Sanando Heridas (Healing Wounds)

Celina de Sola is Co-Founder and Vice President of Programs at Glasswing International. Her work focuses on designing and implementing innovative, community, and evidence-based initiatives that bring together institutions and people for joint action. Celina has over 20 years of experience in international development and social change, having worked as an international development consultant; a resource specialist for Latino immigrants in the United States; and leading responses to complex humanitarian crises and natural disasters in over 20 countries worldwide. Celina is an alumnus of Harvard University’s School of Public Health (MPH) as well as the University of Pennsylvania (BA) and its Graduate School of Social Policy and Practice (MSW). She is an Obama Foundation Fellow, Skoll Awardee for social entrepreneurship, a member of the Inter-American Foundation’s Advisory Council, a Tällberg Foundation Global Leader, an Ashoka Fellow, a LEGO ReImagine Learning Fellow, and a Penn Social Impact Fellow.  

Violence instills terror, takes lives and livelihoods, exacerbates poverty, desperation, community and family disintegration. Victims are 5.5 times more likely to perpetrate violence or be re-victimized (WHO), fueling the cycle of violence and trauma, and overwhelming people and public systems created to provide care. In El Salvador, many violently injured persons are treated at hospitals with limited capacity to address their psychological trauma. It’s critical to reduce the burden of trauma by expanding access to mental health.   

We propose replicating Sanando Heridas, the first hospital-based trauma intervention in Central America. Staff and patients learn about the symptoms of trauma, explore and practice coping strategies and self care activities, creating a system that is informed and skill in addressing trauma.  

A hospital trauma-informed ecosystem will expand access to mental health intervention, build workforce and individuals’ capacity to reduce harm from violence and trauma, and strengthen resilience for systems and individuals. 

Latin America is home to only 8% of the world's population, but 37% of its homicides (World Bank, 2018). Homicide rates in El Salvador, Guatemala, and Honduras are among the highest globally. Studies have found that patients with an initial penetrating trauma injury are likely to return to the emergency room. According to the World Bank,  more than 40% of violently injured young people return to the emergency service in the future with violence-related injuries, and up to 20% are victims of homicide during the five years after the first injury,  highlighting the need for intervention in hospitals.

Despite extreme rates of violence, and evidence that untreated trauma can perpetuate violence and victimization, most Central American communities are still mental health deserts (less than 2% of the health care budget in the region is allocated to mental health (WHO, 2015)).  Citizens are not provided with the care and support to manage the chronic or acute crises of violence and trauma. Also, many health-care providers remain uncertain about the benefits of mental health services, especially for those patients believed to be gang members. These represent enormous challenges and opportunities to improve the mental health ecosystem throughout the region. 

Sanando Heridas has several layers. The first is the program interventionists who are recruited and trained  to assess patients for trauma symptoms, provide immediate psychological first aid and care, and train them to recognize, manage, and cope with their trauma in the long-term. Together they develop a safety plan to meet the patients’ needs, including a discharge plan. Based on the needs, and security risks, the program uses a network of institutions and providers as a referral system to provide specialized services and additional benefits to patients. This referral system is now a part of the national healthcare system.

The Interventionist also trains hospital staff on the physical, emotional, and behavioral manifestation of trauma. Staff use their own experience with work-trauma to tune into their trauma reactions. These exercises build awareness and empathy for patients and for each other. During the training they practice deep breathing and other grounding techniques. These trainings enhance social cohesion at work as it fosters more open communication and peer support. It also increases compassion for patients resulting in improved patient-interaction, and greater interest in referring trauma patients to follow-up care, and also identifying and referring patients to Sanando Heridas. 

Program engages patients treated for interpersonal injuries,   those whose emotional and mental state have been affected by witnessing a violent act, as well as hospital staff. Patients have been exposed to violent events, mainly related to four types of injuries: (i) beating, (ii) gunshot wounds, (iii) stab wounds and (iv) others that may include explosive weapons, threats, and others. Additionally, the program also treats people whose emotional and mental state have been affected by witnessing a violent act.  

The program trains existing service providers as interventionists, who after performing an assessment on patients, then provide immediate psychological first aid and care to help individuals recognize, manage, and cope with their trauma in the long-term. Jointly, patients and interventionists develop a safety plan that emcompases the needs of the beneficiary, and includes action items to follow up and provide additional support. The training also includes self-care for service providers, simultaneously contributing to individual and institutional resilience. Based on the patient's needs, and security risks, the program uses a network of institutions and providers as a referral system (‘trauma-informed ecosystem’) to provide specialized services and additional benefits to patients.

Sanando Heridas is a program that elevates mental health and puts victims of violence at the center (all victims of violence, including victimizers) by providing them with holistic services and developing positive coping skills. As an evidence-based approach for violence prevention, it elevates the importance of trauma-informed practices and seeks to create a sustainable trauma-informed-care ecosystem. Moreover, Sanando Heridas raises awareness of the deeper and lasting effects of trauma in the short and long term in a person’s life, and how trauma-informed care contributes in breaking the cycle of violence by reducing relapse and retaliation against others or themselves. 

