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Internship Project: Nomad Children & Infectious Diseases
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Maham Daher



Joined: 14 Feb 2005
Last Visit: 06 Aug 2006
Posts: 20
Location: Berkeley, CA
PostPosted: Wed May 25, 2005 2:40 pm    Post subject: Internship Project: Nomad Children & Infectious Diseases Reply with quote

Hi All,

I am excited to have our first ADP intern, Ahsen Altaf on board!

Ahsen has already worked in tandem with an NGO called CRAC-PPA to prepare a proposal that he would like to implement during his 6 week internship. He is extremely enthusiastic about this proposal, which to me seems to be well thought out and researched. CRAC-PPA has a track record in conducting similar projects in the past. Sajjad has met with Ahsen and is also excited about his enthusiasm and ability to conduct the project.

1. I have attached Ahsen's proposal for your review and Q&As.

2. I have listed a few questions I had in mind and wanted to generate some more questions/ discussion to pass on to Ahsen and Sajjad.

3. A response on this proposal is time sensitive as we only have a weeks remaining before the internship begins. Incase, ADP does not want to support this proposal, then we need to find an alternative NGO for Ahsen to work with.

4. As for the timing, I would like to limit the Q&A to the forums and only to our next meeting (June 5?) after which it would be best to have a quick vote.
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Maham Daher



Joined: 14 Feb 2005
Last Visit: 06 Aug 2006
Posts: 20
Location: Berkeley, CA
PostPosted: Wed May 25, 2005 2:42 pm    Post subject: Reply with quote

Here is a list of Initial Questions I had on the project:

• Has CRAC-PPA or Godh had any experience with similar projects in the past?
o Ahsen has already responded and informed me that yes CRAC-PPA has conducted similar projects. We can get details if need be.
• Regarding, project implementation, who will be conducting the vaccinations and the seminars? Is Godh going to organize this?
• The first two objectives are clear though we need to address how we will measure project impact?
• The project involves at least 2 rounds of follow up vaccination. We will need to make sure that there is compliance with the vaccination regimen.
• Objective three will be a bigger challenge and require a lot more effort. What is the incentive for pharmaceutical companies to provide these vaccines? This goal will certainly require more than one week. If it remains as a third goal, then it will need to be better defined and appropriately fleshed out.
o As a response to my question, I have learnt that objective 3 is a secondary goal. Were they to get support from pharmaceutical companies, CRAC-PPA would then extend this model to help additional populations of at risk children in future projects. I think we should evaluate the proposal focusing on achieving objectives one and two.
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Omar Biabani



Joined: 28 Jan 2005
Last Visit: 06 Jan 2008
Posts: 93
Location: Boston, MA
PostPosted: Wed May 25, 2005 4:32 pm    Post subject: Reply with quote

'Godh' is an urdu word that means 'lap'. Since this NGO deals with children, the meaning here suggests 'mother's lap'.

I like the idea very much. Correct me if I am wrong anywhere, my intent here is to help clarify the project further

- Does CRAC-PPA and Godh have a website? I could'nt easily find it. Here is what I found about Godh

http://www.crin.org/organisations/viewOrg.asp?ID=490

- CRAC will use the services of Godh, which have a better understanding and relationship with the nomad family of Lahore, and provide

a) Vaccination to 200 children
b) Education on preventable disesase (STI's only - Hep. B/C, HIV)

- I am sure finding 200 out of 34,000 wont be a problem at all for Godh. What age group will be targetted ?
- Are the seminars 4 days long followed by vaccination on 5th day?
- Where will these seminars be held ?
- How will the selected children get there?
- Why not feed them a whole meal, a good meal, instead of refreshments?
- Who will make sure the same group gets the second dose after one month AND a booster dose after 6 months ?

- Who will choose/provide the 'community mobilizer' as it is the most important aspect of the project ? According to the proposal, community mobilizer will serve dual purpose - mobilize the nomad community to participate in this project AND teach the children at the seminar - Correct?

- Since both, girls and boys, will be a part of this exercise, does it make sense to have an all girls session (50 girls) and all boys session (50 boys) taught by a female and a male respectively? The reason I say this is because it may not be easy to ask questions regarding sexually transmitted diseases in a mixed gender crowd and the whole theme of this project revloves around 'educating' the young ones about such infections.

- What role will Godh play in this project besides identifying the target group ?

- What role will CRAC-PPA play in this project besides identifying the target group ?

- The proposal suggests that CRAC-PPA's core expertise is Child Abuse prevention and management. Also, they are currently focusing on training of teachers, doctors and other service providers to Detect, Report, Manage and Rehabilitate cases of child abuse. Isnt this project different from the work they are focusing on?

- I am not sure at this point what 'external monitoring' can ADP provide in this case.

I will post the rest of the questions later.
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Maham Daher



Joined: 14 Feb 2005
Last Visit: 06 Aug 2006
Posts: 20
Location: Berkeley, CA
PostPosted: Thu May 26, 2005 11:28 am    Post subject: Reply with quote

Hi All,

I heard from Ahsen. He is busy with exams until Friday. He will respond to our questions after that. Cheers.
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Justin Stone



Joined: 08 Feb 2005
Last Visit: 12 Mar 2007
Posts: 145
Location: Cambridge, MA USA
PostPosted: Fri May 27, 2005 9:10 am    Post subject: Reply with quote

Hi everyone,

There's one thing I am confused about. Is ADP supposed to consider this project for funding? Or, are we just deciding whether we should place Ahsen on the project? If it's just a matter of whether we should place Ahsen, I say 'yes' even if the project doesn't meet the ADP criteria. He is very invested in the project, and there will likely be other projects with CRAC-PPA suitable for ADP funding in the future. With relationship building and NGO eval as primary goals for the internship program, this makes perfect sense.

If we are considering funding the project, I'm concerned about the timeline. We would need to come to a decision after just one meeting to discuss. This will put a lot of pressure on the PC to be proactive in anticipating member concerns and gathering info quickly. I think it can be done, but want to be realistic about the expectations.

