Specialty Healthcare for All - No Matter Severity or Race

We seek to address the significant gap in health services for migrants in Tijuana, Mexico, especially services in Creole and for more severe populations. For years, dire conditions have forced migrants to leave their homes to come to Tijuana to seek asylum for safety and a chance at life, with the largest caravans starting in 2018. In 2020, the US government closed the border to migrants and asylum seekers under the pretext of addressing COVID-19 under Title 42. This has resulted in migrants from all over the world - Latin America, Africa, Asia, Europe - being forced to remain in Mexico while they wait for their asylum court case date which can take months to years. Overall, this has resulted in a dramatic influx of millions of displaced persons having to share health resources that were already extremely limited before the pandemic. Prior to the pandemic, the public healthcare system in Baja, California functioned beyond the capacity of its resources. For example, though pediatric care was provided to some Mexicans, it was not accessible to a significant amount of the population, evidenced by the 30,081 child mortalities and 25,833 infant mortalities reported in Mexico in 2020. Additionally, the resources available to the population were not sufficient. In 2020, according to UNICEF, only 43% of Mexicans have access to safely managed drinking water, and 57% had access to safely managed sanitation services. Now stretched well beyond capacity, many basic public healthcare services are not available even for local residents or qualifying migrants. Both refugees and Mexicans are sometimes turned away from obtaining life-saving health services at the local general hospital in Tijuana. Migrants especially face many obstacles to seeking care due to cost, shame, stigma, language, and risk of persecution if they leave the shelter. They also have a greater likelihood of health problems due to traveling under difficult conditions to get to Tijuana, are more likely to experience sexual or physical violence, and are at risk of contracting worse disease due to shelters being overcrowded, which results in diseases like COVID-19 and scabies quickly spreading. In one survey of migrants in Tijuana, 96% of migrants reported feeling unsafe due to fears and experiences of being assaulted, kidnapped, extorted, and subjected to physical and sexual violence in Mexico, especially LGBTQI individuals.

There is especially a great need for health services in Creole and specialty services like psychiatric, pediatric, and obGyn services. There has been an especially elevated numbers of Haitian migrants due to back-to-back crises, including earthquakes, the assassination of their president, hurricanes, and the US disproportionately sending more Haitian migrants back from the US. However, Haitians are especially mistreated and abused in Mexico, not only by the general public but also by healthcare services and other professionals. As a result, they sometimes feel safer going to fellow Haitians they trust for help. With regards to psychiatry, in a May 2021 assessment of migrant mental health done in the shelters we work in, 96% of the migrants meet criteria for at least one mental health disorder and 88% meet for at least 3 disorders. In an internal August 2021 needs assessment, UNICEF estimated that at 13 of the 30 shelters we service, at least 9% of the population are very severe and need psychiatric services but do not get it in addition to the less severe cases not receiving services despite likely benefiting from psychiatry. Furthermore, the is a great need for pediatric and Ob/Gyn services because we often see one caregiver helping take care of multiple children due to the other caregivers being killed and women arriving to the border pregnant due to experiencing sexual assault. Many women also have complicated pregnancies due to other health problems and stressors they are experiencing and require Ob/Gyn clinicians specialized in high-risk pregnancies.

Our solution has three parts. First we propose task shifting specialized services to generalist and less experienced clinicians in order to meet the needs of the community for more specialized services via electronic systems like electronic medical records, messaging systems, and online trainings and consultations. Task shifting has been used widely in low resource settings to provide quality healthcare under appropriate supervision and consultation (Dupuy, 2010; WHO, 2008). Our staff and volunteers are able to see about 35% more patients by consulting with the specialist in our networks (e.g., pediatricians, neurologists, psychiatrist, child psychologist, dermatologists, emergency doctors, imaging specialists, obGyn doctors, acupuncturists, emergency doctors), attending online trainings, and participating in group consultation/individual supervision. The specialist consultations and training programs are provided for free via online messaging platforms, trainings, and regular tele-meetings. In particular for training, we collaborate with various universities like Stanford, UCLA. Through this person-centered process, we also empower the local Mexicans and migrants that we have hired for staff to be able to learn more skills to help their communities. Additionally, since psychiatry is especially limited in Tijuana, MX, we will hire a part time psychiatrist and full time nurse to support the psychiatrist in getting vitals and supporting telepsych. Telepsychiatry using this model has been successfully implemented at a low cost in many places (Chakrabarti, 2015). 

