Nelson Moreta climbs into a canoe carved out of a tree trunk, a makeshift ferry to carry him across the Artibonite, the wide, shallow river that divides the island of Hispaniola into the Dominican Republic and Haiti. 

We’re on the far western side of the Dominican Republic in Elias Piña, the country’s poorest province. Except for a lone guard who waves people by without concern for passports, the river is the only sign of a border. The melody of konpa, the popular music of Haiti, drifts across the water and into the DR, one of many migrants to breach the porous border.

Moreta, a 53-year-old Dominican, spent 17 years working as a promoter of Barceló rum. But in 2011, he began working for Socios En Salud (SES), Partners In Health’s Dominican sister organization. Today he’s crossing the river to visit two Haitian HIV patients who live in Haiti, just across the border from the Dominican hospital in Banica. As a community health worker, his mandate is to provide social support and accompaniment to patients, no matter the obstacles.

“There are too many people with needs, too many people who are sick and don’t know it,” he explains.

Started in 2011 with funding from the U.S. Agency for International Development, Socios En Salud works to bolster HIV services at three existing Dominican Ministry of Health facilities. SES staffers conduct HIV education and testing in communities, provide training and supplies to local clinicians, and offer psychosocial support to patients through social workers and community health workers, such as Moreta.

While the SES-supported facilities are within the DR, a large percentage of their patients are Haitians who move to the DR for work—often without papers. While the economic opportunities are better in the DR, Haitians face new challenges, including discrimination and isolation, Moreta says.

“I defend the Haitians 100 percent no matter where they are,” he says. “They’re our brothers, and they live in bad conditions. They need a helping hand.”
 

Moreta passes through a nearby market on his walk from the river to his patient's homes. Photo: Stephanie Garry/Partners In Health.

After a half-hour walk under the blistering Caribbean sun, we arrive at the house of Francisco Ubiele, 50, where he lives with his family. It’s a small wooden home with eroding concrete floors, a tin roof, and curtains for bedroom doors. Also at the house is Mason Alcilie, 48, another man with HIV who lives nearby and has come to share his story.

After a few minutes, Ubiele and Alcilie open up about their experiences. Late last year, they fell sick. At first, they thought it was some kind of fever, and they tried to wait it out. By the time they went to the hospital in Banica, about an hour and a half closer than the nearest PIH clinic in Haiti, they were nearly unconscious.

Ubiele’s family carried him to the facility on a mattress. A friend of Alcilie’s hauled him on the back of a motorcycle to the river crossing. From there, friends had to carry an alarmingly gaunt Alcilie from the canoe to the shore because he could hardly stand.

Mason Alcilie, now 48, was gaunt and nearly unconscious when a friend brought him to PIH-supported clinic last year. Photo: Benigno Antonio Nuñez Faña/Partners In Health.

At the hospital, the men tested positive for HIV and were immediately enrolled in the SES program, and shortly after began antiretroviral therapy. After spending more than a week in the facility, they returned home and were linked with a community health worker who would meet them at the river to give them their medicine, vitamins, and food packages. But now Moreta goes a step further by visiting them several times a week to make sure each patient is taking his medicine as directed and doing well.

Unlike many of SES’s patients who are HIV positive, Ubiele and Alcilie aren’t worried about others in the community knowing they have the virus. “I was sick, and now I feel good. It doesn’t matter if people know,” Alcilie says.

We thanked the patients and stepped outside the house, back into the brilliant light of midday, and began our trek back toward the river.

Nelson with Alcilie (left) and Francisco Ubiele (right). The health of both patients improved markedly after starting daily treatments. Photo: Stephanie Garry/Partners In Health.

Moreta reflected on the achievements of SES, explaining that one of the major victories has been community outreach and testing for HIV. Before SES began its work, the hospitals in Elias Piña offered HIV testing and care, but few sought out these services. Now, SES conducts multiple community outreach activities each month. Since the start of the project, the number of active patients enrolled on antiretroviral therapy has more than doubled from 22 to 70.

As much as Moreta believes in helping Haitians on principle, he also knows that it’s in his country’s best interests to fight HIV. He pauses, and points out that Ubiele fell ill after visiting his wife, who lives in La Romana, a large city more than 200 miles east of Elias Piña. She doesn’t know that her husband is sick, and she likely doesn’t know her HIV status, Moreta says.

PIH/SES staffers like Nelson offer a hopeful sign that Dominicans can—as they did after the 2010 earthquake in Haiti—see that their fates are inextricably entwined with their western neighbor.

A former journalist, Stephanie Garry works on the communications team at Partners In Health. She was a Peace Corps Volunteer in the Dominican Republic from 2009-2011

When Dr. Gaby Chalup arrived in the community of Plan de la Libertad, in Chiapas, Mexico, she didn’t expect to be delivering babies. “In theory we are not supposed to attend births in our communities,” says Chalup, 28, one of eight Mexican social service year physicians, called pasantes, working with Compañeros En Salud, PIH’s Mexican sister organization. Each pasante spends a year working in one of the remote, under-resourced government clinics that are scattered across the Sierra Madre Mountains.

Plan de la Libertad is a three-hour trek from the nearest hospital, Chalup says, noting that the 1,400-person community never had a resident doctor before her arrival. While it would take time for Chalup to earn the trust of the community, it didn’t take long before she was thrust into practice.

On her third day on the job, she found herself in a nearby adobe house where a 17-year-old lay on the bed, exhausted and in pain from a labor that had begun seven hours prior. Chalup had seen the young woman two days earlier and referred her to the hospital, but the family opted for a local midwife and home delivery. After assessing the situation, Chalup decided that the girl now needed to get to the hospital.

But 50 minutes later, and still many miles from a hospital, Chalup helped the woman deliver her baby in the bed of a pickup truck. It wouldn’t be the last delivery, or the most challenging.

A few months later, Chalup was working in the clinic when a family came in seeking help for their daughter. The woman’s water had broken three days prior, yet there was no dilation. Again, Chalup knew that getting the patient to the hospital was necessary so that labor could be induced, but some of the patient’s family members insisted that the baby be born in the village, “like all the rest.” Chalup did her best to explain the complications and persuade the family to go to the hospital.

“With all of the patients I have seen in similar situations, the babies have not come out on their own.” Chalup told the family.

At that moment, the woman’s father arrived and listened intently to Chalup’s advice. Soon after, Chalup accompanied the patient to the hospital where labor was induced and a healthy baby was born.

In her nine months working in Plan de la Libertad, she’s helped deliver three babies—“almost four!” she says. “I just have this luck.” Unlike the first two, the most recent delivery was planned and didn’t involve pickup trucks or familial negotiations. “I accompanied her from the diagnosis when I told her, ‘Look, you’ve got two little lines. You’re going to be a mom!’ up to when they said to me, ‘Doctora, when the baby comes, we want you to be there during the labor.’”

Chalup happily agreed, and after completing the requisite paperwork, packed up a little “birth” backpack and awaited the call. A few days later, at 5 a.m., Chalup heard a shout from outside her window: “Doctora Gaby!” Chalup shot up, grabbed her backpack, and ran out the door, shouting, “I’m coming!” Forty minutes after arriving at the patient’s house, she helped deliver another healthy baby.

That request will certainly not be the last. Slowly—with each birth, with each checkup, with each vaccination—Chalup is gaining the trust of a community that has long struggled to access quality medical care. Though she didn’t anticipate obstetrics featuring prominently during her time in Chiapas, Chalup is delighted with the experience. When asked about her hopes for her remaining time in Plan de la Libertad, Chalup responded, “I hope there will be more births.”
 

Emma Goodstein has been collaborating with the PIH team in Chiapas, Mexico since June 2012. Originally from Portland, Oregon, she graduated from Wesleyan University in 2010 with a degree in history and has since worked in various positions in the health care field in Portland and New York City. She will be entering Emory School of Medicine this fall.

Believe a better world is possible

Never lose your fierce idealism. Let it be tempered by pragmatism, humility, and a willingness to learn, but never let anyone tell you that the better world you imagine is not possible. It is, through the power of partnership. - Emi K.

The data have done their job

It is our moral imperative to realize global health equity in our lifetime. This is not an easy task, but my murky vision of truth involves conveying the message that we need everyone’s hearts, minds, imagination, resources, and friendship to see this job to the end.  We have mountains of evidence reminding us that all signs point to poverty, oppression, and structural violence. And, until we collectively step up and systematically take care of every single person all of the time, we will find ourselves stumbling back into structures that add to collective despair rather than support human potential. My murky vision of truth tugs at my conscience and constantly reminds me that the data have done their job, and now the time has come to do ours. - Ashley D.

Five words

Five simple words: Be kind to each other. - Aziz H.

Think differently, imagine boldly, and act collectively

Our generation of health advocates stands on the shoulders of giants, to be sure: Giants who have improved the lives of thousands, who have forged change in small pockets of communities across the globe. Now we must find a way to make health justice the rule, to fight for equal health access and opportunity: to change the lives of millions. We cannot do this alone. Rather, we must build trusted partnerships -- across all disciplines, races, languages, and geographic communities -- rooted in our shared values of respect for human dignity, health equity and justice. We must challenge ourselves and each other to think differently, imagine boldly, and act collectively. And we must do it now.” - Amy T.

See through new eyes

In my work, I am fortunate enough to work with refugees from all over the world. Sometimes when I am working with a skilled interpreter, the interpreter will turn to me and say, "This might take a little longer because we don't have that concept in our culture." When we open ourselves to other cultures, we begin to develop the amazing capacity to see through new eyes, to hear through new ears, and to think from different perspectives. When we bring these new eyes, ears, and perspectives to bear on problems that have long been considered intractable, new solutions emerge, new energy is generated to push toward solutions, and new faith enters our hearts that even the most difficult problems can be solved. - Loren B.

Contribute to the next generation

When you actively seek to collaborate rather than passively accepting the effects of collaboration you will find people willing and interested in what you have to say. You may not always convince others to follow your ideas, but every single time you share them you leave a little bit of yourself behind. Please look around you and think of the generations that came before and contribute to the next generation. You are using the resources past generations left for you and you're adding what you have to them for the people who are to come. Spread your ideas wide, share yourself broadly, and collaborate actively. - Greg K.

Be driven by something grand

Some things are easy. Positive world change is not one of those things. My motto is: "You can't not do something, if the only reason not to is laziness." This motto gets me out of bed in the morning, pushes me through my 3 p.m. lethargy, gets my butt to volunteering after work. The reason my motto works for me is simple: I do not want laziness to be the primary motivation of my life. I want something greater, something more noble, something that helps others, to be the determining factor of my actions, and thus, my identity. If you ever think "should I?" but hesitate, or procrastinate, or give up, I can tell you that I was once like that, but am no longer. Let your life be driven by something as grand. Your life deserves it. - Annie D.

Always good advice

Be good to your mother. - Jim W.

On Mother’s Day we celebrate our own mothers, and honor mothers around the world who often risk their health and survival to bring forth life in difficult or even dangerous conditions. On my recent trip to Haiti, I saw firsthand the importance of reaching further, of pushing ourselves to re-imagine what’s possible in providing dignified, quality health care to women throughout motherhood and beyond.

Haiti has the highest rate of maternal deaths in the Western Hemisphere—one of every 93 women dies in pregnancy or childbirth. Haitian women have long faced obstacles to receiving quality health care during pregnancy and delivery. Some live far away from hospitals and often can’t afford transportation. Others may be reluctant to return to a hospital or clinic because their previous encounters were negative.

To overcome these obstacles—in Haiti and around the world—Partners In Health works to strengthen entire health systems. We focus on implementing sustainable systems that provide hospitals with proper equipment, supplies, medicines, and staff training. It’s not enough to provide safe birth kits, for example; those kits must be a part of a system that values health, safe pregnancy, and childbirth as human rights.
  
I spent a week in St. Marc, Haiti, where I visited Hôpital San Nicolas (HSN), which is run by PIH in close partnership with the Haitian Ministry of Health. Erin George, a Boston-based nurse midwife with PIH, showed me around the maternity ward and together we took stock of the supplies. While it was equipped with the basics, our quick survey made clear the disparity between what we provide laboring women at hospitals in the U.S. and what women in low-resource settings have access to. 

I also had the opportunity to witness my first birth during the visit. As the woman labored, the nurses and doctor continued to check her progress and noticed that she was quickly becoming exhausted. I watched a nurse carry over a bottle of juice, open it, and hand it to the panting mother. She took a sip—a brief moment of reprieve—and gave birth to a beautiful, healthy baby girl. The nurse’s compassion, humility, and respect for the mother were inspiring.

About 90 kilometers east of HSN is Hôpital Universitaire de Mirebalais (University Hospital), a shining example of what we can build when we push ourselves to re-imagine what’s possible in low-resource settings. The recently opened hospital is a state-of-the-art facility where women can access not only pregnancy and birth care, but comprehensive health services throughout their lives.

University Hospital complements the commitment and compassion of Haitian health care workers. It’s designed so that women can discreetly access services at one location. The maternity ward is spacious and full of natural light, with curtains separating each bed. A private courtyard with a fountain is a calming space for women in labor. In the recovery ward, a bassinet sits proudly next to each recovery bed—a safe place for mother and newborn.

The ward was silent in the days leading up to the hospital’s opening. But when I closed my eyes, I could imagine every bassinet occupied by a new generation of boys and girls, a generation that will be raised by mothers who have access to a health system that offers dignified care and truly celebrates the accomplishment of motherhood.

While we all take great pride in what University Hospital will offer the women of rural Haiti, we know that not all women will be able to give birth in this hospital. That’s why we continue to work toward improving services at hospitals and clinics in Haiti and around the world.

On this Mother’s Day, we invite you to join PIH in celebrating the mothers of Haiti, Rwanda, Malawi, Lesotho, and beyond. Working together, let us re-imagine what is possible when we commit to a high standard of health care for every woman throughout her life.