Many questions bave been raised which will need to be addressed. In addition, my particular concern is monitoring and impact. 200 out of 34,000 is not a very significant statistic. While I don't question the impact for the 200 immediate recipients, I want to emphasize that too many ADP projects are taking on the characteristics of compelling one-offs. It would be sad if we lost site of our most ambitious goal r.e. fascilitating/inspiring large scale institutional change. This project would be more compelling if:

-The objective of pharmaceutical company sponsorship for an ongoing/expanded program was explored in more detail, OR
-We think of this as a pilot program, and outline plans for continuing investment and expansion of the program after initial success.

I don't doubt the potential impact on society of programs of this kind, but without a broader vision for how the 'aid' is applied, I think we can expect the public health crisis to continue indefinitely. I like the project very much, but want to know that there is 'vision', or ADP is applying 'vision' to it.

I hope that's helpful.

~Justin
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Omar Biabani



Joined: 28 Jan 2005
Last Visit: 06 Jan 2008
Posts: 93
Location: Boston, MA
PostPosted: Fri May 27, 2005 1:51 pm    Post subject: Reply with quote

I believe Ahsen is eager to work as an ADP intern with an NGO AND his internship is not contingent on ADP's approval of this project. I agree that it will take time to understand the project and come to a conclusion.

The second point that you have raised is a very important one. How to look beyond the immediate scope (time and impact) of a project? Yes, the need to vaccinate 200 is there and the project is a great place to start but like Justin said, 200 out of 34,000 (0.6 %) should be a START with a vision to go from 0.6% to 60% or more.

One thing that crossed my mind was, Why not start the project by getting support from pharmaceutical companies (AND other companies as well). Let them know that an organization is willing to do a pilot program which should then be scaled (supported) by other organizations.
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Maham Daher



Joined: 14 Feb 2005
Last Visit: 06 Aug 2006
Posts: 20
Location: Berkeley, CA
PostPosted: Fri May 27, 2005 2:46 pm    Post subject: Reply with quote

If we are considering funding the project, I\'m concerned about the timeline. We would need to come to a decision after just one meeting to discuss. This will put a lot of pressure on the PC to be proactive in anticipating member concerns and gathering info quickly. I think it can be done, but want to be realistic about the expectations.

1. Yes Ahsen would like to implement the project as part of his 6 week internship which would require ADP funding. Of course, if we don’t approve this project then Ahsen can either work with a different NGO or on a different project with CRAC-PPA.

2. Discussing this at only one meeting shouldn’t be an issue. After all we have the forums available to continue the discussions online and have the relevant issues addressed. So far, Ahsen has been proactive in responding to our questions quickly.

3. I personally am quite excited about this project: Not only is Ahsen very invested in it, but this is the first time we actually have an ADP member who is taking his own initiative to conduct a project together with an NGO to benefit a segment of the underprivileged population within his own community. My understanding is that this is the very type of civic engagement ADP that has been trying to encourage all along among Pakistani youth. In fact, I believe that this type of civic devotion is what has led AID India to be successful.


Many questions bave been raised which will need to be addressed. In addition, my particular concern is monitoring and impact. 200 out of 34,000 is not a very significant statistic. While I don\'t question the impact for the 200 immediate recipients, I want to emphasize that too many ADP projects are taking on the characteristics of compelling one-offs. It would be sad if we lost site of our most ambitious goal r.e. fascilitating/inspiring large scale institutional change. This project would be more compelling if:

-The objective of pharmaceutical company sponsorship for an ongoing/expanded program was explored in more detail, OR
-We think of this as a pilot program, and outline plans for continuing investment and expansion of the program after initial success.

4. I agree with you that it would be ideal if we could get CRAC-PPA to use this project as a starter and then expand to a larger scale, potentially with the help of pharma companies. But I think that getting other companies on board can be something Ahsen can work on alongside conducting both (1)the initial 200 vaccinations and (2) educating nomad children on protecting themselves from infectious diseases.

5. Once we can demonstrate success with educating and vaccinating the original 200 children, this would make it a better sell to get support from other companies. Also, we’ll need to lay out an incentive for them e.g. tax breaks. I strongly feel that having their immediate support is unnecessary to get the project started.

6. The arguments of having a very limited impact on 200 out of 34,000 street children applies to many of the other projects we have funded in the past e.g. the DIL healthcare training would train only 76 teachers and impact at most a few thousand children out of tens of millions who could desperately benefit from public health and first aid awareness.

7. I think if we can get the commitment from CRAC-PPA to expand the project after our initial support, it would be a good starting point. From the out set, we can also have Ahsen start looking into the possibility of getting pharma companies on board.

8. Given that ADP can only offer limited small scale support in the 2-3 K range and that too without having a presence in Pakistan itself, we can’t expect to have immediate institutional impact. Yes we can begin to facilitate such impact through small scaled projects such as this.
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Ahsen Altaf



Joined: 25 May 2005
Last Visit: 19 Sep 2005
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Location: Pakistan
PostPosted: Fri May 27, 2005 4:42 pm    Post subject: Answers Reply with quote

Hi,

Please find attached answers to the queries posted Mr. Biabani. The NGO helped a lot in answering these questions and I think that it is very eager to do the project.

On the new questions that you've posted, one important issue that I feel that needs to be addressed is that though the project may be vaccinating 200 children in absoulute number, it is actually vaccinating more than 200 because of the 'external benefits' vaccinating these 200 people would bring. To gauge the entire benefit of the project, the social benefits need to be internalized. 200 children vaccinated means that the other children are in turn automatically less threatened. Though this may be a small benefit, it is still - none the less - an added benefit.

As far as talking to pharmaceutical companies is concerned, I think that it should be done at the end after there are some results to show them. If pharamaceutical companies are willing to support the project, it will be superb. But, it needs to emphasized that the chance these companies will take it up as part of their corporate responisibility is indeed slim. However, convincing them to do so is still worth a shot. I have a teacher in Remington Pharmaceutical who taught me finance and I plan to discuss the feasibility of this with him. However, he is presently not in Pakistan and I will talk to him as soon as I get the chance. There is another person in Aventis that I am hoping to contact but the thing is that Multinational Pharmaceutical give little leverage to their setups in Pakistan. So, in order for a Multinational Pharmaceutical to take this up, it would probably have to get it Ok'd from its global head office.