As part of improving services via electronic systems, we also will be developing an electronic medical record system, which we have already received a grant to develop but need funding for more tablets to be able to give remote care consistently. The electronic medical record system will help reduce potential errors, improve the efficiency of our services and medication distribution in our pharmacy, and improve continuity and integrated care via all providers being able to see the patients notes. Integrated care that has continuity is essential for addressing barriers to access to care and being trauma-informed so a patient does not have to repeat their story between providers. Furthermore, the data from the electronic medical record system will allow us to track patient progress and identify ways to improve care and reduce potential instances of discrimination based on identity in services and outcomes. 

Lastly, to increase access to services, we plan to provide a warmline for resource connection and skills to deal with stress specifically for the Haitian refugee population that we serve. We previously had a warmline for migrants but that was primarily utilized by the Spanish speaking population due to lacking translators. The warmline followed a psychological first aid model of connecting patients with a range of resources that volunteers who covered the call line had access to via an electronic guide that we developed and provided distress tolerance/mental health support for those needing it. Additionally, patients needing additional support were referred to our clinicians, including the online and in-person psychotherapy that we still provide. This hotline was so popular that Doctors without Borders adopted it and it has been a model cited by UNICEF for creating a similar mix use warmline for refugees in the United States since most warmlines only offer resources or mental health support but not both. Unfortunately, such a line does not exist in Creole. Therefore, we plan to hire Haitian migrant women as translators to cover the line in Creole and a female Haitian psychotherapist for our more severe callers to get culturally and linguistically appropriate care. As part of the Spanish line we had made, we developed audio files in Spanish that we sent to migrants that they could listen to help them calm themselves. Numerous migrants reported this helped them sleep, eat and overall cope better. Our Creole translators will help us make audio recordings like this in Creole as they are currently lacking. In the process of hiring Haitian translators, we also hope to empower Haitian migrant women and help our Haitian patients to feel safer in being able to get health services without being discriminated against. Through this process we seek to build trust and engage Haitian migrants in receiving health services despite the history of mistreatment they have experienced in Tijuana, MX.

The Refugee Health Alliance is a 501(c)(3) nonprofit organization that advocates for and provides ethical, holistic, trauma-informed, and culturally-inclusive medical care to all displaced and vulnerable populations along the US-Mexico border, including migrants, asylum seekers, and deportees of all ages in collaboration with activists and existing healthcare organizations. Our solution would help those needing more specialized services such as more patients who speak only Haitian Creole, children due to there being less pediatric services available, all ages needing psychiatric care, mothers with high-risk pregnancies, and LGBTQI patients needing gender affirming psychotherapy and other LGBTQI specific services. Occasionally we also have patients with other less common health problems the proposed solution would help. For example, we have needed consultation with neurologists and child psychologists to help identify autism, and dermatology addressing the skin issues that especially arise in these crowded conditions or conditions of living on the street where clean water has historically been unavailable. When a case is too severe for us to meet the needs, we have been able to help save lives by having our specialist providers write humanitarian parole letters for the patient to cross into the US to get emergency health services. For example, in consultation with our specialists, we were able to identify that a 3 year old migrant had a form of cancer that could kill him very soon and the local Tijuana Hospital said they did not have the resources to help. Therefore, our specialist providers wrote a letter and we were able to cross him to a children’s hospital in California for emergency services. This life-saving event was even highlighted by the Los Angeles Times: https://www.latimes.com/california/story/2021-10-22/child-cancer-treatment?_amp=true&fbclid=IwAR2h3LorLOyJquaIQ0iUH-LjswHbLqhHnHSTjLY2dzwP2BSwnfIeHT_NYa0

Overall, as this case demonstrates, our providers having access to a range of specialists to help save lives regardless of race, gender, age and sexual orientation.

RHA serves children and adults of all ages through its integrated medical clinic, midwifery clinic, mental health program, and outreach services to over 30 local shelters in Tijuana, MX. We not only increase access to care by meeting patients where they live via our weekly visits to shelters and the central position of our clinic, but also we provide food, water, and a hygiene center that address the social determinants of health and increases people’s awareness of our organization and services so they feel more comfortable coming to us for help. Specifically, we feed 200 to 300 migrants a week, and about 500-600 people a week use our hygiene center that provides clean water for showers, drinking, and other cleaning and toileting needs. RHA’s comprehensive services allows our team to care for 300 to 400 patients a week through our medical services. Patients feel comfortable seeking assistance at our various sites because our services are integrated and RHA has had an established presence of being a trusted source by shelters, other nonprofits and migrants since 2018. 

