Partners In Health Articles PIH a "Safety Net" in Haiti During Weeks of Unrest PIH CEO Dr. Sheila Davis spoke recently with leaders at Zanmi Lasante, as PIH is known in Haiti, and provides the latest information about the past six weeks of unrest across the country.

I’m reaching out to share with you an update on the ongoing crisis in Haiti, and what PIH is doing to make sure health care continues to reach every patient in need.

The protest movement that began last summer has escalated to massive demonstrations over the last six weeks. Throughout the country, hundreds of thousands have taken to the streets to protest the devaluation of local currency, high inflation (20 percent), and the alleged misuse of billions of dollars meant for social programs and infrastructure investments.

Protesters are demanding that President Jovenel Moïse step down and for a transitional government to assume power until new elections are held. President Moïse has so far refused to do so, further inflaming the protest.

Unofficial estimates say over 200 people have been injured and 20+ killed. It is impossible to predict when demonstrations will end, but movement leaders are vowing to maintain an “unlimited mobilization.”

Zanmi Lasante has kept the doors open and the lights on in every single facility."

The team at Zanmi Lasante is displaying extraordinary courage and shown incredible dedication amidst the strife, even over concerns for their personal safety. With gas stations running dry, grocery shelves emptied, banks closed, and health facilities shuttered throughout the country, Zanmi Lasante has kept the doors open and the lights on in every single facility.

As other hospitals shut down, more people are traveling to our facilities to seek urgent care. The hospital we support in St. Marc delivered 720 babies last month -- a 144 percent increase over the same period last year. While we’re proud to stand as a safety net for the entire Haitian health system, we know that many more mothers are unable to find a safe place to give birth as this crisis escalates.

Staff are scrambling to secure fuel for generators, dodging stones and tear gas—all to care for each other and our patients, many of whom struggle to meet their most basic needs on a good day. If PIH was founded on the idea of providing care that prioritizes the needs of the poor, then our colleagues are exemplifying the best of PIH. But they are in urgent need of fuel, food for patients and themselves, and basic supplies.

I will share updates as the situation progresses. Meanwhile, please keep Haiti and Zanmi Lasante in your thoughts and, if you can, consider making a donation to help us stay open.


Fri, 18 Oct 2019 09:52:48 -0400
CEO Dr. Sheila Davis Reflects on 5-Year Anniversary of the Ebola Outbreak in West Africa It has been five years since I went to Liberia and Sierra Leone to launch Partners In Health’s Ebola response. The memories from that first trip are very vivid. I remember sitting on empty planes arriving to airports, where most people were trying to leave the countries. I remember repeated temperature screenings in and out of every place we went, including along the roadways when we would need to get out of our car and line up to get our temperature checked before piling back in. I still have a pair of pants from those days with bleach stains up and down the legs, as we had to step in pans of bleach every time we went in buildings. And then there was the endless handwashing.   

It was a challenging time organizationally, as this was the first time we were entering two new countries to respond to a disaster of epic proportions. PIH responds to crises—acute and chronic—in every place we work: the tragic Haiti earthquake almost 10 years ago, hurricanes, floods, fires, cholera outbreaks, and the omnipresent crisis of devastating poverty. The decision to respond to Ebola was not a moral dilemma; we knew we could provide help and ease suffering. But the logistical challenges of setting up operations in two new countries simultaneously was another story. 

The decision to respond to Ebola was not a moral dilemma; we knew we could provide help and ease suffering."

I remember every PIH country site offering to send staff and provide operational support, although all sites run with not enough of their own staff on a daily basis. It was never a question that we should go and that everyone would pick up the slack, as many staff were needed immediately to provide logistics, operational, and on-the-ground support. The sense of solidarity that staff throughout all PIH sites showed to people they have never met, in places they have never been—that’s what was and remains the most compelling part of the PIH community. 

In Liberia, we were asked by the Ministry of Health to work in four of the southernmost counties, where there was limited access to any care, and the distances between sites on very difficult roads proved nearly impossible. We set up Ebola screening units and began working immediately to strengthen and rebuild the shattered health system. We remain in Maryland County today, home to J.J. Dossen Hospital and Pleebo Health Center. These facilities have transformed from empty, broken buildings with few—if any—staff, to bustling places full of clinicians, staff, and patients. They are also home to lifesaving surgeries and innovative community programs addressing mental illness and maternal and child health. Together with the government, we revitalized the entire country’s multidrug-resistant tuberculosis program, and patients now have access to care in a safe, dignified facility with expert clinicians. 

In Sierra Leone, we had planned to work in Kono District, where our sister organization Wellbody Alliance had been for a number of years. Instead, we were asked to go to Port Loko, the hotspot of the epidemic. True to our mission of partnering with the public sector, we joined the Ministry of Health in providing care at the Maforki Ebola Treatment Unit. We saved thousands of lives through the care delivered by PIH in partnership with the government in very difficult circumstances in the ETU, in community care clinics, and at Princess Christian Maternity Hospital—the high-risk hospital in Freetown, where women were dying in the parking lot. During our efforts, we hired more than 900 Ebola survivors to become part of our staff as community health and outreach workers and in all other aspects of our work. 

new mother of twin girls receives care in Sierra Leone
Kumba Komba is cared for at the Koidu Government Hospital postpartum area in Sierra Leone. She safely gave birth to twin girls via C-section at the facility. Photo by Jon Lascher / Partners In Health

We have remained in Sierra Leone, and now the once empty Koidu General Hospital is thriving and serving more than 500,000 people in Kono District. We are focusing on reducing maternal mortality by building a comprehensive maternal center of excellence, and have transformed the mental health hospital in Freetown. Just as in Liberia, we’ve brought our expertise from other PIH sites to tackle MDR-TB and provided the first comprehensive care for patients ever available in Sierra Leone. 

When I visit West Africa now in my current position as CEO, I will see the amazing influences of Haiti, Rwanda, Malawi, and all PIH sites. If Ebola were to strike again in the places we work, I know that the outcome would be very different because of our past six years of experience in Liberia and Sierra Leone. We responded to a disaster, and we stayed. Our mission of responding to human suffering and providing quality health care for all is what connects us throughout the world, and what will sustain us moving forward.

Wed, 16 Oct 2019 13:00:56 -0400
How Three Girls Defied the Odds to Join First Medical Class All over the world, millions of girls are denied basic human rights, such as access to health care and education. Since 2012, October 11 has marked the annual International Day of the Girl, a celebration that advocates for girls’ empowerment and human rights.

This year, at Partners In Health, we are celebrating girls who have broken down barriers, defied stereotypes, and beaten the odds to work toward their dreams.

Promoting gender equity is a central mission at the University of Global Health Equity, a PIH initiative in the rural, northern Rwanda community of Butaro. When admitting its first class of medical students, the university prioritized the education of young women, who have been historically underrepresented in higher education and medicine in Rwanda.

The inaugural class includes 30 students, two-thirds of them women. Every one of them has a strong belief in health equity and providing for the poor. Today, we share the stories of three of these young women, each of whom had experiences as young girls that have inspired them to pursue careers in global health. 

For this International Day of the Girl, we celebrate their achievements, and their journeys toward becoming the next generation of women leaders in global health.

female medical student in Rwanda
Alima Uwimana

‘We are still so grateful’

Alima Uwimana, 20, could hardly believe where she was when she stepped foot on campus in Butaro, alongside 29 strangers who would be her classmates and community for the next six and a half years. For her entire life, until that moment, her new reality had never seemed like a possibility.

Uwimana grew up in a rural village in western Rwanda, near borders with the Democratic Republic of Congo and Burundi. Her family often struggled with money, and never thought they’d be able to send her to university. 

But Uwimana, the youngest of 10 children, now could be the first to graduate from college. Of her six sisters, she is the only one to make it to high school, where she excelled in the sciences and worked hard to maintain good marks.

She now is attending UGHE on a full scholarship, thanks to the generosity of UGHE donors and a partnership with Rwanda’s Ministry of Health.

“We were all laughing and smiling so much,” Uwimana said, recalling the moment she and her family learned she would join UGHE’s inaugural medical class. “We were so thankful. My family had no idea it was possible for me to get a full scholarship. We are still so grateful.” 

Uwimana is an aunt, with 28 nieces and nephews, and she wants to help each of them believe in themselves and pursue their passions, as she did.

“I want to show them that even though they may not have a lot of money, if they have commitment and patience and if they study hard, they can achieve their dreams,” she said.

Uwimana knew her dream at a young age. She remembers watching television as a girl and listening to Rwanda’s newest minister of health at the time, Dr. Agnes Binagwaho—now UGHE’s vice chancellor—outline her vision for the country’s health system. Binagwaho called for quality health care for all and an agenda that focused on the poor and vulnerable. 

I feel that I will achieve my dream of being a medical doctor who will be serving the vulnerable and the poor who are in need.”

Uwimana thought about her own family, who had faced so many challenges with the health system due to financial difficulties, and how Binagwaho’s vision could affect them. 

One of Uwimana’s brothers lost his abilities to speak and hear, due to ailments that could have been cured had their family had the money for the specialist he needed. Her nieces and nephews, the very ones she hopes to inspire with her career, have often suffered from malnutrition, and her siblings have gone into debt to get them treatment. 

Listening to Binagwaho, Uwimana began to understand not only her feelings while watching her family’s struggles, but also how she could help. She could become a doctor who cared for those in need, regardless of their economic status. She thought that maybe she could even be Rwanda’s minister of health and, like Binagwaho, change the system so families like hers could get the health services they needed. 

“I was inspired by the way she put the health of the citizens first, and she is the one who first saw that everyone deserves health regardless of financial capacity,” Uwimana said. “I was inspired by her and thought, one day, maybe I could be like her.” 

Now, as a first-year medical student at the university led by Binagwaho, Uwimana can’t help but smile when asked how she feels about studying under the woman who inspired her, years ago, to pursue this path. 

“I’m so happy and excited. I feel blessed being here,” she said, glancing toward the entrance to Binagwaho’s office. “I feel that I will achieve my dream of being a medical doctor who will be serving the vulnerable and the poor who are in need.”

female medical student in Rwanda
Marie Immaculee Dusingize

‘A smile is enough’

Marie Immaculee Dusingize, a 19-year-old from Rwanda’s Southern Province, knows the inside of a hospital far too well for someone her age. 

When she was 10, she started complaining of debilitating stomachaches. She couldn’t keep food down and had to resort to an extremely strict diet to minimize her pain. Dusingize spent many days and nights in different hospitals and health centers seeking treatment, but to no avail. To this day, she still experiences aches and pains and maintains the same rigid diet.

Her time in the hospital, while challenging, opened Dusingize’s eyes to the problems people face seeking health treatment. Her experiences left her dissatisfied with the quality of available health care, but it was the inequities she saw in the experiences of other patients that truly had an impact on her.

“I remember someone rich came in with just the flu and got treated right away, while someone with a serious kidney condition had no money for the exam and was turned away,” she said . “How can poor people die in front of the door of the hospital just because they don’t have money to pay?”

When I become a doctor, it will be my chance to give out what I have never been given or what I have seen others deprived of."

Dusingize has always looked out for others in need. Early in high school, she noticed how many graduating students would throw away most of their things at the end of the year. She thought about her neighbors—who couldn’t afford basic needs like shoes, clothing, and school supplies—and realized she could do something. So she stood next to the trash can, and when students came to throw their things away, she would ask them to give them to her instead.

“My friend saw me by the trash can and asked what I was doing, and when I explained it to her, she helped me announce it to the school. We decided to make it permanent,” she said. And that was the origin of her nonprofit, Charity Foundation. “Every time we throw away things we no longer need, those things may be useful to those who can’t afford them.” 

Dusingize attributes this selflessness to her mother, who showed her the power of a helping hand. Her mother has been by her side throughout her years of illness. While her mother has no formal medical training, Dusingize says she has been a healer in her own way. 

“What I learned from her is that we should give what we have. It’s not necessary that we say that, because I am not a medical doctor, I can’t help,” Dusingize said. “A smile is enough. She could always smile at me and say words that would make me forget that I was even sick, so I really regard her as a medical doctor.” 

The values that Dusingize draws from her mother have guided her to where she is today. 

“When I become a doctor, it will be my chance to give out what I have never been given or what I have seen others deprived of,” she said. “I feel like the world will be mine to change.”

female medical student in Rwanda
Eden Gatesi

‘We share the same vision’

Eden Gatesi didn’t get to spend much time with her mother when she was growing up. Her mother was a nurse, and would leave early in the morning to take care of patients, then return home late at night. The precious time they spent together, however, had a big impact on Gatesi.

“What impressed me most was even the little time she could spend at home, we would get visitors coming over to thank her for saving the lives of their beloved ones,” Gatesi recalled. ”That showed me that dedicating my life to being a health professional would help me to have an impact on my community and save their lives as my mom does.”

Although Gatesi knew she wanted to follow her mother’s footsteps, she felt pressured by societal and cultural norms. Many people in her life didn’t understand how she could spend so many years at school, and felt she should instead focus on raising a family. She didn’t know a single female cardiologist, the profession she knew she wanted to pursue. Gatesi, herself, began to experience doubts about whether she should follow her dreams.  

All that changed in 2016, when Gatesi was invited to attend a prestigious camp called Women in Science, organized by the UN-backed nonprofit GirlUp. The camp was an opportunity for girls from across the globe interested in science and technology to come together for two weeks of leadership development training. 

“It was a great honor for me,” Gatesi said. “It was my first time ever leaving the country, because the camp took place in Malawi, but it was a very good experience for me to meet girls from all over the world. We don’t share the same culture, but we share the same vision and same ambition.”

Being around these like-minded girls, who all had dreams of having an impact on the world through science, removed any doubt from Gatesi’s mind about becoming a cardiologist.

..the future of Rwanda’s health sector is really bright because it has us—girls and boys who are passionate about becoming doctors and are not hindered by people’s mindset and view of gender.”

Gatesi returned home with a renewed belief in herself. But she knew there were many other girls who hadn’t had an opportunity like hers, and might still be experiencing the same doubts that she had. She joined a group called Dear Doctor, which brings together students who have an interest in careers in medicine, as a way to give back to girls like herself. 

“I came back to school wishing to help other girls who think that they can’t (be a doctor),” she said. “Joining the Dear Doctor club helped me to show them that they really can.”

As part of the club, Gatesi helped organize events where girls discussed challenges females face in the medical field, and invited doctors to speak about their careers. She also facilitated visits to nearby hospitals to meet with patients, and coordinated student internships with local health centers. 

Now, as a member of UGHE’s majority-female, inaugural medical class, Gatesi brings the lessons she learned growing up to a university that prides itself on its commitment to equity. Here, she has found another community of people who share her vision, and said she feels optimistic about this new generation of leaders.  

“Starting my journey at UGHE, where we are 20 girls and 10 boys, it has shown me that the future of Rwanda’s health sector is really bright because it has us—girls and boys who are passionate about becoming doctors and are not hindered by people’s mindset and view of gender.”


Thu, 10 Oct 2019 22:08:53 -0400
"The Right Medicine": Young Woman Triumphs Over MDR-TB Cylian B. Kargbo is planning for her future. “My birthday is coming up!” the 12-going-on-13-year-old from Calaba Town, Sierra Leone, proudly announced, looking ahead a few weeks when she would celebrate with, first and foremost, “pizza!” Further down the line, Cylian has even bigger dreams: “I want to be a lawyer—study abroad, then come back to Sierra Leone to help the people in my country.”

Warm, thoughtful, and fiercely intelligent, Cylian has a bright future ahead, from her next month to her next 10 years. But it wasn’t always guaranteed. Plans for law school or even a birthday party began slipping away when, last July, she experienced her first symptom of multidrug-resistant tuberculosis (MDR-TB).

“Side pain,” Cylian remembered simply, citing the reason her family first took her to Ola During Children’s Hospital the capital city of Freetown. There, she was diagnosed with and treated for malaria, but her pain persisted. By October, said her father, Manso Kargbo, it got so severe that Cylian was unable to sleep.

Cylian's father, Manso Kargbo
Cylian's father, Manso Kargbo, ensured  his daughter got the care she needed. 

Another trip to the hospital resulted in a diagnosis of tuberculosis (TB). But even TB drugs did nothing to improve Cylian’s health, which was deteriorating faster and faster. By the third week spent in her local emergency room, Cylian was in and out of consciousness, on oxygen, and unable to digest food. The Kargbo family’s friends and neighbors suspected witchcraft, and suggested that Cylian be seen by a traditional healer.

Doctors and nurses had another theory: MDR-TB, the drug-resistant strain of the world’s leading infectious disease killer.

An Escalating Illness, and a Lifesaving Partnership

Though TB was eradicated long ago in most wealthy parts of the world, poverty and a lack of strong health systems have allowed it to plague Sierra Leone, where, according to the World Health Organization, roughly 300 cases of TB are found per 100,000 people. For comparison, high-income countries find less than 10 new cases of TB per 100,000 people—around the rate at which MDR-TB cases present in Sierra Leone. The specialized drug regimens and care required to cure patients with MDR-TB were never available in the country, leaving countless people to die and the deadly airborne disease to proliferate.

This unjust reality faced a turning point in April 2017, when Sierra Leone’s National Leprosy and Tuberculosis Program, led by Dr. Lynda Foray, and Partners In Health (PIH) jointly established the country’s first and only MDR-TB treatment program, located at Lakka Hospital in Freetown. The National Tuberculosis Program brought in the critical equipment to diagnose MDR-TB, the lifesaving drugs to treat it, and the hundreds of team members to deliver the care. Despite this commitment, a gap remained—which PIH swiftly filled.

Lakka Hospital in Freetown, Sierra Leone
Lakka Hospital, located on the outskirts of Freetown, Sierra Leone, is the country's only facility offering MDR-TB care. 

PIH infused Lakka with the other resources necessary to cure MDR-TB: a robust supply chain to ensure the availability of critical equipment and drugs for managing TB complications; the addition of clinical mentors with expertise in the disease; and continual building renovations to make receiving and delivering care more comfortable and dignified.

Together, Sierra Leone’s Ministry of Health and Sanitation (MOHS) and PIH also ensure 24-hour electricity and running water at the facility, in addition to providing support packages to outpatients who couldn’t otherwise afford food or transportation to the hospital for check-ups.

Lakka Hospital's pharmacy, stocked with help from PIH
The pharmacy at Lakka Hospital, jointly stocked by PIH and Sierra Leone's National TB Program.  

So far, clinicians at Lakka have treated more than 322 MDR-TB patients, and have seen a cure rate of 74 percent—among the best success rates globally, even with only a handful of doctors working specifically on TB within the country.

Saving Cylian, Through Food, Medicine, and Care

Support from the government and PIH arrived at Lakka not a moment too soon, and neither did Cylian. “When they referred me to Lakka, I was unable to walk, I was unable to eat for myself,” she said. Nor was she able to stand or sit on her own. “Her condition was so critical,” Kargbo said. “There was no flesh; only bones. You could count her ribs.”

Dr. Rashidatu Fouad Kamara, MOHS lead clinician at Lakka; Dr. Mariama Mahmoud, the facility’s now medical superintendent; and TB doctor Dr. Michael Mazzi reassured Kargbo that his daughter would get better, and immediately began her on treatment. This consisted not only of medication, but also food, which her body desperately needed to tolerate harsh MDR-TB drugs and grow stronger. PIH and the National TB Program began a special meal program, with foods rich in protein and fat, and asked Cylian what she liked to eat. Fried rice, her favorite, became a regular menu item, and was arguably as essential as drugs.

“With that special food, it was like magic,” Kargbo said. “Cylian’s health was changed within two months. She started to walk. Dr. Kamara and Dr. Mazzi exercised with her every day.” This success inspired hospital staff to introduce enriched meals to other TB patients in similar situations; today, they equally benefit from an enhanced diet.

A meal provided at Lakka Hospital
Meals provided at Lakka are an essential part of treatment for MDR-TB, and help patients heal. 

Kargbo stayed with his daughter for more than one month as she recovered, then sent one of Cylian’s cousins to stay and keep her company. But even in the family’s absence, he knew Cylian was in good hands. “I’m so grateful,” he said. “It was not only the nutrition and feeding they provided to Cylian, but they also provided psychosocial counselling. I think of that—to have people get close to Cylian, to embrace her.”

With this comprehensive health care, Cylian’s health only continued to improve. After five months at Lakka, she was healthy enough to be discharged and continue treatment at home. And soon later, she was declared free of MDR-TB.

“Imagine—when Cylian was first taken to the hospital, she cannot walk, she cannot breathe properly without oxygen. Now, she can breathe for herself. She can walk. She can eat. She’s gained weight,” Kargbo said. “With timely intervention, Cylian recovered within a short time. I can embrace my child in her healthy condition.”

A TB Advocate is Born

Cylian isn’t the only one looking forward to the days ahead; her father is, too. “I hope for Cylian to achieve all her dreams,” he said. “Whatever she wants to be, that will be determined by Cylian. And I will give her the support to reach those heights. If you have a dream, you must have somebody to help you reach it.”

Last March, hinting at what type of attorney she might someday become, Cylian urged her government and PIH to continue fighting to eradicate TB and MDR-TB in Sierra Leone and around the world. Paying a visit on World TB Day to the facility that helped save her life, she shared her story in front of patients, staff, and Dr. Alpha Wurie, Sierra Leone’s Honourable Minister of Health and Sanitation. Her speech ended in an appeal for more support for Lakka, and for others to seek treatment there.

“We beg other patients who have TB, do not sit in your house,” she said. “Let them come and see the doctor and they will give them the right medicine.”

Thu, 10 Oct 2019 15:12:19 -0400
Battling Mental Illness, One Home Visit at a Time Community health workers are the bridge connecting their neighbors, friends, and family to local clinics across the 10 communities in which Partners In Health works in rural Chiapas, Mexico.

In July, Compañeros En Salud—as PIH is known in Mexico—launched a new initiative that trained five workers in the provision of mental health care, with the hopes of soon growing their number to 10.

This innovative program directly addresses a mental health care gap in Mexico. There are an estimated 210 psychologists and four psychiatrists in the entire state of Chiapas, home to 5 million people. Broken down by population, that means there are roughly four psychologists for every 100,000 people, compared to 12 psychologists for every 100,000 people in the rest of Mexico. About 1.4 million people in Chiapas suffer from depression and other mental illnesses.

There are simply not enough properly trained clinicians available to address the burden of mental illness in Chiapas.

That’s why PIH’s community mental health workers in Monterrey, Honduras, Laguna del Cofre, Salvador Urbina, and Capitán are key to reaching the most vulnerable patients battling depression and anxiety. After patients have been diagnosed by a PIH-supported clinician in these rural communities, they are connected with a community mental health worker, who visits their home regularly to provide counseling and support.

In honor of World Mental Health Day, each community mental health worker below shares why she is committed to providing care to her neighbors, friends, and family.

Zoemia Salas Morales

Zoemia Salas Morales, Community Mental Health Worker

“My work consists of making home visits to patients who have been diagnosed with depression and anxiety, giving them short therapy sessions so they can understand their feelings better and get tools to overcome these conditions.

Sometimes it’s hard to be a community mental health worker. After doing my work, I have to get back home, cook for my family, take care of my husband and children, do the laundry, and clean the house. Even then, some people in the community judge me because they think I should be staying at home, that I’m not doing enough for my family. But they don’t understand I’m doing this because I want to help people, even if it means walking long distances to get to my patient’s houses.

There are some patients who refuse to get treatment because they’re ashamed of themselves. They fear people around them will find out they’re suffering from a mental illness, but that’s just a stigma we’re trying to overcome. I like to keep learning about mental health, because it’s so much different from physical pain. Sometimes people don’t realize that what’s being hurt is their feelings, and how important it is. I’m here to help them have a safe space to talk about it.”

Roselia Díaz

Roselia Diaz, Community Mental Health Worker

“I want to help people suffering from mental illnesses, because in the past I’ve suffered from them too. I can understand how my patients are feeling, and I want them to know that if I’ve been able to overcome these problems, anyone can.

It has been hard for me because I’m a very shy and anxious person. But while I help others, I know I’m helping myself too, conquering my own fears, and turning them into self-confidence.”

Juana Roblero

Juana Roblero, Community Mental Health Worker

“The community mental health workers’ program immediately called my attention, because I knew my mom had suffered from depression and I didn’t know how to help her. I thought that if I became one of them, not only would I be able to help out my mom, but the rest of the people in the community, too.

Sometimes we don’t have any idea of what others are going through. And sometimes even these people can’t exactly explain how they’re feeling. That’s when I come in, helping them out with these problems, giving them hope.”

Carolina Guzmán

Carolina Guzman, Community Mental Health Worker

“As a community mental health worker, I feel like there are a lot of things depending on me and my perseverance. It is important not to give up on others. Because after all, I’m doing this to help them, and helping is never a burden. When it comes straight from your heart, it will never feel like it’s hard, or impossible.

I know I still have a lot to learn, but I’m positive that every single day I’m becoming a better person.”

Nelcy Roblero

Nelcy Roblero, Community Mental Health Worker

“People know me because I’m a hard-working woman, and my passion is to help other women, men, and children. I’m very happy to be a community mental health worker, because now people don’t have to travel long distances to the closest towns in order to get this kind of attention.