We can however convince pharmaceuticals, apart from tax breaks, that though this may not mean higher profits for them it will give them good publicity given the charges of irresponsible behaviour that have been levelled against them by several NGOs. How they market this however would depend on them. We could also perhaps convince pharmaceutical companies to form a coalition to carry this project forward. However, there would always be that little extra publicity for the company which decides to act as leader and comes volunteers first.

Just some ideas that I had.

Thank you for your time.

Regards,

-Ahsen.
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M. Sajjad Haider



Joined: 23 Apr 2005
Last Visit: 18 Jul 2008
Posts: 55
Location: Pakistan
PostPosted: Thu Jun 02, 2005 2:07 am    Post subject: Reply with quote

I shall be meeting with the Program Coordinator (Sarah Asad, whom Ahsen has been working with) for this project at CRAC-PPA on Friday. I believe a lot of the questions put forth in this forum have been answered by the document attached by Ahsen. If you guys have any further questions, please post them here ASAP so Ahsen or myself can ask her these questions.
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Bilal Arif



Joined: 08 Feb 2005
Last Visit: 01 Oct 2007
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Location: Arlington, MA
PostPosted: Thu Jun 02, 2005 10:02 am    Post subject: Reply with quote

Guys,

I am assuming that vaccination will be administered to kids that have gone through a medical and are healthy? The reason for this question is that there is a ‘universal’ vaccine available for Hepatitis B but not for Hepatitis A&C and many other STI’s. I am concern that if these individuals already have Hepatitis A, B, C and/or any other blood borne disease, providing vaccine for Hepatitis B would not beneficial.

I did not see this information on the forums and apologize if my question was answered previously.

Bilal
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Justin Stone



Joined: 08 Feb 2005
Last Visit: 12 Mar 2007
Posts: 145
Location: Cambridge, MA USA
PostPosted: Thu Jun 02, 2005 12:33 pm    Post subject: Reply with quote

Hi everyone,

First of all, great work on assembling the concept and moving so quickly to enable the implementation alongside the internship program. Regarding questions for CRAC-PPA, in addition to the issues that have been raised, I'd like to emphasize three concerns:

1) Follow-up
How will Godh (or CRAC-PPA) ensure that the children return for the second and thrid doses? I saw the general response, but the specifics are not clear.

2) Metrics
Intuitively, I think we all know that this will be an effective project for the individuals vaccinated and trained, and the impact will exceed the actual number of recipients. What other metrics could we use to define its impact? Do people feel the outcome is so obvious that we don't need to produce metrics beyond how many children are educated and vaccinated? Are there public studies of similar initiatives we can refer to?

3) Impact
As an individual project, I think it is very strong. Maham is right to point out that it meets most ADP criteria as well or better than other projects we have funded. Still, like other ADP projects, I beleive it will fall short of the long-term goal of fascilitating insitutional change unless the proposal contains some clear expectation that ADP will continue to support/develop/expand/complement the initiative in the future.

While it is a very constructive project, on such a small scale it really does nothing to address the larger public health crisis. This is fine as a starting point, but I want to make sure we think of it as that; not an end in itself. Some very good ideas have been raised r.e. how we might continue to develop this over time. My request is that you sketch out a plan for this within the proposal. I know we need to vote on the project after this week's meeting, so I'm not looking for a lot of detail at this point. For now, it would be enough to include the intent and possible approaches as part of the proposal.

Let me know if I can clarify anything...

Thanks!

Justin
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M. Sajjad Haider



Joined: 23 Apr 2005
Last Visit: 18 Jul 2008
Posts: 55
Location: Pakistan
PostPosted: Fri Jun 03, 2005 10:21 am    Post subject: Reply with quote

i met with Sarah Asad (the project manager for CRAC) today, i was overall very pleased with how they do thier work and CRAC seems to be a motivated unit of individuals. they only have 3 people working for them. Sarah is the only paid one the other 2 members are there on a volunteer basis. Despite that, CRAC is doing 2-3 other projects aswell. They all have busy schedules through work and other activities yet they have been taking time out for CRAC's events. This particular project will mainly be handled by Ahsen on CRAC'S part (speaking at the seminars, making sure the mobilizers do thier work and most importantly taking care of the vaccinations) and the rest will be taken care of by GODH.

as for the questions that were asked. well as for medical tests to check whether children do not have other illnesses which would nullify benefits of the medications, she said she would let me know if that can be done as she herself didnt quite know of the technical medical details.

about the children coming back for the 2nd and third doses, well the 200 children that have/will be chosen are from a pool of candidates already under the supervision of GODH by ways of a non formal education that they are imparting to these guys. So they have contact and more importantly trust developed with them for them to come back for future vaccinations.

evaluation of this project for CRAC is based on how many people come back for the later vaccinations and they are pretty sure that they will be able to achieve a high retainment keeping in light the point mentioned above.

lastly, the long term plans for this project are somewhat hazy at the moment. this is for several reasons. 1) CRAC is very small and already spread quite thin 2) lack of funds for furthuring this project (Ahsen hopes to get some support from pharmaceuticals but this may be more of a bonus if we get it) 3) depends a lot on how people percieve this....some very good campaigns have been destroyed due to the rumours or protests from religious leaders that these campaigns are the workings of the jews. so a long term strategy is yet to be developed and for the moment seems unlikely but in my mind this project is still very much one we should invest in...it has the right goals in minds, it has a good impact on children and it will help us in developing a good relationship with an organization working extremely hard for the benefit of children.
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Maham Daher



Joined: 14 Feb 2005
Last Visit: 06 Aug 2006
Posts: 20
Location: Berkeley, CA
PostPosted: Tue Jun 21, 2005 7:07 pm    Post subject: Reply with quote

As the project stands currently, ADP is very interested and would like to go
ahead with both the vaccination and educational seminars. But we'd like the NGO
to lay out a longer-term strategy for the future.

