In this issue:
- READ, CONNECT, ACT: A Day of Nationwide Book Parties on Global Health
Join author Tracy Kidder and PIH physician David Walton for a live Webcast on November 12.
- From the desk of Heidi Behforouz ... Community Health Workers and health care reform
The director of PIH's project in Boston tells how community health workers could be a key to improving outcomes and reducing costs.
- Cruel and unusual—PIH board member takes cases to US Supreme Court
Bryan Stevenson and the Equal Justice Initiative challenge sentencing children to life in prison without a chance of parole.
- PIH helps launch report calling for increased US commitment to global health
On October 29, PIH joined with 24 other organizations to launch a Global Health Initiative request for US funding over the next six years.
- Newly built school opens in Domond, Haiti
Construction is completed on a brand new school for Domond.
- PIH and Rwandan Government graduate first class of OpenMRS trainees
Successful beginnings for an effort to increase local capacity for developing health-related information technology
- Quadruplets delivered at Butaro Hospital, Rwanda
- Some observations from the field
A journal report from Peru by volunteer Geoff Gusoff
- Plus 2010 PIH calendar, a new book co-edited by Paul Farmer, PIH photo exhibit in Santa Clara, Twittering, and PIH's move.
Above photo: Installing solar panels in Boucan Carre, Haiti.
From the desk of Heidi Behforouz ...
Community Health Workers and health care reform
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Heidi Behforouz
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My name is Heidi Behforouz. I am the Director of the Prevention and Access to Care and Treatment or PACT Project, PIH’s domestic project, where we employ community health workers—inspired by those in Haiti, Peru, and Malawi—to provide home-based services to the most marginalized HIV/AIDS patients in the city of Boston.
We hear a lot of talk these days about health care reform. The new lingo includes phrases like “public option”, “single payer”, and “global fees.” Perhaps the most interesting phrase is that of a “patient-centered medical home”: the concept that all medical care should be patient-centered and that all clinics and hospitals should be revamped to create a home-like atmosphere for patients and provide wrap-around services that address patients’ most complex needs.
I find the term “interesting” because the community health workers of PIH, including those of the PACT Project here in Boston, have been creating patient-centered medical homes all along.
We don’t need to start fresh; we just need to look around and acknowledge community-based models of care that are highly effective but largely unrecognized, perhaps because much of the care is being delivered by “paraprofessionals” who have not been extensively schooled in the biomedical model and don’t prescribe to hierarchical or office-based care. Their schooling and expertise is in the art and science of what we call accompaniment.
With the proper training and support, these accompagnateurs effect results. Here in Boston, not only have we demonstrated significant clinical improvements in the majority of our patients, we have reduced preventable hospitalizations by 40 percent and cut overall medical expenditures of our Medicaid patients. Clinic-based practitioners have also come to value the role of the CHWs—seeking their services for more of their patients and welcoming their input in case conferences and during office visits. We have been creating, in essence, patient-centered medical homes that offer quality care at lower cost.
Over the next five years, PACT is expanding its scope of work to utilize CHWs for the care of patients with other chronic diseases, including diabetes, heart disease, pulmonary disease, and mental illness. A managed care organization that is a Medicaid vendor here in Massachusetts will subcontract with PACT to provide CHW services to its highest risk patients: those with the poorest outcomes, the worst health care utilization patterns, and the highest costs. Our hope is that our CHWs can complement the work of office-based practitioners, improve the health of these patients, and reduce preventable emergency room visits and hospitalizations. If successful, we will have laid the groundwork for CHWs being recognized as legitimate health care professionals who deserve payer reimbursement and a place in the medical home … just as doctors, social workers, and nurses do.
Accompaniment is a beautiful thing. As practiced in the central plateau of Haiti, the foothills of Rwanda, or Boston’s inner city, it just may be the right phrase around which to reform health care, both here and abroad.
(These remarks are excerpted from an inspiring talk Heidi Behforouz delivered at the PIH Symposium on October 3. Click here to read the full text of Heidi's speech.)
Bryan Stevenson and the Equal Justice Initiative bring the case of children sentenced to life in prison without parole to the US Supreme Court
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Joe Sullivan, sentenced to life in prison without parole at age 13, is now 33 and confined to a wheelchair
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Bryan Stevenson (foreground) and Brandon Buskey (seated) of the Equal Justice Initiative
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Bryan Stevenson, the Executive Director of the Equal Justice Initiative who also sits on PIH's Board of Directors, is preparing to argue two cases before the Supreme Court of the United States on November 9. The cases will address whether it is constitutional to sentence a child to life in prison without parole for an offense committed during a temporary, and especially challenging, period in human development: adolescence. EJI believes that such a harsh sentence is cruel and unusual and also violates international law and the Convention on the Rights of the Child, which has been ratified by every country in the world except the United States and Somalia.