I like it when patients come to me and tell me how much I’ve helped them. I enjoy watching them flourish, because more than a worker, I would like for them to see me as a trusted friend, lending a hand to them, showing them that they’re not alone. Beyond the poverty and marginalization, there are so many capable, strong, and loving people around here.”

Wed, 09 Oct 2019 14:49:14 -0400
Dr. Kilongo Papy Mulailwa Thanks PIHers for Supporting New Surgical Theater Thanks to this support, we exceeded our funding goal for this project and work can begin on a new surgical theater to help Dr. Papy, the heroic general surgeon serving the 500,000 people in Kono District, keep his patients safe from infection.

Dr. Papy sent along this video with his personal thanks.

Wed, 09 Oct 2019 13:58:44 -0400
Mental Health Care for Homeless Begins with Clean T-Shirt, Warm Meal, and a Bath Three years ago, Winston Appleton had all but given up on life. He slept rough in the shadow of decaying mansions in Harper, Liberia. He lived on a diet of mud and “Italian white”—the Liberian term for low-grade heroin. He talked to himself, using discarded plastic straws to inhale the smoke, vapor drifting up towards the crumbling eaves. Unaware of his surroundings, he sometimes fell asleep in the middle of the road.

When Partners In Health’s mental health team first spotted Appleton in the rainy season of 2016, he was hallucinating and walking around unclothed. They tried to invite him to a nearby clinic for access to care, but when they greeted him he shied away. They knew they needed to patiently earn his trust. 

The process started with a clean t-shirt. The PIH-ers left it out for him along with new pants and shorts. Then they offered him warm bowls of rice and sauce and cold sachets of drinking water. Next they gave him a toothbrush and toothpaste, and gently offered him the chance to bathe in the local river, a common spot for Harper residents, many of whom lack running water. After a few weeks, Winston agreed. Finally, wearing clean clothes and feeling good about himself for the first time in decades, Winston went with the team to the clinic, where they were able to diagnose him with schizophrenia and prescribe him an antipsychotic. 

Such is the transformative work of PIH’s homeless outreach program in Liberia. Since it began in 2016, Program Manager Bethuel Nyachienga and his 12- person mental health team have helped 149 homeless people in Maryland county, home to the district of Harper, access not only medication but toothpaste, soap, and clean clothes. The results speak for themselves: since being diagnosed and entering into care, more than 50 percent of patients have moved back in with their families. 

Homeless Outreach in Liberia

Mental health services are extremely limited in southeastern Liberia, where traditional medicine and beliefs of witchcraft carry great weight. There, homelessness is often preceded by mental illness; many people are ostracized from their families and communities once symptoms show. 

But collaborating with traditional and faith healers and community leaders, PIH is working to change that dynamic. Since 2016, the team has treated more than 1,500 people for mental health conditions at three clinics in Harper and Pleebo districts and J.J. Dossen Hospital. They include the 149 people who benefited from the homeless outreach program.  

It’s not in any book. We started it to create dignity. … And then we see that they start to be accepted in society.”

Supervised by psychiatric nurses, community health workers in Harper and Pleebo districts approach homeless patients and gain their trust through daily visits, which often involve bringing them food and clean water to drink. Over time, patients accept clean clothes, assistance with finding privacy to bathe, and the chance to visit a clinic for a mental health assessment. If they are placed on medication, community health workers monitor their side effects daily, while also encouraging them to reunite with their families and attend their regular clinic appointments.

The idea came from Nyachienga, whose work in Liberia builds on his background treating patients in Dadaab refugee camp in Kenya. “It’s not in any book,” he said. “We started it to create dignity. They have no place to sleep, nowhere to eat, and no one to talk to. We give them clean clothes. We give them food. We give them medication. And then we see that they start to be accepted in society.”

Garmai Cyrus, PIH’s mental health coordinator in Liberia, said that something as simple as hygiene makes a significant difference in patients’ lives.  “Bad hygiene separates people,” she said. “Wearing dirty clothes, not bathing, not brushing your teeth changes a whole lot. As we started offering hygiene care to these patients, we saw that something else was happening; they were becoming more acceptable in the community.”

The outreach program is now a cornerstone of PIH’s mental health care approach in Maryland county.

The first person whose life the program transformed was Sophie Prowd, a woman in her early 30s who had lived half her life on the streets of Harper. Her trouble started when she showed symptoms of psychosis and her husband took her to a traditional healer, who said Prowd was a witch. Prowd was sent to live with her father in Harper, but he wanted nothing to do with her, maintaining strong convictions that she was cursed.

Noticing Prowd’s matted hair and dirty clothes, Nyachienga offered her the towel from his own house. A haircut soon followed, and after a few days, she agreed to medication for her diagnosis of schizophrenia. As the treatment began kicking in, a local business owner, Linda Howard, offered to cook for Prowd and ensure she took her medication. The two subsequently struck up a friendship, and one rainy night, Prowd knocked on Howard’s door and said, “Auntie, it’s too cold in the street.” Delighted that her new friend had become confident enough to speak up and advocate for herself, Howard invited her in to stay with her and her family.

mental health patient who now works at friend's restaurant
Sophie Prowd, who was diagnosed with schizophrenia and used to live on the street, is now connected with care, doing well, and working at her friend's restaurant in Harper, Liberia. Photo by Stephanie Chang / Partners In Health

Three years later, Prowd is still living with Howard’s family, and now manages and sells drinks at the family restaurant, which is the biggest in Harper. When Howard was away recently in neighboring Cote d’Ivoire, Prowd took care of the business in her absence. “Every time I buy a soft drink from Sophie, I take great pride in knowing how far she has come,” said Nyachienga.

Step by step and toothbrush by toothbrush, the program is bringing relief from the crushing weight of mental illness stigma. Every day it is turning patients’ lives around and reducing stigma in the community. “We meet them where they are,” said Cyrus. “We respect them for that. Sometimes they don’t feel like getting in the car to go and bathe. We will simply say, ‘Are you ready today?’”

Partnering with Traditional Healers

Nyachienga likes to tell people in southeastern Liberia that mental illness can be healed—and he has dozens of patient stories to prove it. The team has also taken the rare step of engaging traditional and faith healers—the local communities’ trusted, respected gatekeepers—to join together and help them provide access to treatment. 

Many local healers have gone from voicing skepticism about mental illness to accompanying patients through care by checking for side effects to medication and ensuring they attend clinic appointments. Doing so, they retain their position as trusted figures and serving as a vital link in the chain of access to mental health care. 

“People believe in them, they trust them, they look up to them for everything,” said Cyrus, adding that some patients prefer to be accompanied by traditional healers when they go to the hospital. “So we started talking to them about what mental illness is, showing them how their work recognizing the signs and symptoms of mental illness is important.” 

People believe in them, they trust them, they look up to them for everything."

In a part of the country where witchcraft is used to explain atypical behavior, particularly that without a visible cause, how did they explain mental illness?  “We used the brain to explain it to them,” said Cyrus. “A lot of people went through the war in Liberia, so we explained that if your brain has had trouble seeing bad things, it’s the interpretation of the brain that we can treat.” 

The traditional healers have so far been able to help reach around 500 people in Harper and Pleebo communities and enroll 65 people into mental health care. As a result, many of them will never have to experience the indignity of sleeping in the street, or lacking access to food, water, and soap. 

The Future of Mental Health Care 

The homeless outreach program is part of a treatment plan that shows that good mental health really is a spectrum—from clean clothes to medication and restoring confidence and self-respect. The team hopes to further expand its work, running more income-generating programs and perhaps even opening a halfway home for patients who can’t return to their families. 

woman selling rice in market in Liberia
Jewel, who was diagnosed with bipolar disorder and is receiving mental health care, started a rice selling stand in her local market with a $100 grant from PIH.

The Liberia team also realizes that the vital need to provide mental health care to homeless populations isn’t confined to Maryland County, which is why they traveled to neighboring Sierra Leone to train their colleagues on how to deliver care to homeless patients in Kono District. Their mentorship helped Sierra Leone’s mental health team initiate their own homelessness outreach program this year, which so far has provided ongoing care and support to 13 of the most vulnerable people in Kono.

As for Appleton back in Harper, he’s among those who haven’t yet been able to go home. His schizophrenia began during the war, and his family is no longer interested in reconnecting with him. But as Nyachienga said, Appleton is now a part of the extended PIH family and is often found sitting outside the gate to the office, chatting with the team, visiting the pharmacy for medication refills, and—most importantly of all—smiling.

Wed, 09 Oct 2019 09:36:12 -0400
The Social Worker Extraordinaire Helping Breast Cancer Patients Oldine Deshommes never has an empty office. The social worker is a go-to resource for every cancer patient passing through the double doors of the Roselene Jean Bosquet Center at University Hospital in Mirebalais, Haiti. Her role is to connect them with support and resources, which she always delivers with a broad smile and a warm hug.

Deshommes has worked with Zanmi Lasante, as Partners In Health is known in Haiti, for nearly 10 years, starting shortly after the devastating January 12 earthquake by providing psychosocial support to survivors living in temporary shelters in the capital of Port-au-Prince. She then transitioned to serving cancer patients at the PIH-supported Bon Sauveur Hospital in Cange before moving with the rest of PIH’s oncology team in 2013 to University Hospital in Mirebalais, where there are now three physicians, four nurses, and one psychologist meeting patients’ cancer care needs.

In 2018 alone, clinicians provided care to 569 patients at the oncology clinic at University Hospital in Mirebalais, treating everything from breast and cervical cancers to leukemia and gastrointestinal cancers. Deshommes surely met, and helped, the vast majority of those patients.

In honor of Breast Cancer Awareness Month, Deshommes reflects on her career as a social worker, shares the barriers cancer patients face in Haiti, and addresses what remains to be done to provide patients with the best care possible.

How did you get into social work?

From an early age, I was always available to listen, advise, and help family members and friends manage difficult situations. That's why in the Faculty of Human Sciences at the State University of Haiti, I opted to study social work, a profession essentially of helping others. It's about helping people use their own resources and community resources for their needs. 

What are some barriers women face in accessing cancer care in Haiti?

The challenges within our health system in Haiti, the low economic level, and the low education levels of the majority of people living in Haiti are reasons why women who have breast cancer most often arrive at the hospital at an advanced stage of the disease.

Many stayed longer at home before going to the hospital for lack of money or lack of awareness. Others claim to have spent all their money on medical care before coming to University Hospital in Mirebalais. The care offered here is certainly free, but our patients come from all regions of the country. They therefore need money for transportation, food, and other daily expenses. Some patients miss their appointment at the hospital for lack of financial support. 

breast cancer patient visit in Haiti
Deshommes (right) leaves a home visit with breast cancer survivor, Marana Toussaint (center), who lives near University Hospital in Mirebalais.

A vast majority of the patients you support are battling breast cancer. Tell us what concerns they have, and how you help.

The majority of patients are or have been small traders, who during their illness have spent all their savings and have nothing left to continue the fight against cancer. Some receive financial help from their extended family or friends. But sometimes those people who help do not continue, because they become discouraged or lack money themselves. At University Hospital in Mirebalais, we give financial help to those who are in need. But many patients are in this situation, and we do not have much money to give this type of assistance, so it is not enough to help everyone.

Patients suffer because they can’t afford school fees for their young children. They are worried about their future in a country like Haiti, where there is not really a structure that can take care of these children.

And yet, we cannot stop thanking those who donate to our patients. In our oncology service at University Hospital in Mirebalais, prostheses and special bras are given to patients who have had a mastectomy. We know they are concerned about their physical appearance. We also give wigs and scarves to those who are in chemotherapy. These donations also contribute to the work we do to improve the quality of life of our breast cancer patients.

 You facilitate group sessions for women battling breast cancer. What benefits do you see women gain from these sessions?

Support groups allow patients who are experiencing similar situations to get together for counseling and emotional support. Through these sessions, patients realize they are not the only ones to live this difficult experience. Some patients come out of their social isolation and make friends. The psychosocial team leading these groups sometimes gives information on cancer, treatments, and services offered at University Hospital, as well as general information about resources patients could use. We also hold psychoeducation sessions. These groups allow us to better understand and act on the overall suffering of cancer patients.

It makes me think about what we can always do. Every minute counts." 

What have you learned from breast cancer patients over the years, especially those who are in palliative care?

In palliative care, the person often questions his life—what she had time to do or not. It makes me think about what we can always do. Every minute counts. Over time, patients taught me at least two lessons in life:

1) I understand how important it is to look after our relationships with others, especially those who are dear to us. Social support is very important in the management of palliative care patients.

2) Our love for those who are sick makes it sad to think about their imminent death, but can also give us the courage to plan what we can for their future and also to live serenely the last stage of life. I consider this a victory in the fight against cancer in palliative care.

Is there anything you wish you could do for your patients, but can’t, due to financial constraints?

We know that loved ones have an important place in the care of patients suffering from cancer, so we encourage them to accompany their sick parents to their appointments at the hospital. We try to give them psychosocial support, help them better understand cancer and its treatments, and organize special support groups for them. But it is difficult for us to accompany them as we would like. Because the majority of patients are themselves struggling to find money for transportation, they find it difficult to pay transportation for another two or three people who would accompany them. If we would like caregivers to come to appointments too, we would often need to help with transportation, but we do not have enough money to always do it.

cancer patients and family members await care
Cancer patients and their family members await care as oncology nurse, Ms. Guerdie Duvert, passes with a tray of chemotherapy.

What other resources exist in Haiti to support cancer patients and their families?

 In Haiti, there are not really community-based social support organizations to help cancer patients. The Haitian state does not have a strong policy or health system to care for cancer, a disease that causes a lot of deaths and can also have repercussions on patients’ socioeconomic situation. Patients often cannot work during treatment, which leads to the impoverishment of families, children who are forced to leave school, or children whose mental health is affected by the loss of their parents. Sometimes this leads to juvenile delinquency.

At University Hospital, when a patient's needs cannot be met, we would like to be able to connect her to other social support community organizations. We make referrals to a cancer support group based in Port-au-Prince, but it cannot always meet patients’ needs. We would like to have more resources to help patients and more places to which we can refer them and their loved ones who are suffering from cancer. 

Tue, 08 Oct 2019 22:28:32 -0400
Heart Patient, Advocate, and Soon-to-be-MD As we come together for World Heart Day on September 29, we celebrate Erneste Simpunga and other people living with a range of heart diseases within the communities where we work. 

Simpunga, 29, was diagnosed with rheumatic heart disease at age 16, in his home country of Rwanda. After a lengthy journey to surgery, he had two heart valves replaced in July 2008, at Brigham & Women’s Hospital in Boston. The experience inspired him to become a doctor, and on November 8, 2019, his 30th birthday, he’ll graduate from the University of Rwanda’s School of Medicine and Pharmacy.

While he hopes to conduct his residency and his fellowship in the U.S., Simpunga’s long-term goal is to work in Rwanda, as a cardiologist, cardiac surgeon or professor of clinical anatomy. Rwanda currently has about seven cardiologists for its population of 12 million.

In the years following the surgery that saved his life, Simpunga has been an ardent patient advocate. He’s spoken at events including the 10th anniversary of Partners In Health’s work in Rwanda; the 2016 Team Heart Boston Gala; a global forum on noncommunicable diseases (NCDs) in Sharjah, United Arab Emirates; and at related events in Kigali, Rwanda’s capital.

He is a member of Rwanda’s NCD Alliance, and has served on the first advisory committee for the alliance’s “Our Views, Our Voices” patient advocacy initiative.

Here, he shares some of his incredible life story.

Frightening news to hear

In May 2006, when I was 16 and in secondary school, I got a very somber diagnosis from one of the two cardiologists in my home country of Rwanda.  

He told my father not only that I had rheumatic heart disease (RHD), but also that because of the disease, one of my heart’s four valves needed to be replaced. A second valve needed surgery or even a replacement, as well.  

It was frightening news to hear—but my family and I had known it was coming.

By the time I was able to see that doctor, a cardiologist in the capital city of Kigali, I had been suffering debilitating symptoms of RHD for more than two years.

The summer of 2005 was when I finally determined that something was seriously wrong with my health. I then stayed for some time at the health center closest to the small community where I grew up, in Rwanda’s Eastern Province. Care providers at the health center gave me several inaccurate diagnoses, before, eventually, I was referred to a district hospital, and then finally to the University Teaching Hospital of Kigali.  

There, we learned that there was a long line of patients waiting for treatment ahead of us, and a cardiologist could see us in four months if we used health insurance to pay for the visit.

I was very thin, with a hugely distended abdomen and built-up fluid in my legs. I was short of breath nearly all the time, even when I was at rest. I couldn’t walk briskly uphill for more than 30 seconds—as I had to do on my daily walk to school. Rwanda, itself, is known as the Land of 1,000 Hills. Because I had to move slowly, walks that used to take me just 10 minutes now took more than an hour—and if I tried to walk any faster, I would get heart palpitations and sometimes faint.   

An unbearable cost for care

Knowing all of that, my family decided to see the cardiologist at his private clinic, rather than wait, and to pay 100 percent of the cost.

That cost quickly grew.

The cardiologist said our family would need to find about $15,000US, because the surgery I needed couldn’t be performed in Rwanda, and I would have to go to India.

He added that, in most cases, the outcome was really good, especially for young people like me—even though my condition seemed advanced.

We looked at him for a moment, in silence, as we took in that news. Then, my dad said:

“Doctor, this is my first time to hear of such a disease. We used to think my son might have HIV or tuberculosis, given how thin and tired he is. Are you telling us the truth, that this is a heart disease? Are there any other patients like him?”

The doctor insisted on his diagnosis, and reiterated that a good outcome was likely if proper treatment began as soon as possible. However, we had to tell him that our family could not afford the cost.

The doctor said another option, then, would be to wait for visiting teams of foreign doctors who could perform the surgery I needed, and who would come to Rwanda and treat local patients through future partnerships with the Rwanda Ministry of Health. But that could take a year or two, or more. The doctor’s concern was that the longer we waited, the less potential I had to be a candidate for treatment from those teams, because my condition could worsen.

Rwanda already was working with an Australian cardiac surgery team, by chance, and had been for two years—but that was a pediatric team. At 16, I was too old for pediatric treatment and would have to wait for a cardiac surgery team that was treating adults.

That was just one example of the many hurdles that arose.

So, the doctor and my family made a plan, while we waited.

“I will put him on daily medications and I will need to check on him while we wait, possibly every month,” the doctor said.

The long wait for surgery

 Luckily, I did well on the medications, which included about 180 pills a month and penicillin injections. I later learned that other patients with a similar disease, and similar treatment, were not so lucky—some saw their conditions worsen despite the medications, and needed hospital visits up to twice a month.

I remained on the medications, awaiting surgery, for two years.

Heart patient following cardiac surgery in the United States
Simpunga visits his cardiologist at Boston's Brigham & Women's Hospital in July 2008 following surgery, which was possible with support from PIH and Team Heart. Photo courtesy of Erneste Simpunga

At last, in April 2008, I was presented to Team Heart, a medical nonprofit that’s based in Boston and has worked for more than a decade to build sustainable cardiac care in Rwanda. Team Heart brings volunteer doctors and nurses to Rwanda every year for surgical missions, working with the Rwanda Ministry of Health, collaborators including Partners In Health, and many others.

Their visit in 2008 was Team Heart’s first trip to Rwanda. They planned to see 12 patients. As it turned out, I was the sickest—so sick, in fact, that I wasn’t a candidate for surgery in Rwanda.

However, I was given a second chance. In July of that year, Team Heart and PIH brought me to Boston, where my surgery was performed safely by some of the same doctors who had visited Kigali just months before.

After doctors successfully installed two artificial valves in my heart, I stayed in Boston for three months, living with my lead surgeon and having regular checkups with cardiologists. The extended stay gave me a unique opportunity to attend the 2008 Rwanda Day in Boston, and to meet Rwanda President Paul Kagame and the country’s minister of education at that time. I thanked both of them for supporting the medical partnership that was enabling me to live a healthy life, return to school and so much more.

But challenges still remain.

Replacing two of my heart’s four valves means I have to take three different medicines—totaling about five pills every day—and see a cardiologist at least twice a year, for the rest of my life. One of the medicines is a blood thinner, which requires me to have my blood tested once a month. This is not always easy.

When I returned to Rwanda after my surgery and recovery in 2008, there was only one hospital in the country, in Kigali, that could do the monthly blood test I needed.  Resources have grown since then, with the help of the government, and now blood tests are offered in several districts.

I am grateful that the country has continued to advocate for people with heart conditions. There now are about five visiting teams that offer heart surgeries, and the government is providing scholarships for aspiring cardiologists. I am also happy that the country has affordable health insurance and everyone is enrolled in the system.

From patient, to advocate

The major challenge I see is our very poor patient-doctor ratio, especially in specialized areas like cardiovascular medicine. Enormous demand is created when a country has just seven cardiologists and one cardiothoracic surgeon for 12 million people, and while that number slowly is improving, there is still a long way to go. When I was sick more than a decade ago, there were just two cardiologists in Rwanda, for its more than 9 million people at that time.  

International help is direly needed. For example, top-ranking medical schools could provide more support for young Rwandan doctors specializing in cardiology. More also can be done to ensure postoperative medications are always available for patients, who need to take them every day to continue feeling well. Additionally, health care providers at the community level must be trained on how to diagnose RHD earlier, to potentially prevent more serious complications down the road.

I know the Rwandan government is aware of these issues, and working to address them. But system-wide change takes time, and more partners are needed to accelerate the process.

Overall, my wish for Rwanda is to have a young generation free of rheumatic heart disease. I encourage anyone experiencing symptoms to not ignore them, and seek out care that they might need. For those fighting the disease and those with lifelong care, like me, my wish is that care and resources across Rwanda one day will equal what is available in developed countries.


Sat, 28 Sep 2019 13:28:48 -0400
PIH Leader in Devex: UN Health Declaration Undermines Equity Truly achieving health care for all will require global solidarity and cannot involve different sets of services for different countries and communities, determined by their wealth and whims of the markets, Dr. Jean Claude Mugunga wrote in an opinion piece published this week in Devex, an online news and information source focusing on global development.

Mugunga is a physician and associate director of monitoring, evaluation, and quality for Partners In Health. His opinion piece follows the United Nations General Assembly’s adoption Monday of a political declaration on Universal Health Coverage (UHC)—a declaration that Mugunga says “definitely doesn’t align” with his beliefs.

Dr. Jean Claude Mugunga
Dr. Jean Claude Mugunga

“A (version of) UHC that means a few select services for everyone while the rest of the services are left to the market does not serve to promote equity,” Mugunga writes. “It also exaggerates the agency of resource-poor countries to ‘determine’ these sets of services. Overall, this serves to undermine the meaning of health as a human right.”

Mugunga says that for himself and his family, the issue is “not just a policy debate.” He was born in rural Rwanda, shortly after world leaders’ 1978 adoption of the Declaration of Alma Ata had raised hopes of sustainable, equitable global systems that would ensure health care for all.

“We had been excluded from the fruits of modern medicine for the entirety of our lives to date. And this had been painful. Like my four older siblings, for example, I was very prone to malaria-induced fever and seizures,” he writes. “But Alma Ata meant that my mother would no longer have to wait or sell valuable livestock or land to secure user fees to take me to the nearest health facility.

“That hope was short-lived.”

Mugunga describes how, in the decades since, commoditization and privatization of health care has veered the UHC discourse away from the ideals of Alma Ata. He then applies his data analysis expertise to the financing gap for achieving UHC in low- and middle-income countries, and makes the case that high-income countries can bridge that gap with a tiny portion—about 0.18 percent—of their gross national income.

“In an era of globalization, there needs to be an increasingly globalized notion…for who bears responsibility for protecting and fulfilling the right to health,” he writes.

Read Mugunga’s full piece here.

Thu, 26 Sep 2019 15:04:10 -0400
Opinion: Universal Health Coverage Must Meet the Needs of the Missing Billion This opinion piece was written by PIH’s Dr. Dan Palazuelos, director of community health systems, and Dr. Joia Mukherjee, chief medical officer, in anticipation of the United Nations General Assembly High-Level Meeting on Universal Health Coverage in New York City, starting September 17.

We remember when we first met Aminata* from Sierra Leone. She is an adolescent, about 14 years old, with visual impairment. There are no schools that can teach her in her home country. She is an orphan and sometimes helps her aunt prepare fried cakes that she sells in the market. A community health worker from our organization, Partners In Health, identified her as vulnerable and brought her to the clinic. There it was found that she has HIV. She says she hasn’t yet had sex, but she begins to cry when asked. Because her mother died of unknown causes, we don’t know if Aminata was infected at birth, is indeed sexually active by choice or for survival, or is a victim of sexual violence. 

We do know this: Aminata is at risk of premature death, of not fulfilling her potential. As an orphan girl with HIV/AIDS and visual impairment, there will be many challenges for her to stay healthy—the cost of transportation to the clinic and the support of her overstretched aunt to provide her with an education and food insecurity. These and many other social factors will make it difficult for Aminata to adhere to antiretroviral treatment, to protect herself against unwanted or premature pregnancy, and to live a healthy life. Without community-based care and social support to target a vulnerable young woman such as Aminata, we know she will fall sick more often, is more likely to get pregnant against her will, will receive less education, and will have fewer opportunities for employment and income generation.