Katie Temes works on the Training Team at Partners In Health and coordinates the efforts of the Women's Health Working Group. She is an aspiring nurse-midwife and hopes to practice nurse midwifery in resource-poor settings, both domestically and globally.
 

In honor of International  Nurses Week, we’ve explored how nurses embed themselves in rural communities in southern Mexico and how they mentor one another at clinics throughout Rwanda. Today we focus on how nurses operate in one specific hospital, Hôpital Universitaire de Mirebalais (University Hospital), the first teaching hospital in central Haiti. It’s a facility that depends on the nimbleness of nurses and their unwavering commitment to improving the patient experience.

University Hospital  also will serve as a site for clinical rotations for Haiti’s national nursing schools, and offer nurses advanced training in several specialty areas, including emergency care, neonatal intensive care, and surgery.

Sheila Davis, PIH’s chief nursing officer, recently sat down with Alexandra Millien, nursing manager of University Hospital’s outpatient clinic, to discuss how nursing is evolving in Haiti, what University Hospital means to the community, and how the hospital is elevating the standard of nursing across the country.

Davis: How long have you been a nurse, and where did you work before?

Millien: Since 2007 I’ve been a nurse. I was previously working in Belladère [a PIH/Zanmi Lasante district hospital] at the pediatric outpatient and inpatient areas. It was a good experience.

Tell us about your first nursing job.

First I worked in a nursery for children. After that, I worked with Management Sciences for Health, running some of their maternal-child health programs across sites. And then the earthquake happened, and I was responsible for running nutrition services for the four camps that Zanmi Lasante ran in Port-au-Prince. And then I transitioned to Belladère.

And what’s your job now at Hôpital Universitaire de Mirebalais (University Hospital)?

Nursing manager for the outpatient clinic.

What excites you about working at University Hospital?

This is a large hospital with a lot of new equipment that we’ve never had access to before. It’s a really incredible opportunity to provide the highest standard of nursing possible.

When patients come into University Hospital, what do you want them to say about nursing care?

The first thing I would hope for is that they are very satisfied. Our main goal is making sure our patients are getting the care they want and need so that they’ll return again when they need to.  For instance, if they have to come back and get a surgical procedure, we hope they won’t be scared because they know from their first experience that they’ll be in good care.

How do you think nursing in Haiti is changing?

In comparison to 10 years ago, there have been lots and lots of increases in medical technology around the world. We’ve come really far along. And in 10 years from now, nursing will continue to evolve with new technologies and advancements.

What should the global nursing community know about University Hospital?

Nursing at University Hospital is being prioritized. Every month there’s an evaluation of nurses—there’s a new standard. Every person at every stage of care is doing everything they can that is best for their patient.

What would you ask the global nursing community?

I’d ask the international nursing community to help Haitian nurses stay up-to-date on all new advancements, because a lot of time our training is outdated and others have opportunities quicker than we do. We’d like training opportunities for Haitian nurses to happen in a timely fashion so they’re not behind the times.

And why did you become a nurse?

[Laughs] Because I like to take care of people.

Yet Rwanda has achieved remarkable gains in public health; it’s the only country in the region on track to meet all the health-related Millennium Development Goals by 2015. How’s this possible given the dearth of docs? While it’s a complex answer worthy of a dissertation, it doesn’t take a Ph.D. to realize that nurses have played an instrumental role in the country’s turnaround.

But ensuring that thousands of nurses with varying levels of education and professional experience deliver consistent care is a logistical and pedagogical challenge. Fortunately a program pioneered by Partners In Health in close collaboration with the Rwandan Ministry of Health (MOH) provides an innovative and cost-effective solution that’s fundamentally changing the quality of care nurses provide.

Known as MESH—short for Mentoring and Enhanced Supervision at Health Centers—the program links experienced nurse mentors to staff nurses at rural health centers. It’s similar to the clinical mentoring that’s common in wealthier countries, just far more flexible.

“This is a simple solution that yields remarkable improvements in quality of care,” says Anatole Manzi, MESH-QI program director. “It’s simple in the sense that we use existing resources to address huge quality and systems gaps while boosting nurses’ confidence.”

Mentoring the Mentors

In many developing nations, formal continuing education for nurses isn’t standardized. To keep them abreast of best practices and new policies, countries often host massive weekend-long seminars in large cities. For those in rural clinics, travel to these events is costly and time consuming. And determining whether the participants actually apply what they learn in real-life clinical scenarios is impossible. This one-shot approach leads to inconsistent skill levels among nurses, which directly affects the health of the poor.

MESH alleviates these shortcomings through layered mentorships and continued follow-up meetings. Inshuti Mu Buzima (IMB), PIH’s Rwandan sister organization, works with nurse supervisors who are hired by the government and specialize in four clinical fields: child health, women’s health, HIV care, and adult acute care.

Before these nurse supervisors are deployed, IMB helps polish their mentoring skills so they can be effective educators once in the field.

“Educating nurses to be good mentors is important and rarely happens in any country,” Sheila Davis, PIH’s chief nursing officer, says. “Being a good clinical nurse doesn’t necessarily mean that someone can be an effective mentor.
A vital part of MESH is assuring that our mentors are experts clinically and that they have the skills to provide specialized support for nurses in the health centers.”

Over several days, the mentors are introduced to theories of adult learning and hone communication techniques for delivering feedback to the less-experienced nurses they’ll encounter. This initial training is reinforced through monthly follow-up meetings led by IMB.

After the training, mentors visit their assigned posts every four to six weeks to work alongside the nurses. These trips usually last between two and three days, during which the mentors guide the nurses’ decisions and review what worked and what didn’t.
 

Bridging the Gap 

MESH first launched in November 2010, when PIH and the MOH implemented it at 21 health centers spread across two rural districts that serve approximately half a million people.

After a few months, mentors discovered that nurses across sites struggled to screen and treat children under 5 who had symptoms such as diarrhea, fever, and acute breathing and feeding difficulties.

The mentors reported this gap in care to the MOH, which responded by having its Child Health Unit organize trainings focused specifically on childhood illnesses. After the trainings, the nurses’ abilities to manage child illnesses improved significantly, according to a recent article in the peer-reviewed journal Nursing Outlook.

“Identifying a need and being able to implement a strategy that can improve patient care effectively and efficiently is exactly how health system strengthening should happen,” Davis says.

Other data showing the benefits of MESH have recently started to surface. A year into the program, participating nurses increased the accuracy of their clinical performance by nearly 20 percent for child and maternal health, and by 13 percent for adult health.

“We are thrilled to get these results within such a short time,” Manzi said. “MESH is not a magic secret; rather it’s a shift in thinking and strategic planning. I am excited to see fewer kids dying due to bad quality of care, fewer women dying while giving births, and more successes at IMB-supported sites and throughout Rwanda in general.”

Based on the initial success, the Rwandan government has decided to expand the HIV portion of MESH throughout the entire country. There’s little doubt that this will help the country sustain and build on its impressive health gains.

1. Donate

It seems simple—and perhaps too easy—but a donation in solidarity really is the most effective way to help us put more local nurses on the job and give them the tools they need to save lives.

PIH employs hundreds of talented nurses in poor communities around the world, but to succeed they need medicine, supplies, training, and more colleagues.

Donate now

Anyone can donate, but nurses should take special satisfaction in knowing that fellow nurses make up nearly 83 percent of PIH clinical staff.

2. Get educated, get involved

Globally, nurses deliver 90 percent of all health care services. The nurses we know are passionate, fiery advocates for patients’ rights and for their fellow nurses. These numbers—combined with hard-earned credibility and a will to bring about change—make nurses a potent force in the movement for global health equity.

Invite your fellow nurses to get educated and get involved by following PIH:

3. Share your knowledge

Through the wonders of the Internet, it is now possible for health care experts around the world to collaborate, eliminating geography as a barrier to knowledge.

Global Health Delivery Online (GHDonline.org) is a platform of expert-led communities where health care implementers collaborate to improve the delivery of health care.

The communities are open and eager for new voices. Sign up now to start contributing:

4. Volunteer or find a job with PIH

While PIH prefers to hire locally, our field teams do occasionally request volunteer help. Our volunteer opportunities include 12-week or longer positions for experienced nurses. Learn more about clinical volunteer opportunities here.

In addition, PIH regularly recruits top talent to fill knowledge gaps and bring fresh perspective to our cause. You can see all PIH volunteer and employment opportunities here.

5. Volunteer or find a job with another global health organization

In recent years, the number of organizations focused on global health has increased dramatically. We’re fortunate to call many of these excellent organizations partners, and highly recommend that you explore the volunteer and employment opportunities they offer.

PIH Partner Projects
These organizations are working to implement the PIH model across the globe. A list of volunteer and employment opportunities with them is available here.

Global Health Service Partnership (GHSP)
Global Health Service Partnership is a capacity-building model based on education. The Peace Corps and the nonprofit GHSP together are deploying American physicians and nurses for one-year assignments as embedded faculty at medical and nursing schools in Malawi, Uganda, and Tanzania.

Learn more about the GHSP here.

Human Resources for Health Program (HRH)
The Ministry of Health in Rwanda has partnered with a consortium of top U.S. institutions of medicine, nursing, health management, and dentistry that are committed to sending faculty to schools of medicine and nursing, and hospitals throughout Rwanda.

You can learn more about how to get involved with HRH here.

Rosa Huet Pale goes home only on the weekends. Monday through Friday, the 23-year-old nurse is in Plan de la Libertad, a small, hard-to-reach village in Chiapas, Mexico. Most nights she sleeps in the home of a community member.

“My hometown is about six hours away. Sometimes I only go home twice a month,” she says.

PIH’s Mexican sister organization Compañeros En Salud (CES) began working in Chiapas in 2011 with support from Green Mountain Coffee Roasters. The focus is on bolstering primary care services at understaffed and under-resourced clinics, a mission that leans heavily on the versatility and commitment of nurses like Pale. Nurses embedded in the region are vital to long-term strategies for fighting non-communicable diseases. They’re also expected to be among the first responders to emergencies and complete reams of documentation to track each patient visit.

On any given day, Pale says, she could go from vaccinating kids in the clinic to checking vitals at a patient’s home, to doing a Pap smear and advising on family planning methods.

“Just today we had three home visits, all of them related to maternal and child needs. Very early this morning, the doctor delivered a baby in the home of one of our patients. This morning I measured and weighed the newborn, and later in the afternoon we returned and I administered the first vaccinations,” Pale said. “Next week I will screen the baby’s metabolism …. Home visits get us closer to the life of our patients.”

Nursing in Chiapas, where more than half the population lives below the national poverty line and there aren’t enough doctors to staff every clinic, is difficult. Challenges range from vaccine shortages to making sure clinical waste is properly disposed.

Then there’s the sheer remoteness of villages such as Plan de la Libertad, which is wedged among the peaks of the Sierra Madre de Chiapas—a mountain range that spans from southern Mexico to Honduras. The rugged geography hinders the delivery of care: If a patient of Pale’s needs a complicated procedure, he or she may have to travel hours to reach a hospital, a financial burden that affects the entire family.

“Getting a patient out of the community is difficult and requires coordination and help from the family and the community,” she says. “Sometimes the doctor and I, or at least one of us, will go with the patient to provide assistance along the way.”

For an area that has long been neglected, CES is making steady progress toward integrating primary care services. And while Pale will continue to fret over the countless day-to-day obstacles and make personal sacrifices, she doesn’t lose sight of her larger mission.

“More than anything, what inspired me to become a nurse was the desire to help people,” she says.

Travel back with me to the early 1980s, when I first went to Haiti. A college class at Duke University got me interested in health disparities and also piqued my curiosity about Haiti, where I headed shortly after graduating. I ended up in a sleepy market town in central Haiti called Mirebalais, living in the rectory of an Episcopal church and working in a hot, overcrowded clinic.

My job was to take vital signs and to give moral support to the beleaguered young physician. We became good friends, and in time he confessed how tired he was of working in such a shabby facility. But he never did much to change it. The doctor, not yet thirty, had been schooled for scarcity and failure, even as I’d been schooled for plenty and success. Even though he himself was not poor, working in that clinic had lowered his expectations about what was possible when it came to providing health care to those living in poverty.

And who could blame him? The same verdict was being drawn by most “experts” in international health at that time. As today, Haiti was the poorest country in the hemisphere and thus had one of the greatest burdens of disease; the magnitude of its challenges was difficult for me to comprehend. But the assumption that the only health care possible in rural Haiti was poor-quality health care—that was a failure of imagination.

I’ve since learned that the great majority of global public health experts and others who seek to attack poverty are hostages to similar failures of imagination. I’m one of the bunch too, of course, and am telling you this because it’s taken me a long time to understand how costly such failures are. Every day in clinic offered vivid reminders of the toll exacted by a lack of imagination.

It wasn’t a failure to work long hours—we all did that—but rather a failure to imagine an alternative to the kinds of programs that the public health literature deemed “realistic,” “sustainable,” and “cost-effective”—three terms already in circulation by the late 1980s. Most of my Haitian colleagues were, like the doctor, unconvinced that excellence was possible. My experiences in Mirebalais that first brutal and instructive year inspired a lifelong desire to see, in Haiti, a hospital worthy of its people.

Mirebalais, in 1983, was also where I met Ophelia Dahl, and Father Fritz and Yolande Lafontant, who took me in as a volunteer. All of us had figured out, with hope and angst and revulsion, that rural Haitians deserved better medical care, and a couple years later, this group founded Partners In Health along with a few others picked up along the way.

None of us imagined that a greater affront to Haiti would occur on January 12, 2010, when a massive earthquake laid waste to Port-au-Prince. The quake forced us into the role of a disaster relief organization in addition to that of a health care provider. It also made us completely rethink our plans to build a hospital in Mirebalais. With Haiti’s national nursing school destroyed and its medical school damaged and closed, with most of Port-au-Prince’s hospitals down or in shambles, where would the next generation of Haitian health professionals train?