In 2006, I moved back to El Salvador after years of leading international humanitarian efforts in conflict zones and natural disasters sites, where I found that criminal and gang activities were fueling a rapid rise in violence. I knew about a program in the US that worked to address trauma in a hospital setting. I thought that this might work in El Salvador since hospitals tend to be neutral environments and is the place where everyone comes for treatment, both the injured person and those who sometimes cause injuries. 

One of the US program staff, and a hospital nurse (who later became our first program staff)  came to El Salvador to collaborate with us to design a program that could fit our context. Because of high rates of violence and concern for safety, we could not operate in the community. Instead, we created a brochure that acted as the case manager, which took patients through the process of learning about their trauma symptoms, practicing coping and self care activities, and using supportive people in their lives. This process was replicated with hospital staff so they could too understand the impact of personal and work trauma on their emotions and behavior.

I was born in El Salvador right before our civil war. I lived a sheltered life in this conflict-torn nation until my family was forced to move to the US when I was six years old. I spent every holiday in El Salvador, so constantly had to navigate two worlds - my life in an affluent US suburb, and my other life inside a protected bubble surrounded by an impoverished and dangerous El Salvador. I found it distressing witnessing how children my age suffered and struggled, this motivated me to organize student volunteer activities starting at age 12. Later, in graduate school, I worked with undocumented immigrants who fled violence in Mexico and Central America. This work exposed me to the extreme challenges, trauma, and loneliness that immigrants faced, and the lack of community support to help them cope and navigate their new lives in the US. I always found myself trying to fill gaps in a system designed without knowledge of the population’s needs. I realized my efforts were palliative and unsustainable, and began thinking about how a mental health ecosystem could alleviate acute distress and equip people with hope, a sense of agency, and the skills to thrive.

Glasswing’s expertise in trauma intervention is rooted in over a decade of work in developing trauma-informed mental health practices in hospitals, schools, and communities, evaluating program impact and conducting feedback sessions with program beneficiaries. Sanando Heridas has been funded by partners such as USAID, the Inter-American Development Bank, and replicated at both institutional and community levels. In El Salvador alone, Sanando Heridas has strengthened the capacity and skills of almost 4,000 public service providers. Moreover, in 2019, an independent evaluation by the World Bank illustrated that Sanando Heridas reduced the likelihood of recidivism for violent injury by up to 30%, and that by training personnel in trauma, the rate of referral of patients to specialists increased by up to 58%, demonstrating their improved trauma assessment capacity. 

The current political context offers opportunities to influence national policies that favor a new approach to public security, which focuses on violence prevention. Our existing partnerships with government institutions (Ministry of Education, municipalities, public health system, law enforcement, Immigration) place Sanando Heridas in a unique position to continue expanding in the region, as the program has also been adapted for:

• Staff training in government centers for returning migrants (El Salvador-Honduras) to better respond to the mental health needs of migrants.

• Police training in Guatemala and Honduras. Police have shown improvements in self-regulation, impulse-control, and empathy. 

• School-based Well-being Committees that address the ‘mental health deserts’ in communities by facilitating individual and collective grieving, as well as detecting and referring cases of abuse. 

For the first 3 years of the program, obtaining buy-in from the Ministry of Health and government hospital staff was difficult, seeing as – despite the vast number of violent injuries they treated – they didn’t recognize the importance, or their role, in addressing psychological trauma. Our strategy was not only to present scientific evidence (often through peer-based learning), but also provide short, interactive training in self-care and trauma education, to help healthcare workers manage their own vicarious trauma. Once they were able to understand the often-devastating symptoms they faced, it was easier to empathize with patients.

Another challenge was that the US-based intervention models that inspired this program included significant home and community-based case management. This was virtually impossible for us to do because of the extreme risk it posed to our team and our clients, due to gang violence. We had to find alternatives to ensure ongoing support so clients could continue healing once they left the hospital. Aside from conducting remote, telephonic interventions, we also decided to focus on decentralizing access to mental health support. We did this by establishing more ‘trauma-informed communities’ through training, and helping to set up/activate detection and referral systems in communities. 

Working in a region plagued by violence and trauma, polarization, and instability, leveraging empathy, and optimism are critical to bringing together ‘unlikely’ partners with vastly different ideologies and backgrounds. Knowing that to transform our countries, we need to break molds and shift paradigms, I often propose ideas that seem impossible until we see them through.

Believing deeply in collaboration, my role is often to ‘convene and catalyze’ across disparate stakeholders, ensuring communities are at the table. 5 years ago, we decided to overhaul San Salvador’s ‘Central Park’, a neglected and dangerous space right in front of the country’s most important public hospital. We had to overcome significant push-back due to extreme political polarization. It required contagious optimism, aspirational thinking, and perseverance. 

At a time when the US Administration had cut all aid to Central America because of the migration crisis, we also had to build bi-partisan support -for this and many other violence prevention projects- with visiting US Congressional Delegations. I had to garner trust and credibility, and engender a shared vision among people that weren’t necessarily aligned with each other. Against all odds, we succeeded, and the park is now one of the only safe spaces for families.