Unfortunately, in many of the 10 countries where PIH works, the vulnerability of people with disabilities, chronic illnesses, and several constrained social situations is woefully common. In any country, the cycle of poverty is worsened significantly when people have disabilities. This is even more catastrophic when the health system itself is debilitated by insufficient staff, supplies, or dignified infrastructure. We at PIH believe that achieving truly universal coverage, and health as a human right, can be achieved through investments in community health workers connected with robust health systems. And we believe the measure of such systems is how well they will reach patients like Aminata.

That is why PIH strongly supports the Missing Billion report on achieving universal health coverage (UHC) with attention to people with disabilities. The report--spearheaded by the London School of Hygiene & Tropical Medicine and the Office of the WHO Ambassador for Global Strategies, but with input from UNICEF, PIH, and others--shines a strong light on a stark reality; people with disabilities are, on average, more vulnerable to poor health, with much lower access to health care services and less health coverage, which results in worse health outcomes.

UHC will be the focus of United Nations High-Level Meetings during the U.N. General Assembly this month. What will it really take to achieve UHC, and to do real justice to the often-used slogans of “reaching the unreached” and “leaving no-one behind”? We believe that the measure of UHC must be how well it reaches the most vulnerable, not the “low hanging fruit” or the 80 to 90 percent coverage commonly accepted as sufficient. Rather, we believe systems to deliver UHC must be guided by a focus on equity, and we must aim to reach that final 10 to 20 percent to be truly equitable.

Worldwide there are approximately 1 billion people with disabilities, and many live in abject poverty. A health system that is designed to reach these populations will be better equipped to serve everyone else. The Missing Billion report makes recommendations to governments, funders, global policy makers, and all other stakeholders.

But as we have seen with so many reports before it that speak truth to power, we know it takes so much more to make these insights a reality. It will take the strengthening of health financing, metrics, data, evidence, legal frameworks, and improved service delivery to address health disparities. We will never reach UHC without reaching the most vulnerable, including people with disabilities and the poor. Aminata’s story, and the Missing Billion report, provide clear guidance. Are we ready to listen?

* Name and clinical details changed to protect anonymity


Mon, 23 Sep 2019 11:07:06 -0400
New Emergency Ward a Game Changer in Sierra Leone There was a gentle hum of conversation as Doris Miatta Komba moved swiftly between the beds in Koidu Government Hospital’s emergency ward. The 32-year-old Ministry of Health nurse is in charge of the new emergency department, a critical area of care that didn’t exist until this May. Her attention was caught by a monitor at the far end of the room. She signaled to a second nurse, who moved to her side and placed two fingers over the wrist of a patient lying attached to the monitor by a clear tube.

The patient—who is male, in his mid-thirties—was admitted to the emergency ward the day before with hypertension, and if it hadn’t been for the timely care he received from these nurses, he would have likely died. He lay in one of six beds in the ward, all of which were occupied by patients with serious and urgent medical conditions, while Komba and her team delivered the specialist care they have been trained to provide.

Koidu Government Hospital, or KGH, is the only hospital in Sierra Leone outside the capital of Freetown to have an emergency ward. It serves a population of more than 500,000 people in and around Kono District. Staff are proud to be pioneering an approach to the care of critically ill patients that could, in the future, be replicated at other hospitals across the country. Since opening in May, more than 430 patients have been admitted and treated at the emergency ward.

Before the hospital’s emergency ward opened, patients admitted with acute, serious medical conditions needed to wait for a bed to become available in one of the main wards before they received the care they desperately needed.

“We can now identify the sickest patients and provide timely care,” said Dr. Chiyembekezo Kachimanga (or Dr. Chembe, as he is known across PIH), clinical educator for PIH in Sierra Leone. “The moment a patient arrives, they are attended by a nurse who is consistently there. Two nurses are on shift at all times. And the emergency medicines are all there too; a pharmacist comes every morning to top them up. Quick access to the right medication and care is a crucial time-saver when treating someone who is critically ill.

 “With this department,” he added, “we hope to reduce mortality at KGH. If we manage symptoms quickly, patients are less likely to die.”

Innovation in emergency care

The emergency ward operates alongside a triage system introduced earlier this year. At triage, a patient’s symptoms are categorized by a clinician into one of four colors: red and orange flag a need for immediate medical attention, and green and yellow signify regular clinical care. Since May, 75 percent of all patients admitted at KGH have required acute medical care, and 11 percent of these patients were flagged as orange or red and so referred straight to the emergency ward.

The patient that Komba has successfully stabilized was marked as red at triage the day before. “Hypertension symptoms usually cause the patient to become unconscious or have severe breathing problems,” she shared. “All of the vital signs are usually off, so they need a lot of support.

“When patients initially come to the emergency ward, they are afraid,” she said. “It is our job not just to assess them, but also to assure them.”

Komba and her staff do this medical and emotional work, all while carrying out an “ABCD” assessment—checking for airway obstructions, breathing issues, circulation irregularities, and disability or dehydration.

After completing the ABCD assessment and successfully stabilizing her patient that day, Komba called the attending doctor to complete a follow-up examination and prescribe the required medication for hypertension.

Working smarter, not harder

The emergency ward has slotted into KGH’s other operations seamlessly. Having a well-equipped, separate space for treating critically ill patients has relieved a huge amount of pressure from hospital staff. Previously, they were required to treat these patients, who were dispersed throughout the hospital’s wards, making it difficult to provide the necessary focused, specialist care.

Clinicians now ensure that all patients are triaged upon arrival at KGH. When patients are discharged from the emergency ward, usually after three to four days, they are able to provide appropriate recovery care in one of the hospital’s regular wards.

Chembe was initially surprised to learn that the most common patient cases admitted to the emergency ward are related to non-communicable diseases, such as hypertension, diabetes, and hepatitis. “When we opened the ward, we didn’t anticipate this would be the case at all,” he shared. “Once patients have been stabilized, we link them directly with the NCD clinic. Our aim is always to make sure that once we discharge patients, they have enough medicine to tide them over to their next NCD appointment.”


Emergency department nurses at a hospital in Sierra Leone
Nurse Doris Miatta Komba (sitting) and a colleague complete paperwork for patients at the new emergency ward in Koidu Government Hospital in Kono District, Sierra Leone. Photo by John Ra / Partners In Health

Training for better care 

The emergency ward’s clinical team, made up of Ministry of Health and PIH staff, has received in-depth training on both the new triage process and emergency medicine to ensure that patients receive the best possible treatment. Chembe, Komba, and Moses Bangura, a PIH clinician working at KGH, travelled to Liberia in May to receive a two-week training in advanced emergency clinical care. And in January, 30 PIH and Ministry of Health staff in Freetown and Kono will receive additional training on the management of critically ill patients, especially those suffering from respiratory distress, shock, trauma, and an altered mental status--all common reasons for emergency care in Sierra Leone.

“I am still organizing training topics for emergency care,” Chembe shared. “I want it to become a continuous training schedule. Our clinicians have provided feedback that they want more training—they want to keep refining their skills and to gain a deeper understanding of the science behind why certain procedures need to happen.”

The emergency ward at KGH marks a bold step in strengthening the health care system in Sierra Leone. As word spreads about its quality services, critically ill patients are travelling hours to get treatment, from the capital of Freetown and as far away as neighboring countries, such as Guinea.

“When patients see after three days that they are feeling better, they are so appreciative and happy,” said Komba proudly. After stabilizing her hypertensive patient, and with his medication stored safely in her cabinet, she could rest assured that she had done everything she could to save his life, something that might not have been possible just five months ago. 


Mon, 23 Sep 2019 10:45:31 -0400
Research: Health Systems, Like Patients, Can Suffer From Misdiagnosis As HIV care advanced following the introduction of antiretrovirals, clinicians observed a curious phenomenon: Some patients’ health unexpectedly got worse, rather than better, shortly after they began treatment.

It seemed that HIV treatment awakened patients’ immune systems, allowing them to fight ailments that previously had lain dormant, or unchallenged, because HIV had suppressed their body’s ability to respond. This led some doctors to think patients were getting sicker, when actually, they were starting the arduous process of getting better.   

The phenomenon, of unexpected initial setbacks, became known as immune reconstitution inflammatory syndrome. Failure to recognize it could lead doctors to change treatment plans prematurely or incorrectly, and potentially endanger patients’ lives.  

A newly published study shows that the same phenomenon applies to health systems, and that failure to recognize it can lead to the elimination of new programs or funding streams, before they have a chance to succeed.

“Without substantial or measurable early impact, funders and program implementers may question the utility of their intervention, methods, and goals,” says Dr. Anatole Manzi, director of clinical practice and quality improvement for Partners In Health.

Anatole Manzi
Dr. Anatole Manzi, PIH director of clinical practice and quality improvement (Photo by Zack DeClerck / PIH)

Manzi is lead author of the study, titled: “Health System Reconstitution Syndrome: An Often Misunderstood Phenomenon in Global Health Practice.” Oxford Academic’s Health Policy and Planning journal published the study in August. Several PIH leaders, including CEO Dr. Sheila Davis and Chief Medical Officer Dr. Joia Mukherjee, join Manzi as co-authors. 

The study reveals that programs or interventions put in place to improve health systems often are assessed too early. As a result, funding has been cut from many programs that could have effectively improved health outcomes and saved lives, had they simply been given more time to unfold.

Manzi asserts that when a country or community implements a program to improve a health system, the quality of health care services initially can appear to suffer. There are several reasons why this might occur. Health care workers start finding and reporting more cases, so disease rates rise. And as more people learn to trust what was once a broken health system, demand for services increases—sometimes faster than staffing levels or available resources.

It’s crucial for health system implementers and funders to be aware of this dynamic, the study states, to more accurately assess new programs.

“It’s important for the Global Fund to Fight AIDS, Tuberculosis and Malaria, and other funding institutions, to understand this evolution of health interventions, because they’re affecting our health outcomes,” Manzi says. “Unfortunately, the [current assessment] requirements are setting up countries to fail.”

While the overall effectiveness of programs to strengthen health systems has been assessed in the past, this study is the first to break down the specific evolution of implementation. Manzi and the study’s co-authors use a World Health Organization framework to break down implementation into four phases: quiescent, reactive, restorative, and stability.

The quiescent phase occurs directly after the launch of an intervention, and is when the health system gears up to respond to change.

Delays in effectiveness most frequently happen in the second, or reactive, phase—often marked by baseline data that gets worse, not better. Unfortunately, that often coincides with the time when programs are evaluated for the renewal of a grant or other source of funding.

Manzi suggests that funders continue timely evaluations of projects, but hold off on funding decisions until later reviews. To avoid misinterpreting positive outcomes as negative, he urges program implementers and funders to recognize symptoms of the reactive phase, and avoid prematurely abandoning or changing intervention strategies. Greater consideration of contextual factors for different health systems also can reduce premature decisions to stop funding, and prevent negative implications on implementation, policy, and global health research.

Should programs reach the third, or restorative, phase, practitioners start to see significant improvement in the health system.

Finally, programs reach their desired outcome in the stability phase.

“This is an untold story. Most grants have a renewal timeline of one year or two,” Manzi says. “In many cases, the project is in the reactive phase at the end of the grant. It’s unfortunate for projects that were going to succeed.”

An intervention to eliminate malaria in Rwanda, for example, saw an unexpected increase of cases during the reactive phase, due in part to health workers finding more malaria patients through better data collection, monitoring, and reporting. As the project moved into the restorative and stability phases, though, teams saw remarkable improvements in malaria case-finding and management. Those improvements would not have occurred if funders had pulled the plug after initial results.  

A community health worker visits a family at home in Rwanda
Community health worker Niragire Irene (at rear, blue headscarf) visits a family at their home in eastern Rwanda's Cyarubare District in 2018. Health system improvements that boost screenings and community visits initially can create misleading data, suggesting implementers and funders should take a long view when assessing effectiveness. (Photo by Cecille Joan Avila / PIH)

Another example has occurred in Lesotho, where a slight decline in primary care services followed the launch of a national health reform. Again, the short-term setback primarily was related to a more streamlined system for data collection and reporting.

Stakeholders also must consider the entire scope of impacts and needs that health system interventions can cause.  When only partial impacts are considered, some indicators can begin to improve, while others may significantly worsen if the health system can’t handle the demand.

This often happens with vertical programs, which target one aspect of care rather than health system as a whole. For example, an intervention to increase the number of people who use health facilities can lead to a breakdown in services, if other important elements like medical supplies and human resources are not considered.

That’s why understanding the implications of health system reconstitution syndrome is critical for global health stakeholders, including program implementers, policymakers, researchers, and global health funding institutions.

“Given that typical funding grants for health system strengthening projects range from one to three years in length,” Manzi says, “monitoring and quality improvement early in the intervention becomes critical as a means to shorten the reactive phase and prevent early abandonment of the intervention.”

As global leaders and communities around the world raise their voices to advocate for universal health coverage, and care, it will be crucial to redesign tactics for effective implementation, research, and health financing. Strongly considering these dynamics, and contextual factors for different health systems, will help stakeholders ensure effective implementation of improvement projects, and ultimately, better health outcomes.     

Read the full study here.

Fri, 20 Sep 2019 15:32:11 -0400
UGHE Welcomes Inaugural, Majority-Female Medical Class Delphine Mizero doesn’t want to become a doctor because of money, she writes in a booklet introducing the University of Global Health Equity’s inaugural medical class. She wants to become a doctor “because of the incredible work” that saved her life, when she had only just arrived in the world.

“I was born with a tumor in my chest that filled with fluid. My mother told me that there was a hot debate about whether to operate on it or to let me, an innocent baby, die because it was too expensive to get treatment,” Mizero writes. “Because we had no insurance then, the operation was very costly, and my mother sold some assets to afford it. My mother told me that she was also extremely afraid of the operation because she had not heard (of) or seen a baby that young having a surgery. It was hard for my mother to decide, but she later accepted the risk and decided on the operation.”

When Mizero grew older and learned the story, it instilled her with a drive to help underserved communities access better medical care. She attended Gashora Girls Academy of Science and Technology in Rwanda’s Eastern Province, where she focused on physics, biology, and chemistry, captained the soccer team, and interned at a local health clinic.

Delphine Mizero
Delphine Mizero said she wants to become a doctor "because of the incredible work" that saved her own life, when she was born with a tumor in her chest that was filled with fluid, and required an operation that was difficult for her family to afford. (Photo by Danny Kamanzi / UGHE)

Then she applied to UGHE, a Partners In Health initiative in the rural, northern Rwanda community of Butaro. Mizero was one of 685 applicants, all vying to be the first students to undertake the groundbreaking university’s six-and-a-half-year medical program. Thirty students made the cut, creating an acceptance rate of just more than 4 percent. That’s on par with 2019 acceptance rates for medical schools at Harvard University (3.4 percent), the University of Chicago (4.8 percent), and Johns Hopkins University (6.1 percent), for example.

UGHE made gender equity a priority in admissions, as part of efforts to increase the number of female doctors in Rwanda and beyond. The Class of 2025 is comprised of 20 women and 10 men, all from Rwanda—and all, like Mizero, with personal experiences of inadequate health services that have inspired them to work toward positive change in their home country. 

Benitha Uwera, for example, said her mother has had long-term lung issues, and her father has battled significant spinal problems.  

Benitha Uwera
Benitha Uwera said her parents' longtime struggles with lung and spine problems motivated her to apply to UGHE, and hopefully reduce unnecessary deaths in rural areas that are far from hospitals. (Photo by Danny Kamanzi / UGHE)

“My parents both went all the way to India to get cured, but nothing has really improved their health condition,” she writes, in the same booklet as Mizero. “I saw my parents in so much agony and pain, and I had a desire since my childhood to grow up and become a useful doctor who will help sick and suffering people. Also, many people are still unnecessarily dying in rural areas, because the hospitals are too far away, and for others, they are economically disadvantaged.”

UGHE’s mission and curricula are designed to train doctors who will help meet that exact need. The private, independent UGHE was launched in 2015, as a Partners In Health initiative with significant investment and collaboration from the government of Rwanda. Construction of the university’s 250-acre campus began a year later. Partners In Health is known locally as Inshuti Mu Buzima, and has worked in Rwanda since 2005. In January, a distinguished crowd of government and global health leaders, including Rwandan President Paul Kagame, formally opened the campus with a celebratory inauguration, and Master’s in Global Health Delivery students moved in.

The newly arrived medical students now have joined them, adding to an increasing bustle around UGHE’s dorms and academic buildings.

“The inaugural cohort of medical students is great,” said Dr. Agnes Binagwaho, UGHE’s vice chancellor and a former Rwanda Minister of Health. “They are motivated, with a clear vision, and are ready to contribute to improving the health status of their country, leaving no one out.”

UGHE’s nationally accredited medical program confers a Bachelor of Medicine, Bachelor of Surgery/Master of Science in Global Health Delivery, combining a bachelor-level medical degree with the university’s existing master-level global health degree.

UGHE's academic facilities include a brand-new science lab
Emmanuel Kamanzi, director of campus development at UGHE, shows a science lab that is part of sparkling academic facilities for university students, including the inaugural medical class that arrived in July. (Photo by Mike Lawrence / Partners In Health)

The curriculum will build upon existing requirements for medical doctors in Rwanda and across East Africa, with academic innovations designed to train a new generation of health professionals who strive to deliver more equitable care.

Studies begin with six months of introductory coursework to establish an academic foundation around themes including patient care, health sciences, and social determinants of health. Just across a valley, the nearby, PIH-supported Butaro District Hospital will help students gain firsthand medical experience during the program, which will emphasize hands-on learning with patients and health systems in rural areas.

Incorporating UGHE’s existing Master’s in Global Health Delivery into the medical program will ensure that graduates not only gain a solid foundation in the health sciences and clinical practice, but also acquire the knowledge and management skills needed to build and maintain effective, equitable health systems.

Students will put that education and training into practice directly after graduating. Each of UGHE’s new medical students has signed an agreement known as umusanzu, which means “contribution” in the local language of Kinyarwanda. Under umusanzu, students pledge to work with the government of Rwanda in underserved communities for at least five years after completing their studies, in exchange for a full scholarship to UGHE. The scholarships are funded by private charitable contributions.

UGHE's campus, seen from Butaro District Hospital
UGHE's campus, seen from PIH-supported Butaro District Hospital. The hospital's proximity will enable medical students to gain firsthand experience and training at the hospital. (Photo by Mike Lawrence / Partners In Health)

Umusanzu is at the heart of UGHE’s mission of building the next generation of global health leaders. The university believes that financial capacity should not determine someone’s ability to pursue a career in global health, and that removing financial barriers to education will create a more diverse field of medical professionals and lead to more equitable health outcomes.

“We take pride in providing equitable access to health sciences education, as we believe that equity in education is the basis of equity in health care,” said Professor Abebe Bekele, UGHE’s founding dean of health sciences. “We do not want our students to pay us back for the education they receive here, but rather we want them to pay it forward by serving those who have lacked access to quality health care in the past.” 

That commitment seems to align closely with Mizero’s goals. She said she’s looking forward to the medical program’s community involvement and comprehensive curriculum, which extends beyond clinical care to develop humanitarian values, such as cultural literacy and social justice.

“I am highly concerned about the general well-being of the community, especially the least privileged, underserved, and most vulnerable,” Mizero wrote. “Thank you again, UGHE, for being a ladder on which I climb up to achieve my dream."

Fri, 13 Sep 2019 16:32:55 -0400
U.S. News Lauds Fabrice’s Story, Rwanda's Revitalized Health Care A new in-depth article by U.S. News & World Report praises Partners In Health’s “pivotal” role in the transformation of Rwanda’s health care system, particularly in child cancer care, which the online news magazine highlights through former Wilms’ tumor patient Fabrice Irakoze, now a healthy 11-year-old. 

The Sept. 5 article, “Rwanda’s Model: Progress, with More Work Ahead,” includes comments from several PIH and Rwandan health leaders and is part of an expansive special report on child cancer care around the world. The special report includes opinion pieces, a photo gallery, and vignettes from Hong Kong, Jordan, Lebanon and other locations, collectively titled, “Childhood Cancer: Seeking a Better Global Solution.” The package coincides with Childhood Cancer Awareness Month, recognized every September by cancer organizations around the world. 

The Rwanda article features treatment at the Butaro Cancer Center of Excellence, part of the PIH-supported Butaro District Hospital campus in the country’s rural north. PIH has worked in Rwanda since 2005 and is known locally as Inshuti Mu Buzima. PIH, Rwanda’s Ministry of Health, and other partners opened the cancer center in 2012. The facility now sees nearly 2,000 patients per year, from across Rwanda and nearby countries. 

Dr. Cyprien Shyirambere, director of oncology for PIH in Rwanda, told U.S. News that the center’s growth and success has defied expectations.

"When we started this cancer center people were saying that we would do harm, to treat cancer you need all the resources that are available in high-income countries," Shyirambere says in the article. "But a child like Fabrice shows it is possible to treat cancer in a country like Rwanda if you have a strong health system, if you have access to basic chemotherapy, a dedicated team of doctors and nurses and you have protocols and a committed government."

Fabrice Irakoze was 4 years old in 2013, when he developed a fever that wouldn’t go away. At a district hospital in Kigali, Rwanda’s capital, he and his mother, Cecile Nzamwitakuze, were given what she thought was a deadly diagnosis: a kidney cancer known as Wilms’ tumor, or nephroblastoma.

But during six months of chemotherapy in Butaro, as PIH also supported the family with food packages, school fees and materials, and transportation costs, Fabrice steadily improved. He now has been cancer-free for six years, and returns to Butaro for annual checkups with Shyirambere.

U.S. News uses his story to show how strong health systems and comprehensive care can transform a country. Dr. Joia Mukherjee, chief medical officer for PIH, told the online magazine that wealthy nations must increase commitments to system-wide improvements in the global south.

"These problems are long-term problems that we need to solve together with international solidarity that's lasting," Mukherjee says.

Read the full article here.

Tue, 10 Sep 2019 14:58:05 -0400
Students in Sierra Leone Share Stories as School Year Begins On a rainy July day in Sierra Leone, children across the country walked to their local schools with pencils in hand, to take their end-of-year exams. If they passed, they would be accepted into the next grade level when school returned in September.

As children and young adults all around the world know, summer goes by fast, and many of those students now are beginning the new school year. But for students served by Partners In Health, challenges far greater than final exams could have stood in their way.

PIH has worked in the West African nation since 2014, when responding to the Ebola outbreak was the immediate need. But through a continuing partnership with the national government, PIH's role has only grown. Staff now supports comprehensive care for a population of more than 500,000 in the country's eastern Kono District, with two health facilities and more than 100 community health workers reaching families in their homes, every day. PIH also supports national tuberculosis and mental health programs based in two facilities in the capital, Freetown.     

In all of its work, PIH knows comprehensive care extends beyond physical health. That's why PIH also provides social, mental, and economic support, to help people, families, and communities thrive. Ensuring children can return to school after illness is a vital part of that care. Here, four children and young adults who have faced vast challenges—such as HIV, TB, and diabetes—share their stories and their spirit. And, as September arrives, they share their excitement to get back to school. 

Emric Ansu at his family's home near Koidu, Sierra Leone
Ten-year-old Emric Ansu, at his family's home near Koidu, Sierra Leone, says he hopes to be a doctor one day but right now, his favorite part of school is writing—and football, as evidenced by his notebook with Manchester United star Paul Pogba on the cover. 

Emric Ansu

In a village just outside of Koidu, 10-year-old Emric Ansu hides shyly behind the entrance of the home he shares with his aunty, Massah, and five cousins. But as soon as he sees the familiar faces of PIH community health workers arriving, he runs outside with a smile to welcome them.

Emric had lost both of his parents to HIV by the time he was just 3 months old. Massah immediately made the 155-mile journey to Freetown to collect him, and has cared for him since. Sitting outside their home, she briefly paused to go inside, and returned with a crumpled photo in a plastic sleeve.

“This is my brother, just before,” Massah said. 

Across Sierra Leone, HIV still carries a heavy weight of stigma. But that didn't deter Massah from doing everything she had to do to save Emric’s life.

As soon as he was in her care, she had him tested for HIV. The results came back positive. In Kono District at that time, a decade ago, HIV treatment wasn’t easy to come by, let alone pay for. But Massah repeatedly found ways to ensure Emric had the antiretroviral medication he needed to survive. Those efforts became increasingly difficult, though, as Massah started her own family—today, she’s raising five of her own children along with Emric, on her own, while also supporting her mother, who suffers from disabilities. Earlier this year, PIH stepped in to help, providing free medication and health care to make sure Emric could continue his treatment and stay in school.

“It’s always hard,” Massah said. “Sometimes we don’t have enough food for the family, and when Emric can’t eat I don’t give him his medication, because without food it’s too strong and it makes him sick.”

PIH’s Acute Needs Program is designed for this kind of situation, and provides cash or food supplies to enable patients like Emric to stay on medication.

Emric turned 10 this summer, a milestone for any child. But in Sierra Leone, most families don’t have the means to celebrate every year and instead recognize birthdays every five years, if they can.

“But we still danced,” Emric said, smiling.