I have encouraged Ahsen to discuss this with CRAC-PPA and add a section in the
proposal broadly outlining first steps to doing this. He will chalk out details
through the course of his internship. Ahsen has been very quick to get in touch
with CRAC-PPA in this regard and will get back to us.

Here is the email exchange we've had:

> Hi Ahsen,
>
> Thanks for your email. I think the group will be fine with going ahead with
> both the vaccination and education if we can lay out a strategy for how
> CRAC-PPA and Godh can help address Hep-B and other infectious diseases among
> the nomad children in the long run.
>
> They want to support this small project targeting only 200 children as a
> pilot project only if there is a strategy for scaling it in the future to
> address the larger problem. They want to demonstrating success with this
> pilot and then pitch/ market to large donors to set a path to making a
> larger future impact.
>
> Some ways to go about it would be:
>
> 1) Contacting larger donors such as WHO, UNICEF, Canadian Aid Organization,
> Agha Khan Foundation, high net worth individuals in Pakistan as well as
> Pharma companies.
> 2) A low cost method would be to train individuals within the nomad
> community itself to conduct several rounds of seminars educating a larger
> group of children about infectious diseases. Since Godh is trying to impact
> the larger nomad community, I am sure this would be of interest to them as
> well.
>
> I am sure both CRAC-PPA and Godh would be very interested in figuring out
> ways to scale this project. We would like for you to develop a strategy for
> this during your internship that they can then begin to implement after the
> pilot.
>
> For now, it would be best to talk to CRAC-PPA and Godh about this. We need
> to get their commitment to set a strategy for scaling it and their ideas on
> how to go about it. You can flesh out the details later on.
>
> Once you have talked to them, we can just add a paragraph or two to the
> proposal suggesting in broad terms how CRAC-PPA and Godh envision scaling
> the pilot to have longer term impact for addressing the larger problem.
>
> Two other things to talk to CRAC-PPA and Godh about:
> 3) If we really want to pitch this pilot successfully to larger donors, we
> need to come up with concrete metrics to measure its success in addressing
> the problem for the 200 children we do target. One suggestion for doing this
> is to survey the children after the first seminar and each round of
> vaccination to get a sense of how the educational seminars have impacted
> their awareness. This measure is very soft. If you can suggest more concrete
> ones, we can make a better sell to large donors.
> 4) A concern that an ADP member had was screening the children for Hep B
> prior to vaccination. I personally don't think it will be cost effective to
> do this since roughly only 10% of the children may already be infected.
> However, can you just CRAC-PPA/ Godh an approximate cost for pre-screening.
> This would involve laboratory tests and hiring a clinical worker.
>
> Thanks for all the hard work you have put into this proposal.
>
> Best,
> Maham
********************************************************************
Ahsen's Response:

Hi.

I have forwarded the concerns raised to CRAC-PPA and I will call Sara in the morning and ask her to reply asap.

I have already talked to an instructor of mine about contacting larger donor organizations and he says that to get a grant from them, you need to have a very well organized and fully prepared research proposal with an extensive literature review, demonstration of the need and some sort of quantitative or qualitative research that can be shown as a social impact assessment report.

So, he says that this process takes a lot of planning and focus. I am absolutely willing to work on writing such a proposal, but I think that it can be better written after I have done some field work and can give the process of writing its due time. So I think that it would be a better idea, like you suggested, to do this during the course of the internship.

In the mean time, I can talk to some other people and think of some other ideas that can be implemented to ensure the sustainaibility of the project.

Thankyou for being so helpful.

-Ahsen.
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Maham Daher



Joined: 14 Feb 2005
Last Visit: 06 Aug 2006
Posts: 20
Location: Berkeley, CA
PostPosted: Tue Jun 21, 2005 7:43 pm    Post subject: Reply with quote

This project was discussed at the ADP Meeting on 6/12. Since then we have had a lot of discussion offline. I am posting the discussion thread
below so the larger group can benefit:

I posed the following questions about what was discussed at the meeting:

-What were the main points discussed?
-Were there any major concerns that people had that we need to address?
-Is there a need to go back and raise any points with CRAC-PPA?
-If folks did have any major reservations, I really believe strongly
enough in the project to iron them out before going to vote.

********************************************************************
Omar's Response:

Hi Maham,

We discussed the project yesterday and over all the group response was
positive. The group understands the time sensitivity and dual nature
of this project - the proposed project itself AND ADP Internship this
year. The group came up with 3 queries/suggestions that will further
improve the wholeness of the project

1) As Bilal pointed out, Whats CRAC-PPA's take on screening the
children before providing the vaccination and whether it makes sense
to immune them to Hep-B even if they already have other types of
Hepatitis?

2) As an ongoing process of improving the screening of 'ADP projects'
and selecting the ones which have a longer and deeper impact, it was
suggested that perhaps as a part of this internship, the intern can
develop a strategy on how the project can be expanded/scaled. This
will help the intern to study and analyze the real challenge of how to
go from 200 (0.05 %) to 20,000 (60%) nomads over a period of , say 5
years, with ADP's project serving as a model/proof of success.

3) Metrics, as explained by the proposal/answers, suggest that only
the number of returning children will serve the purpose. Since
CRAC-PPA are established organizations, can we do better than just
recording the number of returning children. I hope the number of
returning children is near 100% else for every 2 kids who do not show
up for a booster shot means 1 percent waste of resources.
One suggestion that comes to my mind is that CRAC, in collaboration
with PPA can monitor the level of diseases (Hep -A/B/C and others)
amongst the nomad community over a period of time - 4 samples with a
spread of 6 months ~ 2 years. This random sampling (maybe as low 15
people) will provide some cogent supporting data to scale the project
100 times (200 to 20,000)

With time being an important factor here, it was decided to put this
proposal for a vote so that we know the answer sooner than later. What
do you think? Should we hold it off a few more days until we get the
answers to the above 3 or should we go ahead with voting right now and
work on these 3 points in parallel ?

- Omar

********************************************************************
Justin's Response:

Hi everyone,

Personally, I'd like to see an answer to Bilal's question before voting.
Based on the discussion and past experience, I think the vote would likely
be against if we go forward prematurely.