Partners In Health supporters had sent thousands of donations for rebuilding. But they wouldn’t be enough to rebuild something really bold and beautiful; we needed something bigger, many times bigger. Together, a crew revised plans more than a dozen times, enlarging their scope again and again, and making it, in the end, a 205,000-square-foot medical center. That was three times the size of anything we’d ever attempted to build before. Let’s say that these plans were our response to inveterate failures of imagination.

To some, the hospital is just a building in progress, one project among many. But for me, it’s emblematic of our respect for the Haitian people and of our aspiration to make the fruits of science and the art of healing more readily available to people in sore need of them.

How does this story relate to you? First, try to counter failures of imagination. A great many people, including public health experts and some of our own coworkers, shook their heads and advised against the more ambitious version of the Mirebalais hospital. I’m not saying they were wrong. It will be a long time before we can declare this effort a success. Hospitals are the bedrock of every health system, but they are large, expensive, complex institutions to run. The complexity of hospital-based care is one of the reasons public health starts with the low-hanging fruit: vaccines, family planning, prenatal care, bednets, hand washing, and latrines.

But the more difficult health and development problems—from drug-resistant tuberculosis, mental illness, and cancer to lack of education, clean water, roads, and food security—cannot simply be left for a better day. What about the higher-hanging fruit? Do the tools and strategies of global health permit us to care for people with more complex afflictions? Can we answer more of the need?

The short answer: of course we can, with innovation and resolve and a bolder vision than has been registered over the several decades.

Second point: as you seek to imagine or reimagine solutions to the greatest problems of our time, harness the power of partnership.

Partnership has been the font of our work since it began in Mirebalais three decades ago. It’s why we refer to our collective as Partners In Health in a dozen languages. Sometimes, these are partnerships among service providers, teachers, and researchers. Always they are partnerships among people from very different backgrounds (within one country or across many). Sometimes the partnerships link different sorts of medical expertise—surgical, medical, psychiatric, and so on. Sometimes they bring together people who design and build hospitals with those who know how to power them with renewable energy or link them to the information grid.

Above all, such partnerships link those who can serve with those who need services—and seek to bring the latter group into the former, by recruiting them to act as community health workers, for example. By moving people from “patient” to “provider” and from “needy” to “donor,” we can help break the cycle of poverty and disease. That’s our sustainability model.

Partnerships are not always easy to maintain. Often competition rules when collaboration should prevail. People working to fight poverty are, like my doctor-friend in Mirebalais decades ago, too often schooled for scarcity. Where joblessness is the status quo, building new hospitals and schools can bring disappointment to some: everyone wants to work there—and usually not because they want a better job, but because they want a job, period. If someone else gets a job, our colleagues assume that they will not.

This sort of limited-good, zero-sum thinking is to be expected among those living in poverty, who know from firsthand experience that good things usually are in short supply. But such thinking is less acceptable among goodwill groups (foreign or homegrown) and among development experts seeking to attack poverty. Poverty will not surrender to a zero-sum strategy. And neither will the other great challenges before us, from global warming to prolonged and equitable growth of the world’s economy.

Remember that your own success will not come without real partnership. Do not think of it as coming at the cost of someone else’s success. As new challenges arise to the survival of all dwellers on this planet, your generation, more than any other, will need to embrace partnership.

Adapted from To Repair the World: Paul Farmer Speaks to the Next Generation (University of California Press, 2013).

Dr. Paul Farmer is chief strategist and co-founder of Partners In Health, Kolokotrones University Professor and chair of the Department of Global Health and Social Medicine at Harvard Medical School, and chief of the Division of Global Health Equity at Brigham and Women’s Hospital in Boston. Check for his speaking events in your area.

It was by way of a joke that Dr. Paul Farmer introduced Ann Polaneczky to a crowded room at PIH’s Boston office. “What comes to my mind when I think of Ann, is stool,” Farmer said, causing the 24-year-old civil engineer to blush with pride. When the collective burst of laughter tamped down, Farmer qualified the punch line by expounding on the importance of Hôpital Universitaire de Mirebalais’ (University Hospital ) wastewater treatment system, and how Polaneczky helped shape it. 

“The wastewater treatment system at Mirebalais, the guts of the hospital, is truly remarkable. It takes the wastewater, the gray water as it’s called, and runs it through a pretty sophisticated but easy-to-maintain system that gets checked every day,” Farmer said. “We never had that in Haiti—not just in a hospital, we never had it at any public-sector institution. It’s hard to know why these things are so significant without knowing how absent they are in a lot of places in the world. This system is just one example of how a modern hospital runs that’s worth getting to know.”

With that sentiment in mind, we asked Polaneczky, PIH’s project engineer, to walk us through five of her favorite feats of engineering at University Hospital.

Wastewater Treatment System

Photo: Partners In Health

What it does: Every drop of wastewater produced at University Hospital—whether from a toilet, an operating room sink, or dirty laundry—passes through this low-energy, low-maintenance system. The water first enters a biological treatment process known as aerobic digestion in which naturally grown bacteria decompose organic waste and devour pathogenic organisms, such as Vibrio cholerae—the bacterium that causes cholera. From there, the water is treated with chlorine for further disinfection. Right now, the system can treat 50,000 gallons of wastewater per day to U.S. EPA standards. If needed, Polaneczky says, it can be expanded to treat 75,000 gallons a day. 

Why it’s important: The immediate benefit is that the system significantly reduces the threat of waterborne diseases, such as cholera and dysentery. But there’s a less tangible benefit that Polaneczky is keen on: “We want to show that it’s possible to treat wastewater in an efficient, economical, and sustainable way in Haiti and other low-resource countries,” she says. “This shows that it can be done.”

Incinerator 

Photo: Partners In Health

What it does: This school-bus-size machine allows University Hospital staff to properly dispose of biohazardous medical waste and used sharps, including syringes and scalpels. Polaneczky explains that the system meets U.S. EPA emission standards. How? The waste is burnt in a controlled fire in the machine’s first chamber. The resulting smoke is captured in a second chamber that reaches 1,000 degrees Celsius—similar to the temperature of liquid lava—and essentially gets vaporized. The end result is steam and a small pile of ash.

Why it’s important: Properly disposing medical waste is critically important, yet many health care facilities in Haiti don’t have the necessary equipment to do so. It’s not uncommon for human waste to be mixed with sharps and garbage, and then burnt in crude devices or trash pits. The noxious fumes are bad for the environment and human health. As University Hospital integrates into Haiti’s health system, the incinerator may serve as a central location to dispose of medical waste produced at other PIH/ZL sites. 

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Fiber Optic Network

Photo: Stephanie Garry/Partners In Health

What it does: Polaneczky describes the fiber optic network as the “backbone of the hospital,” providing high-speed Internet access throughout the facility. A robust server package donated by HP optimizes it. High-tech and resilient, University Hospital’s IT system supports everything from patient registration to inventory management to digital radiography.

Why it’s important: University Hospital is the first teaching hospital in central Haiti. When medical education and training begin, Haitian doctors can consult with partners in Boston and beyond as needed through video conferencing and other digital technology, which extend from the operating rooms to the hospital’s classrooms. On a day-to-day basis, the network improves efficiency and facilitates monitoring, evaluation, and quality improvement projects.

Medical Gas System

Photo: Rebecca E. Rollins/Partners In Health

What it does: Behind the walls of University Hospital is a labyrinth of copper pipes and vacuum and air lines that ensures patients in need of oxygen have quick access to it—whether they’re undergoing surgery, being cared for in the emergency room, or in recovery. A major asset of University Hospital is that it has its own oxygen concentrator, a device that removes nitrogen from the air to produce medical-grade oxygen.

Why it’s important: Without this system, we’d need to have bedside oxygen tanks available for any patient in need of oxygen, which is both expensive and logistically difficult. Additionally, suction and compressed air would need to be supplied for patients. Quick access to these oxygen and suction tubes allows us to deliver better care to more patients. 

HVAC

Photo: Partners In Health

What it does: Given that University Hospital stretches over 200,000 square feet and includes a pharmacy that stores temperature-sensitive medications, effective climate control was a must. The hospital boasts four 12.5-ton rooftop cooling units and a separate 20-ton condenser for the pharmacy. In areas of the hospital where air conditioning would be a luxury, the designers opted for energy-efficient ceiling fans and elegant design that fosters natural air flow.

Why it’s important: It’s not about just keeping cool. “The HVAC system supports infection control in operating rooms and allows us to preserve medical equipment,” Polaneczky says. University Hospital’s HVAC system, she explains, utilizes HEPA filtration and laminar flow, meaning the air is pushed from ceiling to floor rather than across a room, which minimizes the risk of surgical infections. 

In March, 8-year-old Belizaire Selfanord started to feel sick after he came home from school.

By the following morning, he was so ill with diarrhea and vomiting that he could hardly stand up. His mother, a widow raising six children alone, knew where to go—the Partners In Health cholera treatment center in Mirebalais, in central Haiti.

Inside the fenced collection of large tents, Dr. Thelisma Heber asked him a few questions about his symptoms, but there was no doubt Belizaire needed IV fluids immediately. “He’s a severe case. You can see his eyes are sunken,” Heber said.

Belizaire’s mother, Sentane Pierre, helped him onto a wooden bed with a hole and a bucket beneath. Heber examined him, pulling the skin on his belly. It was stretchy like bread dough—a sign of dehydration. According to data from Partners In Health and our Haitian sister organization, Zanmi Lasante, PIH/ZL has treated twice the number of cholera cases this January and February than during the same months last year. As the spring and summer rainy season in Haiti begins, PIH/ZL clinicians are concerned that cholera could spike again, especially because emergency cholera funding has largely ended, causing many prevention and treatment activities to cease.

“In most of the areas we serve, it seems that we are the only cholera health care provider, and that puts more pressure on our services,” said Dr. Ralph Ternier, director of community care and support at PIH/ZL.

PIH has treated more than 100,000 patients for cholera and has worked to prevent cholera’s spread since the epidemic began in late 2010. PIH/ZL also supported the delivery of Haiti’s first cholera vaccination program, which has since provided evidence for wider use of the vaccine in Haiti. PIH/ZL continues to operate cholera treatment centers in central Haiti, and conduct prevention activities and educational outreach. In January and February, PIH/ZL treated more than 2,000 patients for cholera.

The impact of the loss of funding is clear. It has threatened the quality of care at the few centers that still provide cholera treatment, Ternier said, because fewer staff have been on hand to care for patients. And because untreated cholera can result in more infections, a lack of treatment also affects prevention. When people fall ill in communities without a treatment center, they not only go without care but also spread the bacteria, which could then infect others.

“How many people will have to die in a stupid way? Dying of diarrhea is stupid,” Ternier said. The cholera epidemic has killed more than 8,000 people in Haiti and sickened more than 650,000, according to Haiti’s Ministry of Health. “Donors get distracted unless there’s a big spike in numbers and people start to die rapidly. Otherwise people have gotten used to the idea that cholera is here.”

Belizaire wasn’t the only patient Heber and the rest of the staff were treating at the cholera treatment center. Heber, 40, examined and admitted a half-dozen patients in less than an hour. He triaged them to either receive oral rehydration solution or, for more severe cases, to be hospitalized and given IV fluids. In different tents designated for men or women, two sisters and their father were also receiving fluid from IVs. They each had to pay for a car to bring them to the cholera treatment center as they each became sicker over the course of the night. Heber said families can become infected when they eat the same contaminated food or water, don’t wash their hands, or take care of a sick relative.

Heber said that continuing to fight cholera can be difficult, as Haitians and foreigners perceive that the crisis is over. Because Haiti lacks proper water and sanitation systems, individuals must try to prevent the disease themselves through hand-washing and good sanitation, but they can’t always afford to buy soap or treat their water.

“It’s a big battle to combat cholera,” Heber said.

Shin Daimyo is a kinetic presence at Partners In Health. The 28-year-old program manager for the mental health program bounces through our Boston office daily, weaving clinical and programmatic insights with gut-busting one-liners. He’s as good-humored as he is dedicated to expanding mental health services in the countries where we work.

From tackling health issues on the Obama campaign to developing clinical protocols for mental health services in Haiti, Daimyo’s work has always focused on delivering high-quality health care to vulnerable populations. But he’s the first to admit that the path toward making his passion a reality has been tough to navigate at times. Recently, Daimyo authored a chapter in Do Good Well: Your Guide to Leadership, Action and Social Innovation, a book that noted New York Times columnist Nick Kristof dubbed “a practical field guide for young people wanting to change the world.”

We caught up with Daimyo to discuss what doing good well means in the world of mental health and to learn more about how PIH is innovating simple and scalable models of care for mental health in low-resource settings.

Q: Hey, Shin! Thanks for taking the time to chat. So why don’t you start by explaining to readers what you do on a day-to-day basis at PIH?

Thanks for having me! As the program manager for mental health, I’m responsible for the overall management of our programs in Haiti and Rwanda, and I also provide support to burgeoning clinical work and research in Mexico and Lesotho. On any given day, I'll be meeting to develop clinical protocols for depression; talking with a potential partner to provide clinical supervision to our psychologists, social workers, and physicians; and developing indicators to track mental health patient outcomes, among other tasks. I work with a great team of people who bridge a range of disciplines and nationalities.

One project our team has been working on is building a long-term strategy for epilepsy care that can be scaled up across resource-poor settings. An underlying goal of all our programs is to expand the capacity of local clinicians to deal with the high rate of mental and neurologic disorders. Recently, our partners in Haiti at Zanmi Lasante received a large grant from Grand Challenges Canada to develop a community-based model of mental health care and expand and bolster mental health services at all our health centers and hospitals in Haiti. In collaboration with Harvard Medical School, we also manage the Dr. Mario Pagenel Fellowship, which sends senior psychiatrists to Haiti and Rwanda so they can provide clinical and programmatic supervision to local staff.