John Suluku, manager of the Acute Needs Program for PIH in Sierra Leone, recently visited Emric and asked to see some of his schoolwork. The energetic youth ran inside to collect it and returned moments later, holding a small notebook with Manchester United footballer Paul Pogba on the cover and “Exam Book” written at the bottom.

Emric’s dream is to be a doctor, but for now, what he loves most is exactly those two things—football and writing. He said he's not nervous at all about returning to school in his village. 

“I love school. I’m excited," Emric said. "My best friend is Philip. He’s not in my class, but we play together.”

Bintu Bailor
Bintu Bailor was diagnosed with tuberculosis this spring, just days before her end-of-year exam. She received treatment at PIH-supported Koidu Government Hospital, took the exam, and passed, clearing the way for her return to school this fall.  

Bintu Bailor

Bintu Bailor, 17, sat on the doorstep of her family’s home earlier this summer with her sister and cousins, in their home village near Koidu, waiting for PIH community health workers to arrive for their regular visit.  

They had been seeing the health workers often. Two months prior, just weeks before Bintu’s end-of-year exam, she was diagnosed with TB at PIH-supported Koidu Government Hospital.

Immediate treatment and support got her back on her feet. Bintu had a short hospitalization at Koidu, and took the exam just days after her release. She passed.

“Now I can be in secondary class one when we go back to school next month,” she declared proudly on that day earlier this summer, at her family’s home. “I just love to study, even when I’m not at school. I really like math.”

Her care has continued. PIH supports Bintu with transportation to and from the hospital, for medicine refills and regular checkups. The experience has left a lasting impression on Bintu.

“I’m feeling much better,” she said. “Now, I want to be a nurse and work for PIH. I like the way people treat me in the hospital when I go there. That’s why I want to study to become a nurse.”

Anita Bungura
Anita Bungura, 14, became critically sick last year, and became one of the first patients in Sierra Leone to be diagnosed and treated for type 1 diabetes. She now knows how to administer her own insulin and check her blood sugar, and has returned to school.  

Anita Bungura and Joshua Kamara

Anita Bungura sat patiently with her parents on a July day, on a bench outside the non-communicable disease clinic at Koidu Government Hospital, waiting to see the doctor.

Late last year, the 14-year-old had become critically ill.

“I wanted to drink a lot of water and needed to go to the bathroom very often,” Anita recalled.

In November, Anita and 20-year-old Joshua Kamara became two of the first patients in Sierra Leone to be diagnosed with, and treated for, type 1 diabetes. In a country with a high prevalence of infectious diseases such as HIV and TB, patients like Joshua and Anita—with non-infectious diseases—often had gone unnoticed.

During initial treatment, PIH provided transportation to and from the clinic for Anita and Joshua twice every day, so they could get insulin and blood sugar checks. The support saved their lives.

Joshua Kamara, 20, has learned to manage his diabetes with support from PIH
Joshua Kamara, 20, has learned to manage his diabetes with support from PIH, and has graduated from secondary school. 

Gradually, PIH doctors taught Anita and Joshua to administer lifesaving insulin and check their blood sugar levels on their own. PIH staff also arranged for Anita’s insulin to be stored at a local clinic, where it could be kept cold, and provided Joshua with a clay pot to store his insulin and keep it cool, as well. Community health workers have continued to make regular home visits to each family, and both Anita and Joshua were able to return to school this spring. 

Six months after his diagnosis, Joshua graduated from secondary school—an achievement he had long thought was out of reach.

“When my father died in 2010, I had to look after myself by doing labor to get myself food. I had given up hopes of completing school,” Joshua said. “I didn’t know about diabetes before, but (a PIH doctor) taught me about it. He showed me how to use a syringe, the amount of insulin I needed to use in an injection, and how to measure my sugar levels.”

With his health vastly improved, Joshua now hopes to continue his education even further.

“I used to lie in bed and feel like I was going to die,” he said. “But I feel happy and good now. Getting a good education is the way forward for me. That is my priority.”

The support from PIH has given Anita dreams of a bright future, as well.

“I’m in Form Three now and I want to be a nurse," she said. "I have learned a lot from the nurses and I feel a lot better now, so that’s what I would like to become.”

Thu, 29 Aug 2019 15:12:08 -0400
Q&A: SE Liberia's Only Surgeon Describes Lifesaving Role(s) Dr. Gerald Ekwen is not only the sole general surgeon at Partners In Health-supported J.J. Dossen Hospital in Harper, Liberia. He’s also the only surgeon in all of southeastern Liberia, where in Maryland County alone, PIH serves a population of about 170,000.

People also come to J.J. Dossen from neighboring counties and neighboring countries, such as Côte d'Ivoire. Ekwen has boosted obstetric services, too, helping his PIH colleagues track and reduce maternal deaths and increase the rates of women giving birth in a health facility, rather than at home.

PIH’s medical director for Maryland County, Dr. Abdissa Kabeto, said nearly 70 percent of expected deliveries occurred in a health facility in 2018, up from 35 percent just three years earlier—a vital improvement in Maryland, where PIH also supports the Pleebo Health Center.

“The southeast of Liberia is underrepresented and underdeveloped, and requires a lot of support from all of us,” Kabeto said.

Ekwen is an essential part of those efforts. He began his surgical career in 2014 at hospitals in his native Cameroon, and now works with 12 operating room nurses or support staff at J.J. Dossen, performing about 15 surgeries per week. Since Ekwen joined the PIH-Liberia team in 2018, he has conducted about 400 lifesaving surgeries, covering everything from endoscopies to emergency procedures.

His work addresses a need that extends far beyond Liberia. Five billion people worldwide lack access to safe surgeries, according to the World Health Organization. The shortage is most severe in low- and middle-income countries, where nine out of 10 people have no access to basic surgical services.

Ekwen sat down recently to talk about surgery in a rural setting, a daily routine that often extends late into the night, and how he couldn’t find J.J. Dossen’s operating room during an eventful first day on the job.        

Why did you become a surgeon?

After working in rural Cameroon for a while, I saw the challenges and burdens of surgical diseases in rural settings. I realized that, to make a difference in people’s lives, I needed to do more than just prescribe drugs. I needed to do surgeries also. That’s what caught my attention and my interest. I saw people suffering from treatable conditions because there was no surgeon.

Dr. Gerald Ekwen at J.J. Dossen Hospital
Dr. Gerald Ekwen at J.J. Dossen Hospital. (Kyle Daniels / PIH)

How is practicing surgery in a rural area different from an urban setting?

Here in rural Liberia, you’re expected to work as a urologist, as the orthopedic surgeon, the gynecologist, the obstetrician, and the general surgeon. There are even times when you’re called to do internal medicine and infectious disease care.

Many times, you find that you are alone in terms of support. You have to either connect to others through email or phone to discuss cases. When you work in a city or in teaching hospitals, you have all of these people around you. So when you have a case, you put your heads together and come up with a solution. In a rural setting, there’s no other surgeon, so you have to make the decision.

Working in a place with limited resources, you can make quite a huge difference in people’s lives. If you hadn’t been there, lots of people would have died, or would have had disabilities, because there was no surgeon. You are needed more than in a city.

You’ve certainly been needed, and welcomed, here. What brought you to Liberia?

I had read about the work of PIH in Rwanda and their push for global surgery equity. Our visions intersected in many areas, including the provision of a preferential option for the poor in health care. While reading through the PIH website, I came across a new job listing for Liberia.  I saw it as an opportunity to positively impact lives where I was needed most. The opportunity to build local capacity also prompted my interest and, ultimately, my decision.

I hear you had a case from the moment you arrived in Harper. Can you tell me about that day?

In the morning, I was going around the hospital with PIH’s medical director for Maryland County, Dr. Abdissa Kabeto, to introduce myself to the team. We had just finished in the x-ray unit and were in the PIH office in the hospital, talking with another director, when we heard shouts from the ER. We were like, “That is not normal. People are screaming and shouting. Is someone dead? What’s happening in the ER?”

We stepped out to see what was happening, and there was a crowd gathering. We saw a man in a pool of blood, sitting on the floor in the ER. What really scared me was that I had just seen him a few minutes ago in the x-ray room. They said there had been a small explosion, and a piece of metal got into his hand and caused a laceration of his artery.

He was pouring blood, so I had to jump in immediately. I couldn’t allow him to just die in front of me. I compressed the artery and wrapped it in a bandage. But I didn’t know where the operating room was yet, so I asked, “Can you take me to the OR?” We rushed into the OR, and I borrowed some scrubs. They were too big for me, but I just put them on. It was an emergency. 

We finally got the artery and bleeding controlled. A major challenge now was how to reconstruct the artery; since I’d never worked here before, I didn’t know what instruments I had, what sutures. So it was a little challenging for me on the first day. But despite the stress and the tension, we composed ourselves, repaired the artery, and saved the life of this patient.

What does a typical day look like for you?

I start around 7:30 a.m. I’m already in the hospital and want to see patients. I begin by going to the ER to get a quick round of what happened overnight and see any patients who came during the night—those having abdominal pain or surgical emergencies that the ER staff have not identified.

Then I do ward rounds. Afterwards, on Mondays and Wednesdays, I go to the surgery clinic, where we see patients for consultations. New patients are first, then we have those who are pre-op, and lastly those who are post-op and coming for review. Tuesdays and Thursdays are mainly elective days.

By 4 p.m., we often start getting emergency cases. For some reason, patients often come later in the day or at night. You see the ambulance start dropping patients. We operate until maybe 9 or 10 p.m. on Tuesdays or Thursdays. Sometimes until 2 a.m., if it’s a particularly complicated patient.

On Fridays, I try to scale down and give some breathing space for the OR team to recover, because obstetrics has a lot of emergencies and cesarean sections on Thursdays.

J.J. Dossen Hospital campus in Harper, Liberia
PIH-supported J.J. Dossen Hospital serves 170,000 people in Maryland County, Liberia, as well as people from neighboring counties and countries. (Photo by Rebecca E. Rollins / PIH)

You have an impressive track record of ensuring safe surgeries at J.J. Dossen Hospital. To what do you attribute this success?

Our team is working hard to make sure our surgeries are safe. Sometimes I see the OR team, after I’m done with a case, sitting there and waiting with a patient. They become the recovery or ICU nurse, sitting there until the patient comes around, before they transfer the patient to a ward. This is making a lot of difference in reducing deaths.

I’ve seen our anesthetist stay with a patient until 2 a.m., sitting with him after a surgery that finished at 9 p.m., giving him fluids and making sure he has oxygen, until he was fully awake and transferred to the ward. Our team follows patients even when they’re on the ward, through phone calls and text messages. All of this is helping to ensure the patient has continuity of care. That is what is making the difference.

Surgery is a team sport. You have to rely on your anesthetist, your scrub technicians. You have to motivate your ward nurses. That is what we can say we are winning on. We’re getting more involved in the management of the patient. Team members begin to feel like it’s our patient. If the patient gets well, it’s our success—not the surgeon’s.

How do you maintain your optimism in the face of difficulties?

Touching and transforming people’s lives, and bringing high-quality health care to those who are truly in need, is a great thing.  Many times, all they can tell you is “thank you,” but that’s more than enough. My perspective on life, doing to others what I expect to be done to me, and my deep love for fellow humans all keep me optimistic, in the face of any difficulty.

Tue, 27 Aug 2019 12:34:01 -0400
Research: Haiti Training Program Propels Vital Emergency Care Haiti’s growing network of emergency doctors has its roots in an innovative program that pioneered emergency medical training in the Caribbean nation, paved the way for Haiti’s ongoing expansion of lifesaving critical care, and created a model for filling a severe gap in care found in developing countries around the world.

BMC’s International Journal of Emergency Medicine published results of the program in April 2018, in a study titled: “Addressing the Immediate Need for Emergency Providers in Resource-Limited Settings: the Model of a Six-Month Emergency Medicine Curriculum in Haiti.” The program addressed a well-known but hard-to-tackle problem: Short, quick trainings of a week or two helped meet immediate needs for some emergency and critical skills, but did not give doctors enough hands-on experience or expertise to manage the breadth of emergency care needs. Meanwhile, multi-year residency programs trained highly skilled specialists, but took too long to fill immediate demands and gaps in care. 

Haiti’s devastating 2010 earthquake, which killed nearly 300,000 people and injured hundreds of thousands more, made the dire need for emergency care in Haiti starkly clear.

Dr. Shada Rouhani, Partners In Health senior adviser for clinical operations, said she and colleagues in Haiti developed the six-month training program in the years immediately following that disaster, at a time “when there was no in-country emergency care capacity.”

The situation reflected chronic shortages of emergency care found in low-resource settings worldwide.

The 2018 study described the “tremendous need for improved emergency services in low- and middle-income countries, to reduce the burden of infectious diseases, non-communicable diseases, and injuries.” Citing numerous sources, including the World Health Organization, the study added that up to 90 percent of trauma-related deaths worldwide occur in low- and middle-income countries.

“Like all specialties, there are too few emergency care providers,” said Dr. Regan Marsh, director of clinical systems for Partners In Health. “In many ways, emergency care (still) is relatively new on the global health stage, in terms of importance.”

Dr. Cassandre Edmond, left, and Dr. Regan Marsh review an ultrasound in 2014
Dr. Cassandre Edmond (left), then an attending physician in the University Hospital emergency room, and Dr. Regan Marsh, then the hospital's co-director of emergency medicine, review an ultrasound for a patient who had been struck by a motorcycle in January 2014, about two months before Marsh and colleagues launched an emergency medicine training program that would galvanize care across the country. (Photo by Rebecca E. Rollins / PIH)

Rouhani and Marsh are two of the study’s co-authors, and worked together for several years as co-directors of the emergency department at Hôpital Universitaire de Mirebalais, or University Hospital, in Mirebalais, Haiti. Zanmi Lasante, as PIH is known in Haiti, opened the 300-bed teaching hospital in 2013, in partnership with Haiti’s Ministry of Health.

The training program was a national partnership, as well.

“This program was successful because it was done with the Ministry of Health and it was done within the national system,” Rouhani said. 

The study’s co-authors also include Dr. Fernet Leandre, former co-executive director and current chief of programs for PIH in Haiti, and Dr. Kerling Israel, former director of medical education at University Hospital.

Leandre said prior to 2014, medical professionals received basic training in emergency care at the Hospital of the State University of Haiti, in Port-au-Prince. Equipment and standard-of-care protocols were not up to date, creating challenges with handling medical emergencies across Haiti’s health system, from primary care to hospital levels.   

Leandre said that in the absence of strong systems, lifesaving equipment, and specialized staff, many emergency medical situations—such as road accidents or strokes—can become “a death sentence.”

He and his colleagues knew that a better emergency system began with better education.

The group developed and implemented a six-month emergency medicine training program, designed to provide substantive instruction and experience in an efficient timeframe to boost staffing for emergency care. Fourteen physicians from across Haiti joined the program, held from March to August 2014, and received classroom instruction as well as supervised clinical time.

Israel said Marsh and Rouhani’s experience working with local staff in emergency settings at University Hospital, and with the hospital’s medical education department, gave them a strong understanding of local context that was invaluable in designing the program’s curriculum, and ensuring it was relevant in Haiti.  

All 14 physicians completed the program successfully, the study notes.

“All improved from their pre-test to post-test. At the end of the program and nine-month post-program evaluations, participants rated the program highly, and most felt they used their new knowledge daily,” the study states.

Marsh said the majority of the program was spent on the job, as each participant had to spend 180 hours in University Hospital’s emergency department, working in conjunction with herself, Rouhani and other visiting faculty in emergency medicine.

“Everyone said that was a key component of the learning,” Marsh said.

Dr. Mirrielle Bien-Aime at University Hospital in 2013
Dr. Mirrielle Bien-Aime checks on a patient in University Hospital's emergency room in July 2013. The following year, she would complete the hospital's six-month emergency medicine training program, which combined classroom lessons with extended time in the ER. (Photo by Rebecca E. Rollins / PIH)

The program’s effectiveness continues to resonate today, as the six-month training paved the way for a three-year emergency medicine residency program at University Hospital. The program is thriving, and remains the only emergency medicine residency in Haiti.

“The six-month training was very important in the preparatory phase of the residency program,” Israel said. “It allowed leaders to anticipate specific needs and hurdles to overcome, and plan accordingly.”

Israel added that two family physicians who participated in the course were able to continue in-depth emergency medicine training, and have become key players in the residency program.  

The residency began in 2014 and graduated its first class in 2017. The latest group will graduate in coming weeks.

“We now have 12 fully fledged Haitian emergency docs—and we’re about to have 18,” Marsh said.

Marsh said the training program and residency have improved services and resources not only at University Hospital, but at health facilities across the country.

“The training program strengthened the first network of emergency medicine providers (in Haiti),” she said. “It’s a great success story.”

The program could lead to success stories in other countries, as well, as a model for filling vital gaps in emergency care. Rouhani, Marsh and others held an emergency medicine training with the PIH team in Liberia in May, for example, and will return in October for additional instruction.

“There is growing momentum at a number of our sites, and Haiti is a nice example of fulfilling the potential,” Rouhani said.

International awareness and recognition of the need for emergency care is growing, as well.

At a May session of the World Health Assembly, the decision-making body of the World Health Organization, attendees created a resolution that noted, “the lack of investment in frontline emergency care is compromising effectiveness, limiting impact and increasing cost in other parts of the health system.”

Additionally, the resolution called on all member states to, “create policies for sustainable funding, effective governance and universal access to safe, high-quality, needs-based emergency care for all, without regard to sociocultural factors.”

Outside the emergency department at University Hospital in Mirebalais, Haiti
The emergency department at University Hospital in Mirebalais, Haiti, has become a hub for emergency medicine training and resources that are improving services at health facilities across the Caribbean nation.  (Photo by Rebecca E. Rollins / PIH)

Rouhani said the lasting impacts of the Haiti training program—and the nationwide growth of emergency services—serve as a real example for others.

“The speed at which it has developed, the fact that it has become self-sustaining, and the fact that over the course of a short time you’ve seen huge impacts for patients, who are now receiving higher quality emergency care,” she said, listing positive results. “There are patients who are alive today who would not have been alive if these emergency care programs and systems hadn’t been there.”

Tue, 27 Aug 2019 10:59:39 -0400
Dr. Paul Farmer Talks Health Equity, Empathy with Bay Area NPR In a Bay Area NPR interview this week that ranged from Congo and Rwanda to Palo Alto, Harvard and Haiti, Dr. Paul Farmer focused strongly on a common thread that connected the diverse topics.  

“If you don’t have an equity agenda in mind….I think you’re looking at the wrong target,” Farmer, co-founder and chief strategist for Partners In Health, said to host Michael Krasny on KQED’s Forum radio show.

Farmer returned Tuesday to KQED and Forum, spending a full hour on the San Francisco NPR affiliate’s call-in news program. Farmer has appeared on the show previously in recent years, and he and Krasny enjoyed a familiar, friendly rapport as they discussed the ongoing Ebola outbreak in the Democratic Republic of the Congo, how to build trust and stronger health systems in communities where PIH works around the world, and how simple acts of empathy can improve health care equity for all.

Farmer had returned less than two days earlier from a visit with PIH teams in Rwanda. During his time there, Farmer spoke at the Aug. 11 graduation at the University of Global Health Equity, a PIH initiative in the country’s rural north; attended the opening of the nearby Cancer Support Center, which will provide housing and supports for patients in extended care at Butaro District Hospital; and met with health leaders helping Rwanda prepare for potential Ebola cases, should the deadly virus cross the border from neighboring Congo.

Farmer’s whirlwind schedule led Krasny to ask, in a lighter moment, if Farmer ever worried about burnout. Farmer joked that he’d be more worried if he had become a banker, or another profession outside of health care.

“I happen to have chosen a vocation,” Farmer said, referring to his leading role with PIH over more than three decades. “I find it very bracing and fun, so the chances of burnout are much lower.”

Farmer also took questions from listeners during the hourlong program, with people calling locally from around the Bay Area and from as far away as Toronto.

Listen to the full interview and conversation here.

Fri, 23 Aug 2019 14:13:35 -0400
Meet New CEO Dr. Sheila Davis: "Firefighter," HIV Advocate, and Nurse Poet Dr. Sheila Davis knows about her reputation as a firefighter at Partners In Health. She led the organization’s Ebola response in West Africa from 2014 to 2016, then helped transition the teams to rebuilding the health systems in Liberia and Sierra Leone. She was the first one called to help the Haiti team when Hurricane Matthew wreaked havoc in Haiti in October 2016, and when flooding wiped away entire neighborhoods in Lima in the spring of 2017.

Each time, Davis was the steady hand that guided PIH through the literal, or figurative, storm. So it was no surprise that she emerged at the top of a global search for PIH’s next CEO, following the retirement of Dr. Gary Gottlieb at the end of June.

Davis joined PIH as a nursing coordinator in October 2010 and became the chief nursing officer in March 2013. As such, she was instrumental in planning and opening University Hospital, the 300-bed teaching facility built in Mirebalais, Haiti, in the wake of the devastating 2010 earthquake. She has since established PIH’s nursing strategy, while heightening the professionalism and inclusiveness of the organization’s thousands of nurses, midwives, and community health workers. She took on the additional role of chief of clinical operations in January 2017.

Davis sat down recently to talk about her work as an HIV advocate, the positive response she’s received from nurses on her appointment as CEO, and her vision for PIH’s future.

What drove you to become a nurse?

It’s not like I had a calling. My family was very social justice-oriented. My sister is a teacher. My other sister went into human services. My brother went into politics and worked in homeless shelters. My dad is an educator, my mom a social worker. For some reason, nursing just appealed to me because it was a way to work closely with the whole person. It just totally fit.

You were among the first cohort of nurses to care and advocate for patients with HIV. What inspired you to join that movement?

I grew up in rural Maine, where there was nobody I knew who was openly gay. Everybody looked exactly like me. It was very small town. When I moved to Boston to go to school at Northeastern, my nurse preceptor at my clinical site was a gay man whose partner was dying of HIV. This was in January of 1985. I remember visiting him at a local Boston hospital after we got out of work. The nurses hadn’t gone in. The trays were piled up outside. And I remember being very angry and saying, “I’m not going to join this profession because this is horrible. People aren’t treating him like a human.”

It just turned on an advocacy part of me. For me, nursing, social justice, and advocacy were entwined from the very beginning. I became involved with the AIDS advocacy movement in Boston, with AIDS Action, and became a buddy for people who were dying of HIV. I was part of Act Up, an AIDS activist group. Then through my Northeastern co-ops, I worked at the National Institutes of Health when there were a lot of protests happening. The AIDS community was really mobilized and would storm buildings and block entrances fighting to be heard. The media and politicians were not paying attention, so something had to be done.  

At that point in the AIDS crisis, everybody died, so it was end-of-life care. I was really privileged and honored to be with people at that point in their lives. Many of the patients were people who were marginalized by society—gay men, people who injected drugs, and those who traded sex for survival. People were disowned by their families and many were alone, so we became people’s families and spent time with them as they were dying.

Sheila Davis walks to a helicopter during Ebola response in Liberia
Davis walks to a United Nations helicopter as part of a PIH team responding to the Ebola outbreak in Liberia in October 2014. Photo by Rebecca E. Rollins / Partners In Health

Can you talk about your time with the Association of Nurses in AIDS Care, or ANAC?

My first job after graduating from nursing school was at George Washington University Hospital in Washington, D.C. on a unit that had only HIV patients. It was just a very bizarre time; our scrubs were the same pink that matched the blood-borne pathogen sign that was hung on every door—a crazy coincidence.  Even as nurses, we were ostracized. People would ask me, “As a white, heterosexual woman who doesn’t use drugs, why are you doing this? Why do you care?”

There were no books on how to take care of people with AIDS then. There were nurses in San Francisco and New York City who were doing it, and they started an organization, ANAC. We all just found our way to this group. That became such a sense of community, and source of knowledge regarding how to care for people. All of us are still good friends, 30 years later. We lost so many people. A lot of gay men went into nursing because of HIV, and we lost many nurses too. Every year at the conference we have a Celebration of Life, our memorial service. It is very special to all of us. That’s the one time of year where I really cry, because it’s when I take the time to remember all the people I lost and can grieve together with people who lost so many too.  

ANAC is also how I got involved in global work. Although we were all in our early 30s, we were the HIV experts. Because HIV treatment had not been around for very long, there was a small group of us who knew how to treat HIV with antiretroviral (ARV) drugs. They were not easy to take then and made some people really sick. I started working in South Africa, which was amazing. I was not someone who had ever planned on working outside of the United States, but went because I was needed. I am so glad I had the opportunity to do it, because it really changed my life.

ARVs were first introduced in 1996. As a nurse, it must have made your head spin to see HIV change from a terminal illness to a chronic condition.

People talk about the Lazarus effect (from antiretroviral drugs that have dramatically positive effects on HIV patients). It truly was people who were on death’s door. I was taking care of women at Massachusetts General Hospital who would say, “I just need to see my children get through high school.” Now those women have grandkids. It happened in such a short amount of time.