Also, I'd like us to address the metrics issue. Omar has put forward a very
good suggestion. However, because the project is just a drop in the ocean,
a random sample of the wider nomad community would probably not reflect any
impact of our project. Perhaps using Omar's approach and following these
200 children, or those in their immediate communities... Maham, do you have
any thoughts on this? Perhaps we can get feedback on the idea from
CRAC-PPA, based on their resources and continuing contact with the children.

Finally, the point about selecting projects that will build towards longer
and deeper impact is extremely important. However, the consensus at the
meeting seemed to be that we should judge this project by the same criteria
as previous projects in the interest of time, and use the internship
component as a way to address lasting impact. While not quite achieving the
ideal, this would be a great step in the right direction.

~Justin
********************************************************************
My Response:

Hi All! Omar and Justin thanks for your comments/ suggestions. My thoughts are:

1. In response to Bilal's questions, I did some quick research of my own.

a) It would not be cost effective to pre-screen the children before vaccination. The screening would involve costly lab tests and require hiring healthcare professionals. Since we have no reason to expect the majority of the children to already be infected with hepatitis B, it would not make sense to incur the costs of screening them. For the small percentage that could potentially be already infected, no harm or good will occur from the vaccine.

b) As for children who may have other forms of Hepatitis e.g. A or C, it makes complete sense to vaccinate them.

Hep A is an acute form of the disease that most people recover from in a short period of time. These people would still be vulnerable to infection from Hep B which is a different strain of the virus, but is more serious, So it makes sense to protect them. Hep C is a more serious chronic form of the disease, and again caused by a different strain of virus. It weakens the liver and can lead to cirrhosis and liver cancer. In the medical literature, Hep C patients are advised to get vaccinated against Hep B to protect their already weakened liver from further damage.

2. As for measuring impact by following the children over a period of 6 mths to 2 yrs, I don't think it is a feasible approach. The purpose of monitoring the children would be to determine what percentage remain disease free i.e. we would be testing the effectiveness of the vaccination. We would then be able to say that because of the vaccination the incidence of Hepatitis B e.g. was 5 in 200 (2.5%) rather than 40 in 200(20%). Doing the screening and the monitoring of the 200 children
over time is a very costly approach just for measuring impact.

I also don't see the real need for it as there is plenty of evidence in the medical literature to indicate that yes the Hep B vaccine is very effective. In fact the vaccine is known to provide protection against the disease and carrier status for at least 20 years.

I think instead we might want to focus on measuring the effectiveness of the community seminars that will actually educate and increase awareness about Hepatitis and other STDs among the nomad children. Maybe we can have CRAC-PPA survey the children after each seminar to get a sense of how beneficial it was in increasing their awareness.

3. Lastly, I really like the idea of using the internship component of the project to flesh out how to make this project have a longer term impact. I am sure Ahsen will be very open to developing this. I have some suggestions regarding this. One is to train members from within the nomad community itself about infectious diseases and then have them conduct regular seminars over a longer time period to increase awareness among nomad children.

4. I agree with Justin that it would best not to vote prematurely. I would like to hear what everyone thinks about the three points above.

- Is there a need to discuss metrics/ impact further with CRAC-PPA now?
- Or are we comfortable with fleshing out details after we have voted?
- Are people ok with using the internship component of the project to develop a strategy for longer term impact?
********************************************************************
Justin's Response:

Hi All! Omar and Justin thanks for your comments/ suggestions. My thoughts are:

1. In response to Bilal's questions, I did some quick research of my own.

a) It would not be cost effective to pre-screen the children before vaccination. The screening would involve costly lab tests and require hiring healthcare professionals. Since we have no reason to expect the majority of the children to already be infected with hepatitis B, it would not make sense to incur the costs of screening them. For the small percentage that could potentially be already infected, no harm or good will occur from the vaccine.

JS: I understand it would not be cost-effective. Do you have a ballpark estimate to help with our learning? One thing I don't understand: if the children are essentially a representative sample of the community (not screened for Hep B), and we expect few would be infected, is Hep B immunization a 'critical' need? Shouldn't approx 10% be infected? (less in children, I suspect). I'm really asking out of ignorance.

b) As for children who may have other forms of Hepatitis e.g. A or C, it makes complete sense to vaccinate them.

Hep A is an acute form of the disease that most people recover from in a short period of time. These people would still be vulnerable to infection from Hep B which is a different strain of the virus, but is more serious, So it makes sense to protect them. Hep C is a more serious chronic form of the disease, and again caused by a different strain of virus. It weakens the liver and can lead to cirrhosis and liver cancer. In the medical literature, Hep C patients are advised to get vaccinated against Hep B to protect their already weakened liver from further damage.

JS: Sounds like we're saying the vaccination will be helpful to at least 90% of the children – some more than others, while the remaining 10% or less will not be harmed. More importantly, the vaccination will 'buy' their confidence and willingness to partake of the education component. This is reasonable, but I can't help but think of the program budget which devotes roughly 95% to vaccination related costs. If the Hep B vaccination is not a 'critical' need, is there a more cost-efficient way to gain and build trust with the children?

2. As for measuring impact by following the children over a period of 6 mths to 2 yrs, I don't think it is a feasible approach. The purpose of monitoring the children would be to determine what percentage remain disease free i.e. we would be testing the effectiveness of the vaccination. We would then be able to say that because of the vaccination the incidence of Hepatitis B e.g. was 5 in 200 (2.5%) rather than 40 in 200(20%). Doing the screening and the monitoring of the 200 children
over time is a very costly approach just for measuring impact.

I also don't see the real need for it as there is plenty of evidence in the medical literature to indicate that yes the Hep B vaccine is very effective. In fact the vaccine is known to provide protection against the disease and carrier status for at least 20 years.

I think instead we might want to focus on measuring the effectiveness of the community seminars that will actually educate and increase awareness about Hepatitis and other STDs among the nomad children. Maybe we can have CRAC-PPA survey the children after each seminar to get a sense of how beneficial it was in increasing their awareness.