Violence prevention is complex; it requires human connection, healing, and involves the broader community, to restore hope and shift paradigms. By fostering a more profound knowledge and understanding of the causes and consequences of violence and trauma, harmful norms and paradigms can be shifted. Sanando Heridas is unique because it equips people and institutions (in underserved contexts) with the skills and tools to prevent and mitigate violence and trauma in order for conflicts to be resolved, healing to take place, and communities to be transformed. Experts have long agreed that this region has been exposed to some of the highest and most unrelenting violent and traumatic events, and the long-term impact on individuals drives poverty, forced migration, more violence, and retraumatization. Sanando Heridas seeks to democratize access to mental health and wellness by interrupting the multi-generational cycles of violence and trauma and building trauma-informed mental health ecosystems throughout Central America. 

If we equip local stakeholders and strengthen systems to provide the necessary care, referral services, and support to mitigate the consequences of theirs and others’ trauma, then  we will improve the institutional response, preventing the likelihood of victims turning into perpetrators as well as laying the foundations for long-term healing. 

Current number of people being served: 2400

Number of people serving in one year: 3200

Number of people serving in five years: 7,800

These numbers are based on our projections for the expansion of the Sanando Heridas hospital-based intervention in the Northern Triangle Countries (El Salvador, Honduras, Guatemala). The beneficiaries would be: 1-Patients that have been victims of violent acts; 2- Healthcare staff in Hospitals; and 3-Healthcare staff in Health Centers.

Organizational Goal #1: Build the protective factors of children and youth facing extreme adversity, through trauma-informed education and health programs that: foster experiential learning; build social and emotional competencies; provide positive role models and social networks; and empower kids to be change agents.

Organization Goal #2: Increase community resilience through access to trauma-informed, community-based mental health support that addresses psycho-social needs while also engendering a cultural shift around the importance of trauma care. 

Organizational Goal #3: Accompany implementation with ongoing feedback from program participants, evaluation, and learning, as well as rigorous practice-based research, in order to be responsive to changing context and ensure desired impact is being achieved. 

In order to maintain its sustainability, and continue to both expand and deepen our impact long-term, Glasswing has maintained a diverse portfolio of funding that has expanded over time. 

Some of Glasswing’s main funders are:

• US Government: US Agency for International Development (USAID); US Department Of Labour; US Embassies
• Corporate partners: over 50 local and multinational corporations, including: Hanes, Citi Foundation, Morgan Stanley, Telus, Banco Agricola, Puro Surf, Google
• Private foundations, including: Novo Foundation, Summit Foundation, Tinker Foundation, Open Society 
• Foundations, Pestalozzi Foundation, IDRC, Howard G. Buffett Foundation 
• Development institutions, including: United Nations agencies (UNDP, UNICEF, UNESCO), Inter-American Development Bank (IADB) 

 Glasswing also works closely with public agencies, peer non-profit organizations, research partners, as well as communities, who provide technical and in-kind support, as well as infrastructure/spaces. These include, for example:  

• Government: Ministries of Education and Health, public agencies responsible for Child Protection, Migration, Youth, Employment, Law Enforcement, Municipalities 
• Partner Organizations: YouthBuild International, Catholic Relief Services, Fe y Alegria, Fepade, and other community organizations
• International High School network of New York City (US programming)
• Research Partners: World Bank, University of Chicago, New York University, J-PAL
• Volunteers (community, corporate, public servants)

Glasswing builds partnerships across public, private, and civil society, leveraging human, financial, and material resources to achieve the greatest – and most sustainable – impact. Glasswing’s innovative model includes the following characteristics:

1) Assets-Based Approach: We build on and strengthen communities’ existing resources, which not only enhances local ownership but also contributes to sustainability. We believe that every person, regardless of educational or socioeconomic level, has the potential to effect positive change in their community. This approach is cost-effective and avoids duplications, while empowering individuals as agents of change. Community-based development must be founded on dignity and a deep belief in the human potential.

2) A Global Vision with Local Operations: Our leadership is composed of individuals with diverse international experience, which brings a global perspective into all of our work. 98% of our staff is located in Central America, from where we design, implement, and oversee all of our own programs. This ensures that we have the flexibility to respond to each country’s unique context more cost-effectively.

 3) Powered by Volunteers: Volunteerism is an integral part of all of our programs – not only for its economic value, but also for its power in fostering social cohesion. Volunteerism allows all types of community members to be involved and engaged with vulnerable youth, which multiplies the impact of the programming while strengthening the social fabric of the community.

This award would embody a public recognition of the vast human potential in Central America, a region that has been stigmatized and characterized by violence, gangs, and hopelessness for decades. At a time when youth from high risk communities are perceived as a liability rather than an asset, the Elevate Prize would galvanize hope and inject a renewed sense of opportunity. 

Moreover, the funding that this award provides would enable Glasswing to deepen and expand the Sanando Heridas program, particularly in communities that are extremely difficult to access and receive little - if any - support. Glasswing would be able to transform and democratize access to basic mental health interventions, by integrating the hospital-based trauma program into the National health system by training healthcare staff on trauma education and intervention.