We also have an extensive network of collaborators and specialists that consult with our existing staff of local Mexicans and migrants, especially Haitians, to support specialized services. Our model of crowdsourcing professional volunteers (e.g., about 5 professionals a week and 5 to 15 specialists a week) allows us to serve more migrants while having a core group of staff to ensure we always have enough providers who can consult with our specialists as needed. We specifically have a group of 15 specialist providers all our staff and volunteers can send questions, which they regularly do. If those providers do not have the answers, they can tap into their networks and our larger network of volunteer professionals to get the necessary support for our patients. Additionally, we collaborate with a variety of other health service providers in Tijuana including UNICEF, UNHCR, International Organization for Migration (IOM), HIAS, Families Belong Together, and Prevencasa. We also are able to tap into the expertise of our collaborators at various universities and hospitals in the US and Mexico, like UCLA, Stanford, Children’s Hospital of Los Angeles, Children’s Hospital of Tijuana, UCSD, the Autonomous University of Baja California and numerous others. In fact some of these collaborators, like Stanford, UNICEF, and UNHCR and our specialists on our team have provided various specialty training such as for high risk pregnancies and trauma-informed psychotherapy approaches for children through our online platforms. This has helped increase our staff’s capacity to serve more patients. Through this process, we have already invested in our staff to take on more complex cases. Additionally, we have interns from the local universities in psychology and other areas of health that we are training to be specialists in this through online supervisions with leaders in the US in migrant mental health and child clinical psychology.

Furthermore, because we have a network of US providers that volunteer for our team, we are also uniquely positioned to be able to help our most severe patients gain humanitarian parole. Immigration courts prefer humanitarian parole letters written by providers from the United States and thus our Mexican colleagues are not as well-positioned to utilize this option under current border policy that allows for severe patients to cross when there are not enough resources in Tijuana to address the severity of the need.

We are also well positioned to provide these services based on the variety of services we already have in place and are working on developing. For instance, we are well-positioned to provide a Creole warmline as we already have Haitian Creole translators and as mentioned before have had a very successful warmline that migrants have used to get connected to resources and help to cope with their stress. Given we already have an established psychotherapy program that supports those needing more support to deal with their stress, we have therapists that are well-positioned to support patients in engaging in telepsychiatry services and that can check on continued psychiatric medication adherence. Not only do our mental health volunteers support our patients but we also have support in place for our staff, especially our Haitian staff to address secondary trauma and feelings of frustration that may be triggered in trying to help their community. We have used technology previously to provide online resources to support the mental well-being of our staff. 

Additionally, we recently obtained a grant to help us with developing our electronic medical record system through Hikma Health, but we need additional funds to obtain things like tablets and pay for WIFI to support the use of this system we are developing. The electronic medical record system we are developing will help us better monitor patient outcomes as well as check that patients are not being discriminated against based on their identity using data from their outcomes and services received. 

Lastly, we are a majority women led board (12 out of 14, with one member that identifies as non-binary), many of whom are women of color. Our organization was also founded by majority women. We hire migrants and staff eager to learn and support our population whenever possible to empower the local community and future generation of providers. Gender based violence is unfortunately significantly common among migrants and we seek to help especially address the needs of this population in a trauma-informed way. Overall, these aspects of our organization are inline with missions of the refugee focused and women empowerment focused funders that are participating in the MIT Solve program.

