivar(UASB) in 2008, the consortium expanded to support thelaunch the following year of an innovative Doctoral pro-gram on “Collective Health, Environment and Society” toprovide a strong foundation for the emerging nationalnetwork. The Universities of Bolivar (co-author JG, aprofessor who is a Master’s graduate and current UASBPhD student) and Machala (co-author PV, a professorwho is a UBC PhD graduate with support of the EcuadorEco-Health program) meanwhile are preparing certificatecourses to be operated in 2011 to build capacity in prior-ity areas for their context, and workshops with activepractitioners are being conducted in areas such as disas-ter preparedness in collaboration with co-author LP.Also in 2009, an innovative way to link directly withpolicy-makers was begun through a direct alliancebetween the UASB PhD program and the OrganismoAndino de Salud, now led by the former EcuadorianMinister of Health, which represents Andean Regiongovernments affiliated with the Pan American HealthOrganization. The “Observatorio Regional de SaludColectiva, Ambiente y Sociedad” [Regional Observatoryon Collective Health, Environment and Society] (led byco-author JB with participation of members of the inter-national team as a part of the group of professors deliver-ing the PhD program modules including co-authors JS,AY, AR and other international experts) identifies prior-ity research areas capable of macro and meta level ana-lyses of evidence related to health concerns and policiesat a national and sub-continent / regional level [19].These are directly linked with the PhD initiative thatitself has an Andean (i.e. multi-country) charter – provid-ing a strong policy-relevant orientation for the 18 action-research doctoral investigations that are now underway.From a “bottom-up” perspective, locally establishedaction research projects have laid foundations for largerscale applications engaging broader arrays of policymakers and funding agencies to enable further knowledgetranslation and innovation. Some examples of local initia-tives that led to sustained impact include the following:Spiegel et al. BMC International Health and Human Rights 2011, 11(Suppl 2):S5http://www.biomedcentral.com/1472-698X/11/S2/S5Page 3 of 7In the urban community of Machala, three feasibility pro-jects were undertaken as Master’s theses to strengthencommunity based dengue prevention and control,through direct involvement of school children, healthpromoters and community members as well as the pur-suit of alternatives to heavy pesticides use. Building onthis foundation (established with assistance from co-authors WB, BH and AY), a 3 year trial applying a com-prehensive integrated surveillance program was launchedin 2010 with funding from the WHO Tropical DiseaseResearch Program (TDR) and IDRC, notably with the 3Principal Investigators being i) a Master’s program grad-uate who heads the province’s Vector Disease Controlprogram (co-author EB); ii) the PhD program director(co-author JB); and iii) the UBC-based Ecuador Eco-Health project director (lead author JS), with active invol-vement of Canadian and Ecuadorian graduate students.The provincial Ministry of Health is directly involved andcommitted to province-wide scaling up once results areevaluated with an active participation of local schoolboards, health units and community organizations.In the rural setting of San Jose de Balzay, a communityheavily involved in the artisanal production of clay tilesand roofing materials, lead poisoning (from glaze used inthe production process) was diagnosed and alternativematerials and work practices incorporated to alleviatethis problem as the result of a student thesis in the firstmaster’s cohort. By working with local community orga-nizations and an active national Non-GovernmentalOrganization, Acción Ecológica, the University ofCuenca, in partnership with the UASB and UBClaunched (in December 2010) a new form of “eco-healthcentre” (Clinica Ambiental del Sur) based on the linkingof prevention at a population level with primary careclinical attention in underserviced areas. It is noteworthythat as new initiatives are being undertaken, opportu-nities are being increasingly created for women research-ers who have been previously under-represented in theranks of the leadership. For example, direction of theClinica initiative as well as the second cohort of the Mas-ters program was assumed by a young female PhD trai-nee (co-author FS) in 2010.A further action research program addressing foodsecurity, food sovereignty and health equity has beeninitiated, with submissions for international peer-reviewedfunding in early 2011, by co-authors JS, AR and JB, alongwith other members of the authorship team together withadditional community and policy-maker partners–withfunding for 5 years approved to begin in late 2011. Toreinforce concentration on practical applications of knowl-edge, this group includes the national Ministry of Health,the Ministry of Agriculture (reinforced by the hiring ofa Master’s program graduate as national director of theirrigation program), the Ecuadorian section of thedevelopment bank Banco del Sur which is interested inproviding credit for more sustainable and equitable formsof agriculture, the national organization of small-scaleindigenous and non-indigenous farmers (FENOCIN), andpeasant coastal