Now we’ve gotten the virus under control, and HIV is a treatable chronic disease, but the social situations that put people at risk and make life hard, we didn’t change. We always said that if we could ever treat HIV, that would be a game changer. And it was for most people. There is not a biological reason why many marginalized groups were overrepresented in HIV. It’s because their lives were harder; they were poor and they didn’t have access to good health care. Targeted information on how to prevent the spread of HIV was not getting into the communities that needed it. When people did try and get care, they were not treated with dignity or respect. People who live in the shadows are vulnerable to all types of infections and diseases, and HIV was no different.

What attracted you to PIH’s work?

I started working at Mass General in January of 1997, and it was the beginning of the turning of the tide for HIV. Joia [Mukherjee, PIH’s current chief medical officer,] was an infectious diseases fellow working with me before she started at PIH. I stayed in touch with her when she left. The HIV world was pretty small, so I knew other people also who worked with PIH. And I actually went to Haiti in 2001 with a friend who is a nurse, and she knew Loune [Viaud, the executive director of Zanmi Lasante, as PIH is known locally], so I was able to meet her long ago.

I knew of and had met Paul [Farmer, PIH’s co-founder and chief strategist,] in the HIV world in Boston. I also had read many of his books. I was critical of the fact that he talked a lot about community health workers and doctors, but not much about nurses in treating HIV in his early books. That has changed a lot. Paul is now one of our best nurse advocates out there. Nurses have been virtually invisible in global health sadly. We are the largest group of professional health workers globally, but are rarely in any leadership roles. Although we were running many of the HIV programs globally, you never saw nurses presenting at conferences or being recognized as the experts, which was very frustrating. I am glad that is finally starting to change,

Then, in 2010 after the earthquake, a nursing colleague named Donna Barry, who was leading PIH’s advocacy and policy work at the time, and Joia reached out and said, “I think you should come here.”

Graduation ceremony for Nightingale Nurse Fellows
[Front row, from left] Dr. Paul Farmer, PIH co-founder and chief strategist, Cory McMahon, director of nursing, CEO Dr. Sheila Davis, and Marc Julmisse, deputy chief nursing officer, attended the first graduation of Nightingale Nurse Fellows in June 2018 in PIH's Boston office. Photo by Zack DeClerck / Partners In Health

What are you most proud of having accomplished so far?

At PIH, a number of physicians had the opportunity to go to develop professionally while working at PIH. They did master’s degrees. They traveled to other PIH sites and represented PIH globally at conferences and had the opportunity to learn from each other. We never had nurses who did that.

I’m proud that that was able to happen, because there’s so much wealth of experience that was pretty siloed and hidden. We started really investing in nurse accompaniment, and that’s how the PIH Nightingale Nurse Fellowship developed, to give nurses the concrete skills that we need to lead—things we don’t learn in school.

As the new CEO, what words would you use to describe PIH?

I think gritty is a good word, because I think it’s very real. It’s earth. It’s in it. It’s being at the ground level where things happen.

A lot of people may do what we do, provide health care, but not in the way that we do it. Not in the way that we’re listening to others and having the contextual experts driving what we do—and do it from the communities, all the way to the ministries and the global stage. That’s very unique.

What are some of the big challenges ahead, and how do you hope to tackle them?

We have a lot to do. We have great people working very hard to take care of those who are vulnerable and suffering. This takes “the five S’s” we always talk about: staff, stuff, space, systems, and social support. We need funding and the political will to put people first.  

Your announcement as PIH’s new CEO sparked an outpouring of support, especially from nurses. How did you absorb that, and what message does your new role send to the larger nursing community?

There’s this Michelle Obama quote that I love. She says, “When you've worked hard, and done well, and walked through that doorway of opportunity, you do not slam it shut behind you. You reach back and you give other folks the same chances that helped you succeed."

I do feel that responsibility. We all should be doing that. The support from nurses all over the world has just been astounding. It’s standing on the shoulders of these giants, and nurses who worked so hard for so many years and never have been recognized.

In many senses, nurses have not had an opportunity to be seen as leaders of a global health organization of this caliber. A nurse in charge of a large Harvard-affiliated NGO? In the past that would have been unheard of. It’s been a battle to have nurses recognized as leaders. That is changing now.

Tell us about your life outside of work.

My daughter is a huge part of my life. As a single mother, she was beside me through the early days of HIV and grew up as part of that community. And my family—my dad and everybody are really important. I like poetry, reading, and writing. The ocean for me is really rejuvenating year round. And then communities, like ANAC, feed me. I have led a life of service in a lot of ways. There are places where the ugliness is, because nurses are witness to very difficult things. Not everyone can relate to that, so you find your outlets. My poetry is fairly raw, because that’s where I can let it out. I only share with a few people now, but maybe more someday.

Do you have a favorite poet? And is there any passage or phrase you turn to for inspiration or solace?

Mary Oliver was my mother’s favorite poet. There are a few of her works that I think are very important that I do think about. And Maya Angelou. There’s that poem, “When Great Trees Fall.” When my sister died a few years ago, I was devastated. I found how poetry can be just so comforting and put words to something that you can’t explain. I go back to that poem a lot.

Mon, 12 Aug 2019 11:03:33 -0400
'We Get to Set the Tone': UGHE's First On-Campus Students Reflect on Landmark Year Nicole Jabo, 25, assessed the financial burden of type II diabetes on adult patients in her home country of Rwanda.

Her classmate Leila Dusabe, a 27-year-old from Burundi, examined barriers to voluntary male circumcision, hoping to increase rates of a practice that’s widely viewed as a preventative measure against HIV.

They described their capstone projects earlier this year while seated in a well-equipped classroom—flat-screen monitor, Wi-Fi connectivity, whiteboards, movable tables and walls—at the University of Global Health Equity, a Partners In Health initiative in northern Rwanda. Joining them were two of their classmates: 34-year-old John Bosco Kamugisha, from southern Uganda, and 37-year-old Peter Muriuki, from Nairobi, Kenya.

The projects are the culmination of their studies in UGHE’s one-year Master of Science in Global Health Delivery program, which 24 students, including these four, began in September and completed this month. They have been the first class to live and study full-time on UGHE’s new campus, formally inaugurated in January in the rural region of Butaro.

Mountains surround the campus, which is not far from Volcanoes National Park—extinct volcano Mount Muhabura looms on the near horizon, in fact, its peak sometimes shrouded by clouds. The borders of Uganda and Democratic Republic of the Congo also are just miles away, close enough that when referring to those countries, people at UGHE often point over nearby hills as if to say, “just over there.”

The UGHE campus, seen from nearby Butaro District Hospital
The UGHE campus, seen from the nearby, PIH-supported Butaro District Hospital, was formally inaugurated in a January ceremony and is a bright, visible beacon for miles around the Butaro community.

But as the four students discussed their experiences and work at UGHE, what it meant to be the first class living on campus, and their interactions with the Butaro community, their heads were far from the clouds. They had immediate concerns, such as studying and projects ahead of graduation in August.  

Kamugisha's capstone tracked hand hygiene among health care workers at PIH-supported Kirehe District Hospital in eastern Rwanda, to reduce transmission of infections between staff and patients.

Muriuki's capstone sought to better integrate agriculture into prenatal care, by recruiting women in early stages of pregnancy for farming programs that could improve not only their own nutrition, but also their babies’.

“When mothers are better nourished, it means the children are better nourished, as well,” he said.

Dr. Rex Wong, director of UGHE’s Bill and Joyce Cummings Institute of Global Health—and academic leader for the master’s program—said in previous years the capstones were individual projects, conducted independently by students taking classes part-time.

With this year’s advent of full-time students, UGHE staff adjusted the format. 

“We wanted to really create a program that’s more applicable to the real world, so we decided to do group projects,” Wong said. “That’s the real world—you have to work with people.”

Students also had to partner with a Rwandan organization for their capstones. Muriuki and his capstone partner, for example, worked with Gardens for Health International to explore prenatal agriculture programs.

“We treat the organization as a clientyou see what they need,” Wong said. “That means students are not just creating a project that nobody can use. It’s practical, and mutually beneficial.”

The collaborations also could create networks for students, potentially leading to internships or full-time jobs after they graduate. But UGHE leaders are just beginning to see how that might play out.

“This is our first cohort doing it,” Wong said.

One of many firsts for this year’s class.

A main building on the UGHE campus, surrounded by Butaro hills
Sidewalks on the UGHE campus often are wide open, but the medical school class that arrived in July has added to the foot traffic at the dining hall, classroom, reception and office building shown here. 

UGHE is an initiative of Partners In Health, which strengthens health systems in 10 countries around the world. PIH began working in Rwanda in 2005, and is known locally as Inshuti Mu Buzima. The private, independent university was launched in 2015, with significant investment from the government of Rwanda. Construction of the campus began a year later, with classes and part-time studies temporarily based in Rwanda’s capital, Kigali. Part-time students complete UGHE’s master’s program in two years, rather than the single-year program that the on-campus students have pioneered.

UGHE’s 250-acre (100-hectare) campus is about 80 miles north of Kigali, with distinctive white buildings adorned with traditional, patterned art known as imigongo. The campus has housing for up to 200 students and staff, a dining hall, and six academic buildings. There’s also a recreation center and outdoor basketball court, a dining hall with floor-to-ceiling windows and locally catered meals, and land for expansion in coming years. 

And for several months earlier this year, Jabo and her classmates were the only students living there.

“It feels like you move into this place and you have a house all to yourself,” Jabo said. “It’s been really nice, but we’ve had to be flexible in a way, with all the different changes.”

Those changes have included ongoing construction and touch-ups, and a January inauguration ceremony with guests including Rwanda President Paul Kagame. All of that came along with ongoing preparations for UGHE’s first batch of medical students, who arrived on campus in early July to start a six-year program.

But dealing with a new and changing living situation—while also, of course, completing an intensive, yearlong master’s program—is nothing these students couldn’t handle.

After all, they got to UGHE in the first place. The university received more than 300 applications across 26 countries in 2018, for the 24 spots in this year’s class. The students who made the cut come from 11 countries—there’s representation on campus from Malawi, Tanzania, Kenya, Uganda, Rwanda, Burundi, Nigeria, Sierra Leone, Nepal, Canada, and the U.S.

UGHE buildings are adorned with traditional Rwandan art patterns
Campus buildings are adorned with distinctive traditional patterns known as imigongo. 
UGHE buildings are adorned with traditional Rwandan art patterns
Dormitories for students have broad views of nearby hillsides and communities in northern Rwanda, not far from the Uganda and Democratic Republic of the Congo borders.

Bringing all of those backgrounds together and guiding students to success takes an academic leader with a global outlook. Wong certainly fits that bill: he’s lived in 14 countries, is familiar or fluent in seven languages, and previously directed a hospital management program at Yale University. He also is an engaging, kinetic personality with energy to spare.

But he slows down and smiles when talking about how UGHE’s diverse students have learned from each other and grown over the past year. The only language that’s remotely common to the students’ 11 countries is English, which is the language of classes and educational materials on campus.

Interacting with each other in a shared, mostly non-native language has vastly improved the students’ communication skills and global perspectives, Wong said.

“In September, when I first saw them, they couldn’t even stand up and talk to people—I mean, they could—but you see how they stand up and present themselves now,” Wong said. “It changes month to month and week to week.”

Wong said the student body’s multicultural makeup creates constant lessons inside and outside of UGHE classrooms.

“You cannot even stage it; you just have to let it happen organically,” he said. “We are all learning from each other.”

He mentioned a recent class that included a discussion of needle exchange programs. Many of the students had worked with such programs before, and all contributed different experiences—sometimes with conflicting opinions about cultural norms and practices.  

“Just like anywhere else, there are always personality issues and different cultural competencies,” Wong said. “Sometimes you offend people because you didn’t know (their background or perspective). But I think that happens on any campus, anywhere.”

Dr. Rex Wong leads the master's program at UGHE
Dr. Rex Wong is director of UGHE’s Bill and Joyce Cummings Institute of Global Health, and academic leader for the master’s in global health delivery program. His stand-up desk reflects Wong's energetic, on-the-go personality.  

One thing you might not find on just any campus is the high level of poise and personal maturity held by UGHE students. Whether from diverse life experiences or professional expertise, it quickly becomes apparent that these are not the carefree collegians found in many western universities. These are driven, passionate students who are approaching their studies with purpose.   

Kamugisha, for example, came to UGHE from Masaka Regional Referral Hospital in central Uganda, where he works in Global Emergency Care.

“Doing this master’s will help me perfect my leadership, managerial and research skills,” he said of UGHE’s global health delivery degree.

Dusabe is a public health practitioner in Burundi, and said her year of study will provide invaluable professional development.  

“When I heard about UGHE, I thought about the quality of the education, first of all,” she said. “The exposure and quality of experience I will gain from here will be really good for me.”

Muriuki, the oldest of these four students, said he’s worked for more than 10 years on the research side of the health industry, in areas including maternal and neonatal health, child health, and nutrition, often with vulnerable populations such as people living in Nairobi slums. 

“I was ready to upgrade my skills—and that included skills in research, because I saw that UGHE was research-focused,” he said. “Equity in health care is one of the big topics and debates happening around the world, and I wanted to learn what I could do to ensure equity.”

Jabo is the youngest of the four, and the only one who came to UGHE straight from undergraduate education. She graduated last year from the University of Texas at Tyler, about two hours east of Dallas.

She said UGHE felt like an opportunity to immerse herself back into the culture of her home country, and get a close look at Rwanda’s health system.

“One of the things that most drew me here was that I wanted to work and live in Rwanda. It just seemed very timely that this university opened and it aligned with so much of the work I wanted to get involved with,” Jabo said. “It’s like learning about the health system of my country once again, and being an active participant in some of the solutions, now and in the near future.”

Dusabe said the small community on campus this year has enabled a lot of open dialogue with UGHE staff, guest lecturers and professors from institutions around the world, Rwandan health leaders, and others.

“We really hope that continues (in coming years),” she said.

Kamugisha has taken a local focus, doing his best to meet people in the Butaro community surrounding the campus. He attends Mass at a nearby Christian church and takes regular evening walks in the community.

“By now, I know most of the people around Butaro,” he said, adding that residents have been helping him perfect his Kinyarwanda language abilities.

Jabo and her classmates are well aware that being the first students to live and study on UGHE’s still-new campus brings responsibilities, along with the perks.

“I feel like we get to set the tone for even the other students who come after us,” Jabo said. “Whatever traditions and types of things we leave here, will continue for years and years to come.”

A security guard overlooks surrounding hillsides at the University of Global Health Equity in northern Rwanda
A security guard takes in a view from campus. MGHD student John Bosco Kamugisha said he took regular evening walks through surrounding Butaro communities, and attended services at a nearby church, to meet as many local residents as he could and help lay a foundation for growing ties between Butaro and the university. 


Fri, 09 Aug 2019 10:14:30 -0400
NPR Highlights PIH Child Cancer Care in Rwanda A recent piece in “Goats and Soda,” National Public Radio’s global health and development blog, shows how Partners In Health is leveraging strong collaborations to provide low-cost, lifesaving care for children with cancer in northern Rwanda.

The July 26 piece, How to Bring Cancer Care to the World’s Poorest Children, features the Butaro Cancer Center of Excellence. The facility is part of the PIH-supported Butaro District Hospital, operated in close collaboration with Rwanda’s Ministry of Health. PIH has worked in Rwanda since 2005 and is known locally as Inshuti Mu Buzima. The cancer center opened in 2012 and now sees nearly 2,000 patients per year, from across Rwanda and from nearby countries where affordable, quality cancer care is scarce or nonexistent. 

The NPR piece cites a PIH study—published in 2018 in the Journal of Global Oncology—that showed children with cancer could get full treatment, follow-up care, and social support at the Butaro facility for a fraction of the costs found in high-income countries.

"There's this myth that treating cancer is expensive," Dr. Christian Rusangwa, deputy chief medical officer in charge of chronic care for PIH in Rwanda, and a co-author on the study, said in the NPR piece. "And that's because the data is almost all from high-income countries."

Read the full NPR piece here.

Tue, 06 Aug 2019 14:43:00 -0400
New Hepatitis B Clinic Launches in Sierra Leone Mariama Alieu was heavily pregnant when she was admitted in June to Koidu Government Hospital in eastern Sierra Leone. The 30-year-old mother of four said she’d suffered ill health for more than a year without receiving the correct diagnosis and felt like she would “always have the flu.

“My chest hurt and there was so much pain in my bones,” Alieu remembered feeling. “A bitter fluid would always come up my throat.”

At the hospital, doctors examined her, ordered the proper tests, and received news from the laboratory that Alieu tested positive for hepatitis B—a disease she’d never heard of up until her diagnosis. She was immediately started on antiviral therapy, which she will take for the rest of her life.

A new hepatitis B clinic

Alieu is one of the first patients to be treated at PIH’s newly opened hepatitis B clinic at Koidu Government Hospital in Kono District, in partnership with Sierra Leone’s Ministry of Health and Sanitation. Staff will strive to care for as many people with the condition as possible through screening, monitoring, and treatment, with the goal of enrolling 75 people into care within the first year. All these services are free of charge. 

PIH and government partners hope that what’s accomplished in the new hepatitis B clinic will inform a forthcoming national treatment guideline that will be applied in clinics and hospitals across Sierra Leone. They also will vaccinate 200 medical students in Freetown and vaccinate or treat all clinical and non-clinical staff at Koidu Government Hospital in coming months. The partners’ plans were announced during a joint press conference and seminar hosted in Freetown on Friday, July 26. 

Hepatitis B conference in Freetown, Sierra Leone
Dozens of Ministry of Health and Sanitation staff and clinicians gathered during a recent PIH-led press conference and seminar on hepatitis B in Freetown, Sierra Leone.

Of the five types of viral hepatitis (A, B, C, D, and E), hepatitis B is one of the most prevalent forms worldwide. It is an infection of the liver that is transmitted through the blood or body fluids of an infected person and, if left untreated, can cause irreparable damage to the liver, altering its function completely. Around 350 million people have the infection, 10 times more than those living with HIV. 

The World Health Organization estimates that nearly 10 percent of the population in Sierra Leone is infected with hepatitis B, a sharp contrast to the less than 1 percent of the population in the Caribbean and North and South America. Yet despite its high prevalence, clinical testing, immunization, and treatment across Sierra Leone is limited. 

Screen, treat, monitor, repeat

That is no longer true at Koidu Government Hospital. Patients admitted with HIV or tuberculosis, as well as maternal health, blood bank patients, and the newborns of mothers with hepatitis B, will now be automatically referred to the hepatitis B clinic for screening via a blood test. 

“By increasing screening, we will catch patients earlier,” said Dr. Marta Patino, an infectious disease specialist working at KGH. “We need to make sure the entire structure is in place—screening capabilities, a database, clinicians ready to treat the patients, everything.”

blood test for hepatitis B in Sierra Leone
A laboratory technician conducts a blood test for hepatitis B at PIH-supported Koidu Government Hospital in Kono District, Sierra Leone.

People who test positive for the virus will be continually monitored through regular appointments at the hepatitis B clinic. And those meeting the criteria for therapy, like Mariama, will be started on antiviral treatment, which is a lifetime daily tablet. 

“It’s crucial to stop growth of the infection and worsening of the disease, both for the individual’s health and to prevent the spread of infection to others,” Patino said. “The liver needs to be preserved to live a long, healthy life. Some of our younger patients have been refused opportunities, like joining the military, because of this illness.” 

Preventing transmission of hepatitis B

Koidu Government Hospital clinical staff face a huge risk when exposed to the blood of hepatitis B patients, which is why PIH will introduce a vaccination and treatment plan for all clinical and non-clinical staff, or around 1,000 people. Those found positive for hepatitis B, who also meet the criteria for treatment, will be provided therapy and monitored regularly through the hepatitis B clinic. Staff who are negative will receive a three-dose hepatitis B vaccine, which is a standard occupational health measure in most health facilities around the world, but not something commonly provided in health facilities across Sierra Leone. 

Children under 6 are one of the most likely groups to develop a chronic form of the infection, and so transmission of hepatitis B from infected mothers to newborns is another focus for the hospital’s clinicians. Looking ahead, they hope to vaccinate newborns of mothers living with hepatitis B within 24 hours of their birth, as this has been shown in many countries to reduce the rate of chronic infection to less than 1 percent among immunized children. 

Back in June, Alieu’s top concern was how her diagnosis would affect her newborn. “I worry about my pikin,” she said, referring to her baby in Krio. “But I believe in God that the doctors will help me.” 


Thu, 01 Aug 2019 10:58:06 -0400
Research: Hepatitis C Trial Shows Strong Results in Rwanda A recently published study showed strong success for treating hepatitis C with new antiviral medicine in Rwanda, potentially creating a model for broader treatment plans across the region.

Several of the study’s co-authors are affiliated with Partners In Health, which is locally known as Inshuti Mu Buzima and has worked in Rwanda since 2005. The 2017, PIH-led study tracked 300 patients who had 12 weeks of treatment at Rwanda Military Hospital in the nation’s capital, Kigali, and resulted in successful treatment for 87 percent of them. Co-authors found no previous large-scale, antiviral hepatitis C treatment studies in sub-Saharan Africa, where limited treatment data is available and where new treatments for the virus only have been introduced in recent years.

“This is the first large-scale prospective study reporting direct-acting antiviral outcomes in sub-Saharan Africa,” the study states. “The high adherence and treatment success without intensive support measures…support the feasibility of (hepatitis C) treatment decentralization and scale-up in sub-Saharan Africa.”

The successful trial and evidence of effective antiviral treatment among Rwandan patients was followed by the Rwandan government's December 2018 launch of its plan to eliminate hepatitis C in the country by 2024—significantly sooner than the World Health Organization’s target of 2030.

“This research allowed us to provide evidence that hepatitis C treatment is effective and safe, and can be used in Rwanda, and hence, in comparable settings in sub-Saharan Africa,” said Fredrick Kateera, chief medical officer for PIH in Rwanda and a co-author of the study.

The government’s roadmap plans to screen more than 4 million Rwandans and treat about 112,000 people living with hepatitis C—an often-overlooked, highly treatable liver disease. With a projected budget of $113 million, officials aim to treat 90 percent of all infections, expand the health workforce, provide medications, develop monitoring tools, and launch vertical micro-elimination along with wider, community-based awareness and treatment campaigns.

Co-authors shared results of the antiviral drug trial in a report titled, “Treatment of Chronic Hepatitis C Virus Infection in Rwanda with Ledipasvir–Sofosbuvir,” which appeared in the December 2018 issue of the Lancet Gastroenterology & Hepatology Journal. Co-authors also presented their findings at the 2018 International Liver Congress in Paris.

PIH’s research helped the Rwandan government successfully negotiate a lower cost for the medication, prompting the progressive elimination plan described in a recent editorial. That editorial, “Rwanda Launches a Five-Year National Hepatitis C Elimination Plan: A Landmark in Sub-Saharan Africa,” appeared in the April 2019 Journal of Hepatology.

“We sought to test the drug in an African population to characterize its impact,” said Kateera, who worked on the trial alongside Dr. Neil Gupta, formerly chief medical officer for PIH in Rwanda. “Through ongoing negotiations, the price of direct-acting antiviral drugs in Rwanda is expected to continue to decrease substantially.”

The work highlights how antiviral medication could effectively cure people with hepatitis C and reduce the number of Rwandans living with the virus, currently estimated at 3 to 4 percent of the adult population. More broadly, the plan contributes to a goal of essentially eradicating the viral liver infection in sub-Saharan Africa. 

Globally, 71 million people live with chronic hepatitis C. The often asymptomatic—and therefore undiagnosed—blood-borne virus commonly is transmitted through contaminated injections or transfusions. The virus currently has no effective vaccine and can cause serious scarring of the liver, known as cirrhosis, or liver cancer.

Personal stories emerged from the study.

A 30-year-old Rwandan man, for example, faced severe virus-related symptoms before joining the PIH-led trial, a year after he was diagnosed with chronic hepatitis C. He couldn’t afford antiviral medication, and had dropped to an unhealthy weight after being put on a strict diet to avoid liver damage. Upon enrollment into the study, he began taking medication. With proper nutritional counseling, he gradually returned to a healthy weight. Three months after completing the treatment, there was no trace of the virus in his system.

A Rwandan woman, meanwhile, was planning her wedding when she found out she had contracted the virus a few weeks earlier, while donating blood. She postponed her wedding to undergo treatment.

“The virus was undetectable after this patient completed the treatment as part of the trial. She was so thankful that she invited the study team to her wedding,” said Dr. Fabienne Shumbusho, a Rwandan clinician who co-authored the study.

Researchers leading the trial conducted assessments and evaluations before, during, and after treatment. They also found that the medication does not require extensive follow-up care, making treatment even more accessible.

Those successfully treated in the trial saw a significant improvement in physical and mental quality of life, including reduced symptoms of depression and higher success rates at work. Patients were excluded from the study if they had other advanced ailments, such as uncontrolled HIV. Globally, 25 percent of hepatitis C patients have HIV, according to the Centers for Disease Control.

Some of the patients in the study were less likely to be cured by the medication tested, because they have a unique genotype for hepatitis C that is more common in Africa than other parts of the world. In August 2019, PIH in Rwanda is launching a new study to explore potential treatment across genotypes.  