JS: I think you're right. We don't need to study the efficacy of the Hep B vaccination. More telling would be some measure of the impact of the education component. What about surveying after the vaccination and training as you suggest, and doing some kind of informal follow-up quiz at the second and booster doses. The follow up could be focused on retention and/or anecdotal information about lifestyle choices.

3. Lastly, I really like the idea of using the internship component of the project to flesh out how to make this project have a longer term impact. I am sure Ahsen will be very open to developing this. I have some suggestions regarding this. One is to train members from within the nomad community itself about infectious diseases and then have them conduct regular seminars over a longer time period to increase awareness among nomad children.

JS: Great idea! I'd love to see ADP build a network of informed people in the nomad communities. Perhaps when a project is selected, we should brainstorm possible future extensions like this, so we have a launching point for continued support.
********************************************************************
Khurram's Response:

In my mind, the only issue that remains is about cost-effectiveness. Would the 95% of the budget that is used for Hepatitis-B vaccination be better spent over time by imparting more information to the Nomads rather than vaccinating a small population of them against Hepatitis B? I am not trying to belittle the gravity of the situation nor undermine the importance of what needs to be done with respect to Hepatitis-B and the target population, but I cant help but feel that the vaccination aspect
of this project would be better left for a later day when we can either vaccinate a larger percentage of the targeted population at once, or maybe even till we get some feedback from the preliminary information sessions. Alternatively, we could try to ask interns to pitch an idea to pharmaceutical companies where they match our donations towards vaccinations; a far fetched thought but hey, there are good people everywhere...

best,
Khurram
********************************************************************
Justin's Response:

I share the concern. I’m just wondering if a strong enough case has been made for tying the two initiatives (education and vaccination) together.

-Is there a more cost-effective, but equally effective, way to impart the training?
-As we think about future development of the project, how do we defend our choice to link the two initiatives?

Where do we go from here? Maham, will you or Ahsen be providing answers and modifying the proposal for a vote? We should probably move this discussion back to the forums so others can benefit from it…

Maham, I know you are very invested in the project, so I’d love to hear your thoughts on ‘investment thesis’ as we grapple with these issues…

~Justin
********************************************************************
Jehanzeb's Response:

In any case, here is what I think (much of a brief response to some of
the concerns raised):

- Telling these kids that ADP will vaccinate them will be a huge
incentive for them to attend the sessions and learn something. Some of
these kids will be in their mid-teens, so they can understand what
vaccination is. In return, ADP can ask them to spread the word. The
parents of these kids are also more likely to respond better if ADP
tells them "humm aap kay bachoan ko davai bhee daingay or khana bhee,
oar unn ko beemariyoan kay baray main sikhaingay" ("we will give food
and medicine to your kids in the program and also teach them about
certain illnesses")

- There are two approaches to tackling an issue: do something now
about it although it is at a small scale, or wait till you raise a lot
of money/awareness and solve the whole thing. The latter has been
tried with other diseases before but is not all that effective. I feel
saving 200 (plus more that will get indirect influence) now is better
than talking about how they can save themselves.

- Lastly, the scope of the ADP internship and budget limits what can
be done and that should not be forgotten. This is a project that will
have tangible results and definite impact. Big part of it is the
practical solution, as opposed to just lectures. ADP can optimise the
methodology and lecture design as time goes on, but the first step
would be to approve the project so the efforts can be channelled to
real tasks. Imagine how the pilot program might prove to be a gateway
to curing this problem in the gypsy/nomad family.
********************************************************************
Ahsen's Response:

Sorry for the dealy in responding. Please feel free to make any changes you think might be appropriate. Here is what I think:

There are two ways in which this project can be looked at. It can either be abstract and develop itself to come up with a larger impact after quite a while or it can be very focused and have immediate results.

From what I know about the nomad community and people who are hard pressed in general, I think that it is safe to say that they want to see something tangible done for them. The idea is to help people help themselves by showing them that you really are concerned about the state of their affairs and not just doing a project or anything for that matter for academic goals.

The project needs to be more action oriented and that can only be done by actually doing something … in this case, by vaccinating the children in the community. Only educating them against Hepatitis B won’t be a good option. No matter how much you educate them, without vaccinating them, I don’t think that it will make a major change. Hepatitis B is not like AIDS or some other illness that is caused primarily caused because of a lack of awareness – it is caused because of a dearth of proper vaccination against the disease. The nomad community can do nothing about the vaccination unless they get external help.

Even though the project is targetting only a small set of children among many millions, it has added benefits like educating people about vaccintations and setting an example of how the government (such as Ministry of Health) can help solve this on a larger scale. In addition,
we can drive the point home with the nomad community by showing them the costs and efforts needed in vaccination. As in, if they cannot afford such costs (which we will go through for some of them) on their own, then they'd see how it is in their own self-interest to keep our awareness education in mind if they want to live as healthily as possible.

Here is why ONLY educating them won’t be good enough … I once did a survey of people who live in kachi abadis in Lahore (squatter settlements) and the people living there said that for the past 20 years all people do is come here and talk to us about our problems and what ‘we’ should do but no one considers what they can do.

I think the way to the project should be to start with something that gives results and build on it instead of aiming only at the greater long run impact; then, the nomad community will have to wait for something they need now.

The nomad communities’ needs, like the needs of all the under-privileged in Pakistan, are immediate. From an individuals perspective, there might be no tomorrow to wait for!

Thankyou.
-Ahsen.
********************************************************************
Maham's Response:

Hi All, Here are my thoughts on the project:

1. Adolescents in general are the highest risk group for contracting Hepatitis B, according to the Centers for Disease Control & Prevention. This is certainly true for the nomad street children, who are at high risk of getting Hepatitis B through sexual activity, which they are regularly forced into for survival. Ahen's proposal makes a reference to sexual exploitation and sodomy.

8 to 10% is a pretty high prevalence for the disease in developing countries like Pakistan, relative to under 2% for developed countries. In fact, this 8 to 10% figure is a national average, not necessarily reflective of the higher prevalence rate of a high risk group like the nomad children.