We feel Solve aligns with our mission, values, and commitment to address the health needs of all vulnerable and marginalized individuals in Tijuana, Mexico, regardless of their identity for free. The communities we serve have had to face significant displacement, deportation, political instability and corruption, racism, sexism, natural disasters, and overall political and social exclusion. As a result of these factors, the primary populations we serve are refugees and asylum seekers fleeing structural and non-structural violence. We seek to abolish the arbitrary border put in place by the US-Mexico divide on indigenous land that contributes to unfair differences in health services simply based on what side of the border you live on and where you are from. However, we can not solve these challenges that our clinic faces alone. By applying to Solve, we aim to create progress through partnership to serve those who need our aide. Through our partnerships with local community organizations and universities, and specialists nationally and internationally, we have collaborated to address the social determinants of health, economic disparities, homelessness, food insecurity, legal barriers, structural violence, infringements on human rights, lack of access to education and health services, and discrimination on the basis of any factors, including gender, sexual orientation, race, ethnicity, language, age, and ability. We aim to provide ethical, holistic, and culturally-inclusive care and advocate for all displaced and vulnerable populations in collaboration with activists and existing healthcare organizations along the US-Mexico border. Within our services, we provide the individuals and families we serve with resources to substance use disorder treatment, HIV care, TB diagnosis and medical care, legal services, and mental and dental health resources. For the people we serve, the solutions that we provide are intended to begin with, end with, and involve the people for whom they’re designed.  We would like to have the opportunity to join MIT Solve’s innovation ecosystem so that RHA can provide a long lasting, transformational impact to the people of Tijuana. We believe that Solve and RHA will have a valuable partnership that achieves both parties goals towards solving global challenges.

Our solution is innovative within its context for several reasons. First, we will be the first organization to offer a warmline in Creole to meet the needs of Haitians in our community. None of the other organizations serving this community offer this service. Additionally, we address the barriers to them having access to this line by having the grant pay for the wifi and electricity at our clinic where patients can charge their phones to use our warmline. The combination of a warmline that provides general resources for migrants and helps them with coping with their stress is so novel that as mentioned before, UNICEF and UNHCR are seeking to improve the capacity of existing hotlines in the US to provide this combination of services, which is inline with Psychological First Aid. Psychological First Aid is typically applied in person in disaster and shelter situations and has been found to be quite effective. To ensure Haitian voice in how this is implemented, we will also pay a Haitian provider to be on our board (US board members are not otherwise paid) and participate in decision making. 

While task shifting has existed in refugee health settings, our solution is novel because it takes advantage of how close some of the top health and research centers in the world (e.g., UCLA, Cedars-Sinai Medical Center, Children’s Hospital of Los Angeles, Stanford Health Center; Newsweek, 2022) are to a place where the percentage of refugees has grown by 3,000% from 2014 to 2019 according to Mexican Commission for Refugee Assistance. Specifically, we leverage the expertise of a large range of providers (e.g., pediatricians, neurologists, psychiatrist, child psychologist, surgeons, dermatologists, emergency doctors, imaging specialists, Ob/Gyn doctors, acupuncturists, emergency doctors) at these centers to support our staff in providing care to our most severe patients. Since these centers are relatively close to Tijuana, our volunteer providers are able to come visit at least a few times in person to understand the context better in order to provide culturally competent, patient centered support remotely to foster the capacity of local clinicians in providing services to high risk patients. For example, Stanford Health Care has done this several times as they’ve been in person, have provided trainings virtually, and providing ongoing consultation through our messaging technology. We have also partnered with Harbor UCLA Emergency Medicine to provide several ultrasound training workshops in person and support for continued local educational development. All of this together will enable us to provide a wider spectrum of care without the need for specialists, an issue that has been a problem for the Baja California healthcare system even before the COVID-19 pandemic. 

Lastly, our solution is novel because of how integrated we are in providing a variety of health services close to where on the streets some deportees live and in the context of where migrants live at their shelters. Combining this with providing for basic needs of patients by having the first hygiene center and potable water station for migrants and distributing food to migrants in Tijuana allows us to increase engagement. This is in line with research on how providing food and for other basic needs of patients, as well as integrated care, helps reduce barriers to health service utilization especially for mental health (e.g., our proposed warmline; Archer et al., 2012; Ellis et al., 2011).

Our goal over the next year is to have our electronic medical record system and Creole warmline set up and in regular use. Through having clear outcome data from our electronic medical record system, in 5 years we have a goal that the majority of our donors are established donors that have increased their yearly giving by multiple magnitudes based on being able to have more concrete data on our impact on patients. As a result of our Creole warmline, we hope to increase the number of Haitian patients we serve and the quality of the services, as well as the trust in the service. Through the warmline, our goal is to increase the number of Haitians that know about resources in the Tijuana area and that use mental health services. Due to various factors, including lack of translators and comfort, one of our least used RHA services by Haitians is currently our mental health services despite the need. We plan to quadruple that number over the coming year. 