Fri, 26 Jul 2019 10:54:25 -0400
Listen: Paul Farmer on podcast, "Why Am I Telling You This?" Dr. Paul Farmer, Partners In Health co-founder and chief strategist, recently sat down with Chelsea Clinton for a full episode of the Clinton Foundation’s new podcast, “Why Am I Telling You This?” Clinton has followed Farmer's work for 20 years, since she was a student at Stanford University, and sits on PIH's Board of Trustees. 

In their wide-ranging and dynamic conversation about global health, Farmer and Clinton discuss his fundamental belief that everyone has an obligation to help narrow, and eventually erase, the health divide between the world’s rich and poor. Topics also include why and how Farmer helped launch PIH, well before the phrase “global health equity” existed; combating HIV/AIDS in Haiti and the 2014 Ebola epidemic in West Africa; and building comprehensive health systems in countries as diverse as Lesotho, Rwanda, and Mexico.

The podcast launched May 1. Farmer and Clinton’s conversation is the fifth episode, titled “Paul Farmer Fights for Global Health Equity.”  

Listen to the full podcast episode, here.

Thu, 25 Jul 2019 13:01:55 -0400
Goats, Gardens, and Business Training Empower Mother in Neno On most days, Dalitso Mkango is busy selling her vegetables in the market in the central village of Neno District, Malawi. And if she’s not selling her produce, then she’s at home working in her gardens. Rumor has it that she has some of the best produce around—likely because of the fertilizer she uses, a homemade mixture of manure from the goats she cares for at her home. 

How Mkango, 45, came to own those goats—and to use them for a sustainable business—is a story that stretches over 12 years, through a longtime connection between her family, her community, and Partners In Health, known in Malawi as Abwenzi Pa Za Umoyo.

Staff with PIH’s Program on Social and Economic Rights, or POSER, first met Mkango on a visit to her home in 2007, the same year PIH began working in rural Neno District. PIH collaborates with Malawi’s Ministry of Health to provide comprehensive care for more than 140,000 people in Neno, including support for 12 health centers, two hospitals, and more than 1,200 community health workers.

POSER staff, like those health workers, visit people and families at their homes and in their communities, to provide resources and access to care. But while health workers focus on screenings for disease or physical ailments, access to medicine, and more, POSER teams visit homes to focus on social determinants of health, such as access to food, transportation, education, and economic support.

It was through those local visits that the POSER team met Mkango. During a home visit to understand her circumstances and see if there were ways PIH could support her, the team learned about the severe challenges she and her family were facing.

Mkango had learned she was HIV positive in 2006, but had been unable to access antiretroviral therapy until PIH arrived in Neno a year later. She was caring for her three children and ailing mother, despite many economic and social challenges within her family and her community.

Mkango had been taking her HIV medication diligently since 2007, but still was getting sick—likely because, at least in part, she wasn’t getting enough to eat. With her small garden, she was only able to harvest 10 bags of maize at a time, which was not enough to sustain her household of five.

Beyond providing immediate financial support to her and her family, POSER also began helping Mkango work toward financial self-sufficiency.

In 2008, the team invited Mkango to join five other women in a knitting collective. The six of them learned to knit and created wool products that were sold in the United States. After two years, when international hurdles slowed that business, the women came together and asked POSER to help them start a restaurant. From 2010-12, Mkango worked as a co-founder of the eatery, while completing formal business training that POSER provided as the women worked. In 2012, she graduated with new knowledge in business management, ready to manage and grow her income.

A year later, the POSER team gave her two goats, as part of a PIH-Malawi initiative called Goats Pass On. She now has 12 goats, significantly expanding her financial options—she recently planned to sell one of them to pay for home improvements, for example. And over the past five years, Mkango has been able to dramatically increase the amount of maize she produces, by using manure to boost her fertilizer. While she previously struggled to harvest 10 bags of maize, she now reaps more than 55 bags in each harvest, and has made more than 120,000 kwacha ($160 US) selling what her family doesn’t need. With her cabbage, she’s made an additional 250,000 kwacha ($333 US).

Dalitso also has benefited from business education she received through PIH
As Dalitso Mkango's vegetable business and income grow, she is able to manager her finances with business training she received through PIH. 

And most importantly, her body is much more responsive to her HIV medication.

“I’m just slender, no longer so sick,” she said earlier this year. “Before, we struggled, but now I can grow enough maize and vegetables to feed my family and run my own business. My family has no problems with food or money today.”

Mkango’s story embodies POSER’s mission. Since 2007, POSER has worked with vulnerable families across Neno to overcome financial and geographic challenges and help them realize their right to health. POSER work is rooted in PIH’s belief that medical intervention alone is not enough; in the absence of social and economic support, people can still struggle to care for themselves and their families.

In Malawi, the POSER team distributes more than 800,000 kwacha ($1,066 US) per month to support families with food packages, money for transportation to and from health facilities, household items, and more.  The Goats Pass On initiative is one example of the long-term investments POSER makes in individuals so that they, in turn, can invest in their communities. 

Victor Kanyema, POSER program manager for PIH in Malawi, has known Mkango for years and appreciates how hard she has worked to achieve success with her goats and gardens.

“It’s not easy to manage goats, you know how they are,” he said. “It requires a lot of work, which is a unique part of this program and shows you how committed Dalitso has been to raising her many goats.”

When asked about Mkango, POSER officer Edwin Kambanga smiled.

“She’s always been full of so much energy,” he said. “She’s very special to POSER.” 

In part because of Mkango’s success, the POSER team is working to launch a large-scale, multi-year initiative to expand the goats program and related training. Kanyema is optimistic that many more people across Neno could benefit from goats, and their source of fertilizer.  

With her ongoing HIV treatment and growing economic opportunities, Mkango is doing better than ever—an outcome that Kanyema hopes to replicate across the district.

“We are proud of her and appreciate all of the lessons she has provided to our programming, which ultimately can help others in Neno,” he said. 

Thu, 25 Jul 2019 09:01:54 -0400
PIH Leaders: Care Must Accompany Containment in Ebola Response The world’s latest Ebola outbreak now has spread for nearly a year in the Democratic Republic of the Congo, where the virus has infected more than 2,500 people and killed nearly 1,700.  

PIH has sent two of our top Ebola clinicians to work with partners in the conflict-torn region to help care for the sick, support response efforts, and share lessons learned during the 2014 to 2016 outbreak in West Africa, where the virus infected more than 28,000 people and killed more than 11,000.

Our efforts to rebuild the public health care systems continue to this day in Sierra Leone and Liberia, where we work alongside each country’s Ministry of Health to support comprehensive primary care.

Dr. Paul Farmer, PIH co-founder and chief strategist, and Dr. Sheila Davis, PIH CEO, were deeply involved in PIH’s contribution to the Ebola response in West Africa five years ago. Following last week’s WHO declaration of the current outbreak as global emergency, Farmer and Davis share their thoughts on the necessity of ensuring that patients receive quality care, along with containment efforts, as the international response continues to develop.

Paul Farmer cares for child with Ebola in Sierra Leone
Dr. Paul Farmer visits the pediatric ward of a public hospital in Port Loko, Sierra Leone, where children who survived Ebola were referred for follow-up care in January 2015. 

Joint Ebola statement by Farmer and Davis

Last week, not long after two of our most Ebola-experienced clinicians returned from the Democratic Republic of the Congo, the World Health Organization declared the country’s Ebola outbreak a “public health emergency of international concern,” or PHEIC. 

That brought to mind the last such declaration, made on August 7, 2014. Partners In Health arrived in Sierra Leone and Liberia that fall, to join the global response to what remains the world’s deadliest Ebola outbreak thus far. Over the five years since that time, both of us have played significant roles in PIH’s work in Sierra Leone and Liberia, and learned a great deal from our colleagues in both countries.

We wish to reflect on that ongoing experience, and share some of the lessons we’ve learned, in contemplating the potential significance of this new PHEIC declaration and the dangerous, unstable conditions in the DRC’s North Kivu and Ituri provinces. We seek not only to share lessons, but also to address some of the pressing issues we saw tardily addressed, or not at all, after the last such declaration, in 2014.

In West Africa at that time, the greatest tensions, and much open conflict, stemmed from the unnecessary and wrongheaded elevation of containment over care. Both must be top priorities for responders in DRC, as must the cultivation of trust within communities where there are scant reasons for having much trust beyond the immediate bonds of family and small communities of worship and work.

This opposition of containment and care tracks closely with tensions between public health and clinical duties. In past outbreaks and pandemics, such tension has served us poorly, whether we look at past epidemics of Ebola and Marburg, Zika, or SARS, or reflect on colonial-era epidemics of plague, Spanish flu, or trypanosomiasis. The list goes on. But we both learned this by coming of age as clinicians during the years AIDS came to be the leading infectious cause of death among young Americans. 

Prevention and care are meant to be complementary and, indeed, mutually reinforcing tasks: High-quality and respectful clinical care can help build trust, especially when it is offered for all ranking health problems as opposed to just one. An Ebola response that ignores other causes of premature death, whether in childbirth or from trauma, has usually engendered mistrust and loud complaint, as is now the case in the DRC. 

A control-over-care paradigm is announced whenever case fatality rates (CFR) are high. In the current DRC outbreak, which has gone on for a year, the CFR is well over 50 percent. It can likely be reduced to lower than 10 percent, given the human and material resources of a modern intensive care unit. However, Ebola outcomes in DRC are also shaped by the following:

• Quality of care (which biosecure emergency care units known as ALIMA cubes and new therapeutics are helping to address) and attention to all medical problems, which are neglected side-by-side with these new Ebola interventions and are key to building trust. 

• Widespread resentment, not only to 25 years of armed conflict in the region, but also to more than a century of (neo-) colonial extraction. 

• Blaming the continued spread of Ebola on people’s disbelief in the virus, which posits cognitive deficiencies as the root of problem. Rather, we should view mistrust as an inclination, a cognitive tendency, or a structured disposition towards eluding depredation.

• The employment of Ebola survivors, which fosters community engagement and improves the quality of expert mercy.

• Blaming the WHO for an underpowered response, which is illogical when their—and the current epidemic’s—funding needs have been slow to materialize.

A PHEIC declaration may or may not solve any of these things. Where this one leads will depend on political will, expert mercy and the resources to back it, and a much bigger dose of humility and social justice.

Sheila Davis departs helicopter during Ebola response in Liberia
Dr. Sheila Davis descends from a United Nations helicopter during the Ebola response in Monrovia, Liberia, in October 2014.


Tue, 23 Jul 2019 10:16:18 -0400
Merging Local Birth Practice, Modern Medicine in Sierra Leone Leaning over the pregnant patient before her, Regina Korgbendeh touched the woman’s looming stomach and spoke softly in Kono, a dialect common in eastern Sierra Leone: “Thank you for this child.” Blessing an unborn baby is a custom strictly followed in communities throughout Kono District. Once the prayer was complete, Korgbendeh, 48, led her patient over to a chair, where a waiting midwife asked about previous pregnancies and the woman’s medical history. It’s Korgbendeh’s job as a traditional birth attendant (TBA) to incorporate local customs, like this one, into the medical care provided by Wellbody Clinic, a Partners In Health-operated facility.

Historically, TBAs have been the go-to women in village communities for anything related to pregnancy and childbirth. Neighbors often refer to them as “auntie” or “mother” – terms of enormous respect. After experiencing a traumatic labor herself, Korgbendeh decided to become a TBA to prevent other women from enduring what she went through. Many countries, however, now discourage expectant mothers from relying on TBAs, due to the dangers that women face during childbirth without supervision from a trained clinician. Sierra Leone’s government enacted a law in 2010 banning TBAs from carrying out deliveries away from a clinical setting. If found disobeying this law, the punishment is severe—not just for a TBA, but for expectant mothers and anyone else involved.    

Although there’s no question that safety during childbirth should be a priority, restriction of TBAs doesn’t necessarily ensure good health outcomes for women. A lot of women in Kono, for example, consider health care facilities to be strange, nerve-wracking places, meaning many choose to avoid health care facilities altogether during pregnancy. And with TBAs no longer able to assist them, they are left to deliver without any experienced supervision. This sentiment arguably contributes to the horrifying reality for women in Sierra Leone: a 1 in 17 lifetime chance of dying during pregnancy, delivery, or its aftermath.

A new model for safe birth

Dr. Bailor Barrie understood this when he founded the maternal health program at Wellbody Clinic in 2010. He knew that it wouldn’t be enough to offer high-quality medical care without also ensuring that women felt comfortable seeking and receiving the care. To bridge the gap between tradition and a formal health care setting, Barrie pioneered the employment of TBAs, like Korgbendeh, at Wellbody Clinic. His decision to do this was in contrast to the opinions of numerous institutions, however. The World Health Organization discounted the role of TBAs in clinical practice, saying they are simply “an interim solution,” and the United Nations has previously defined TBAs dismissively as “independent (of the health system), with no formal training.”

At Wellbody Clinic though, Korgbendeh and her team of seven TBAs are proving the experts wrong.

“TBAs have an incredibly special bond with Sierra Leonean women. They can connect on a level that clinicians aren’t always able to,” Barrie explained. “When TBA-handled deliveries became illegal, a lot of women were left feeling abandoned during their labors. They feared bad treatment and costly charges at the hospital. At Wellbody, we felt strongly that by engaging TBAs we would begin to evolve the mindset of communities and, more importantly, meet the needs of women.” 

Korgbendeh, after years of experience supporting expectant mothers, echoed these thoughts. “Girls used to hear rumors that they would be treated aggressively. They worried about injections that prick the skin,” she said. “Some believed the clinical staff would test drugs on them. Giving birth was always something women did as a tight-knit group in ‘the bush’ – a  highly honored tradition in village communities.”

Being Sierra Leonean himself, Barrie has a firm understanding of local culture. He approached chiefs of the 14 chiefdoms within Kono to gain their support for his plan to employ TBAs. Korgbendeh remembers being invited by her village chief to be trained as an official TBA at Wellbody Clinic. “Dr. Barrie showed us how to talk to patients in the community about the risks and dangers of delivering alone,” she said. “Patients listen to TBAs because we’re like mothers to them.”   

When Barrie invited PIH to take full responsibility of Wellbody Clinic in 2014, TBAs were firmly embedded into clinical practice. Their inclusion is something PIH has strongly advocated for ever since. A team of eight TBAs now work hand-in-hand with midwives to deliver maternal care. Each TBA lives in a different area of Kono, guaranteeing that women throughout the district of 500,000 people have access to high-quality care and safe births.

Traditional birth attendant in Sierra Leone
Regina Korgbendeh, 48, chose to become a traditional birth attendant after she suffered a traumatic labor herself in rural Sierra Leone.

Korgbendeh cares for all the women in a region of Kono District called Sefadu. “I’m happy not to deliver their babies myself, though" she said. "Now I’ve been properly trained, I realize how many dangers there are.

“Sometimes after I delivered a baby, I would look down and see a lot of blood on my hands and all over my feet,” she remembered. “It was terrifying. At that time, if a baby died, people would say it was the woman’s fault because she hadn’t pushed hard enough or she hadn’t been cooperative. They would say she had bad water (infected blood).

“Lots of things are done differently at Wellbody Clinic though, and babies don’t die anymore,” Korgbendeh said. “Women no longer deliver on a rug on the hard floor; we lift her high onto a bed. And we don’t cut the umbilical cord with a blade or a piece of thread; everything is clean and we wear gloves. A trained midwife catches all of the dangers and I’m there to soothe the woman.”

Partnership throughout pregnancy

TBAs aren’t just responsible for drawing pregnant women to the clinic either. They accompany women throughout their pregnancies - from prenatal classes and appointments, through delivery and postnatal appointments. The roles of midwives and TBAs are clearly defined. Midwives are trained to administer clinical care, and TBAs play an accompanying role, to both midwives and patients. By providing access to regular training and medical equipment, PIH enables midwives and TBAs to deliver the best possible care, at every point along a woman’s pregnancy.

After blessing her patient’s unborn baby, Korgbendeh said: “This woman hadn’t been to a clinic before today, so she was quite nervous to come. At Wellbody we have a saying: ‘If you push women too hard, you will step on your own toes.’ It’s important not to be impatient, or this woman might not come back to us. When she arrived, staff gave her medicines and a mosquito bed net. She couldn’t believe everything was free. It made her so happy.”

A new mother, sitting outside the postnatal ward with her baby on her lap, expressed gratitude for the TBA who supported her during pregnancy. “My TBA was by my side from month one, all the way to the end. She even visited me afterwards, because a woman’s grave is open for 40 days once she’s delivered her child,” she said, referring to the high likelihood of maternal death after birth. “I now tell everyone in my village to go to Wellbody. I say they will be treated well and given real medicine.”

While the role of a TBA might initially sound like a straightforward one, there’s so much more to it than simply blessing a stomach. A TBA’s position in village communities, such as those throughout Kono, allows her to encourage women to pursue a safer, yet still familiar, type of care.

“Women used to stick together in the village and support one another through pregnancy because this made them feel safe,” Korgbendeh shared. “I tell them that we’re living in a computer world now. There are machines at the clinic to make sure everything is ok with a woman. Why wouldn’t you use that?”

Having access to a safe, compassionate environment during pregnancy is something that all women deserve in Kono, Sierra Leone—and worldwide. PIH recognizes that both the medical and emotional needs of women should be met through their maternal health care. By including and empowering TBAs at Wellbody Clinic, PIH also empower patients and their communities.

“I do this job because I want to help women to see that they deserve the best health care,” Korgbendeh said. “I’m honored to play this role for my community.”  

Read the story as first published on Verve Up.

Wed, 17 Jul 2019 11:04:14 -0400
Cancer Care in Rwanda Goes Beyond Chemo to Heal a Family When Françoise Umutesi looks at her 1-year-old grandson, Blessing, she has the smile of someone who once thought she’d never have the chance to meet him.

Umutesi, 45, is a breast cancer survivor. She had a mastectomy in 2012, at Butaro District Hospital in northern Rwanda. She was one of the first patients at the hospital’s Cancer Center of Excellence, which opened that year. The cancer center now sees nearly 2,000 patients annually, young and old, from across Rwanda and from nearby countries, such as Burundi and the Democratic Republic of Congo, where affordable, quality cancer care is scarce or nonexistent. 

Umutesi’s home is much closer to Butaro than most of those patients’. She lives less than an hour’s drive from the hospital, a multi-faceted medical campus that serves nearly 400,000 people in Burera District and is supported by Partners In Health, known in Rwanda as Inshuti Mu Buzima. PIH has supported Umutesi and her family for years, in ways that extend far beyond health care and reflect PIH’s treatment philosophy of including social, mental, and emotional support along with physical.  

Albert Ndayisaba, the Burera manager of PIH’s Program on Social and Economic Rights, or POSER, has overseen that support. His team helps about 200 students in Burera District with materials or money for education, and about 800 households with economic development assistance such as small business loans.

Gilbert Rwigema, chief operations officer for PIH in Rwanda, said those numbers apply to each of the three districts, including Burera, where PIH works—meaning PIH helps 600 students with education and 2,400 households with economic development, across the East African country. POSER teams also have provided food packages to several thousand people in Rwanda this year alone, and direct support for health insurance costs to several thousand more.

Umutesi and her daughters are just a few of those recipients. Ndayisaba and his POSER team have helped the family with ongoing money for education, food packages from 2012-16, and transportation costs—because even with their proximity to Butaro District Hospital, travel there is rarely easy.

The dirt roads are steep, winding, and rugged in Butaro, a rural region where the Virunga Mountains and Volcanoes National Park loom large on the horizon. Subsistence farming is a way of life for many residents of Butaro communities. Umutesi is a farmer, as well, with land and a small livestock enclosure across the dirt road from their home.

Umutesi has been a Butaro resident for all her life. She was born in the house where she lives, which is owned by her mother, 73-year-old Pauline Nyirabazungu. Nyirabazungu still lives there, too—meaning the birth of Blessing added a fourth generation under their small, shared roof.

Françoise Umutesi works hard on her family's land in Butaro, Rwanda
Françoise Umutesi, a single mother and breast cancer survivor, works hard on her family's land in Butaro, Rwanda. PIH has supported her family with food packages, educational materials and transportation costs over the years, as Umutesi traveled for cancer treatment and her three daughters attended school. 

It is a house full of mothers and daughters. Umutesi has three girls, now grown women. Blessing, the little man of the house, is the son of Umutesi’s 19-year-old middle daughter, Charitine Umamwiza.

On a sunny afternoon in mid-March, Umutesi sat with two of her daughters at a table in the front room, a warm red blanket around her shoulders. Her eldest, 23-year-old Pierrine Uzatuza, held Blessing on her lap. Charitine, the middle daughter, wasn’t home that day, but Umutesi’s youngest, 16-year-old Anitha Dukundane, also joined the conversation.

Ndayisaba was visiting the family that afternoon for a routine POSER checkup, along with Dr. Akiiki Florence Bitalabeho, head of medical education and training for PIH in Rwanda. 

The talk was light, but the topic was heavy. The family shared memories of the time, years ago, when Umutesi was not able to be home, her health was in doubt, and Nyirabazungu had to take care of all of them.

“Life in this house was so difficult,” Pierrine said. “Our grandmother supported us with everything she had.”

In the fall of 2011, Umutesi found a lump in her breast. That November, she had an initial consultation at Butaro District Hospital. Two months later, she stayed at the hospital for a week, and two months after that, in March 2012, she had her single mastectomy. That was followed by a year of chemotherapy, with regular trips to the hospital and exhausting recovery periods that effectively left Umutesi’s mother in charge of the family.  

That initial treatment wasn’t fully effective. Francoise needed radiotherapy, which at the time was not available in Rwanda.

Radiotherapy soon will be more widely accessible in the region—work is underway, for example, to provide radiotherapy at Rwanda Military Hospital in the capital, Kigali. But Kigali is a drive of more than two hours from Butaro, on a rough dirt road down out of the mountains, and most patients needing radiotherapy still need to travel outside the country.

In March 2013, Umutesi went to a hospital in Kampala, the capital of neighboring Uganda. The border is not far from the family’s home, but the trip to Kampala is long. Going by bus can take eight hours. Flights are 45 minutes, but are expensive and first require a long, costly ride to the Kigali airport. Additionally, customs and border crossings are not always certain; as recently as this spring, tensions between Rwandan and Ugandan governments were severely affecting border crossings between the two countries.

Umutesi made the trip by bus—and she made it just once, staying in Kampala for two months to receive radiotherapy.

At that time, Pierrine and Charitine were teenagers in school, and Anitha was just 10. Nyirabazungu, their grandmother, took care of them all. (The responsibility was not new to her. Nyirabazungu had two sons and seven daughters, including Umutesi.)

In the end, the sacrifices and hardships were successful. Umutesi beat cancer and, with regular follow-ups and continued support from PIH, has fully recovered.

PIH staff provide mentoring and support as well as health care
Dr. Akiiki Florence Bitalabeho, head of medical education and training for PIH in Rwanda, talks closely with Pierrine Uzatuza during a visit in March. Pierrine recently earned a college degree, and Dr. Bitalabeho also is keeping an eye on Pierrine's younger sister, Anitha (not shown), to make sure she is on the same path. 

Now on the other side of their mother’s illness, the girls have grown into strong women themselves. Pierrine has an associate’s degree in tourism and works for the Rwanda Wildlife Conservation Association. She’s married and lives nearby. Charitine and Anitha are in secondary school, a fact that has not gone unnoticed.

During today’s visit, Bitalabeho—the medical education and training leader—pressed Anitha on plans for her future.

Anitha mentioned that she was focusing on science and hoped to be a doctor one day. Bitalabeho leaned forward and spoke to her intently, describing potential scholarship options, explaining steps she would need to take to reach her goals, and asking questions about her future.

Just across a valley from Butaro District Hospital, where Umutesi received cancer care, is the University of Global Health Equity. The university is a PIH initiative that inaugurated its campus in January, hosts students pursuing master’s degrees in global health delivery, and will accept its first medical school students this summer.

That university, the University of Rwanda, or other institutions could be within reach, Bitalabeho said, if Anitha continued to work hard. Their discussion was friendly and open, but the doctor used the stern tone familiar to parents and educators worldwide, making sure Anitha knew that she would be watching, and that the stakes were high. 

“I will be looking for her name at the university level,” Bitalabeho said.

As the visit ended, the family stood in front of their home. Umutesi held Blessing, their newest generation. She reflected on how during her surgery and treatment, there were times when she had no hope. But those times have changed.

“I didn’t know that one day, I would be a grandmother,” she said.

Françoise Umutesi enjoys a moment with her grandson
Françoise Umutesi enjoys a moment with her grandson, 1-year-old Blessing, in March. Blessing is the fourth generation to live under the family's roof in Butaro, Rwanda.


Wed, 26 Jun 2019 09:52:47 -0400
Eye Surgeries Give Chiapas Toddler New Outlook on Life Well before his second birthday, Ernesto Roblero’s parents began seeing signs that their infant son was struggling with significant difficulties. But they didn’t know the cause.

Some people in their rural community of Toquiancito, in the southern Mexico state of Chiapas, may have thought it was simply shyness, seeing that Ernesto was reluctant to venture far from his mother, Florinda Roblero. But when he did walk on his own, he would often trip or bump into things—more so than usual for a 1-year-old, his parents thought. Other times, he would come to tears if he wanted something, even when the things he needed were already within reach.