2. The main point of the educational seminars will be to convey and emphasize to the children ways in which they can protect themselves from Hepatitis B. This will certainly increase their awareness about the disease. Unfortunately however, they have limited options for protecting themselves from sexual exploitation. Once they have contracted the disease, there is no actual cure for it. Hepatitis B leads to cirrhosis and liver cancer. In 25% of patients this ultimately leads to death. The best
known way to contain the infection is through vaccination. So it really is the only means to ensure their protection. Besides protecting the children directly, we will also impact the nomad community by protecting family members from infection.

If we both educate and vaccinate. we will be sending a signal to the children that yes this is a serious disease, this is how you can protect yourself, and we will also take a step to help protect you.

If we start small and at least begin to chip away at protecting the lives of these nomad children, we can use success with this pilot study to gain more funding and resources from organizations like the WHO, UNICEF and the Agha Khan Foundation to expand the project in the future.

3. I also want to address the issue that vaccinating 200 children is only a drop in the ocean. This to me is not a strong enough reason for not doing it. We have to start somewhere.

In the past we have chosen to fund cataract surgery for only 50 women where as I am sure there are millions in Pakistan who could benefit. We have also chosen to provide clean drinking water to women in one prison, where as I am sure there are millions who are in dire need of potable water.

We can also argue whether this is a critical need or not, but other projects we have funded such as the AL Hobby club hardly addressed a critical need relative to this serious disease. Infact we can argue whether you really need electronics equipment worth $5K simply to encourage understanding of science concepts through a hobby club.

4. I also want to emphasize that this pilot will give Ahsen the opportunity to figure out a strategy for long-term impact during his internship. This is the first time we will actually be doing this for any project that ADP has so far funded:

Ahsen can focus on 2 approaches: (1) Encouraging educators within the nomad community to impart awareness (low cost but also low impact).
(2) Pitching the success of the pilot to organizations that actually fund vaccination programs e.g. WHO, UNICEF etc.

I feel both methods are complimentary as the first will get the community itself invested in the project where as the second is ultimately what will help contain the disease.
********************************************************************
Thanks for the details (and research) provided here Maham. Sorry for
jumping in a little late. I am glad people are discussing core issues
important to ADP and the project itself. I agree that we neet to
decide a deadline for putting this project to vote, next week sounds
good to me.

Here are a few things I have been thinking about and wanted to share
with you guys.

CRAC-PPA is an established organization comprising of 1500
pediatricians in Pakistan committed to helping children mostly against
abuse and other rights issues. They are teaming up with another
established organization Godh to reach out nomadic children and help
them educate and immune against Hep-B.

- We (ADP and CRAC/Godh) already know the prevalence of Hep-B in the
communities especially the nomadic community.
- We also know the effectiveness of Hep-B and that it would, no doubt,
protect those who are immunized against this vital disease.
- Secondary data, as provided by the proposal, indicates 34,000 nomads
and hence a subset of them will be children - say 50% (17,000)
- What I am trying very hard to figure out is, as the chief architects
of this project, what is CRAC/Godh's vision to address the real
challenge - going beyond 200 children. I know Ahsen has carved out a
plan to get in touch with private organizations to seek future
funding/commitments but who else is thinking about the 17,000 - 200 =
16,800 children in terms of both, education AND immunization.

I would be very comfortable with this project if CRAC along with GODH
indicates that

A) There is a plan to address the larger crowd over a certain period OR
B) This is a true prototype whose outcome will determine the further
expansion of the project.

Option A demands a master plan in place and option B demands complex
metric gathering (vaccination doses is a no brainer as we can't
question their effectiveness or importance, it defies the purpose of
prototyping)

As Justin pointed out, the actual project component is not much
different then ADP's previous projects and I wont treat it different
in that respect but the role of the organization designing and
implementing the project is some what different- or maybe I am missing
something.

Khibaib approached us to help them build wells in prisons. The had a
solid plan of addressing the absence of clean drinking water in
prisons all across Pakistan ( 64 wells out of which they have already
completed 22 ) Although we helped them with only 1 well, we knew that
Khubaib has layed out a plan to fill a gap (unclean drinking water in
jails) all across Pakistan. We started a relationship with them pegged
on Prison Welfare.

Chakwal eye surgeries is a similar case where Munawwar Foundation is a
group dedicated to provide eye care (cataract surguries included) to
those who cannot afford it in the community. Their mission is to
provide eye care to the Chakwal area.

Alif Laila is another organization who is dedicated in reaching out to
the underprivileged kids through its library and hobby clubs. They
already had an electronics club, it was the expansion which was needed
to cater a larger crowd and increae the level of skill/knowledge of
those who would join.

What I would like to see is CRAC's long term strategy to handle Hep-B,
or any other disease for that matter, amongst the children of nomad
population of Lahore.

As far as metrics are concerned, I am not sure conducting a post
seminar&vaccination survey will be beneficial for ADP or future
donors. One of the reasons I wanted CRAC to monitor the disease level
amongst the nomad children was to have some concrete data that can be
shown to private organizations in order to get future funding. As an
example, just to scale this project so that at least 80% of these
children (around 13,000) can be provided this same seminar and
vaccination, it would cost about $160,000. For this kind of money,
some serious metrics should be thought of, especially if we want to
get support from the big donors like pharmaceutical companies. I
personally don't want to create metrics for the sake of creating them.
I am not sure, at this point, what value will an informal survey about
STD education within a nomad community would bring to the table.

I DO think the project has merits and that we should let Ahsen talk to
CRAC to understand their future plans for this program, even develop
some metrics with them if necessary. What do you guys think

- Omar
********************************************************************
Justin's Response:

Thanks Maham. I still haven’t made clear my references to a ‘drop in the ocean.’ You are absolutely right that this project is no less worthy than any other ADP project by this measure. And, I also would not vote against it for this reason. I don’t think many (or any) members would.