We also plan to continue to increase the number of patients we serve and the providers trained in specialized services. For example, on the mental health side, we have already trained a handful of students to be able to see child patients for psychotherapy that would have not otherwise received this training. We have also had countless pre-medical and medical students from the US and Mexico gain training through our medical student rotations and global health fellowship programs. 

In 5 years, we also hope to prevent any patient deaths due to not being able to access to specialty medical care in time. Unfortunately, while we are able to detect high risk patients, every so often we can not get patient to higher levels of services that they would otherwise get in time if it weren’t for disparities in health services and sometimes Mexican hospitals rejecting patients due to capacity or racial discrimination. We hope that through our consultation and training with specialists and increasing the number of patients we can see, we will reduce the mortality rate among the population we serve. Furthermore, in the next 5 years we would like to establish other physical clinics with the same model of integrative, inclusive care at other border cities to extend care and our services partnering with local organizations to continue serving other vulnerable migrant populations.

We keep track of how many patients we serve by program (including the call line, psychotherapy, and psychiatry programs), and the number of volunteers and staff we have at different training levels. We will survey our patients to assess who much trust they feel with our services and their satisfaction. 

The electronic medical record will help us to provide continuity of care and track patient progress and make sure there are no discrepancies in quality of services or outcomes based on identity factors. We will also track patient deaths due to lack of access to adequate care. 

We use Airtable to track our donors and that will help us with tracking progress towards financial sustainability and having established donors that increase their giving annually.

We aim to train a generation of health care providers who are able to find creative solutions to promote health equity in a multidimensional approach, and thereby, create sustainable long term investment in the refugee community through utilization of our learners. We have a model of experts training, supervising, and collaborating with local clinicians and other organizations and students to improve capacity to serve this population. Our multidimensional approach to eliminating barriers to health along the border include advocacy to change laws, parole letters to help change where migrants get their health services, and addressing the social determinants of health to prevent worsening conditions (e.g., providing food, water, and hygiene). We provide integrated care to be able to increase the preventative services and continuity of care. We also aim to increase access to care by having a clinic near where many migrants live on the streets and volunteering to give street medicine where needed and in the shelters and encampments weekly.

Our solution is powered by our electronic health records (EHR) system and telehealth training and consultation pipeline. Our EHR system will be built upon Hikma Health’s existing mobile health data systems infrastructure. We will use laptops, touch screen tablets, and phones as mobile access points to our centralized EHR system at each of our clinics and for our shelter outreach and street medicine as needed. Additionally, we will use Wi-Fi portable hotspots to enable stable access of the system in remote shelter locations and when providing street medicine. 

Our telehealth training and consultation pipeline will utilize some of the same resources that we will use to implement the EHR system. Specifically, laptops and mobile devices will be used to put patients in contact with healthcare providers who are working remotely, such as in the case of patients that require remote psychotherapy and psychiatry. Integrating the EHR system with our telehealth pipeline will also allow us to record consultations and telehealth appointments for future reference, enabling better longitudinal monitoring of patient health. Laptops and phones will also be used for audio recordings and to enable better communication between patients and providers.

The utilization of electronic health records and telehealth services has been used in the care of refugees, but is not widespread. Bringing these technologies to our clinical and outreach efforts will enable our patients to have access to a significantly wider range of care both in person and remote. It would in turn allow us to improve the care given to our patients by having their records accessible at a moment’s notice and providing them with more resources than ever before.

Our warmline will be accessible via normal phone calls and WhatsApp, which is many migrants preferred means of communication. There will be one centralized phone that call line workers can log into from various sites. Additionally, patients will have access to our Wi-Fi and electricity at our clinic to increase their access to these services.

Refugee Health Alliance aims to provide ethical, culturally competent, holistic and trauma informed care to our patient population while empowering affected individuals to advocate for their medical and legal rights. We connect individuals and families to resources, from medical care to mental health and legal services, and collaborate with relevant local community organizations to address the social determinants of health. RHA employs migrants and local Mexicans to empower our patients. We do not refuse services to anyone. We are the main providers of health services to migrants and refugees in Tijuana, especially Haitians as about 70% of our patients are Haitian. We are currently working on a social justice curriculum on power and privilege for staff and volunteers to take in order to ensure we adhere to our commitment to truly equitable health care service provision. To ensure Haitians have an opportunity to express their view on how our services are implemented, we plan to pay a Haitian provider to be on our board (US board members are not otherwise paid) and participate in decision making.