“He was crying a lot,” Florinda said. “I was holding him almost all the time, because if I put him down on the floor, he wouldn’t walk; he would just start to cry.”

“Because he was afraid,” Ernesto’s father, Oscar Roblero, added.

“He was afraid,” Florinda agreed.

The family’s closest option for medical care, then and now, is a clinic an hour’s walk from their community, staffed only part-time by a nurse. As is often the case with public clinics in this marginalized region of Chiapas, there is no doctor. Although travel would be difficult and require money that they had little of, the family made arrangements for the trip to Tapachula, a city some four hours from their home.

There, a doctor gave them the news: Their 1-year-old son had cataracts, in both eyes. What’s more, they were told that the surgeries Ernesto needed would cost 70,000 Mexican pesos, or nearly $3,600. 

“They were charging 70,000 pesos, and we have no money,” Florinda said. “My husband plants his corn crop and beans. That’s all that we grow here. There is nothing more.”

Weakened harvests due to climate change, as well as other factors—including the deaths of Oscar’s parents, within six months of each other—together with ingrained, systemic inequity, all meant that affordable and adequate health care simply hadn’t been within the family’s reach, or means. When they were faced with Ernesto’s condition, they knew they needed help.

The rural community of Toquiancito lies on a steep hillside in Chiapas
The Roblero family's home is one of the furthest from the center of the small, rural community of Toquiancito, on a steep hillside in the Sierra Madre region of Chiapas, Mexico. 

Situations like theirs are exactly why Partners In Health—known locally as Compañeros En Salud—is collaborating with Mexico’s Ministry of Health on an innovative partnership to ensure access to quality medical care for families in impoverished communities in Chiapas. PIH works with the ministry to support health care at 10 clinics in remote areas, serving more than 140 communities in rural Chiapas. Primary care often is provided by first-year physicians carrying out their social service year, known as pasantes, whom PIH recruits by partnering with medical schools in Mexico.

Dr. Valeria Macías, director of secondary and tertiary care for PIH in Mexico, was among the first to carry out her pasantía with Compañeros En Salud, which began its work by establishing a strong primary care program in these clinics.

“When I was a pasante, we had everything for primary care. Sadly, for some patients, this isn’t enough. Some conditions are complicated, and a rural clinic, however well-equipped, is not enough,” she said. “We started seeing a huge need for surgeries, cancer treatments, and other specialized care that we could not provide. We saw patients with conditions that they had been suffering from for years or decades without any relief, because they couldn’t access care. The burden was overwhelming.”

As a result, PIH in Mexico decided to create a referral program to serve as a link between local health centers and government hospitals. The Right to Health Care program is dedicated to helping patients navigate the health care system and find all available resources, while addressing the barriers—such as arranging and paying for transportation and lodging—that patients face when trying to access care and alleviate their suffering.

“Wouldn’t we want the same for ourselves and our families?” asked Macías, who became the first coordinator of the Right to Health Care program, following her social service year. Since its inception in 2013, the program has accompanied more than 1,000 patients in accessing life-altering specialized care.

Ernesto’s family connected with the program through a fortunate encounter in a neighboring community.

“We went to ask for some help and there was a man working who told us, ‘Why not go over there [to a clinic in La Soledad]?’” Oscar said, referring to one of the PIH-supported clinics in the region.

Oscar said the man described how health care providers at the clinic had successfully cured several people he knew.

“And because of that, we took the boy to La Soledad,” Oscar said.

The family traveled more than an hour and a half to arrive at the community clinic in La Soledad, a small community not so different from their own. The visit opened a new world of possibility to them. There, Ernesto’s family met with Dr. Montserrat Quesada, a PIH pasante. The doctor wasted no time in referring Ernesto to the Right to Health Care program, which would accompany him to the Pediatric Specialty Hospital in Tuxtla Gutiérrez, the state capital of Chiapas.

Dr. Francisco Rodríguez, Ernesto and his father, Oscar Roblero, at Pediatric Specialty Hospital in Tuxtla Gutiérrez
Dr. Francisco Rodríguez shows Ernesto and his father, Oscar Roblero, a room where Ernesto would get follow-up care after his cataract surgeries.

Ernesto would come to know the hospital well. The family made several trips, for a series of medical tests and consultations to evaluate Ernesto’s condition and plan his treatment. Each consultation required lengthy travel. From their home, the family would take several modes of public transportation, over several hours, to reach Jaltenango, where they would stay overnight at the headquarters for PIH in Mexico. The next day they would make the three-hour trip to the hospital in Tuxtla Gutiérrez, accompanied by members of the Right to Health Care team.

The trips paid off. Doctors, the family, and PIH staff reached a decision: Ernesto would have surgery in both eyes, one at a time.

Carrying out the surgeries proved to be a challenge. Over several months, numerous factors intervened to push his surgery dates back. The first time, Ernesto fell ill. Then his grandmother passed away, and the date needed to be moved again. Then, in August 2017, they made the trip to Tuxtla for the scheduled surgery, only for hospital staff to discover that they lacked a necessary piece of equipment. Ernesto was discharged and the family made the long trip home, his vision still clouded by the cataracts. Hospital staff asked the PIH team to be in touch in three weeks, to reschedule.

Three weeks later, a magnitude-8.1 earthquake struck just off the coast of Chiapas.

Public facilities, such as schools and hospitals, were closed for inspection to assess possible damage. Hospital administrators made a plan to reschedule disrupted appointments and procedures to dates in the following year—at least four months out.

Without an advocate, a patient like Ernesto—living far away in a remote, marginalized area—was at risk of falling through the cracks during an emergency situation that the overburdened public health system was ill-equipped to handle. Thankfully, he had an advocate in PIH.

After the earthquake, Dr. Francisco “Paco” Rodríguez, then coordinator of the Right to Health Care program, and Miriam Morales, a PIH social worker, went to work advocating for Ernesto. Through the team’s efforts, Ernesto’s two surgeries were rescheduled, and then carried out successfully by year’s end.

Morales emphasized that the entire team was involved in Ernesto’s case.

“We always made sure that one of us from the Right to Health Care team was there with Ernesto and his parents,” she said. “This is a team. Not only our medical staff, but also our logistics staff, know how to navigate the health care system really well and are able to resolve any problem that comes up in the moment, whenever the patient needs it. Accompaniment is a priority in our Right to Health Care program. It was essential so that Ernesto’s treatment was carried out.

“Personally, for me, there is no greater satisfaction than seeing all that was accomplished for Ernesto,” Morales added. “I’m really happy for Ernesto and his parents.”

PIH’s advocacy for the family has continued.

Rodríguez has accompanied them to appointments at the pediatric hospital following Ernesto’s surgeries. He has seen patients through a lot, noting the impact of the adversity they must overcome, as well as the impact that the program has in helping them do so. He watched Ernest playing quietly by himself as they waited outside the ophthalmologist’s office for a follow-up appointment.  

“I think that, due to his condition, Ernesto has developed his own vivid inner world,” Rodríguez observed. “As well as a strong sense of resilience.”

When Ernesto’s name was called in the waiting area, Rodríguez accompanied him as he sat to have his eyes examined, facing bright lights in a dark room. The ophthalmologist, Dr. Alma Leticia González Calderón, decided to give laser treatment for the boy’s posterior capsule opacification, a common follow-up for cataract surgeries, and said she was otherwise pleased with his recovery.

Ernesto quietly tolerated drops in his eyes to prepare him for the laser procedure, followed by another period of waiting and kneeling for the device’s chin platform to be adjusted. With the help of his father and Rodríguez, Ernesto stayed very still as González expertly and patiently orchestrated the lasers, directed with precision at certain points in his eyes.

Ernesto and Oscar Roblero leave Pediatric Specialty Hospital with Dr. Rodríguez
Ernesto and Oscar Roblero leave Pediatric Specialty Hospital with Dr. Rodríguez. The PIH in Mexico team is committed to accompanying patients in every step of their health care.

During a recent visit to the family’s home following the laser procedure, Ernesto’s parents offered agua de carambola—a drink made with star fruit—as well as their gratitude.

“Thanks to Dr. Paco and God, because he helped us,” Florinda said. “Miriam really helped us a lot, as well.”

Ernesto and his older brother, Abimael, were nearby, playing outside.

“He goes out all the time, up and down. He’s all the time seeing little things. If he sees a little red bottle cap, he goes and picks it up, running,” she laughs. “Thank God that now he sees.”

Arriving to this point with her son has been a long road for the family, and there is more that lies ahead. Florinda worries about how Ernesto, now 4, will do in school. But she also has the support and encouragement of the team, who she says have told her how important it is that he go to school when the time comes. She appreciates the accompaniment as they continue on this path. 

“We’re really grateful to all of you,” she said. ”Because just one person, alone, isn’t able to do anything.”

This story originally appeared on the Compañeros En Salud blog, here.

Mon, 24 Jun 2019 15:51:36 -0400
Teen Beats Cancer Through Global Collaboration Mondeh Mansaray sketches the form of his favorite football player with swift, diligent movements of his pencil. Nothing can break his focus as he sits curled-up on a wooden stool and pores over the white page in front of him.

For Mondeh, 14, Saturday morning means one thing: no school. He can sketch in his bedroom, play football—soccer, to Americans—outside with his friends, and help his family with household chores. The relaxed day is a welcome respite from the busy school schedule he follows during the week.

Mondeh’s weekend activities are not unlike those of other youth in his village in Kono District, Sierra Leone. But they are very unlike the grueling routines he knew over the past several years, during extended medical treatment. The scar etched into his neck serves as a reminder of the malignant tumor that used to grow there, and that once left him fighting for his life.

“The swelling would feel painful,” Mondeh recalled. “It was very serious. I was thinking I would not survive the sickness.”

In January 2015, Mondeh was diagnosed with Hodgkin lymphoma, a cancer that targets the immune system; can cause swelling in the neck, armpit, or groin; and is a leading cause of cancer diagnoses for teenagers and young adults globally. Roughly 17 million new general cancer cases were reported worldwide in 2018, including more than 1 million in Africa. 

While cancer care is very limited in Sierra Leone, on West Africa’s coast, Partners In Health is working to change that dynamic. The years that Mondeh spent fighting the disease, and the vital treatment and support he received through collaborations between government health officials, PIH teams, and consulting clinicians around the world, became a model for health care in Sierra Leone that has extended far beyond Mondeh’s own case.   

Like so many, his case started with a lump. For Mondeh, it was on the side of his neck, about eight years ago.

Growing up, Mondeh was always one of the liveliest of the family’s six children, so his parents were confused when he started acting withdrawn and lethargic. Their concern grew when the swollen lump appeared, when Mondeh was about 6. Multiple visits to nearby health centers, however—over the next several years—failed to identify the cause of the growth, or reduce it. It was only when a clinician visiting his village noticed Mondeh, and examined him, that he was referred to the PIH-supported Koidu Government Hospital in eastern Sierra Leone. There, Dr. Yusuf Dibba diagnosed him with Hodgkin lymphoma.  

“When I first met Mondeh, he was struggling to swallow and eat (because of the tumor’s size), so he was losing a lot of weight,” Dibba recalled. “The mass had been growing for around six years at that point, and he had previously been diagnosed incorrectly with TB.”

Mondeh during treatment in September 2016
Mondeh Mansaray sits with his father, Abubakar Mansaray, in September 2016 at Butaro District Hospital in northern Rwanda. The tumor on Mondeh's neck had shrunk significantly by this point in his treatment, but the scars below his ear reflect the initial severity of his cancer. (Photo by Cecille Joan Avila/PIH)

Chemotherapy in Sierra Leone

With cancer care scarce across the country, for even the most common cases, Dibba worked with Jon Lascher, then chief operating officer for PIH Sierra Leone; Dani Kloepper, a nurse working with PIH during the Ebola response, which began in 2014; Dr. Kerry Dierberg, then executive director of PIH Sierra Leone; and Dr. Joia Mukherjee, chief medical officer for all of PIH, to create a treatment plan and connect with colleagues around the world. The plan involved oral and intravenous chemotherapy. The first step was a biopsy of the tumor on Mondeh’s neck, completed at Connaught Hospital in Freetown, Sierra Leone’s capital.

Mondeh said that while he feared for his future, his family did not waver.

“My father was always sure I was going to survive,” Mondeh said. “He would say, ‘Let me believe,’ so I trusted him. When he was around me, he would never be sad or annoyed.”

Mondeh stayed near the hospital for nearly a year, either as an inpatient or at a nearby hotel, with PIH paying for lodging. His father, Abubakar Mansaray, accompanied him everywhere. PIH clinicians in Freetown kept a close eye on Mondeh, working in partnership with Sierra Leone’s Ministry of Health. After just a few months of oral chemotherapy treatment, the growth on Mondeh’s neck started to shrink.

“My body was tired and weak for a few weeks after each time at the hospital, and then I would feel stronger again,” Mondeh said. “I made a friend in the hospital who also had cancer. His bed was near to mine and his stomach was so big. We would walk around the hospital together to stay strong.”

Cancer care in Rwanda

By August 2016, Mondeh had responded so well to oral medicines that he was ready for the next phases of treatment: medicines via IV. Mondeh and his father flew to Rwanda, where they stayed in a PIH guesthouse for six months while Mondeh received treatment at PIH-supported Butaro District Hospital, which has a Cancer Center of Excellence with a pediatric ward.

PIH is known in Rwanda as Inshuti Mu Buzima. Clinicians at Butaro’s Cancer Center provide treatment for more than 3,100 patients, of all ages, from across Rwanda and from nearby countries such as Burundi and the Democratic Republic of Congo—and, further away, Sierra Leone—where quality cancer care is scarce or nonexistent. The distance means that in addition to facing cancer and enduring treatment, patients also are far from home, families, and school or jobs.  

The clinical team at Butaro noted that despite the challenges, Mondeh and his father were adjusting well to life there soon after their arrival in August 2016.

“Mondeh enjoys having his father here to support him. They have a very close relationship, and they call home frequently during the week,” states a clinician’s report from that time. “Mondeh enjoys talking to his mother, as he misses her, and his father uses these phone calls to check in on the family.”

Butaro clinicians gave Dibba and the Sierra Leonean clinical team regular updates about Mondeh.

“I was happy in Rwanda, but I was also scared because it was my first time going to another land,” Mondeh said. “The swell had gone down but they said the disease was inside my body, so I had to go there to continue my treatment.

“I made friends while I was there,” he continued. “We would play football in the field and go to my house and sit and talk.”

Mondeh’s health rapidly improved. He and his father were able to return to Sierra Leone, where Dibba said family members and clinicians welcomed Mondeh “almost like a king.”

Mondeh and his father at home in Sierra Leone
Clinicians said Mondeh's father, Abubakar Mansaray, was by Mondeh's side throughout years of grueling cancer treatment in Rwanda and Sierra Leone. They are shown at home earlier this year, with Mondeh fully recovered. (Photo by Emma Minor/PIH) 

Full recovery  

Dibba saw Mondeh for regular check-ups in the months following his return.

“He pulled through,” Dibba said. “Every day, Mondeh’s father would call me to say, ’Thank you,’ but I would tell him I was just doing my job.”

Dibba added that Mondeh’s father still wouldn’t leave his son’s side.

“Mondeh’s father was imam (spiritual leader) of their village, and he had a farming business, but he stuck by Mondeh over the whole recovery,” Dibba recalled.

As his recovery progressed, Mondeh finally was able to resume his childhood and adolescence. While his case might be among the first cured in Sierra Leone, it won’t be the last.

The World Health Organization projects that the number of new cancer cases in Africa per year—just over 1 million in 2018—will rise to about 2.1 million by 2040. The WHO also expects the continent’s cancer-related deaths per year to skyrocket, from about 693,000 last year to more than 1.4 million by 2040.

That means there has never been a more pressing need for established cancer care in Sierra Leone, to ensure successful outcomes like Mondeh’s are the norm, rather than a rarity.

Mondeh’s recovery was made possible by PIH and Ministry of Health colleagues in two countries working together closely. But Dibba stressed that Mondeh’s recovery does not just represent one life saved—it represents the possibility for cancer care that could save many more patients, who would be cured through access to the right treatment.

“If you don’t do anything, help will not come,” Dibba said. “Mondeh’s treatment was a big lesson for health care providers: You shouldn’t give up because of the limitations. We can’t condemn patients to die because we’ve never done it before. In PIH, we can reach out to people. We find a way.”

Mondeh now is enrolled at a new school, and regularly earns the top spot for performance in his class. Through hard work and support from a personal tutor, provided by PIH to aid Mondeh as he catches up on the school years he missed during his illness, he is well on the way to achieving a newfound dream.

“I plan to be a doctor one day,” Mondeh shared. “When I had that cancer illness, I promised myself I wanted to be a doctor so that I could help other people like me in the future.”

For now, though, Mondeh takes pleasure in quiet Saturday mornings spent sketching in his bedroom, where his most pressing concern is the best colored pencil to use.

Mondeh shows his artwork at home in Sierra Leone
Mondeh Mansaray shows some of his artwork at home in Kono District, Sierra Leone, earlier this year. His recovery from advanced Hodgkin lymphoma now enables him to spend weekends like other teens in his village - drawing, playing sports, and dreaming about the future. (Photo by Emma Minor/PIH) 


Thu, 20 Jun 2019 16:32:31 -0400
Global Lab Leaders Put Successes, Challenges Under the Microscope In Mokenyakenya Matoko’s schedule for moving lab samples from remote health centers in the mountains of Lesotho to testing facilities in the capital, Maseru, there’s a quick sentence that might be easy to gloss over.

“Tuesday morning, car picks up specimens at Lebakeng and Nkau.”

If only it was that simple.

Matoko is laboratory manager for Partners In Health in Lesotho, a small, landlocked nation in southern Africa, where PIH is known locally as Bo-mphato Litšebeletsong Tsa Bophelo. His story about what it takes to move clinical lab samples—including multi-hour drives with lifesaving, time-sensitive blood tests; frozen gel packs; and a canoe—was one of many told by PIH laboratory leaders from nine countries, at the third annual PIH Lab Workshop and Training. The weeklong event was held in Boston in May.

PIH directly supports more than 25 laboratories across 10 countries, and works with a larger network of labs—in areas such as public health, tuberculosis and more—in each of those countries. Some PIH labs are home to broad diagnostic capacity, while others are designed to focus on a single disease, such as TB. While PIH teams in some countries, such as Sierra Leone, have had labs for only a few years, others, like Haiti, have had them for decades. Laboratory expertise and technology also vary across sites, depending on whether staff are catering to a small clinic or a large referral hospital.

But all of them—large or small, new or longstanding—are absolutely vital to PIH’s work supporting  health care and improving patients’ lives around the world. Dr. Joia Mukherjee, PIH’s chief medical officer, recalled times in the early years of PIH when lab materials and testing were extremely limited, if available at all.  

“It is so much more complicated to take care of patients when you have no diagnostic ability. You don’t know what you’re treating; you don’t know how long to treat it,” Mukherjee said to an audience of PIHers who gathered to meet and celebrate the lab group.

There’s a lot to celebrate this year. Daniel Orozco, director of laboratory services for PIH, said the “flagship” Dr. Paul E. Farmer BSL-3 Laboratory soon will be operating at University Hospital in Mirebalais, Haiti, after several years of construction and equipment transfers. The lab’s designation as a Biosafety Level 3 facility, or BSL-3, means it’s a high containment lab where technicians can work with infectious agents, including drug-resistant TB.

“People said to me, ‘Good luck opening a BSL-3 lab in rural Haiti,’“ Orozco said. “And not only have we done it, we also will demonstrate that it’s possible for it to run at a high standard of quality, while working closely with the national TB reference lab at Laboratoire National de Santé Publique (Haiti’s National Public Health Laboratory).”

Daniel Orozco leads a discussion at PIH's annual lab workshop
Daniel Orozco, director of laboratory services for PIH, describes PIH's lab-related achievements and growth over the past year, including the new Dr. Paul E. Farmer BSL-3 Laboratory, which soon will be operating at University Hospital in Mirebalais, Haiti.

Microbiology services to test for bacteria and viruses are starting at PIH labs in Haiti and Rwanda, Orozco added, and capacity is expanding in Liberia and Sierra Leone. Participants in this year’s workshop received training on lab procedures and management, supply chain and procurement, and more.

Participants also focused on Strengthening Laboratory Management Toward Accreditation, or SLMTA, in sessions led by Zimbabwean SLMTA master trainer Edwin Shumba and PIH laboratory program officer Nidia Correa. The training covered basics of SLMTA such as lab management, lab process control, quality assessment, and method validation.

Matoko said the SLMTA training was “extensively informative” in several areas, such as methods to verify manufacturers’ claims about equipment and set appropriate quality standards in labs.

“It was beyond my expectations,” Matoko said. “I’m really hoping that this will impact a lot back home, as far as preparation for accreditation.”

The constant, extensive preparations by Matoko’s lab team were featured in the poster presentations, a highlight of the annual lab workshop since it began in 2017. The poster presentations give participants a chance to showcase their work and learn from the experiences, successes, and growth of their PIH lab colleagues around the world.

Matoko used his poster to describe moving clinical lab samples over Lesotho’s rugged roads and mountains.

Two of the most remote health centers PIH supports in Lesotho are at Lebakeng and Nkau, rural communities several hours from Maseru that are so isolated by mountainous terrain that, in both cases, grassy fields often serve as helicopter pads for urgent visits.  

Matoko said his team visits the health centers by truck to pick up lab samples. The overnight trip requires more than 10 hours of driving, in all. At Lebakeng, the driver calls ahead so someone from the health center can take a 45-minute hike down a mountain—samples tucked in a cooler filled with gel ice packs—and then canoe across a river to hand over the samples.

Work is well underway to shorten that “specimen referral,” as getting lab samples to a testing facility is formally known. PIH works closely with Lesotho’s Ministry of Health, which has provided Lebakeng with a GeneXpert machine to enable TB diagnostics in the remote, mountaintop setting. Plans for a modular building at the facility also are in the works, to provide more space for currently cramped lab work.

Orozco said the three themes of this year’s poster presentations—quality improvement, specimen referral, and lab accreditation—“are all parts of a bigger picture in terms of lab strengthening.”

Zhanel Zhantuarova, a lab quality officer for PIH in Kazakhstan, talked about the heavy amount of documentation required for clinical trials of new multidrug-resistant TB treatment in her country. Some of the paperwork is in Russian, and some in English. Unifying the two can be difficult, because minor differences in language can have major impacts in medical interpretation.

Roger Calderon, laboratory director for PIH in Peru, known locally as Socios En Salud, talked about his team’s work to test for first- and second-line TB drug resistance—one of only three labs in Peru to do both—while shortening test turnaround times from six months to one.

PIH lab leaders gather for a group photo with co-founder Dr. Paul Farmer
Participants in the third annual PIH Lab Workshop and Training gather with PIH leaders including Chief Medical Officer Dr. Joia Mukherjee, fourth from left, and Co-Founder and Chief Strategist Dr. Paul Farmer, center back, below the PIH logo. 

Dr. Paul Farmer, the PIH co-founder and chief strategist for whom Haiti’s new BSL-3 lab is named, praised all of the lab leaders at the workshop and said their work reflects PIH’s fundamental ethic of accompaniment, or “sticking with it over the long haul” while sharing the burden of others.

“You’re really the best at what you do—that’s what I think when I look around the room,” Farmer told the group.

Mukherjee said PIH’s lab teams are “indispensable” and urged workshop attendees to continue their groundbreaking work.

“I think this coordination that you’re all doing together is really going to raise the standard of care for the world’s poor,” Mukherjee said. “So, thank you, because care is better when you know where you’re going. No doubt.”

Fri, 14 Jun 2019 09:27:35 -0400
Malawi Support Program Celebrates First University Grad As Doctor Kazinga awaited the results of his final exams for the University of Malawi-Polytechnic in December, more than his own graduation was at stake.

Kazinga, 28, was hoping to achieve a new milestone for the people he loves most.

“No one had ever gone to university in my family,” said Kazinga, who grew up in Malawi’s Neno District, a rural, mountainous region where poverty is endemic and educational opportunities are slim. 

Kazinga had no need to worry about his grades. He passed the finals and, in March, graduated from the university with a bachelor’s degree in mathematical sciences, a field he has loved since high school. He focused on statistics, and minored in computer applications and programming. 

The youngest of seven, he is the first in his family to complete university studies. That’s fitting given his first name, Doctor, which is not to be confused with the title of Dr.—at least not yet, anyway.

Kazinga also is the first university graduate in Malawi who benefited from the Partners In Health program known as POSER, or the Program on Social and Economic Rights.   

PIH is known in Malawi as Abwenzi Pa Za Umoyo, and provides POSER support to more than 100 families in Neno District. That support includes food packages, new home construction, emergency home repairs, and funding for education, transportation, and helping people launch small businesses. The goal is to provide long-term investments in community members, giving them support beyond health care, to help them break out of the cycle of poverty and lead more productive, healthy lives.

Kazinga and his family are well-known to the POSER team in Neno. He grew up in Mpakati Village, about an hour and a half by foot from the PIH office in Neno’s central community.

Initially, his studies at Mwanza Secondary School—nearly 40 miles from his family’s home, in a neighboring district—were supported by the government’s local Office of Social Affairs. During his junior year, funding issues caused an abrupt end to that support. Kazinga had no choice but to leave the school, even though he was only one year away from graduation.