producers involved in domestic andexport-oriented production (UROCAL).Innovative methods to teach and learn constitute anintegral part of the Ecuador Eco-Health initiative throughthe team’s explicit pursuit of a strategy emphasizing parti-cipation through the formation of a community oflearners combined with problem-based learning centeredon contributing to beneficial community impacts. Knowl-edge sharing has fundamentally taken place within thedynamics of difference (three or more cultures, halfa dozen disciplines, distinct paradigms, three languages,and the great diversity of the Ecuadorian regions). Thisapproach was vividly evident in repeated showings onnational television of a video on the benefits of pursuing amore integrated intercultural approach to childbirth inindigenous communities based on the Master’s thesis ofan indigenous nurse with the national Department ofIndigenous Health. This initiative seeks to incorporateboth traditional and modern practices to improve mater-nal health. With UBC partners, this team is activelypursuing international funding for a network of commu-nities and government agencies that will make timelytechnical assistance possible through innovative use ofcommunication technologies alongside improved localmobile infrastructure.The results to date from the Ecuador Eco-health projectindicate that action research oriented to health equity isquite feasible if there is a commitment from both the “topdown” and the “bottom up”, engaging local policy makersand practitioners in the research process, and then broad-ening the partnerships to consider scaling up. The effec-tiveness of these efforts in terms of health outcome willcontinue to be studied in the coming years.The partnershipFrom the very beginning, collaboration was conceptua-lized from a “North-South-South” perspective. In fact,the feasibility of what would eventually become the Ecua-dor Eco-Health project was initially suggested in 2001 byEcuadorian participants at a Canadian-Cuban Eco-Healthworkshop in Havana, Cuba, including co-author MC,providing the foundation for subsequently shaping howopportunities evolved. To support sustainability of thenetworks being created, two leading Latin Americaninstitutions expert in environmental health, INHEM inCuba and INSP in Mexico, have been members of thepartnership from the earliest days.The concept of building on pre-existing capabilities wascentral from the beginning as a key characteristic of thenational network that would emerge in Ecuador itself,Spiegel et al. BMC International Health and Human Rights 2011, 11(Suppl 2):S5http://www.biomedcentral.com/1472-698X/11/S2/S5Page 4 of 7linking centres with different strengths and experiences.External Canadian involvement de facto served as a cata-lyst for initiating new approaches for pursuing interdisci-plinary research and multi-university partnerships, withmore direct engagement of communities and policy-makers. This was especially evident when the Ecuadorianuniversity partners acknowledged that adequate experi-ence was initially lacking in their ranks to provide facultydirection and support. When one university involved inthe original planning backed out in 2004 because of a fail-ure to consolidate commitment to the emerging direction,an Ecuadorian NGO with extensive experience and exper-tise in conducting eco-health action research (led by co-author JB) was invited to join the consortium to providenational academic direction that built on similar traditionswhose roots were distinctly Latin American and interna-tionally recognized [20]. In this emerging partnership, theinvolvement of a wide range of disciplines at a universityof the scale of UBC facilitated comprehensive pursuit of atransdisciplinary approach in the Ecuadorian context. Tohelp overcome the challenges of language and culture, theCanadian team was furthermore able to take advantage ofVancouver’s multi-cultural character itself to directlyengage Canadians of Ecuadorian and other Latin Ameri-can ancestry in the team!To provide a unifying force amid considerable diversity,strong allegiance to the project’s vision has been likenedby team members to the expression of “amor a la cami-seta” – love of the jersey (for one’s hometown soccerteam) that can overcome competing interests. As sug-gested by the importance accorded to “identity building”in communities of practice [18], such commitment mustbe critically considered if there is indeed to be an institu-tionalization of the values being established.Challenges and successesPursuit of the Ecuador Eco-Health initiative was a veryambitious undertaking – requiring moving from unidisci-plinary to transdisciplinary teams, combining intercul-tural perspectives and moving from research for inquirysake to impact-oriented investigation, while maintainingrigor in methods. This was, of course, in addition to chal-lenges inherent in all north-south collaborations. As noexisting requirements were in place to govern researchethics in the Ecuadorian context, internal processes wereput in place for research undertaken. Notably, in pursu-ing this course, a number of students were inspired bythe experience of Aboriginal communities in Canada toensure respectful relationships [22], and formallyincluded obligations to share research findings with com-munities as an explicit part of public