RHA operates on a grassroots crowdsourcing business model and uses Bronfenbrenner’s ecological theory and the public health triangle approach to inform how we work in the settings where the population we serve lives and provides services on multiple levels (universal, at risk, and clinical/high risk). When we crowdsource, we offer to people to provide their time, expertise, and/or a financial donation. We have hundreds of volunteers - both students and professionals. With regards to finances, our donor acquisition model revolves around communicating with as many potential donors as possible, with the goal of establishing long-term partnerships with community and industry leaders. For example, we then stratify donors based on their current and potential donation amount and utilize our donor relationship management pipeline in order to maintain communications with all donors via quarterly newsletters, updates about the situation and our progress at the border, and pressing needs of our patient population. Special focus is given to individuals or groups that have the largest donations, as these individuals have historically been more likely to continue donating to RHA, and their donations have the potential to scale exponentially. For example, we already have several large donors that have donated for multiple years in a row. Aside from donor management, we delegate our time to apply for nonprofit grants. Overall, we were able to raise about $500,000 in 2021, and plan to raise an even larger amount ($550,000 to $600,000) in 2022.

We will continue to utilize the aforementioned business model. We plan to continue fundraising for this project by crowdfunding, applying for other external grants, receiving funding from affiliated institutions like UCLA, obtaining corporate funding from socially responsible companies and reaching out to alumni associations and recurring donors for support. As mentioned earlier, we have received some funding already to help develop our electronic medical record system. Furthermore, data from our electronic medical record will help with receiving more grants and donations. Through having clear outcome data from our electronic medical record system, in 5 years, we have a goal that the majority of our donors are established donors that have increased their yearly giving by multiple magnitudes based on being able to have more concrete data on our impact on patients. RHA also plans to establish funding partnerships with US universities to allocate some funds toward a rotation that would assist in our staff and Mexican students getting trained. RHA seeks to reduce our psychiatrist’s time over the two years of this grant by having the psychiatrist train general physicians and pediatricians to provide basic psychiatric care and offer consultation to them as needed. We also will offer this training to our collaborators like Prevencasa to also increase overall capacity for supporting migrant mental health in the community.

Since RHA was founded, we have continually grown our organizational sponsor and individual donor base. In 2021, we were successful in attaining over $190,000 through working with different organizations, a 5% increase from 2020. Between 2020 and 2021, we attained sponsorship from 47 different organizations. This is in addition to our large individual donor base. Every year our income has greatly increased. For example, from 2020 to 2021 our income via donations increased by 37%. In 2021, a significant portion of the money raised through partnerships and sponsorships came from organizations that we worked with in the past and continue to work with to this day. We are currently working to create stronger relationships with our individual donors so that we may form long-term partnerships with such individuals, who would therefore be more likely to continue to support our cause while also donating larger amounts over time. We are therefore confident that we will be able to continue to scale our sponsorship model as we grow our operations while maintaining financial sustainability. This confidence is further bolstered by how other organizations that have donated to us and worked with us have high levels of confidence in us. For example, various international nonprofits have written reference letters that speak highly of our work. Furthermore, we have received an award from Al Otro Lado, the main legal services provider for those seeking asylum in the US and deportees along the US and Tijuana border for our work. Al Otro Lado has also donated to us consistently. We’ve also received recognition for helping support migrants' well-being from Centro 32 who is funded by Families Belong Together and support migrant families in Tijuana through their social programs. We are also becoming increasingly well-known as an organization, which will help with increasing our donor base. For example, the Los Angeles times (https://www.latimes.com/california/story/2021-10-22/child-cancer-treatment?_amp=true&fbclid=IwAR2h3LorLOyJquaIQ0iUH-LjswHbLqhHnHSTjLY2dzwP2BSwnfIeHT_NYa0), and Fox News (https://www.google.com/amp/s/www.foxla.com/in-depth/in-depth-covid-update-breakthrough-infections-refugee-health-assistance.amp) have highlighted our program and various members our organization are often invited to talk at events and conferences regarding RHA. Overall, these honors demonstrate the faith our collaborators, funders and others have in us and our strong potential to continue to grow.