Q: When many people think of health issues in the developing world, they often think of infectious diseases such as HIV/AIDS or tuberculosis. Are you seeing a shift toward greater awareness of mental health in low-resource countries?

That’s a complicated question, and I think it’s important to look at it from the perspective of local governments and development partners, such as bilateral organizations and foundations. We are starting to see a shift among low-income countries in terms of their prioritization of mental health, especially as more and more countries develop mental health laws and policies. This is most clearly seen with our work in Haiti and Rwanda. The Haitian government has voiced strong support for our Grand Challenges Canada project to scale up services over the next three years at our joint sites. Our plan is to present a roadmap for delivering similar services in the rest of the country.

In Rwanda, the Ministry of Health has done an incredible job of decentralizing and scaling up mental health services at public facilities, and it continues to invest its own resources to provide mental health care to its population. Inshuti Mu Buzima, PIH’s Rwanda sister organization, works closely with the government to provide technical support. It’s a wonderful model.

As a whole, however, there isn’t enough investment, both politically and financially, for mental health. That’s why funding from donors such as Grand Challenges Canada is so important. It signifies a nascent shift in thinking and prioritization of mental health services that can be sustainable and impactful. We strive not only to provide incredible care to the most vulnerable populations, but to also advocate for increased political and financial commitments to mental health. 

Q: So how did you come to be involved with Do Good Well, and what was your contribution to the book?

Nina Vasan, a lead author of the book, is a good friend and past colleague. We met in 2006 while I was working at the World Health Organization in Geneva in the department of mental health policy and service development. We had many conversations about nonprofits, leadership, movement building, and social change, and were surprised about how many lessons and beliefs were common to our experiences. She ended up recruiting me to the Obama campaign soon after, where we formed a formidable team in key battleground states. We have stayed in touch since then, supporting each other as we furthered our careers in social change. Nina reached out to me about a year ago to help write a chapter.

Q: And what did you decide to write about?

My chapter focuses on how you refine your passions and define your goals, and how to take concrete steps toward a sustainable career in social change.

I empathize with being really passionate about wanting to make a difference, but having no idea or direction on how to get there. I started as a business major in college then changed to psychology. I coordinated alternative spring breaks focused on poverty, the environment, and cross-cultural issues, and I worked with children with serious emotional disabilities. From there I worked in student affairs, applied to three graduate programs in different fields, and did a whole lot of research on at-risk youth. Then I moved on to quality improvement and management work in four hospitals in Lesotho, acted as director for President Obama’s health care work in Florida, and co-founded a student-run global health journal at Boston University School of Public Health, where I earned my master’s degree.

I’m not saying this to brag about all the avenues I’ve been down. The entire time, working for the most vulnerable populations has been my core motivation. But it took a very long time for me to hone in on how I wanted to make my passions a reality, a career. I truly see my role at PIH as the realization of my passions, and my hope is that the chapter helps others do the same.

Q: Noted New York Times columnist Nick Kristof called Do Good Well “a practical field guide for young people wanting to change the world.” And a theme throughout is this notion of social innovation. How is social innovation unfolding in the world of mental health?

People often associate innovation with some sort of new, fancy technology, which is sometimes the case. Other times, however, innovation is just doing something simple in somewhere it has never been done. We live in a world of finite resources, and consequently we must pursue creative ideas that have the greatest benefit to the most number of people.

Back when PIH first started, many people believed HIV drugs couldn’t be effectively provided to people in low-resource settings or in isolated rural areas. When PIH proved this wrong by deploying a simple, targeted strategy founded on community health workers (CHWs), we were innovating, and it worked. Now we’re demonstrating the same thing with mental health. High-quality, community-focused, evidence-based mental health services that are culturally appropriate can and should be provided in low-resource settings. That in itself is something the world is still trying to believe and realize.

Q: In previous conversations, you’ve mentioned the effectiveness of mobile mental health clinics. What are they and are they capable of providing long-term care that some patients struggling with, say, depression or schizophrenia may need?

Imagine a multidisciplinary team of psychologists, nurses, physicians, and social workers packed into an SUV driving to the most remote part of Haiti to provide care. This team meets up with a CHW, who they are in constant communication with, and goes out in the community to screen for mental disorders and provide initial treatment. The CHWs play a key role: Because they are embedded in the community, they can refer individuals to the mobile team when they arrive.

Now imagine this is done on a monthly basis while the CHW stays in the local village to provide follow-up care and appropriate referrals when necessary. This is a long-term model for care, and it’s terrific.

Q: Are there any technological innovations emerging for mental health at our sites?

We are currently developing a mobile health, or mHealth, pilot where our CHWs will utilize cell phones to track, screen, and refer patients from the community to health centers and mobile clinics. The phones will likely have a decision support model— a tool that helps CHWs make clinical and referral decisions based on the types of symptoms the patient has—to effectively support and improve clinical care in the community-based model. It’s still a young project with lots of potential, so stay tuned for more information in the coming months.

Data are at the heart of Partners In Health’s work. They help us identify gaps in care and guide our development of innovative tools that strengthen health systems. But given that PIH works at dozens of health facilities across 10 countries—most with limited infrastructure and few resources—ensuring that we collect the highest quality data and put them to good use can be challenging.

That’s why more than 20 data devotees and quality-improvement champions from six PIH sites traveled to Rwinkwavu, Rwanda, last month for the second annual Monitoring, Evaluation, and Quality (MEQ) Summit, “From Counting to Quality.”

The MEQ Summit is delightfully PIH in spirit, the type of event where you’ll hear a Haitian doctor who works in Malawi translating medical terms from English to Spanish for a Peruvian M&E coordinator. And while discussions of how best to link longitudinal data systems with medical records may seem abundantly esoteric to most people, that’s the type of information the MEQ teams use to help PIH reduce mother-to-child HIV transmission rates.

“It’s good to have a space where different teams can openly share and discuss the challenges they face and the successes they have achieved with like-minded staff from the other sites,” says Jean Paul Joseph, leader of quality improvement at Zanmi Lasante, PIH’s Haitian sister organization. “Even the small efforts that other sites are taking to improve data and patient care can teach us a lot about improving our own programs.”

Take for instance a presentation at the first MEQ Summit in 2012 by the team from PIH/Lesotho (PIH/L). They shared a simple yet effective form to track HIV patients who had stopped coming to the clinic. At this year’s summit, Sophie Motsamai, an M&E clinical manager from PIH/L, was proud to hear that colleagues at several different PIH sites had adapted the form to follow up with their own patients who had fallen out of care.

Among this year’s presentations was a discussion of how to improve the quality of data collected by community health workers (CHWs). It’s a hot issue because CHWs at all our sites play an invaluable role by visiting patients and accompanying them throughout their treatment—whether it’s a two-year multidrug-resistant tuberculosis program or ongoing accompaniment for HIV-positive patients to take their lifesaving medications.

Given their frequent, close contact with patients in the community, CHWs are in a unique position to collect patient data. Because they come from the impoverished populations we serve, however, CHWs’ educational backgrounds can vary widely. As a result, it can be challenging for them to collect accurate data in the field.

But as demonstrated by colleagues at Inshuti Mu Buzima, PIH’s sister organization in Rwanda, simple protocols and easy-to-use tools for feedback and supervision have made it easier to manage how CHWs collect data. Through the use of straightforward data dashboards—tools that automatically turn raw numbers into easy-to-interpret graphs and tables—program managers can quickly identify which CHWs are collecting high-quality, accurate information from the patients they serve, and which ones may be facing challenges.

“Global health organizations face a common challenge in understanding population health and needs at the village level in real time. Improving CHW data collection systems can give us an invaluable window into what is happening and where needs exist,” Lisa Hirschhorn, director of monitoring and evaluation at PIH, says. “This session brought together some of PIH’s most innovative thinkers and talented practitioners who’ve really moved this issue forward.”

Over the week-long summit, hands-on exercises were mixed in with roundtable discussions. Participants honed their abilities to use Gantt charts (a tool to track project implementation and outcomes) in clinical settings and explored the nuances of Geographic Information Systems for mapping the delivery of health services. Each participant returned home with fresh ideas and new tools for using data to improve outcomes for PIH’s patients.

“This year’s most inspirational moment for me was my Rwandan colleague Manzi Anatole discussing his work in mentoring nurses to improve patient care. This approach improves patient care, and the Rwandan team has the numbers to show that,” Joseph says. “All of us have worked together to create a culture of quality improvement and a team dedicated to improving care for our patients. Meetings like this help support a culture of constant improvement.”
 

In 2011, more than 8.5 million people became sick with tuberculosis and 1.4 million people died from it, according to the World Health Organization. That same year, according to WHO estimates, 630,000 people were sick with multidrug-resistant tuberculosis (MDR-TB), a hard-to-treat bacterium that’s becoming more prevalent and can take two years to cure. Fewer than 5 percent of MDR-TB patients receive appropriate treatment.

Despite the burden of MDR-TB, few drugs exist to treat it. On December 28, 2012, the U.S. Food and Drug Administration conditionally approved bedaquiline as part of a treatment regimen for adults with MDR-TB. It is the first drug to garner FDA approval for MDR-TB and the only tuberculosis drug to come to market since 1970.

As World TB Day approaches, Partners In Health spoke with Carole Mitnick, a TB researcher and assistant professor of global health and social medicine at Harvard Medical School, our longtime academic affiliate and partner. Mitnick discussed the factors behind the dearth of new drugs, the benefits of community-based TB treatment models, and the myriad challenges associated with pediatric TB patients.

Q: First, can you explain the difference between tuberculosis, multidrug-resistant tuberculosis, and extensively drug-resistant TB?

The distinction lies in the drugs that are useful to treat this bacterial disease. TB is usually treated with a four-drug, six-month regimen. Upwards of 85 percent of people with TB can be cured with this regimen.

Multidrug-resistant TB is caused by bacteria that are resistant to the two most important drugs in the standard regimen, isoniazid and rifampin. Patients with this form of disease usually have to be treated for 18-24 months, with regimens containing at least five drugs. A lower percentage of patients with this form of TB are typically cured—on average just over 60 percent. Many others die. This is because the drugs are more toxic, less effective, and the disease is often more advanced by the time patients receive proper treatment.

In extensively drug-resistant TB (XDR-TB), the bugs are resistant to the two most important drugs in the standard treatment and the two most important drugs in MDR-TB treatment. These patients often receive treatment for 18-24 months, again with regimens containing at least five drugs, many of which are very toxic and of questionable efficacy. Cure is assured in even fewer of these patients—usually less than 50 percent.

Q: Is the number of MDR-TB and XDR-TB cases around the world increasing? Are certain regions becoming more prone to MDR-TB and XDR-TB? 

All signs point to a growing global burden of MDR- and XDR-TB. The burden is usually thought about in two ways: percent of all TB cases that are MDR and XDR or absolute number of MDR and XDR cases. Percentages are low in most of Africa and Asia. But the absolute number of TB cases is so high that MDR among small percentages translates into hundreds of thousands of cases of MDR-TB each year. Moreover, in Africa, the joint HIV epidemic leaves millions exceptionally susceptible to all forms of TB, and to repeated bouts of TB or MDR-TB. Aggressive treatment of both diseases, such as that provided at PIH/Lesotho, is essential to save individual lives and impact the epidemic.

In Eastern Europe and the former Soviet Union, absolute numbers of TB cases are low, but the percentages of TB cases that are resistant are extremely high and growing. PIH’s Tomsk, Russia, site is, however, one of the shining examples in the region. In the years since PIH intervened, the incidence of TB, the proportion of TB cases that are MDR, and the incidence of MDR have all declined! That’s largely from working with partners to develop a unique ambulatory model to serve prison and civilian populations in the region. 

Carole Mitnik, a TB researcher and assistant professor of global health and social medicine at Harvard Medical School. Credit:Suzanne Camarata

Q: Why has drug development, particularly for drug-resistant strains, been slow? Is there a lack of funding, a lack of scientific know-how, or political roadblocks? 

There are two primary contributors to this problem, which are linked. First, TB is a disease of the poor. The market for anti-TB drugs, largely governments in Africa and Asia, is not seen as a “paying market” with significant profit potential for the pharmaceutical industry, which is motivated by profits.

Second, advocacy for new anti-TB drugs was virtually non-existent until about 10 years ago. The prevailing attitude among those responsible for global TB policy has been that what we had—a six-month, four-drug regimen good for most patients—was the best we could hope for. The battle in TB control, its architects maintained, was simply about rigorous, widespread delivery of the existing tools: drugs that are more than 50 years old; a diagnostic that is now more than 125 years old; and a vaccine that is more than 100 years old. There was a mentality of scarcity among those most concerned about TB, which seemed to preclude demands for innovations in treatment, diagnosis, and prevention. Since drug and medical device research and development is a lengthy process, this drought of imagination has delayed harvest of new technologies for decades.

Q: How significant is the FDA’s conditional approval of bedaquiline?

This is exciting for three reasons. First, symbolically: The approval of the first new anti-TB drug in nearly 50 years is a huge breakthrough, demonstrating that at least one profit-driven company saw value in pursuing a TB indication. Second, it created a regulatory precedent for approval of MDR-TB drugs. Last, and most important, it means that there is an alternative to the current regimens that have high toxicity and inadequate efficacy. There is even the potential that this new drug, and others in the pipeline, could shorten treatment. This would be an important achievement for patients and TB programs currently struggling to complete two years of treatment.

Q: Have you see anything in the early studies of bedaquiline that raises red flags?

The primary issue that dampens my enthusiasm is safety. We know that bedaquiline has potential heart toxicity. And too few patients have been evaluated to really know how safe the drug is, across populations. It should be noted that in the small clinical trials, more patients who received bedaquiline died when compared with patients who received the placebo. This does not mean people shouldn’t get the drug; it merely reinforces that all people who receive this drug as part of an MDR-TB treatment regimen need to be assured the highest standard of care and vigilance while receiving it. 