Read more about the Equal Justice Initiative and the cases of Joe Sullivan and Terrance Graham.
Watch a short video about the case.
PIH helps launch report calling for increased US commitment to global health
On October 29, PIH joined with 24 other organizations to launch a Global Health Initiative request for US funding over the next six years. Dr. Patrick Almazor from Zanmi Lasante, PIH's partner organization in Haiti, participated in a briefing at the US House of Representatives on October 29 as part of the launch.
The report released at the launch calls for:
- Bold coverage targets in each of the six GHI areas—Reproductive, maternal, newborn and child health; HIV/AIDS; tuberculosis; malaria; neglected tropical disease; health workforce—with specific recommendations for those targets
- Continued scale up of AIDS and infectious disease programs and fulfillment of the promises made in the Lantos-Hyde Act last year that reauthorized PEPFAR
- Simultaneous scale up of Reproductive, Maternal, Child, NTD, and health workforce investments and a specific call not to pit needs against each other
- A real increase in funding to a level of $95 billion over the six years--noting that the proposed $63 billion does not leave room to both scale up AIDS, TB, and malaria programs to promised levels AND address other pressing needs.
- Key policy changes in U.S. aid policies that would help transform development including calls for increased transparency, accountability mechanisms, and community-needs/right-based programming.
You can read and download the document at: www.theglobalhealthinitiative.org.
Newly built school opens in Domond, Haiti
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Before construction
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After construction
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September 9th was an exciting day in Domond, as a new school opened its doors to children who had previously attended a school with no doors and no walls.
Education is often the single most valuable tool for breaking the cycle of poverty that drives disease. In Haiti, a country where fewer than half of children aged 6-15 are able to attend school, education is a significant opportunity to improve children’s life prospects. School enrollment is especially low in rural areas like the Central Plateau region, where students' education is often interrupted during the harvest and rainy seasons and schoolhouses are in terrible condition, if not non-existent.
Construction in rural locations can be complicated, especially in Haiti where 80% of the roads are officially in “bad or very bad condition”. Before construction on the school structure could begin workers first needed to fix the potholed “road” leading up to the construction site. Construction was further complicated by the series of four hurricanes that devastated Haiti. But through it all the staff of Zamni Lasante remained committed to the people of Domond and work continued.
While Zamni Lasante (PIH’s Haitian sister organization) has a team of highly trained Haitian professionals that closely oversees the design and construction of all it’s projects, projects like this also offer valuable employment opportunities. In Domond, ZL employed local laborers for a variety of tasks from clearing the land and breaking rocks for gravel to assisting the construction crew on an ongoing basis. In keeping with our vision of pragmatic solidarity, we try whenever possible to employ those who may not otherwise have opportunities to work.
Now complete, the solidly built new school stands in stark contrast to the open walled, tin-roofed structure it replaces. The new school was made possible through investments from generous individual donors in support of a strong partnership for education between Zamni Lasante and the Digicel Foundation.
PIH and Rwandan Government graduate first class of OpenMRS Trainees
"We are trying to empower Rwandan students to take ownership of the software they have developed. Instead of depending on already developed software from abroad that is often expensive, they can build their own to fit the needs of various institutions," [PIH Trainer Rowan] Seymour said.
OpenMRS was pioneered in Rwanda by Partners In Health (PIH) at Rwinkwavu Hospital in the Eastern Province. Rwinkwavu Hospital is the largest health facility in the country that successfully uses OpenMRS.
- The New Times
Read more about this PIH supported training program in The New Times, a Rwandan English language newspaper.
Article: "The New Breed of Health Programmers"
Article: "Gov't Unveils e-Health Programmers"
Quadruplets delivered at rural Butaro Hospital, Rwanda
By Mickey Sexton, Butaro Hospital
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Mother and newborns
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Thursday, July 16, will be a day long remembered by those at Butaro hospital and in particular by Dr. Juvenal, the hero of the day, who delivered an unexpected set of quadruplets. The mother's 20-week ultrasound scan had revealed two babies. Three months later she decided to come to the health center because she had a slight cough – a great decision considering that only minutes later she was in labor.