meetings that wereheld with the involved communities.A paramount achievement realized over the course ofprogram implementation involved transforming themodel for doctoral training for the emerging networkfrom a traditional model involving studying abroad toone that could be undertaken directly at an Ecuadorianuniversity. This was facilitated through the 2008 signingof a Memorandum of Understanding between UBC andUASB which ensured the involvement of internationalprofessors so that accreditation requirements could besatisfactorily met. Ecuadorian PhD students have thusbeen permitted to continue to work in their home set-tings while reinforcing and being reinforced by the emer-ging community of practice that is being establishedthrough the institutional strengthening efforts describedabove. By providing this more sustainable alternative, thechallenge of reintegration following years of absence canbe avoided; something that our program’s one foreigntrained PhD graduate (co-author PV) is now in the pro-cess of addressing. This national PhD design, further-more, has enabled one of the five indigenous members ofthe first cohort to continue to pursue a doctorate focusedon food security challenges in his community.While most graduates are managing to apply their skillsto their pre-existing work settings or moving to newopportunities, we have observed that a number woulddefinitely have benefitted from their employers having agreater appreciation and support of the orientation thatthe program was presenting. In this sense, a communityof practice network provides a more comprehensive wayfor reinforcing implementation and adaptation of thechanges in application of knowledge that are envisioned.An encouraging recognition of the eco-health approachhas been exhibited by the Faculty of Medicine at theUniversity of Cuenca who have committed to furthertraining of their faculty in participatory research andteaching methods as well as to broader applications of aneco-system approach to health.The successes achieved through international collabora-tions nevertheless remain, above all, dependent on theengagement of rooted national expertise, as well as theembracing of different types of knowledge (e.g. local,ancestral) in a coherent conceptual framework. The holis-tic indigenous vision of health (called sumak kawsay in theKichwa language – or “good living” in English) that isframed as the overriding social purpose in Ecuador’s Con-stitution of 2008 [21] is providing an especially timelyopportunity for our project to contribute to this mission.As the global quest of creating more sustainable alterna-tives is itself calling into question the values underpinningWestern development models, our team is especiallyenthusiastic in pursuing opportunities to explore howalternatives can be created.Appreciating different cosmologies and their links toways of seeing and knowing has, in addition, made ourteam especially sensitive to the challenge of working withgraduate students whose knowledge system communicateSpiegel et al. BMC International Health and Human Rights 2011, 11(Suppl 2):S5http://www.biomedcentral.com/1472-698X/11/S2/S5Page 5 of 7more strongly orally and metaphorically than concep-tually and abstractly. This has prompted the question:Should they be allowed to deliver integrative productsother than traditional academic theses? And if so, whatstandards of excellence should be used - only those con-ventionally accepted in Western academia or a pluralityreflecting interculturality? Recognition of project-basedexperiences as an acceptable basis for master’s level edu-cation, an approach being increasingly accepted in Cana-dian universities, has been actively discussed – but, forthe time being, has been rejected for application in theEcuadorian context. However, this will be the subject offurther review in assessing ways to better support inter-cultural learning.In many ways it is premature to pass judgement onthe question guiding this undertaking, namely the effec-tiveness and sustainability of applying a community ofpractice orientation to strengthening capacities to con-duct intervention-oriented research. Nevertheless, theEcuador Eco-Health initiative has vividly demonstratedhow alliances of academic and non academic partnersfrom the South and North provide a promising ways tolearn together about ways of addressing negatives trendsof development. Assessing the legacy of such processes,however, requires longer term monitoring of results andrelated challenges.While it is difficult to measure the long-term impact onhealth of the communities involved in the research, thenumber of trained individuals now continuing to imple-ment internationally-funded peer-reviewed research isitself a testimony to success of this effort thus far.Accordingly, we strongly feel that the consolidation of acommunity of practice beyond the end of the formalfunded capacity development period augurs well for sus-tained application of the core values and vision that wasthe original goal of our endeavour.List of abbreviations usedCIDA: Canadian International Development Agency; FENOCIN: NationalConfederation of Rural, Indigenous and Afro- Ecuadorian Organizations;IDRC: Canada’s International Development Research Centre; INHEM: InstitutoNacional de Higiene, Epidemiologia y Microbiología; INSP: Instituto Nacionalde