By Peter Drobac

A young, widowed mother of five named Patricie was recently admitted to the Burera District Hospital. She suffered from both advanced HIV/AIDS and disseminated tuberculosis. Though there are an estimated 600 new cases of tuberculosis in the district annually, Patricie was only the second person to receive treatment this year. Just a few months ago, there was only one physician to serve a population of nearly 400,000. Many faced limited access to health care, and despite the fertile volcanic soil, childhood malnutrition was rife.

We have seen this before. Three years ago, Partners In Health, in partnership with the Clinton Foundation, arrived in Rwanda to help the government rebuild health systems in two rural districts—Kayonza (Rwinkwavu) and Kirehe. Two hospitals and seven health centers later, hundreds of thousands of Rwandans have gained access to high-quality health care; more than 2,000 HIV-infected individuals are thriving with antiretroviral therapy, village-based accompaniment, and nutritional support; thousands of jobs have been created, many of them for our recovering patients. In Rwinkwavu, the contrast between the post-conflict desolation of 2005 and the lush gardens and bustling activity in the government-run facility of 2008 is striking—even for those of us who have seen this before in places like central Haiti.

So when the Government of Rwanda proposed an ambitious program to strengthen rural health systems throughout the country utilizing many of the core elements of the PIH/CHAI model, we were both humbled and delighted. The resulting framework, developed by the GOR in close collaboration with bilateral and multilateral funders, PIH/CHAI, and other NGOs working in the country, will require years of work, new partnerships, and significant funding.

The first step was to replicate the successes of the Rwinkwavu collaboration, and other health delivery approaches in use in the country, in one of the two remaining Rwandan health districts without a district hospital — Burera. Nestled in the volcanic hills of northwest Rwanda, Burera happens to be the prettiest corner of what just may be the prettiest country in Africa. Yet it is a large district, physical and communications infrastructure are among the nation’s poorest, and the GOR aims to accomplish the Burera scale-up more quickly — and more effectively — than ever before.

To help support such a daunting and critical project, as the implementing partner in the district, PIH needed to identify someone special.  Did we look to Harvard or another elite American university? No. Perhaps a respected international consultant? Hardly. Instead, we turned to rural Haiti.

Patrick Almazor joined PIH's Haitian partner organization, Zanmi Lasante, seven years ago as a newly minted young physician from Port-au-Prince. After several years of serving and training in Cange, Patrick helped to transform the delivery of health care at several facilities in Haiti’s central plateau.  He gained formal training as a public health practitioner, and then crossed the Atlantic to become PIH’s Burera District Director.

 Directly Observed Therapy in Tomsk
 
Patrick Almazor visiting Patricie and her family at their home
 Patrick and Patricie

Those familiar with the philosophy of PIH know that home visits are an integral part of our work. There is no substitute for the opportunity to sit with a patient in his or her home in an effort to understand the social, economic, and structural forces that shape lives and contribute to illness. For this reason, the first home visit in Burera felt like an inauguration of sorts. Dr. Patrick had met Patricie just a few weeks earlier during her initial hospitalization. Though gravely ill, she had survived that hospital stay and begun treatment for both HIV and tuberculosis—starting eight new medications, in all.  Patrick decided to see how she was faring at home.

The walk to her home involved about two hours of steady climbing, and brought us within a stone’s throw of the Ugandan border. Upon arriving, I quickly understood how it is that a child can starve in such a fertile region. Patricie and her five children live in a two-room shack with a thatched roof and a mud floor. Their home is nestled near a picturesque hilltop surrounded by lush fields of sorghum, corn, beans, and vegetables. Yet Patricie’s land is hardly bigger than the poor little house itself—none of those crops are hers. She has scraped out a living by working her neighbors’ land in return for a small share of the crop yield. Due to her illness, Patricie was unable to work at all for several months. Her husband had died years earlier of AIDS. As a result, her five children (though blessedly HIV-negative) clearly suffered from malnutrition and parasitic infection.

The GOR framework provides Patricie with more than medicines alone. She is visited daily by a trained accompagnateur from her own village, who provides a critical link to the health center. Patricie and her family receive both medical and nutritional support. We hope to someday help rebuild her house and help get her children to school, as has been done for hundreds of other destitute families near Rwinkwavu (and thousands in Haiti). Agricultural projects and other income-generating activities are planned, as the support becomes available.

Peter Drobac, M.D., is a clinician who works with PIH, predominantly in Rwanda, and aa Research Fellow in the Division of Infectious Disease and Social Medicine at Brigham and Women's Hospital in Boston.

[published June 2008]

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