Q: The FDA approved bedaquiline for adults. What about pediatric patients? What treatment options are available for children who have drug-resistant TB?

This is an enormously important issue. Anti-TB drugs have almost never been tested explicitly in children or developed for delivery to children. To comply with current FDA requirements for approval of bedaquiline, Janssen Therapeutics [the manufacturer of bedaquiline] has developed a plan to study new drugs in children. Rarely, however, do these plans get implemented. So, clinicians around the world treat based on their best guess for whether and how much of existing drugs to use in children. Pills are cut and crushed, capsules are opened, and medications are stirred into formula, juice, or food.

These practices are extremely imprecise and time-consuming. A TB nurse who works in a public health center that collaborates closely with Socios En Salud, our PIH sister project in Peru, estimated that it takes her a full day to create a week’s worth of doses for a single pediatric MDR-TB patient she is treating. What’s worse is that since children are thought to be “epidemiologically insignificant,” meaning they don’t tend to transmit disease, we have no idea how many children in the world actually have MDR-TB and what treatments they’re receiving. A year-old project by PIH collaborators at Harvard Medical School, called the Sentinel Project for Pediatric Drug-Resistant Tuberculosis, aims to answer these and other critical questions.

Q: Do you see foresee challenges to making bedaquiline available in resource-poor environments?

There are challenges, yes, but they are by no means insurmountable. We’ll need to subvert a tension that has plagued TB control efforts—that is, between providing the best treatment possible to all those who need it and a perceived need to protect against emerging resistance. TB policy has typically favored caution against resistance, which has meant restricting access to the most effective treatments. In contrast, in HIV, since treatment became affordable, the balance has mostly been on the side of providing treatment to as many as possible.

PIH and other partners working within a framework of equity and innovation will need to assure, first and foremost, that effective treatment is delivered widely. Our framework will need to complement the dissemination emphasis with safeguards that assure the new drug is used in a way that minimizes the risk of development of resistance and maximizes patient safety. This is completely consistent with the model PIH and our Haitian sister organization Zanmi Lasante piloted in Haiti, and then brought to scale in Peru; Tomsk, Russia; and Lesotho.

A patient in Lesotho with multidrug-resistant tuberculosis receives care from PIH/Lesotho staff. Credit: Pep Bonet/Noor

Q: Aside from slow progress on drug and diagnostic development, what other obstacles persist in fighting TB? 

Although approximately 500,000 new MDR-TB cases occur each year, a small fraction—less than 5 percent—are thought to receive appropriate treatment. Obstacles include weak healthcare systems without proper investments, collaborations with other sectors, or support to facilitate the distribution of drugs, diagnostics, and information. And we can’t ignore underpaid and overworked providers whose capacity to provide quality care is limited by failures to situate them properly to deliver the promise of health as a human right. 

Q: And what’s the concern over hospital-based models for TB care? 

Continued reliance on hospital-based models is guaranteed to stymie scale up of treatment because the need far outpaces hospital-bed capacity, by orders of magnitude. This gap manifests, in many countries, in MDR-TB treatment waitlists that are hundreds or thousands of patients long. The justification for hospital treatment is often to remove infectious MDR-TB and XDR-TB patients from the community. The deep flaws in this logic are that while awaiting treatment, both before and after diagnosis, these patients have been in their communities already infecting family and neighbors.

Furthermore, hospitals in high-burden TB settings rarely have effective infection control measures to prevent transmission to other vulnerable patients, family members, and staff. Lastly, effective treatment is the best prevention: Once appropriate treatment is initiated, the risk of transmission to others declines precipitously. This has been demonstrated most recently by PIH affiliate Edward Nardell, who presented such findings at the World TB Conference of the International Union Against TB and Lung Disease.

Q: What are some of the clear advantages to the community-based model?

Delivering MDR-TB care in the community—as PIH and partners do in Peru, Haiti, Lesotho, Russia, and Kazakhstan, among other sites—has many benefits, beyond the transmission ones described above. Among the most apparent benefits is that it’s less disruptive to patients and families. Community care also provides a platform for comprehensive services, including attention to the social and economic needs that almost always coincide with medical ones. Working closely with the community creates opportunities for education, which remove stigma around the disease and accelerate diagnosis of additional cases. The success of bedaquiline introduction, and global MDR-TB treatment scale up, depends on expansion of care from hospital to ambulatory models.

Charles Phiri was stuck in one of Malawi’s notorious downpours, steering a Honda XL dirt bike down a washed-out mountain road. Rain streaked across his visor. With every twist of the throttle, globs of mud splattered against his protective jacket.

“My most difficult ride,” Phiri, 30, recalls of the rain-soaked trip to Benje, a hard-to-reach village near the border of Mozambique. “[But] these patients would die if there was not someone to go out and visit them and encourage them to get back on treatment.”

As an HIV Treatment Coordinator for Partners In Health’s Malawian sister organization Abwenzi Pa Za Umoyo (APZU), Phiri spends countless hours traversing the Neno district to consult patients who’ve stopped taking their antiretroviral therapy. It’s a job that has become more demanding in recent years: In Malawi—the seventh poorest country in the world—approximately one in every 10 adults is living with HIV. In 2006, the year before PIH began working in Neno, only five HIV-positive people in the district were being treated with antiretrovirals. By the end of 2012, more than 5,000 people had access to the lifesaving drugs.

Phiri is a critical link in the chain of health care providers who help patients adhere to their daily regimen of pills by making home visits. “I talk to them about their lives, about why they have stopped their treatment,” he says. “I talk to them about the consequences of stopping treatment.”

Though remarkable in its simplicity, this approach works. Research from PIH-supported programs in Rwanda has shown that similar community-based care not only leads to higher retention and adherence rates among patients—meaning they stay in care longer and are more apt to take their drugs on time—it helps identify issues such as food insecurities and depression, factors that may compel people to stop taking medication.

But long distances between patients, not to mention inclement weather and few paved roads, pose challenges. To help Phiri and others reach patients in a timely manner, PIH/APZU teamed up with the nonprofit Riders For Health, which secured a handful of Yamaha AG 200s and Honda XLs—lightweight dirt bikes that are ideal for Neno’s terrain. Now the bikes allow PIH/APZU to cover nearly 7,000 kilometers each month.

Among the most tangible benefits of the bikes is that they’re far cheaper than larger, less fuel-efficient trucks. Every kilometer traveled in a truck costs 80 cents compared with 30 cents for a dirt bike. And the bikes are cheaper to obtain. Whereas a truck could costs tens of thousands of dollars, a dirt bike and the necessary training for one rider is only $5,550. 

“The bikes help free up our limited fleet of cars and cut down on gasoline costs,” Victoria Smith, external relations coordinator for PIH/APZU, said. “There are so few paved roads in Neno—for the most part the roads are packed earth and rock, and many of the routes to get to patients’ homes are mountain trails that intersect with rivers, fallen trees, and rocky hills.”

While all riders are equipped with a full-face helmet and protective gloves, jackets, and pants, the goal is to make sure these items are last-resort defenses. Before anyone jumps on a bike and heads into the field, they must pass a two-week training course with Road Safe, a Malawian driving school. After that, they enter a one-week program facilitated by Riders For Health that’s led by a retired professional long-distance motorcycle racer.

According to Phiri, the trainings instill a high level of confidence. “I never thought I was going to fall off,” he says when talking about the ride to Benje. “The road was muddy and windy, and I managed to stay on the whole time.”

With numerous riders trained, we’re now leveraging the nimbleness of the bikes to identify treatment gaps in Neno. Take for example PIH/APZU’s Geographic Information Systems Assistant William Mwale, who led a recent expedition to plot the precise locations of villages where the hardest-to-reach chronic-care patients live.

By cross-referencing the locations with patient data from an open-source electronic medical record system, PIH/APZU was able to build maps and measure the proximity of existing health centers to patients. The maps identify underserved areas where physical and/or socioeconomic barriers are likely to prevent people from accessing care.

And the dirt bikes help us get around at least some of those barriers.

Zerida Nyinaguhirwe is one of the first breast cancer patients to complete cancer treatment at Butaro Hospital, a Ministry of Health hospital in Rwanda that is supported by Partners In Health—and where the national Cancer Center of Excellence was inaugurated July 18, 2012. Her story demonstrates the importance of timely care while reminding us that cancer does not discriminate between the rich and the poor.

My name is Zerida Nyinaguhirwe. I am 53 years old, from Burera District in the northern province of Rwanda. I am a subsistence farmer and live by myself; after my husband and I learned that I was unable to conceive children, he divorced me.

One Wednesday morning while digging in my garden three months ago, a stick accidentally hit my breast. After two days, my breast had swollen. This was not normal for me, and the following week I visited a nearby health center for a checkup. Because the health center had no specialist or equipment to diagnose my problem, I was referred to Butaro Hospital. In January, a tissue sample was taken from my breast for testing, and the doctor told me to wait until they called me with my results.

In March, I had a phone call from the hospital letting me know that my results were ready. At the hospital, I was put in a beautiful room with bright lights. “Zerida, your results show that you have breast cancer and it’s treatable,” the doctor said.

I was shocked to hear this and knew it was my time to die. I asked the doctor, “What do you mean that it is treatable, yet I have never seen anyone who has survived it?”

“Many people have been treated for breast cancer and have survived. You are going to be among them,” the doctor said.

This encouraged me. Right away, I asked the doctor what the treatment would be—I was willing to receive any type of cancer treatment.

I was told that I was going to have chemotherapy and surgery to remove the breast. My initial treatment was scheduled at Rwinkwavu Hospital, another government hospital supported by PIH in the eastern province that had been treating cancer for some time. As Rwinkwavu is a five-hour drive from where I live in Burera District, I could not afford the transport costs; thankfully, they were to be covered by PIH. I had never received such complete care. I had great hope that my treatment would be successful.

In the first weeks of my treatment, I felt okay, but as I continued it became very difficult and I thought I was going to die. The drugs’ side effects turned my nails black, suppressed my appetite, caused my hair to fall out, made me feel weak all the time, and I thought I was going to lose my eyesight. My family, friends, and fellow cancer patients also thought I would die, so I pretended to them that I was strong and would get better.

In May, I was given a transfer to Butaro Hospital for the continuation of my treatment. This change was amazing for many reasons. Butaro Hospital is near my home, therefore my transport bills would be less costly to PIH and my family was given much relief. Throughout my time in Rwinkwavu Hospital, my family had always asked to accompany me, but I never allowed it because it was too expensive and I was given enough care at the hospital. But still, my family members were not comfortable with me being alone.

I stopped taking medicine in mid-June, and the doctor told me to come back on July 19 for breast surgery. During this break my hair started to grow, I got my appetite back, and my nail color normalized. My family, friends, and I were encouraged by the recovery, which positively prepared me for my surgery. Deep inside, I was wondering what I was going to look like with one breast and how I would explain this to others.

The surgery was a success. All my family members, friends, and I were happy about it and we believed that my cancer would be cured. While at Butaro Hospital, I met many other cancer patients—we encouraged each other and became like a family.

To my fellow women, breast cancer is common these days and requires prompt attention. In case of any unusual feeling in the body, you should visit the nearby health center right away. For those that also have cancer, following your treatment plan is the first step to recovery, despite difficult side effects. More so, it is important to be positive and encourage others to be aware that treatment is possible for cancer.

I am grateful for Partners In Health and the government of Rwanda, because they have made cancer care available and affordable. As a poor woman of my age, I would not have managed cancer treatment and transport costs on my own. For my entire treatment, I only paid 7,800 RWF ($12.50).

Thanks to medications and surgery, I am now treated for breast cancer and hopefully cured. I am doing well, although the doctors warned to be careful about any unusual feelings. “Cancer can always come back and to any other part, anytime” the doctor said. I now can’t carry heavy material or dig because I still feel some pain where I had surgery.

Lastly, I would like to thank the doctors and nurses at Butaro and Rwinkwavu hospitals, who took care of me tirelessly. Above all, I would like to send my sincere gratitude to His Excellency President Paul Kagame, for his good governance and for inviting Partners In Health to Rwanda, as they have taken cancer care to another level.

March 8 is International Women’s Day, a global day to celebrate the social, economic, and political achievements of women while advocating for women’s rights. Founded in 1910 by German women’s rights leader Clara Zetkin, International Women’s Day is honored across the world and is an official holiday in nearly 30 countries, including Kazakhstan, Nepal, and Russia—three countries with deep ties to Partners In Health. 

Even as we celebrate progress in women’s rights globally—for example, in Rwanda women hold 56 percent of seats in Parliament—women continue to face significant inequities in health care. In the developing world, women without access to modern contraception accounted for an estimated 63.2 million unintended pregnancies in 2012. A recent study in The Lancet estimated that more than 100,000 women could be saved from maternal deaths each year if they simply had access to effective contraceptive methods. And data from the World Health Organization show that 99 percent of the more than half a million maternal deaths each year happen in developing countries.

Women face health inequities because of their specific needs around sexual and reproductive health care, and because they often lack adequate resources to pay for care. All the factors of gender inequity—including limited access to education, legal systems that fail to protect women, and gender-based violence—are exacerbated by poverty. For these reasons, HIV disproportionately affects women and girls: More than 50 percent of people now living with HIV/AIDS globally are women.

So how does Partners In Health address the particular challenges poor women face? First, by taking a rights-based approach to health. We believe health is a human right for all people—women and men—and that our work must be done in a human rights framework that values participation, empowerment, and equality. This is most evident in our community health worker programs, largely staffed by women, who are tasked with the critical role of educating and accompanying community members. By paying community health workers, PIH engenders economic opportunity and independence that allows women to help feed their families and keep their children in school.

Second, PIH develops programs and health services that address the unique health care needs of women. These include prioritizing broad access to modern family planning methods that meet the specific health and cultural requirements of the population, as well as actively reaching out to women for care before, during, and after pregnancy.