Salud Pública; PI: Primary Investigator; TDR: Tropical Disease Research;WHO: World Health Organization; UASB: University Andina Simon Bolívar;UROCAL: Coastal Regional Union of Peasant Organizations; UBC: University ofBritish Columbia.AcknowledgementsThe Ecuador Eco-Health project has been financially supported by theCanadian International Development Agency (CIDA) through its UniversityPartnerships in Cooperation and Development Tier 1 program. In addition,funding for associated projects has been provided by the CanadianInstitutes of Health Research (CIHR), the International Development ResearchCentre (IDRC) and the World Health Organization’s Tropical Disease Researchprogram. Salary support for Project Director JS was provided by CIHR andthe Michael Smith Research Foundation of British Columbia; with salarysupport for associate director AY provided by the Canada Research ChairProgram.We would like to especially acknowledge the contributions of VeronicaMoreno and Rosamelia Andrade, project coordinators over the course of theproject; Marcello Veiga, Fabio Cabarcas and other international team andEcuadorian instructors who have contributed to the academic programs; theEcuadorian tutors Arturo Campaña, Maria de Lourdes Larrea and MarcelloCevallos instrumental to the success of the initial phase of the project; therectors and project coordinators of the participating universities whoprovided direction in management committee meetings over the course ofthe project; Arturo Quizhpe, the Dean of Medicine at the University ofCuenca; Mariano Bonet of the Instituto Nacional de Higiene, Epidemiología yMicrobiología (INHEM) in Cuba; Enrique Cifuentes and Horacio Riojas of theInstituto Nacional de Salud Publica (INSP) in Mexico; and the trainees,countless community participants, practitioners and policy makers directlyinvolved in the emerging community of practice we describe. We also thankSozan Savehilaghi, Karen Lockhart and Justin LoChang and other involvedgraduate students from the University of British Columbia Global HealthResearch Program team.This article has been published as part of BMC International Health & HumanRights Volume 11 Supplement 2, 2011: Global health research case studies:lessons from partnerships addressing health inequities. The full contents ofthe supplement are available online at http://www.biomedcentral.com/1472-698X/11?issue=S2.Author details1University of British Columbia (UBC) – Global Health Research Program,School of Population and Public Health, Vancouver, British Columbia,Canada. 2Universidad Andina Simón Bolívar, Quito, Ecuador. 3Observatorio enSalud Colectiva, Ambiente y Sociedad, Organismo Andino de Salud, Quito,Ecuador. 4Servicio nacional de control de los enfermedades transmitida porlos artrópodos (SNEM) – Ministerio de Salud Pública, Machala, Ecuador.5Universidad Técnica de Machala, Machala, Ecuador. 6Universidad de Cuenca,Cuenca, Ecuador. 7UBC- Faculty of Land & Food Systems, Canada. 8BC Centrefor Disease Control, Vancouver, British Columbia, Canada. 9UBC – Faculty ofMedicine, Canada. 10UBC - School of Community and Regional Planning,Canada. 11Universidad Estatal de Bolívar, Guaranda, Ecuador. 12InstitutoNacional de Higiene, Epidemiología y Microbiología, Havana, Cuba.13University of Northern British Columbia, Canada.Authors’ contributionsJS and AY conceived the initial project, and developed it from the earliestphase with co-authors LP and WB, and shortly thereafter with the closecollaboration of coauthor JB who spearheaded the development andimplementation of the emerging community of practice in Ecuador,including the shaping of academic research programs to support this. Co-authors AR, MP, BH and MC have been actively involved as members of theinternational team contributing to the curriculum development, teachingand research activities involved in the project. Co-author EO led the teamsupporting the pursuit and writing up of thesis research. Co-authors EB, JP,FS, PV and JG have actively involved as both trainees and leaders ofresearch, teaching and research application activities in Ecuador. JS preparedthe first draft of this manuscript in collaboration with co-author JB. Allauthors helped to write and revise this manuscript.Competing interestsAll authors declare that they have no competing interests.Published: 8 November 2011References1. Breilh J, Tillería Y: Aceleración Global y Despojo en Ecuador: El Retrocesodel Derecho a la Salud en la Era Neoliberal. Quito: Universidad AndinaSimón Bolívar y Ediciones Abya Yala; 2009.2. Breilh J, Campana A, Hidalgo F, et al: Floriculture and the health divide: astruggle for fair and ecological flowers. 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Canadian Institutes of Health Research (CIHR): CIHR Guidelines for HealthResearch Involving Aboriginal People. 2007.doi:10.1186/1472-698X-11-S2-S5Cite this article as: Spiegel et al.: Establishing a community of practiceof researchers, practitioners, policy-makers and communities tosustainably manage environmental health risks in Ecuador. BMCInternational Health and Human Rights 2011 11(Suppl 2):S5.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitSpiegel et al. BMC International Health and Human Rights 2011, 11(Suppl 2):S5http://www.biomedcentral.com/1472-698X/11/S2/S5Page 7 of 7

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