At 6.30 a.m. the doctor on call contacted Dr. Juvenal to ask if he would keep a close eye on the progress of the mother's labor. On his arrival, Dr. Juvenal realized that the mother's abdomen was enormous—measuring 49 cm (more than 36cm is considered abnormal). He performed another ultrasound scan which, to everyone’s surprise, revealed three babies. The scan also showed that the first baby’s head was sitting in the pelvis and thus ready to deliver.
Knowing that the babies would be very premature, Dr. Juvenal was aware that they should ideally be delivered somewhere with a specialist in neonatal care. Nevertheless, he also realized that it was far too late to think about transferring the mother. To his relief, the first and second babies delivered without difficulty, coming out head first. Both were girls and, despite being small, were well. However, the third baby was in the breach position (feet first rather than head first).
Dr. Juvenal sought the advice of Medical Director, Dr. Tharcisse and PIH Obstetric specialist Dr. St Fleur – who advised action. Feeling a huge weight of responsibility on his shoulders, Dr. Juvenal broke the amniotic sac surrounding the third baby. Because the baby was so small, he was able to ease out a third girl by her feet.
By this stage, excitement was building within the maternity department. Imagine the disbelief when Dr. Juvenal announced that he thought there was another baby to come. Not needing any advice this time, he ruptured the sack containing the fourth baby girl and delivered her easily. That just left the placenta (a single placenta shared by all four girls!) to be delivered. The chances of a woman giving birth to quadruplets is in the region of 1 in 800,000. The odds of them sharing a single placenta run into tens of millions. Incredibly, all four babies were in good health and all weighed between 1700 and 1800g.
It wasn't long before word had spread, the courtyard was filled with people trying to catch a glimpse of the little celebrities and the news had been announced on national radio. The girls’ mother seemed to cope incredibly well with what must surely have been an overwhelming situation. With five children already, she was coming to terms with the fact she now had nine children to care for.
After a stay at the neonatal unit of CHUK hospital in Kigali, mother and children returned to Butaro hospital where they have been carefully monitored by doctors, nurses and nutritionists.
Ministry of Health staff and PIH staff have worked hard to provide nutritional assistance to a mother who would otherwise not have been able to feed the four babies. All four children are doing excellently, and now all weigh between 3.5kg and 3.9kg.
Dr. Juvenal expects that he will never feel such pressure and excitement again.
Some observations from the field
By Geoff Gusoff, PIH volunteer in Peru
 After two weeks of accompanying health promoters from Socios en Salud (the Peruvian sister organization of Partners In Health) on visits to patients homes, I've made a few observations. The first is that if you made a topographical map of Lima by using household income instead of meters to measure altitude that map would be almost a direct inverse of the actual topographical layout of Lima. That is to say the poorest people seem to live in the hills, and the higher up you go in the hills, the poorer people are. As it was explained to me, during Lima's population explosion in the last generation, droves of people moved from the country into the city and began these squatter settlements or "pueblos jovenes" in the unclaimed, unaccommodating hillsides. As new families move in, they simply build higher and higher up the hills. The cruel irony of this arrangement is that the people with the best views of the grandeur of the city have the least access to its resources.
I have also been made aware of the important distinctions that define the different levels of poverty here. The health promoters I have traveled with assess socio-economic status not primarily by asking about family income, but by noting whether the walls are made of wood or metal, whether the floors are dirt or cement, whether a patient has three meals or fewer, whether there is running water or electricity, etc. These factors not only define one's level of poverty, but also one's chances of responding well to treatment, so SES provides things like cement floors, waterproof roofs, windows, food and other resources to support the patients and their families. These modest improvements can literally mean the difference between life and death for the patients and their family members. (And in seeing all this I have to remind myself that Peru is not a poor country by world standards: it's 116 out of 229 countries in GDP per capita).
I've also learned a few things about tuberculosis treatment. A central focus of SES' work is to support patients being treated for Multiple Drug-Resistant Tuberculosis (MDR TB). Due to the complexity and cost of treating this disease, MDR TB used to be considered "untreatable" in resource-poor settings like the "pueblos jovenes" of Lima. It wasn't until Partners In Health started treating poor patients in Lima in the mid-90's with "first-world" success rates that the international health community started taking seriously the option of treatment. It's crazy realizing that every patient I see would have been deemed terminal just 10 - 15 years ago and now the vast majority are completely cured.
But what I've learned most is that the SES employees are inspiring people and their impact is truly tangible.
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