For example, PIH/Lesotho has made tangible progress toward Millennium Development Goal 5, which aims to reduce maternal mortality around the world. Through its Maternal Mortality Reduction Program, PIH employs community health workers specially trained in accompanying women through pregnancy and birth, thus ensuring that pregnant women have access to skilled care at a health clinic in the remote, mountainous terrain of Lesotho. This effort has paid off already: In a country where one in 32 women will die of pregnancy- and childbirth-related conditions, there have been few maternal deaths reported at the government clinics supported by PIH/Lesotho.

Third, by targeting poverty as the root cause of disease, PIH seeks to change systems that perpetuate inequality. Removing financial barriers to health care, whether by eliminating user fees or providing transport stipends, makes it easier and safer for women to get care. By working with governments and the public sector to build health systems that meet the needs of their citizens, we’re disrupting the cycle of poverty and disease.

As PIH celebrates the achievements of women, we remember there is still much to do. Preventing the “stupid deaths” of women—whether due to maternal causes, HIV, or gender-based violence—requires that we all commit to realizing the political, economic, and social rights of women in every country.

Thank you for standing shoulder-to-shoulder with our patients, community health workers, and staff around the world as we break down the barriers that drive inequality.

Erin George is a nurse-midwife and a 2012-2013 Yale Law School Gruber Fellow in Global Justice and Women's Rights. Through this fellowship, she is serving as the nursing and midwifery advocacy coordinator for PIH in Boston and Haiti. Jennie Riley is the project coordinator for PIH/Lesotho, providing programmatic management and support for all aspects of PIH’s work in Lesotho. Together they lead the PIH Women's Health Working Group.

Social service year physician Dr. Valeria Macias and Dr. Patrick Newman from Brigham and Women's Hospital conduct a patient consultation. Credit: Eva Quesada, S4C

“I didn’t know what to expect,” Dr. Abelardo Vidaurreta says. “I didn’t know where I was going.”

Such uncertainties were rare for the 27 year old. But after finishing medical school at Tecnológico De Monterrey, an elite university that produces some of Mexico’s finest physicians, Vidaurreta ditched the urban commodities he was accustomed to and went to work with Partners In Health’s sister organization Compañeros En Salud (CES) in southeast Chiapas. It’s among the poorest and most isolated regions in Mexico, nestled at the tip of the country along the Guatemalan border. 

The move wasn’t entirely impulsive. In Mexico, newly graduated medical students are required to spend a year working in a public health clinic to earn their professional license. Often they’re assigned to far-flung outposts with few resources and even less oversight. This baptism-by-fire approach can be overwhelming. It can also be frustrating, especially for the community members who are left seeking medical care from a rotating cast of fresh-faced doctors who’ll stick around for only a year. 

Vidaurreta had heard of CES when his social service year arrived, but he didn’t know much about the group, let alone its plans to revitalize a primary health care system in a long-neglected region. Doubts loomed when he agreed last February to be among the first doctors to spend a year working alongside CES in Chiapas.

“I thought I was going into the jungle,” Vidaurreta says. “I thought I was going to be alone.”

Dr. Abelardo Vidaurreta, among the first social service year physicans to work with CES, stitches up a patient's kneee. Credit: Balam-ha' Carrillo, S4C

Now, as CES—whose work is supported by Vermont-based Green Mountain Coffee Roasters—celebrates its first anniversary and more than 10,000 patient consultations, Vidaurreta jokes that he was wrong on both counts. The landscape is more Martian than jungle, marked by towering mountains and a startling lack of infrastructure. And while he would encounter countless challenges in the field, he wasn’t going to be tackling them alone.  A core mission of CES is to alleviate that daunting sense of solitude by pairing the new doctors, known as pasantes, with resident physicians from Brigham and Women’s Hospital in Boston. 

“They’re doing all the work,” says Dr. Patrick Newman, 29, one of the first resident physicians from Brigham and Women’s to take part in the program. “But we see their consults with them, answer their questions, help guide their thinking, help to challenge their thinking, and encourage their ongoing growth.”

Learning Exchange

Newman is quick to point out that the exchange of insight flows both ways. For instance, he recalls visiting a family whose newborn had a cleft palate. His instinct was to hospitalize the baby, insert a feeding tube, and perform surgery when the child reached an appropriate weight—standard procedure in the U.S. 

“That was my first suggestion. But it was obvious after talking with the pasante and visiting the family that doing so would result in absolute and total financial ruin for the family,” Newman says.  “You have to understand that there are cultural aspects to care that the pasantes are going to understand better than we ever will.”
 

Dr. Abelardo Vidaurreta, one of the first social service year physicans, checks a patient's eyes at a clinic in Chiapas, Mexico. Credit: Balam-ha' Carrillo, S4C

In the area where CES works, patients might travel more than an hour for a simple blood test. Getting to a hospital could take half a day. And though there are brick-and-mortar clinics, it’s been years in most cases since a full-fledged physician has staffed one. To make sure the pasantes are equipped to provide the best possible care in this difficult setting, they receive monthly visits from CES staff and attend regular workshops.

“Accompaniment is present at all levels throughout CES. It’s really the backbone to what we do,” Newman says. “This project is unique in that it was set up to tackle a different set of health issues than many other Partners In Health sites. We are very much focused on establishing a primary health care system in the same way you would think about going to your primary care doctor here in the U.S.”

As a middle-income nation with ample doctors, Mexico presents as many opportunities as it does obstacles. While infectious diseases such as HIV and tuberculosis exist, they don’t pose the same burden as chronic ailments such as diabetes, metabolic disease, and high blood pressure.

An Epidemiological Transition

“I expected to find more patients with infectious diseases,” Dr. Jafet Arrieta, CES’ director of operations, says. “But we started finding these diseases that are supposed to be first-world diseases. Then I realized Chiapas is already facing an epidemiological transition. They live in third-world conditions, but they are facing first-world diseases. That is a challenge because there is no comprehensive primary care system.”

To lay the groundwork, CES partnered with local Ministries of Health to pilot its program in two clinics last February. By August, the program had expanded to six clinics. Now CES is seeing an average of 1,500 patients per month. As the pasantes and other members of CES gained credibility in the communities, new opportunities to engage residents on health issues opened up.

“We have offered 35 workshops that have covered 20 different topics, from dental health to family violence to chronic disease,” Arrieta says. The workshops have attracted more than 3,500 attendees. “Even when people live in this level of poverty they want to learn about their health. They’re eager to learn, they just haven’t had the chance.”

Dr. Patrick Elliott from Brigham and Women's Hospital accompanies social service year physician Dr. Valeria Macias through a patient consultation. Credit: Balam-ha' Carrillo, S4C

With a year down, Arrieta can reflect on CES’ successes. News that those who spend their social service year in Chiapas with CES work closely with resident physicians trained at Harvard spread quickly. It’s a good selling point that helps attract new medical talent to what might otherwise seem like an undesirable location. But ensuring that the positive outcomes of CES are sustainable and replicable will take time. The pasantes, Arrieta hopes, will be compelled to stay in Chiapas and help break the cycle of poverty rather than heading to a major hospital or big city when the social service year ends.

There’s progress toward that direction: Vidaurreta’s year as a pasante has come to an end, but he’s continuing to work in the region as a CES program supervisor. He still encounters new uncertainties and difficult cases in the field. But when he has to, Vidaurreta knows he can reach out to his colleagues in Boston for advice.

“They now know how we work, how we live, and how the people here live. We have learned a lot from them, and I think they have learned a lot from us,” Vidaurreta says. “This experience touches everyone.”

In the past decade, deaths associated with HIV in Rwanda have plummeted by 78 percent—the largest such drop in the world. Meanwhile, the likelihood of a child dying before turning 5 fell by 65 percent. Between 2005 and 2010, more than 1 million Rwandans lifted themselves out of poverty. These are just a few of the many jaw-dropping statistics cited by Partners In Health Co-founder Dr. Paul Farmer and colleagues in a recent BMJ analysis that explores how Rwanda’s comprehensive approach to strengthening its health system after the 1994 genocide has transformed the country.

Rwanda’s turnaround is largely the result of its leaders prioritizing equity, human development, and health care for the poorest and most vulnerable. Since 2005, PIH and our sister organization Inshuti Mu Buzima (IMB) have partnered with the Rwandan government to improve access to health care in three rural districts: Butaro, Rwinkwavu, and Kirehe. We serve more than 800,000 people through 40 health centers and three hospitals—all public facilities.

A strong foundation of community health workers reinforces the health system and brings health care into every home. We work to support the Rwandan government’s efforts, including its remarkably successful National HIV Program. At the same time, we partner with the Ministry of Health (MOH) and local communities to develop low-cost, high-impact solutions that can be scaled up to improve health outcomes across the country.

Together with the MOH, we’ve built Butaro Hospital into a Center of Excellence in Cancer Care that is now a flagship center for medical care and education in east Africa. We laid the groundwork for a mentorship program that has dramatically improved nursing skills and is now being deployed countrywide. Our push to link communities with clinics and clinics with hospitals has greatly expanded access to health care.

But our commitment extends far beyond operating rooms and pharmacies. To counter the root causes of illness in Rwanda, we offer socioeconomic support to those in need, including transportation assistance, payments for school and health insurance fees, and microloans to start small businesses.

Of course, many challenges remain. Childhood malnutrition, high anemia rates among women and children, and neonatal mortality persist. Rwanda’s government is acutely aware of these issues and is collaborating with myriad stakeholders to effectively tackle them.

Still, as detailed in the BMJ article, Rwanda is poised to become the only country in the region on track to meet each of the health-related Millennium Development Goals by 2015. This isn’t a fluke, nor is it due to a stroke of good luck. It’s the result of a targeted and strategic approach.

Other countries struggling to improve health in the face of persistent poverty would do well to look toward Rwanda for insight.

Published February 22, 2013, in The New York Times:

A Chance to Right a Wrong in Haiti
by Louise C. Ivers

On Thursday, the United Nations secretary general, Ban Ki-moon, rejected a legal claim for compensation filed in 2011 on behalf of cholera victims in Haiti. Through a spokesperson, Mr. Ban said the claims, brought by a nongovernmental organization, were “not receivable” because of the United Nations’ diplomatic immunity.

Regardless of the merits of this argument, the United Nations has a moral, if not legal, obligation to help solve a crisis it inadvertently helped start. The evidence shows that the United Nations was largely, though not wholly, responsible for an outbreak of cholera that has subsequently killed some 8,000 Haitians and sickened 646,000 more since October 2010. The United Nations has not acknowledged its culpability.

Now, as the cholera epidemic appears to worsen, Mr. Ban and the United Nations have an opportunity to save thousands of lives, restore good will — and, yes, fulfill the mandate that brought the organization to Haiti in the first place: stabilizing a fragile country. The United Nations should immediately increase its financial support for the Haitian government’s efforts to control the epidemic. While that may not satisfy everyone, it will go at least some way toward compensating the people of Haiti for the unintentional introduction of the bacteria that caused the epidemic.

Before October 2010, cholera — a diarrheal illness caused by consuming water or food contaminated with the bacterium Vibrio cholerae — had never been reported in the country. In the epidemic’s first year, the striking loss of life attracted international media attention. Even in its third year, the outbreak continues to sicken thousands.

There were 11,220 cases nationwide during the month of December — significantly more than the 8,205 cases seen during December 2011. Our clinic in St. Marc treated more people with the infection last month than in the previous eight months combined.

That soldiers at the United Nations camp were responsible for introducing the bacteria seems apparent. After local and national protests and an Associated Press investigation, Mr. Ban empaneled a group of international experts to determine the disease’s source. Their report stated that evidence “overwhelmingly supports the conclusion that the source of the Haiti cholera outbreak was due to contamination of the Meye Tributary of the Artibonite River with a pathogenic strain of current South Asian type Vibrio cholerae as a result of human activity.” The strain was not indigenous to Haiti.

The report also found that sanitation conditions at the United Nations camp were not sufficient to prevent contamination of the local waterway with human waste. Investigators found that the potential existed for feces to enter the tributary from a drainage canal in the camp and from the open septic disposal pit that was used to handle the waste.

A research study published in January 2011 in The New England Journal of Medicine lent further support to the claim that the cholera came from the United Nations camp, as did an August 2011 study in another scholarly journal.

The interplay of biosocial factors inherently involved in epidemics make it difficult to pinpoint causality. If Haitians had better access to clean water and sanitation, of course, the cholera epidemic would have had a smaller impact and thousands of deaths might have been averted. (By comparison, there were few, if any, deaths from cholera in countries with effective water and sanitation systems where the organism appeared as part of this same epidemic — including the United States.)

But all of this is background to the urgent matter at hand. The United Nations recently started a 10-year initiative to eliminate cholera in Haiti and the Dominican Republic, based on a plan that was developed with multiple partners, including the governments of both countries. It is a collaborative and comprehensive approach that aims to eliminate transmission of the disease with substantial investments in water and sanitation infrastructure, as well as through prevention and treatment.

On Feb. 27, Haiti’s minister of health will introduce one important component of this plan — an initiative to expand access to cholera vaccination.

If the United Nations were to finance this initiative, along with the rest of the government’s anti-cholera program, it could have a significant and immediate impact on stemming this epidemic. As of now, however, the United Nations plans to contribute just 1 percent of the cost. That is not enough.

Meanwhile, the organization’s stabilization mission in Haiti is budgeted for $648 million this year — a sum that could more than finance the entire cholera elimination initiative for two years.

It’s time for the United Nations to rethink what true stabilization could be: preventing people from dying of a grueling, painful — and wholly preventable — disease is a good start.

Louise C. Ivers, a senior health and policy adviser at Partners In Health and associate professor at Harvard Medical School, has been leading cholera treatment and prevention activities in Haiti.

February 20, 2013, marks the seventh annual World Day of Social Justice, a day dedicated to advancing a world that promotes a peaceful and prosperous coexistence. 