Nobody is looking for short-term impact beyond the immediate recipients. As long as the project lays the ground work for future impact, and we elaborate on a plan to follow through, I believe the requirement is satisfied…

While we have not always done this with earlier projects, we know now that we should have, and I hope we will focus our attention in the coming
months on revisiting our previous projects with an eye towards refining and scaling…

Also, when I ask whether Hep B is a ‘critical’ need, I’m wondering mostly if there is another std or other disease we should be vaccinating against in combination with the education component. Since 95% of the budget is devoted to the vaccination costs, I want to make sure we are making the most of this aspect of the project.

I’m still interested in getting a ballpark estimate on the cost of screening, mostly for our own learning. Since we can expect more than 20 of the participants will already be infected, it would of course be preferable to not provide the vaccine to those participants. But, if we can say with authority that it is not cost-effective, it is an easy decision to defend.

What did you think about the ideas for follow-up with this group? I think we need to nail down a scope for this. How do you want to proceed? I suggest adjusting the proposal to respond to the questions that we have debated here, and putting it online for a short discussion, followed by a vote.

~Justin
********************************************************************
My Response:

Hi Justin,

Yes that sounds good to me. We can make adjustments to the proposal including the following:

1. Conducting surveys after the initial and subsequent rounds of vaccination to assess the impact of the educational component.
2. Suggestions for how to proceed with a strategy long-term impact.

I will encourage Ahsen to review it and add his thoughts on the second point. I'll post the proposal and the discussions we've been having here onto the forums to open it to the larger group.

We can shoot for a vote next week. I hope you'll be able to take out a few minutes and vote Smile

As for the cost-effectiveness of pre-screening, I still think it will not be cost-effective. We can of course ask CRAC-PPA to give us an estimate of screening costs.
********************************************************************
My Response:

> Hi Ahsen,
>
> Thanks for your email. I think the group will be fine with going ahead with
> both the vaccination and education if we can lay out a strategy for how
> CRAC-PPA and Godh can help address Hep-B and other infectious diseases among the nomad children in the long run.
>
> They want to support this small project targeting only 200 children as a
> pilot project only if there is a strategy for scaling it in the future to
> address the larger problem. They want to demonstrating success with this pilot and then pitch/ market to large donors to set a path to making a
> larger future impact.
>
> Some ways to go about it would be:
>
> 1) Contacting larger donors such as WHO, UNICEF, Canadian Aid Organization, Agha Khan Foundation, high net worth individuals in Pakistan as well as Pharma companies.
> 2) A low cost method would be to train individuals within the nomad
> community itself to conduct several rounds of seminars educating a larger group of children about infectious diseases. Since Godh is trying to impact the larger nomad community, I am sure this would be of interest to them as well.
>
> I am sure both CRAC-PPA and Godh would be very interested in figuring out ways to scale this project. We would like for you to develop a strategy for this during your internship that they can then begin to implement after the pilot.
>
> For now, it would be best to talk to CRAC-PPA and Godh about this. We need to get their commitment to set a strategy for scaling it and their ideas on how to go about it. You can flesh out the details later on.
>
> Once you have talked to them, we can just add a paragraph or two to the proposal suggesting in broad terms how CRAC-PPA and Godh envision scaling the pilot to have longer term impact for addressing the larger problem.
>
> Two other things to talk to CRAC-PPA and Godh about:
> 3) If we really want to pitch this pilot successfully to larger donors, we
> need to come up with concrete metrics to measure its success in addressing the problem for the 200 children we do target. One suggestion for doing this is to survey the children after the first seminar and each round of vaccination to get a sense of how the educational seminars have impacted their awareness. This measure is very soft. If you can suggest more concrete ones, we can make a better sell to large donors.
> 4) A concern that an ADP member had was screening the children for Hep B prior to vaccination. I personally don't think it will be cost effective to do this since roughly only 10% of the children may already be infected.
> However, can you ask CRAC-PPA/ Godh an approximate cost for pre-screening. This would involve laboratory tests and hiring a clinical worker.
>
> Thanks for all the hard work you have put into this proposal.
>
> Best,
> Maham
********************************************************************
Hi.
I have forwarded the concerns raised to CRAC-PPA and I will call Sara in the morning and ask her to reply asap.

I have already talked to an instructor of mine about contacting larger donor organizations and he says that to get a grant from them, you need to have a very well organized and fully prepared research proposal with an extensive literature review, demonstration of the need and some sort of quantitative or qualitative research that can be shown as a social impact assessment report.

So, he says that this process takes a lot of planning and focus. I am absolutely willing to work on writing such a proposal, but I think that it can be better written after I have done some field work and can give the process of writing its due time.

So I think that it would be a better idea, like you suggested, to do this during the course of the internship.

In the mean time, I can talk to some other people and think of some other ideas that can be implemented to ensure the sustainaibility of the project.

Thankyou for being so helpful.

-Ahsen.
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Maham Daher



Joined: 14 Feb 2005
Last Visit: 06 Aug 2006
Posts: 20
Location: Berkeley, CA
PostPosted: Wed Jul 13, 2005 11:23 pm    Post subject: Reply with quote

Update on Long-term Expansion of the Update on Long-term Expansion of Project

After a lot of discussion and Q&A among ADPers about the merits and impact of this project, the main concern was that we wanted CRAC-PPA to consider a plan for extending the project long-term

Ahsen and Sajjad have been in touch with CRAC-PPA in this regard. CRAC-PPA have responded positively. They are interested in expanding this project on a long-term basis and have sent us the following initial suggestions:

• Supporting the nomad children through awareness raising seminars with each round of vaccination.
• Partnering with the government to extend vaccination to the nomad children. The government has already been providing Hepatitis B vaccination to infants. CRAC-PPA would need to begin establishing links with the government with respect to this.
• Training a full time community health worker (CHW) from within the community to impart awareness and education on primary health and reproductive hygiene.
• Having a part time doctor service the community to help manage childhood/ adolescent diseases. The doctor would support the work of the CHW

CRAC-PPA would like to implement this long-term expansion in partnership with Godh. The expansion will of course be contingent on finding additional donors. Ahsen can begin researching some potential donors during the course of his internship.

If you’d like to read the details of the correspondence between ADP and CRAC-PPA, please download the attachment.
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