Partners In Health has worked to pioneer and galvanize a social justice approach to global health since its inception 25 years ago, working alongside displaced peasants in the Central Plateau of Haiti. But what do we mean by a social justice approach to global health, why does it matter, and how is it different than other approaches? 

For PIH Co-founder Dr. Paul Farmer, social justice means providing a preferential option for the poor in health care. For us, this means that the poor and their interests should always be the top priority in all our efforts. We take this approach because it is a moral imperative, but also because it makes good epidemiological sense. Those who live in the throes of extreme poverty bear the brunt of ill health and preventable disease.

Furthermore, these efforts should be carried out in “pragmatic solidarity” with those facing injustices. As Dr. Farmer explains in his book Pathologies of Power, "Solidarity is a precious thing: people enduring great hardship often remark that they are grateful for the prayers and good wishes of human beings. But when sentiment is accompanied by the goods and services that might diminish unjust hardship, surely it is enriched. To those in great need, solidarity without the pragmatic component can seem like so much abstract piety."

Therefore, a social justice approach requires immediate, pragmatic action paired with a larger critical analysis of, and fight against, structural violence. In other words, in our fight to eradicate structural violence, we cannot overlook those suffering now. As Dr. Farmer puts it in Pathologies of Power, "The destitute sick ardently desire the eradication of poverty, but their tuberculosis can be readily cured by drugs such as isoniazid and rifampin."

But what are we supposed to do if we are not a doctor, nurse, or public health professional? What actions can we take in our daily lives to advance the human right to health?

For me, a non-health professional, these are questions I’ve wrestled with long and hard. As someone based in the U.S. with little in the way of technical skills, what difference can I make in the lives of a Haitian man with tuberculosis or a woman in need of a cesarean section in Neno, Malawi?

To me, community organizing—identifying and recruiting volunteer leaders, building community around that leadership, and generating power from that community—is a mechanism through which each of us can contribute to help shift the structures that prevent much of the world from being able to live healthy, dignified lives.

A heartening trend is the ballooning interest in global health among college students, young professionals, religious congregations, and even companies and their employees. Many organizations have grown in response to this inspiring trend: GlobeMed, FACE AIDS, and the Global Health Corps to name three. Each is focused on building deep communities of solidarity and leadership around the common purpose of advancing and realizing the human right to health for far more people around the world.

Looking forward, we need to explore new ways of collaborating to learn, teach, and raise the profile of the social justice approach to global health. We need grassroots fundraising teams so that more people support PIH and other organizations with similar mandates. And most importantly, we need to build more aggressive advocacy campaigns and actions that improve the way foreign aid and development assistance impact the rights of the poor.

PIH’s Chief Medical Officer Dr. Joia Mukherjee once said, “No data in the world, no good vaccine, no potent medicine will get to the poorest of the poor without you. There will be no equity without solidarity. There will be no justice without a social movement.”

On this World Day of Social Justice, let’s reflect on the fact that just as there will be no justice without a social movement, there will be no social movement without community organizing.

If you are interested in joining us in this movement to advance social justice and the human right to health, sign up to be a Community Organizer with PIH | Engage.

Thank you for all that you do—it means the world to us.

Jon Shaffer is the community engagement coordinator at Partners In Health. In this role, he is working to build a community organizing strategy that can strengthen the growing movement for health as a human right. Previously, Shaffer served for two years as the executive director of GlobeMed. He loves tossing the Frisbee, drinking good coffee, and being from Portland, OR.

A small group of people with a common goal: in American mythology, this is where famous rock bands and big businesses often begin. It is where in fact Partners In Health got started 25 years ago—with five American friends who were appalled by the great sickness of poverty in the world and who dreamed of seeing it cured. Needless to say, Partners In Health (PIH) has not succeeded yet. But it has made progress.

In its earliest days, PIH’s infrastructure was a two-room office over a seafood restaurant in Cambridge, Mass., and a one-doctor clinic in a squatter settlement in the Central Plateau of Haiti—in those days a wilderness of extreme poverty and disease. PIH was a grand idea then, and it is a grand idea today, but with a lot more behind it: some 14,000 employees who manage dozens of hospitals and clinics and have built and still are building schools and water and sanitation systems and houses for the very poor. PIH is doing that work in eastern Europe, Asia, South America, Africa, and of course in Haiti, the heartland of PIH, where it is struggling now to stanch a dreadful cholera epidemic and to lay durable foundations for the country’s post-earthquake reconstruction.

In all, PIH directly serves about 2.5 million of the world’s poorest people. It directly serves about 1.3 million in Haiti, in 12 different hospitals and clinics, providing medical care on the scale of a couple of big Boston teaching hospitals but at vastly smaller cost. Some aid organizations are notoriously self-serving, using large portions of the money they receive for their own administration and comfort. PIH spends only 7 percent of the money it receives from private donors on administration and fundraising.

It is mainly because it has grown in service that PIH has also grown in influence. PIH played an important part in the international debates about whether AIDS could and should be treated in places like Haiti and sub-Saharan Africa, debates that have largely been resolved in favor of treatment. But PIH’s role had less to do with talk than with its own AIDS treatment program in Haiti, which provided vivid, incontrovertible proof that the disease could be treated successfully in a deeply impoverished setting.

PIH did much the same thing with drug-resistant tuberculosis. They proved that controlling this disease was possible by devising and administering effective treatment in a peri-urban slum in Peru. They also played the central role in driving down the prices of the necessary drugs. Since then more than 100 countries have adopted PIH’s prescriptions for dealing with that dread and still widespread disease. Last summer PIH opened the first comprehensive cancer treatment center in all of rural East Africa. In this and many other ways, the organization continues to defy assumptions that many illnesses can’t be treated in the world’s impoverished places.

The scope of PIH’s work is international, and the heart of it is local. All its work relies on well-trained and salaried community health workers, more than 8,000 of them now, who serve patients in their own communities—“accompanying” those patients, in PIH parlance. This is the essence of PIH’s grand strategy, to address particular problems in particular places, and to learn how solutions in one place can be tailored to another. Part of this strategy lies in making projects indigenous. All too often aid organizations fail to do this, virtually guaranteeing that their projects won’t last, let alone flourish and spread. By contrast, all but a tiny fraction of PIH employees come from the countries and communities that are being served.

Waking up in the morning to news of the world, one can justly feel that violence and chaos are fully in charge. Just personally, I find it more than reassuring at such moments to know that there are some effective counterforces, some people out there trying to offer cures for the world’s great sicknesses. Nothing but hope suggests that these counterforces will prevail. But some basis for hope is far better than none. PIH’s vivid proofs of what can be accomplished in the face of poverty and disease is such a basis. It is, I feel, one of PIH’s most important gifts to the world.

Tracy Kidder, a longtime PIH supporter, is the author of Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World, and Strength in What Remains, among other books. His latest is Good Prose: The Art of Nonfiction.

The burden of tuberculosis in Lesotho, a small landlocked country surrounded by South Africa, is among the highest in the world.

Today Partners In Health Co-founder Dr. Paul Farmer and Executive Director Ophelia Dahl celebrated the opening of Lesotho’s National TB Reference Lab, the first biosafety level 3 lab in the country and one of only two such state-of-the art tuberculosis testing facilities in southern Africa.

The burden of tuberculosis in Lesotho, a small landlocked country surrounded by South Africa, is among the highest in the world. There are 633 new cases of TB per 100,000 people each year. Located in the capital city Maseru, the lab will allow cases of extensively drug-resistant tuberculosis (XDR-TB) to be identified without having to send samples outside of the country. Until now, identifying XDR-TB required samples to be shipped to labs in South Africa, a cumbersome and costly process that hindered care.

“This facility will help us diagnose tuberculosis sooner, thereby reducing transmission and decreasing mortality,” said Dr. Hind Satti, Lesotho country director for PIH. “The lab also provides the capacity to run a national drug resistance survey for the first time and conduct ongoing surveillance for TB throughout the whole country.”

Cases of multidrug-resistant tuberculosis (MDR-TB) and XDR-TB pose significant challenges in the resource-poor and geographically rugged country, where patients often have to travel hours through mountain paths to see a doctor. One study by PIH’s sister organization Partners In Health/Lesotho found that about 70 percent of adult MDR-TB patients also had HIV, and about half had low Body Mass Index, suggesting that they were extremely ill.

PIH/L takes an aggressive approach to fighting TB. If patients are extremely sick, clinicians will often treat them for MDR-TB based on their symptoms and history before tests results come back to ensure nobody dies while waiting for the results of diagnostic tests. After treatment has begun (treating MDR-TB typically takes two years), paid community health workers visit patients daily to make sure they’re taking their medications properly and to monitor for side effects.

This thoroughness has paid off. PIH/L has treated more than 800 MDR-TB patients with a success rate of 63 percent, similar to the success rates seen in settings where far fewer patients have both MDR-TB and HIV. Perhaps most impressive is that less than 1 percent of MDR-TB patients treated by PIH/L refused follow-up care.

It’s among the most basic, most critical, and most overlooked resources needed to run a hospital: electricity.

But in Haiti’s Central Plateau, the flow of energy is intermittent at best. Consider that in Mirebalais, located 30 miles north of Port-au-Prince, the power goes out for an average of three hours each day. This poses an enormous challenge to running any hospital; surgeries are jeopardized, neonatal ventilators stall, the cold chain is interrupted, and countless everyday tasks get derailed. As Partners In Health co-founder Paul Farmer noted during a recent lecture at the Harvard School of Public Health, “It’s not great if you’re a surgeon and you have to think about getting the generator going.”

To make sure the patients and staff at Hôpital Universitaire de Mirebalais (University Hospital) aren’t left in the dark, PIH and its partners looked toward the sun. Stretched across the roof of the new 200,000-square-foot hospital is a vast and meticulously arranged array of 1,800 solar panels.

On a bright day, these panels are expected to produce more energy than the hospital will consume. Before the facility even opened its doors—the official opening is slated for March—the system churned out 139 megawatt hours of electricity, enough to charge 22 million smartphones and offset 72 tons of coal. Perhaps most important is that the excess electricity will be fed back into Haiti’s national grid, giving a much-needed boost to the country’s woefully inadequate energy infrastructure.

Scaling Up

PIH is no stranger to solar energy. In 2007, we collaborated with the Solar Electric Light Fund (SELF) to install small-scale solar-energy systems at five clinics in rural Rwanda. Soon after, similar programs cropped up at PIH sites in Malawi, Lesotho, and Haiti. But scaling this technology to deliver reliable power for a 300-bed hospital demanded elegant design and extensive collaboration.

“The challenge was in the design and engineering, and getting the solar power produced to mesh with the often unstable grids and the backup generators,” said Jim Ansara, University Hospital’s director of design and construction. “At each step of the way, we were attempting things that had never before been done in Haiti.”

Solon, a German company, supplied the solar panels while Massachusetts-based Solectria Renewables manufactured the inverters, devices that convert the electricity and send it to the grid. To get the system up and running, engineers from Sullivan & McLaughlin Companies traveled to Haiti and trained six local electricians how to install and maintain the system. Two of the Haitian electricians will continue working at the hospital full-time when it opens (overall, it's estimated the hospital will create more than 800 new jobs for Haitians).

In order to maximize energy production, researchers from the University of Oregon provided sun charts that showed how to best position the panels. Though Haiti’s ample sunshine is what powers the hospital, the scorching temperature of a sunbaked roof could actually cause the panels to produce less electricity. To work around this conundrum, engineers floated the panels about a foot above the roof and added a coat of white paint, which lowers the surface temperature and bounces more sun rays on to the panels.

“This is an incredibly simple system to maintain once installed,” Ansara said. “All we need to do is rinse the panels quarterly with water.”

Sustainable Savings

In a country ravaged by deforestation, the ecological benefits of this alternative energy source cannot be overstated: Annually, the system is expected to save 210 metric tons of carbon emissions. 

And while a sea of solar panels perched atop a hospital in the mountains of Haiti is certainly eye-catching, it’s just one part of a comprehensive environmental strategy. Other green-friendly features at the hospital include natural ventilation that minimizes the need for air conditioning and motion-sensor activated lights that cut energy consumption by 60 percent when compared with traditional lighting.

This push toward sustainability and energy self-sufficiency translates into significant financial savings. In Haiti, electricity is expensive: The price per kilowatt hour is 35 cents, compared with 5.5 cents in New England. Using solar is expected to slash $379,000 from the hospital’s projected annual operating costs.

When fully operational, University Hospital is expected to be the largest solar-powered hospital in the world that produces more than 100 percent of its required energy during peak daylight hours, an impressive feat for the first-ever teaching hospital in central Haiti. The many lessons learned from the project will prove invaluable as PIH, its partners, and others undertake similarly ambitious and sustainable projects. 

As the three-year anniversary of the earthquake in Haiti approached, a flurry of news articles reported on failures in development and missed opportunities for rebuilding the country. Yet a Jan. 15, 2013, article in The Lancet, “Cautious optimism on public health in post-earthquake Haiti,” shows that significant progress has been made in addressing some of Haiti’s toughest health problems in the wake of the disaster.

Yes, Haiti achieved remarkable gains in public health after the earthquake in some of the most difficult circumstances imaginable.

In the past three years, access to life-saving antiretroviral therapy for HIV patients doubled, according to the article. Meanwhile, treatment coverage of lymphatic filariasis, commonly known as elephantiasis, which causes severe pain and disability, jumped from 35 percent to 90 percent in the same period. Furthermore, the cholera fatality case rate “has been maintained at less than 1% since January 2011.” At the same time, the country’s HIV program made significant progress in prevention of mother-to-child transmission of HIV/AIDS, and a successful measles–rubella and oral polio vaccine campaign for children launched in 2012.

From the perspective of Partners In Health and its Haitian sister organization, Zanmi Lasante, these results are not unexpected. For more than ten years, we have worked shoulder to shoulder with the Haitian Ministry of Health, the U.S. Centers for Disease Control and Prevention, and other partners to strengthen the health system in the Central Plateau and Artibonite regions. Major investments from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) have provided consistent, long-term support to build the capacity of Haiti’s public health workforce, facilities, and community-based programs. These efforts have created a solid foundation for improving health in Haiti. And that platform has grown even stronger after one of the worst disasters in modern history.

Soon the Haitian government will release the details of its plan to eliminate cholera. We urge the U.S. government and other partners in the public and private sector to support this plan and increase their support for health care services.

Based on Haiti’s recent track record in health, we know they will be sound investments.

Three years ago, Haiti experienced a devastating 7.0 earthquake that killed nearly 300,000 people and shattered the country’s infrastructure.

We remember and mourn those who were killed—friends and colleagues, mothers and fathers, brothers and sisters—as well as those who continue to suffer its effects.

Since then, Partners In Health and its Haitian sister organization Zanmi Lasante (ZL) have continued to provide health care to hundreds of thousands of people, including earthquake survivors, with the help of our supporters and partners. We created the Stand With Haiti Fund to address the immediate needs of victims and to work alongside the Haitian government to build and renovate the country’s public health infrastructure, strengthen its public medical education system, and expand PIH’s programs for community development and poverty alleviation.

PIH has fulfilled its pledge to spend the $123 million raised after the earthquake on these efforts. While there is much still to do, the following are examples of some of our work in Haiti.

An aerial view of Hôpital Universitaire de Mirebalais taken Dec. 12, 2012, shows 1,800 solar panels on the hospital's roof.

Hôpital Universitaire de Mirebalais (University Hospital)

PIH completed construction of the $17 million, 300-bed national public teaching hospital that will open in March 2013. Located 30 miles north of Port-au-Prince, the hospital will provide primary care services to nearly 185,000 people in Mirebalais and central Haiti, and provide advanced care to patients who are referred to University Hospital from community hospitals throughout the Central Plateau and Artibonite departments, as well as parts of Port-au-Prince. The teaching hospital will eventually employ up to 800 Haitian staff and serve as the first university teaching hospital in central Haiti, providing residencies and clinical rotations for Haiti’s national medical and nursing schools.

In addition, the hospital’s 1,800 solar panels will produce 100 percent of its energy needs during peak daylight hours and feed surplus energy back into the grid, the first agreement of its kind with Électricité d’Haïti.

University Hospital is PIH’s largest undertaking to date and will improve both the standard of health care for Haitians and strengthen Haiti’s public health infrastructure.

Mental Health Care

PIH responded to the psychological needs of Haitians affected by the earthquake by more than doubling the size of its mental health and psychosocial support team. This work is supported by a recent $1.5 million Grand Challenges Canada grant to improve mental health care in countries affected by disaster and poverty.

In 2013, PIH will train community health workers to identify and support people suffering from mental health problems, including depression and post-traumatic stress, and refer them to appropriate medical facilities. A pilot program will also incorporate the use of mobile phones by community health workers to diagnose and refer patients. The new program will develop a decentralized model of mental health care to be expanded nationally in Haiti.

Dr. Thelusma checked on a 2-year-old patient at a PIH/ZL cholera treatment center in Mirebalais, Haiti, last November.

Oral Cholera Vaccine Campaign

Cholera has killed 7,750 people in Haiti since October 2010. In spring 2012, PIH successfully pioneered Haiti’s first oral cholera vaccine, delivering vaccines to nearly 100,000 people in partnership with Haiti’s Ministry of Health and the nonprofit organization GHESKIO. Since then, the World Health Organization has called for the creation of a global stockpile of 2 million doses of the vaccine.

The United Nations recently included the use of the vaccine as part of a $2.2 billion plan to eliminate cholera in Haiti and the Dominican Republic. Dr. Paul Farmer, PIH co-founder and U.N. Deputy Special Envoy to Haiti, has been appointed U.N. Special Advisor for Community-Based Medicine and Lessons from Haiti as part of this cholera elimination plan.

A container of Nourimanba stands ready for distribution to malnourished children.

Treating Malnutrition

In partnership with Abbott Laboratories and the Abbott Fund, PIH will open a new production facility in early 2013 to combat the long-standing challenges of malnutrition. Located in Corporant, the facility will be used to produce a minimum of 60 tons of Nourimanba (a ready-to-use therapeutic food) to treat up to 6,000 cases of pediatric malnutrition in its first year.

The factory will create dozens of jobs and provide a guaranteed market for more than 250 local peanut farmers. This project also will be integrated into PIH’s agricultural initiatives to improve local farmers’ skills and expertise and strengthen their ability to supply the facility with a reliable supply of high-quality peanuts. Nourimanba has been locally produced and distributed by PIH on a smaller scale since 2006.

Our work of accompaniment is not over. We will continue to provide high-quality care to our patients, and to work with the Haitian government and communities to build and strengthen public health systems. As we remember those who lost their lives, we stand in solidarity with the millions of Haitians who are rebuilding their country, while also mobilizing around all that is left to do.

Christine Niyonsaba came to the Karama Health Center in eastern Rwanda recently with her infant daughter in her arms, ready for their monthly check-up. The 44-year-old mother of eight is HIV-positive.

Once inside the clinic consultation room, Nurse Solange Bazirete weighed Niyonsaba, measured her blood pressure, and took her CD4 count (a measure of immune system strength) before asking a series of questions: Do you take your antiretroviral medicine every day? Do you have any side effects? Does the community health worker come every day?

Bazirete moved on to a squirming Iratuzi, checking the infant's weight and nutritional status and continuing with her questions. Is Iratuzi getting her medicine every day? Is she sleeping under a bed net? Is she up to date on her vaccinations?

At the end of the consultation, Bazirete wrote the next appointment date in a small notebook Christine carries that contains her CD4 counts, appointments, and measurements.

Without treatment, a mother with HIV has a 41 percent chance of transmitting the disease to her newborn infant. However, with new medication regimens and proper medical care, it’s possible to reduce this chance to less than 1 percent.

To achieve that goal, PIH/Inshuti Mu Buzima has created “combined clinics” like the one Niyonsaba and Iratuzi are visiting in this rural village. Called Clinique Combiné, the clinics provide a one-stop medical home in which HIV-positive mothers and their newborn infants can receive care in a single place. This makes it easier for mothers to access services, which improves treatment adherence and retention, reducing the transmission of HIV and maximizing their infants’ growth and development.

It can also take a full day and a week’s wages to travel to a clinic in rural Rwanda, so it’s important that mothers receive the maximum possible care in one monthly visit.

“At IMB, we’re committed to not only preventing the transmission of HIV from mother to child, but we’re striving to eliminate new cases of childhood HIV altogether,” said Dr. Felix Cyamatare, IMB’s director of clinical programs.

In partnership with Rwanda’s Ministry of Health, IMB has established 37 of these clinics at rural health facilities across three districts, starting in November 2010. The clinics integrate services that had previously been offered separately: maternal HIV services, infant services, family planning services, and maternal, newborn, and child health services.

At the “combined clinics,” HIV-positive mothers receive support that includes post-partum care, antiretroviral medication, CD4 testing, breastfeeding support and education, family planning information, nutritional support, and psychosocial services. Their children receive post-partum care, tuberculosis and malnutrition screening, malaria prevention, and continued testing to determine HIV status. Both mother and child receive regular visits at home from a designated accompagnateur. And for those who can’t afford to pay, the costs are covered through IMB’s support of Rwanda’s mutuelle (national health insurance) program.

IMB-supported combined clinics have served more than 1,000 mother-infant pairs since October 1, 2012, and achieved an overall rate of HIV transmission to these infants of less than 2 percent, which achieves Rwanda’s targets for elimination of mother-to-child-transmission. Across sub-Saharan Africa, 17 percent of infants born to mothers with HIV still become infected with the virus.

“This model is one of a kind in sub-Saharan Africa and shows that integrating many services into one point of care is, in fact, possible,” said Dr. Neil Gupta, director of IMB’s infectious disease program. “This has never been done before, and the Rwandan government is interested in scaling up this model for the entire country.”

The combined clinics are just one part of IMB’s broader work to prevent mother-to-child transmission of HIV (PMTCT).

Since 2005, IMB has delivered lifesaving care to HIV-exposed children. Children receive HIV treatment, routine vaccinations, treatment for diarrheal disease, nutritional support to treat and prevent malnutrition, and their families receive home visits and socioeconomic support.

A recent IMB study published in the Journal of Acquired Immune Deficiency Syndromes found a fourfold increase in the number of infants enrolled in the PMTCT program from 2007-2010. During that time, IMB enrolled 1,038 infants, of whom only 27 tested positive for HIV. One of the 27 children died, and none were lost to follow-up. Of the pregnant women enrolled in the program, 94 percent delivered their babies in a health facility, where they received care and medications that prevent HIV transmission during delivery, and 99 percent of the infants received medications to prevent HIV transmission after delivery.

Additional PMTCT innovations include the development of a new electronic medical records system that registers all infants born to HIV-positive mothers, which allows staff to track down any children who miss appointments or have adverse outcomes. IMB also has developed expert nurses in PMTCT who provide ongoing mentorship and training to health centers. Rwanda’s Ministry of Health is currently adopting these models for the national PMTCT program.

“Together, IMB and the Rwandan Ministry of Health are showing that elimination of mother-to-child transmission of HIV—and an AIDS-free generation—is possible,” said Gupta. “And for mothers like Niyonsoba, that possibility is already becoming a reality.”

Supported by a grant from Grand Challenges Canada, the program will help Zanmi Lasante expand mental health screening and treatment—and serve as a national model for mental health care throughout Haiti.

When community health workers found Esther two years ago, she was living in a remote area of central Haiti, plagued by paranoia and voices in her head. Esther was taken to one of Zamni Lasante’s 10 hospitals, where she received social assistance, psychological support, and medication. Today, Esther reports that she is happy and symptom-free.

Fortunately, Esther’s condition was treatable. But the challenge in Haiti—and in the majority of developing countries—is that access to mental health care is extremely limited. In Haiti, there are just five psychiatrists and one neurologist for a population of 10 million.

PIH sister organization Zanmi Lasante (ZL) officially launched a new program today to both expand mental health screening and treatment in the Central Plateau and Lower Artibonite, and serve as a national model for mental health care throughout Haiti.

“This program will provide hope for patients who haven’t been able to face mental illness because of a bare lack of available resources,” said Father Eddy Eustache, ZL’s director of mental health and psychosocial services. “It provides hope for Haitian doctors, nurses, and community health workers who have been craving appropriate training. And it will provide a future for the Haitian people and government to see the eventual creation of a national mental health plan.”

The ZL program is one 15 initiatives around the world to receive funding as part of a $19.4 million Grand Challenges Canada grant to improve mental health diagnosis and care in developing countries, many of them ravaged by conflict, disaster, and poverty.

Over the next year, community health workers in Haiti will be trained to identify people in the community with potential mental health issues, make referrals for psychological and psychiatric treatment, and then provide community-based follow-up care. A pilot program will also incorporate the use of mobile phones by community health workers to help diagnose patients, improve patient monitoring, and report real-time data.

While the new program will improve care for ZL patients, the goal also will be to provide a decentralized model of mental health care to be expanded nationally in Haiti.

Addressing mental illness in Haiti and around the world is critical: The World Health Organization predicts that by 2030, depression will become the number one cause of disability. This burden is greatest in poor countries—where 85 percent of patients like Esther don’t receive the treatment they need.

Members of a PIH/ZL breast cancer support group discuss their challenges with the disease in Cange, Haiti.

In Haiti, the stigma women with breast cancer face carries an emotional weight, but it also can keep them from seeking help before it’s too late.

This year, Partners In Health's sister organization Zanmi Lasante began hosting regular support groups for women with breast cancer. During a recent meeting for mastectomy patients in Cange, oncology social worker Oldine Deshommes encouraged the dozen women attending to share their experiences and challenges with the disease, and their hopes for cancer prevention. One woman who is undergoing chemotherapy following a mastectomy in May told the group she “feels like a new person, rich in life.”

Their courage is remarkable given the fear and misunderstanding about cancer that exists within many communities. Every woman in the group had encountered some kind of resistance from loved ones while deciding to undergo a mastectomy. One 52-year-old patient received phone calls from family, friends, and neighbors pleading with her to decline the surgery, insisting she would die. Women in the group nodded their heads in agreement. One young woman explained how she was abandoned by her family following her diagnosis.

Deshommes encouraged the women to educate others about breast cancer and tell them about their own experiences. “We see women come to us too late, because others tell them they’ll die from the disease,” she told the group. “If women wait too long, cancer can spread. This is why coming in as soon as you find a lump is so important.”

Deshommes led a discussion about staying healthy and reminded the women to regularly check their other breast, demonstrating the proper method for a breast self-exam. The women enthusiastically reported that they already conduct breast self-exams and that they encourage women in their families and communities to do the same or to visit the clinic.

This kind of community outreach is working. Dr. Ruth Damuse, PIH/ZL’s oncology program director, now screens an average of 50 women each week at the breast cancer clinic in Cange—an increase from 15 women a week just one year ago. While some women are referred to the clinic by their doctors, many have begun visiting the clinic on their own. Perhaps most encouraging is that many of them arrive with less advanced stages of cancer.

The women in Deshommes’ support group are living proof to those around them that a breast cancer diagnosis doesn’t have to be a death sentence. From September 2011 to August 2012, ZL surgeons performed 158 cancer-related surgeries—the majority of them breast-cancer related. And access to chemotherapy is increasing—25 patients are currently on IV-administered chemotherapy. ZL also is treating 52 more patients with oral medications, both chemotherapy and other cancer treatment drugs.

As Deshommes brought the group to a close, she distributed breast prosthetics and bras to the most recent mastectomy patients. The women were glowing while they helped each other select the appropriate sizes and reclaim a piece of their self-confidence. “We are all each other’s mothers,” one woman pronounced.

The PIH/ZL oncology program is made possible largely with support from the Avon Foundation and the LIVESTRONG Foundation.