He was spending a few weeks back at his family’s home in Neno when a POSER staff member visited, because of his mother’s poor health. During that visit, the staff member identified Kazinga as a highly driven student, and PIH began paying for his school fees, books, and other materials so that he could continue his education. Then, once he’d obtained his high school diploma, Kazinga attended university in Blantyre, Malawi’s capital, through PIH’s support.

Doctor Kazinga at his graduation in March
Doctor Kazinga at his graduation in March. (Photo courtesy of Doctor Kazinga)

“If POSER hadn’t helped, I would have been done with my studies, because there was no money for school fees,” Kazinga said. “Had it been that they didn’t intervene, I cannot imagine what would have happened. It’s too much.”

Victor Kanyema, POSER manager for PIH in Malawi, said Kazinga is an exceptional young man who always has been hardworking and reliable.  

“I am so proud of all that he has achieved,” Kanyema said. “When he was accepted into university, we worked closely with the PIH staff in Boston to figure out how POSER could continue to support him, despite financial restraints, and make sure he could continue to go to school. We did everything we could to mobilize resources and help with fees, transportation, accommodation, and other basic necessities.” 

Kanyema joined Kazinga, and Kazinga’s father, for the university graduation in March.

“He has been so committed, right through the end of his studies. Something we originally thought may not be possible, we made possible. He is a pioneer,” Kanyema said. “Because of him, another POSER recipient is able to pursue her university studies right now, following in his footsteps. He is making all of us at POSER—and APZU —very proud.”

Kazinga was one of 42 students in the university’s mathematical sciences department, but only 18 of them graduated, reflecting the challenges many students and families face when it comes to paying for education.

Down the road, Kazinga dreams of pursuing a master’s degree in statistics and being involved with research.

He already has a head start in that direction. Kazinga is an intern with PIH’s community health department in Neno, supporting all of the department’s programming, including POSER. He’s using many of the skills that he learned throughout his education to support other people and families across Neno, embodying the POSER spirit of investing in people, so that they can invest in their communities.

Thu, 13 Jun 2019 15:10:24 -0400
PIH Leader for WBUR: "Why You Should Care About Ebola in Congo" Jonathan Lascher arrived in Sierra Leone in 2014 to help lead Partners In Health’s efforts to respond to Ebola virus disease in West Africa, site of the world’s largest and most deadly such epidemic. Now executive director of PIH in Sierra Leone, he has a unique perspective on the current Ebola outbreak in the Democratic Republic of Congo, where the disease has raged for a year in the midst of a war zone.

There are many reasons why Ebola and other deadly infectious diseases ravage countries like Sierra Leone and Congo. But “a broken health system seems to be the single largest contributor to how susceptible a country might be to an outbreak, and how quickly it can be stamped out,” Lascher writes for WBUR’s Cognoscenti, the opinion page of NPR’s Boston-based affiliate.

Before Ebola arrived in either of these countries, residents knew that the local health system was broken and couldn’t be relied upon for quality, consistent care. This was not for lack of desire, but for lack of the staff, stuff, space, systems, and social support necessary to provide health care for the neediest.

“Total annual spending on health care in the United States was over $9,000 per person in 2016,” Lascher writes. “In Sierra Leone, it was roughly $107 per person. In Congo, it was just $20. Headstone epitaphs in Sierra Leone or Congo should read, ‘No electricity to keep donated blood cold’ or ‘Only one ambulance for 500,000 people.’”

These are not problems that countries can, or should, solve on their own, Lascher argues. He says the U.S. should lead the drive for global funding, as President George W. Bush did with the President’s Emergency Plan for AIDS Relief (PEPFAR), to work together toward building strong health systems, especially in those countries that require the most support.

Read Lascher’s full article here.

Thu, 06 Jun 2019 11:23:34 -0400
Dr. Sheila Davis Named New CEO of Partners In Health Partners In Health today named Dr. Sheila Davis as its new Chief Executive Officer. Currently the Chief of Clinical Operations and Chief Nursing Officer, Dr. Davis will succeed Dr. Gary Gottlieb, who in the spring of 2018 informed the board of his intention to step down.  

“Thanks to her vast experience, strategic acumen, unwavering solidarity, and passionate commitment to our mission, Sheila is a brilliant choice to help the organization meet more of the needs of those we serve,” Dr. Gottlieb said.

Partners In Health is a non-profit social justice organization that brings the benefits of modern medical science to the poorest and sickest communities around the world, working to ensure that the universal human right to quality health care is realized. Founded in 1987 by Ophelia Dahl, Dr. Paul Farmer, Dr. Jim Kim, Todd McCormack, and Tom White, it has grown from a small organization in Haiti to a global nonprofit with 18,000 mostly local staff in 10 countries. Last year, it provided access to care to 8 million people.

Dr. Davis holds a doctorate in nursing and has a long history of serving the poor and marginalized—working closely with patients suffering from HIV in the 1980s, both in the U.S. and abroad. For the past decade, she has held multiple cross-site roles at Partners In Health.

After joining the organization in 2010, Dr. Davis was instrumental in the planning and opening of Hôpital Universitaire de Mirebalais, a 300-bed teaching hospital in Haiti. When PIH entered West Africa to help address the Ebola epidemic, Dr. Davis, then Chief Nursing Officer and a member of the executive leadership team, led the organization’s Ebola response. Later, she took on the additional role of Chief of Clinical Operations.

Wearing both hats, Dr. Davis has married her activism, pragmatism, and implementation skills to elevate Partners In Health’s nursing programs and all of the clinical operations, firmly establish the organization’s nursing strategy, and heighten the professionalism and inclusiveness of the organization’s thousands of nurses, midwives, and community health workers.

“Partners In Health has never been better positioned to help provide health care that truly prioritizes the needs of the poor, to show the world that high-quality health care can be provided to all,” Dr. Davis said. “I’m honored and ready to work with my colleagues around the world to do the best for our patients and challenge health inequities globally.

Dr. Davis will build on the legacy of Dr. Gottlieb, a longtime Partners In Health board member who left Partners HealthCare in 2015 to become CEO of Partners In Health a few months after the organization accepted an invitation to respond to the Ebola epidemic. Under Dr. Gottlieb’s leadership for the past four years, PIH has made rapid progress in improving health and health systems, building on its platform of universal health coverage in some of the world’s poorest countries. Also notable during Gary’s tenure, Partners In Health opened the University of Global Health Equity, a health sciences university in rural Rwanda; worked with key global partners to bring the first new drugs in 40 years to treat multidrug-resistant tuberculosis to more than 2,600 people in 19 countries; and expanded innovative cross-site programs delivering mental health care and services for people with non-communicable diseases where none had been available previously. While retiring from his role at Partners In Health, Dr. Gottlieb will continue his academic commitments as professor of psychiatry at Harvard Medical School, serving on the medical staffs of McLean Hospital and Massachusetts General Hospital. He will also continue to serve on the boards of nonprofit and innovative health care companies and in an advisory role as an executive partner at Flare Capital Partners.

“I, along with the Partners In Health Board, could not be more excited to have Sheila at the helm, to lead us through this important next phase and into a promising future,” said Co-Founder and Chair of the Board Ophelia Dahl. “I have full confidence that Sheila will be an inspiring steward of our mission and a fierce advocate for our patients.” 

For more information and media inquiries, contact Eric Hansen at

For a printable PDF of this release, click here.  

Wed, 05 Jun 2019 16:22:30 -0400
How One Prenatal Checkup Saved Two Lives in Mexico Three-month-old Omar slept peacefully in a hammock in the shade while his mother, Olga Veronica Roblero, laid out beans to dry in the sun nearby. They were at the family’s home in the rural Sierra Madre region of Chiapas, Mexico, where Roblero and her husband make a subsistence living growing corn, beans, and coffee. Most families in the region do the same, farming in the mountains of Mexico’s southern end, near the border with Guatemala. Chiapas is known for its coffee, but it’s also—and long has been—a highly marginalized region, where families face enormous challenges in accessing health care. 

The single dirt road near their home mostly bears foot traffic, from people going to and from the small community of Salvador Urbina, about a 20-minute walk south. There, and in nine other remote communities in the region, Partners In Health—known locally as Compañeros En Salud—is collaborating with Mexico’s Ministry of Health on an innovative partnership to ensure meaningful access to quality medical care for families like the Robleros. 

Baby Omar is Roblero’s fourth child. She gave birth to all three of her older children at home, with a traditional midwife, but Omar was born in the regional hospital at Villaflores. How that came to be, and how Roblero was able to have a healthy childbirth, is a story about the vital importance of community-based primary care, an increased emphasis on maternal health, and how PIH is working to change the model of care–both the experience and the perception—for mothers in Chiapas.

Roblero intimately understands the challenges of accessing maternal care. Years earlier, when Omar’s siblings were born, there were no doctors in the area, only a part-time government health worker in the community’s small public health outpost. There also was no public transportation to travel for care. The next nearest health facility is a community hospital in Jaltenango de la Paz, nearly two hours away by car—a luxury most people didn’t have, and still don’t. 

Those conditions meant giving birth at home was not just the norm, but often the only option, for women in Salvador Urbina and other rural communities in Chiapas. 

“I didn’t know what it was like to have a baby in a hospital, until (Omar),” Roblero said.

A "normal" pregnancy

She’s far from alone. More than one third of births in Chiapas took place at home in 2016, according to national data. The region had Mexico’s highest maternal mortality rate that year, and a quarter of the women who died had not had any prenatal care.

PIH is working to stop those deaths, and fill the gap in maternal care, by supporting services at 10 clinics in remote areas, serving more than 140 communities. Primary care often is provided by first-year physicians, known as pasantes, whom PIH recruits by partnering with medical schools in Mexico. 

PIH’s support of the public health clinic in Salvador Urbina has meant that, since 2014, the community has had regular access to care by full-time physicians. That enabled Roblero to receive monthly prenatal care with Dr. Adolfo Cavazos, a pasante carrying out his government-required social service year by living and working in the community. 

Roblero’s pregnancy initially progressed well. 

“I wasn’t having any problems at all,” she said. “All the appointments I had, I went to them. They would tell me the date. They checked everything for me; blood pressure, everything, came out normal.”

That changed at a regular checkup a few weeks before her due date. 

After welcoming Roblero to the clinic, Cavazos began his routine exam and soon became concerned. He consulted with Dr. Marwa Saleh, a family medicine physician working with him in Salvador Urbina that week through a global health fellowship with the U.S.-based HEAL Initiative. Both doctors noticed Roblero’s feet were swollen and checked her blood pressure. They also tested her urine and found high protein levels. 

Those symptoms made the doctors concerned about preeclampsia, a pregnancy-related condition involving high blood pressure that can result in seizures, hemorrhage, or organ damage in the mother, placing her life and the fetus at serious risk. Symptoms of preeclampsia aren’t always apparent, and so it was fortunate that Roblero was coming regularly for her care.  

“There are women who don’t have symptoms, and that’s why it’s so important that they go each month, or month and a half, for prenatal visits, which includes having their blood pressure checked,” said Dr. Jimena Maza, director of primary care for PIH in Mexico.

The physicians explained to Roblero that she needed to be evaluated in a hospital. That’s no simple referral for patients in these communities. Public transportation from Salvador Urbina, for example, is available only twice per day–at dawn and around noon–and often means riding in the bed of a pickup that, sometimes, offers a tarp for cover from the sun or rain. A ruta, as it’s called, often is standing-room-only for the two-hour trip to Jaltenango. 

PIH helps address those needs by giving patients vouchers for transportation and food, and providing lodging near the hospital when needed. In Roblero’s case, the team arranged for her to travel to Jaltenango with Maza. She packed an overnight bag and was joined by her mother-in-law and husband. 

The trip meant that, for the first time in her life, Roblero would set foot in a hospital. 

A new kind of maternal care

Roblero long had wondered what hospital treatment would be like. Her understandable concerns were based on long histories of medical mistreatment not only in Chiapas, but in communities with oversaturated hospitals across Mexico and—for that matter—around the world. Dehumanizing treatment, overuse of medical interventions, and other violations of patients’ rights have characterized cases of obstetric violence against patients, who may fear speaking up for themselves at the risk of not receiving care.

More than one third of women said they suffered some form of mistreatment during the their most recent childbirth, according to a 2016 survey by Mexico’s National Institute of Statistics and Geography. Among them, 11 percent reported being scolded or yelled at, nearly 10 percent reported being ignored when they asked about their childbirth or their baby, and 9 percent reported being kept in an uncomfortable or awkward position.

This resulting fear of facility-based childbirth is one more obstacle to care that PIH is actively working to address, in Chiapas and within other marginalized regions around the world.

At the community hospital in Jaltenango, Fabiola Ortiz, a nurse and perinatal specialist, met Roblero when she arrived. Ortiz is a clinical supervisor for PIH’s team of obstetrics nursing pasantes who work in the hospital and its neighboring Casa Materna, a new birth center that is part of the collaboration between PIH and Mexico’s Ministry of Health. 

Pregnant mother receives care at birth waiting home in Mexico
Alma Rosa Valentin, an obstetrics nurse fulfilling her social service year with PIH in Mexico, examines the swollen legs of Ana Carolina Armas, a mother in her ninth month of pregnancy, at the Casa Materna in Jaltenango. Photo by Cecille Joan Avila / Partners In Health

Dr. Mariana Montaño, maternal health program coordinator for PIH in Mexico, said care at the Jaltenango hospital has an intercultural approach and focuses on the needs of women, who are empowered to make decisions about their care.  

“Women have the right to choose the position of childbirth and a companion to accompany them, and are allowed to move freely or change positions,” Montaño said. “They also receive support with non-pharmacological measures for alleviating pain, and have immediate skin-to-skin contact with their baby after delivery.”

Roblero said the care she received at Jaltenango immediately eased her concerns about hospitals. 

“It was there that I saw that, yes, they take good care of you,” she said. “The doctors and nurses who are there, they were really attentive.”

The hospital team evaluated Roblero and ordered labs while they began to administer magnesium sulfate as a measure to prevent eclampsia. They talked to her about what they were observing, and explained the increasing likelihood that she would need a cesarean section. As a community hospital, the Jaltenango facility was not equipped for some complicated procedures, including C-sections, meaning Roblero again would need a transfer to a properly equipped facility.  

After she was stabilized and travel arrangements were made, Roblero was transferred to a hospital in Villaflores, even further north from her home in Salvador Urbina. There, by way of a successful C-section, healthy baby Omar was born. 

"Here we are, thanks to all of you"

This smooth flow of activities—the diagnosis of Roblero’s preeclampsia and need for a C-section, her successful transfer from her local clinic to a community hospital, and finally the identification of successful transfer to a regional hospital to perform her surgery--demonstrate the positive impact of PIH’s work to strengthen the public health care system. It’s a reality that couldn’t have been taken for granted in years past.

Roblero’s care continued after Omar was born. After she returned to Salvador Urbina, Cavazos and Cecilia Gálvez Roblero, who serves the clinic as a clinician’s assistant, checked in with Roblero regularly, visiting her at home for blood pressure checks to monitor for postpartum preeclampsia. 

Dr. Jessica Standish, another visiting family medicine specialist, accompanied Cavazos to Roblero’s home a week after Omar’s birth to remove her C-section stitches. They gathered in a dark bedroom, which was being rebuilt after suffering damage in an 8.1-magnitude earthquake that struck just off the coast of Chiapas a year earlier. The family was still without electricity, so the doctors had brought along a headlamp. 

Doctor provides home visit to mother after C-section in Mexico
Dr. Adolfo Cavazos, a first-year clinician fulfilling his social service year with PIH in Mexico, removes Roblero's C-section stitches while Dr. Jessica Standish, a visiting family medicine specialist, supervises his work. Photo by Mary Schaad / Partners In Health

Before PIH began supporting the clinic in Salvador Urbina, Roblero would have had to travel for several hours during the rainy season and possibly stay overnight, with week-old Omar in tow, to have her stitches removed at the nearest hospital. But with Cavazos and Standish providing care at Roblero’s home, removing her stitches and re-bandaging the wound took less than 30 minutes. 

Home visits are also conducted by PIH community health workers, or acompañantes, who visit women during and after pregnancy to provide information, resources, care, and support. Acompañantes work in the communities where they live, meaning neighbors are helping neighbors and directly understand local needs and conditions.

“Quality maternal care begins in the community, with first-level care clinics providing good prenatal care, and with the identification of risk factors and timely referral to specialized care if necessary,” Montaño said. “Ensuring that patients have meaningful access to comprehensive care requires effective coordination and communication between first, second, and third levels of care. But it also requires that we address all the barriers to care at each level, whether they’re logistical, economic, or involve regaining confidence in the health system.”

PIH’s work in Chiapas is helping to change women’s experience and their perceptions of maternal care. Most importantly, though, it is changing lives—and saving them.

“If that day hadn’t happened that way, I don’t know. I think I might not have been able, or may not be here. I don’t know if I or my child…” Roblero said, not daring to voice her fears about what would have happened had PIH not been there to help. 

“And yes, here we are, thanks to all of you.”


Fri, 24 May 2019 15:31:07 -0400
Peer Groups Boosting Mental Health, Support Networks in Northern Rwanda */ /*-->*/

Claver Mugenzi is an outgoing man who favors a bright blue suit that’s as distinctive as his engaging smile. He dresses the part as a leader of his church group in the northern Rwanda community of Kivuye, where he’s also involved in local government. But he wasn’t always so civically active. Struggles with mental illness left Mugenzi and members of his family ostracized by their community, where education and understanding about mental illness had been limited.

“Before, when our family had problems, we were thinking that it was bad spirits that had affected us,” Mugenzi said earlier this year. “After joining treatment at the clinic, we improved and (now) are showing how our improvement has contributed to our welfare. We can advise people who are like how we were, before. When we are here in the group, we can support each other.”

Mugenzi was referring to a self-help group that meets regularly at Kivuye Health Center. The center is supported by Partners In Health, known in Rwanda as Inshuti Mu Buzima. Members of the self-help group meet voluntarily, usually once a month, with shared goals of overcoming mental illness, improving their emotional well-being, and even boosting their finances and resources. Members contribute to collective savings every month and use the pooled money to buy livestock, land for farming, and other agricultural needs, or to issue small loans to members.

The Kivuye group is one of 17 self-help groups meeting at health centers across northern Rwanda’s Burera District. The groups total more than 600 members, including people with mental illness and their families. PIH supports the groups in collaboration with Rwanda’s Ministry of Health, as part of a larger effort to bring mental health care directly to communities, integrate mental health with primary care, decrease stigma, and increase local education and empowerment.

The need for a greater understanding of mental health is global. The World Health Organization says depression is the world’s leading cause of disability, affecting more than 300 million people. The WHO also estimates that in low- and middle-income countries, up to 85 percent of people with mental illness do not receive treatment—meaning millions of people suffering from psychosis, depression, and other illnesses have no access to care that could change their lives.

PIH is responding to this growing crisis and, in 2018 alone, supported mental health care for 6,800 people across 10 countries. Rwanda was one of the first countries in which PIH launched a mental health program. The 2009 launch came 15 years after the country’s devastating spring of 1994, when the genocide against the Tutsi led to the deaths of 1 million people over 100 days, and displaced millions more. The genocide decimated the country’s health system, and caused severe, lasting trauma among citizens who had virtually nowhere to turn for mental health care. 

Gains were incremental as the country rebuilt its health system, but for years, mental health care was available only at district hospitals, far away from many people with great need for care but limited means for travel.

PIH’s collaborations with the Ministry of Health have spurred mentoring programs, mental health training for primary care nurses, and more, with a focus on bringing mental health care directly to communities. Education sessions and self-help groups began expanding to health centers in 2015. PIH is working closely with the ministry to scale mental health programs and mentoring across Rwanda.

PIH’s support for the self-help groups extends beyond mental health care. In conjunction with PIH’s Program on Social and Economic Rights, or POSER, group members receive training in agriculture and other income-generating activities, along with material donations such as potato seeds, fertilizer, irrigation pumps, fungicide, and livestock. 

Claver Mugenzi (Photo by Nina Sreshta / Partners In Health)

In Mugenzi’s community of Kivuye, the self-help group started a livestock project and used their collective savings to buy rabbits, chickens, and 12 sheep, which they distributed among members. PIH donated an additional 20 sheep for the group. Members who didn’t get a sheep in the initial round will get the first newborn lambs.

Mugenzi is realizing his potential, as well.

“I have really improved now,” he said. “Even in local government, I have some responsibility. Even in my church, I am among the leaders. Stigma has been reduced. Before, I was not able to do anything, and my knowledge was like zero percent. I was not among the church leaders. No one was caring for me, or thinking I could be a leader.”

Sifa Dorcas, PIH’s social and community support coordinator in Burera District, said changing those perceptions at the self-help groups began with education, and awareness.

“The first task was to help people understand mental illness,” she said. “If you know the illness you have, then you can make a plan, and follow up in the medical system…As the main objective was to improve people's health and promote their reintegration into communities, we emphasized the role of family members and caregivers in treatment, and ultimately, in fighting stigma.”

Dorcas has led mental health outreach efforts in Burera District for years, visiting people in their homes, health centers, and communities. She and Dr. Nina Sreshta, Harvard University’s Dr. Mario Pagenel Fellow in Global Mental Health Delivery, visited six self-help groups in January and February to assess their growth and impacts. Dorcas said development of the groups started slowly, but has grown to include strong economic components built through collaboration and shared resources.  

“By working with nurses and social workers at health centers, we mobilized patients and families,” Dorcas said. “Most groups started saving by contributing 100 Rwandan francs ($0.11 U.S.) every month. Many groups have increased their savings, and some groups have members contributing up to 1000 RWF ($1.10 U.S.) each, every month.” 

Like the Kivuye group, the self-help group at Rwerere Health Center has used its shared savings to buy livestock. Rwerere is about 25 miles west of Kivuye. One sheep in the area costs about 30,000 RWF, or about $33. The Rwerere group bought 21 of them, and PIH donated 20 more. Members use the manure for natural fertilizer, and sell lambs in local markets for extra income. Building on success from that project, the group then bought 13 chickens, and with a loan were able to rent a small coop for them. Members plan to sell eggs to generate additional income for the self-help group. 

As of February, the 17 self-help groups in Burera District had saved nearly 375,000 RWF, or more than $400, with an additional 930,000 RWF—more than $1,000—available for loans to members. Some families have used the money to buy health insurance or rent land for farming.

Sreshta said the visible, tangible successes for people living with mental illness—people who neighbors previously had shunned—can have a dynamic impact on perceptions.

“People with mental illness everywhere, not just in Rwanda, are vulnerable to social stigmatization and isolation,” Sreshta said. “These groups are very inspiring to see. Members develop camaraderie and a sense of agency by supporting each other and intentionally saving money for particular goals. Members talk about how these groups have reduced their feelings of isolation and hopelessness, and have contributed to boosting their confidence and resilience.”

Emmanuel Hakizuwera
Emmanuel Hakizuwera used his land as collateral for a bank loan that enabled his self-group to buy livestock. Photo by Nina Sreshta / Partners In Health 
Emmanuel Hakizuwera feeds a cow at his home
Emmanuel Hakizuwera feeds a cow that he bought for his family, as part of a shared loan with his self-help group for people with mental illness and their families. Hakizuwera said he wanted to "show that we love each other and it is easy to provide and to share.” Photo by Nina Sreshta / Partners In Health

The groups also are strengthening local support networks.

Emmanuel Hakizuwera, a member of the self-help group at Kirambo Health Center, took a bank loan in his name to help the group buy cows, using his own land as collateral. Kirambo is just a few miles west of Rwerere. Hakizuwera and his wife decided to help the Kirambo group because of their daughter, who suffers from epilepsy. He said the self-help group has provided not only education about mental health, but also a better understanding of the importance of treatment, medicine, and follow-up appointments for their daughter. Her condition has improved significantly during Hakizuwera’s participation in the group, and as she receives regular checkups at the health center. 

Hakizuwera and his wife have improved their finances with the purchase of a cow for his family, as part of the loan to the group. They get natural fertilizer for their fields and milk for their children. The group also is growing potatoes on the land Hakizuwera used as collateral.

He said applying for the loan was about more than money.

“My neighbor asked why I chose to offer land and my documents for the loan,” Hakizuwera said. “I wanted to show my neighbors and the community that there is no need to discriminate, including against people with mental illness. I wanted to also show that we love each other and it is easy to provide and to share.” 

Thu, 23 May 2019 11:07:14 -0400
Research: Study Validates Use of Depression Screening Tool in Rural Mexico Widely used screening tools proved highly effective in identifying patients suffering from depression in rural communities in Chiapas, the poorest state in Mexico, according to a study conducted by clinicians and volunteers working with Compañeros En Salud, as Partners In Health is known locally. 

The 2014 study was the first time such tools, known in the mental health field as the PHQ-2 and the PHQ-9, had been used in a rural, marginalized community in Mexico, and indicates how powerful these brief screening tools can be for identifying and diagnosing common mental disorders.

“The study demonstrated that these were valid tools and brought to surface the urgency of mental health issues arising from social and economic factors in rural Mexico,” says Dr. Jafet Arrieta, the former director of operations for PIH in Mexico and principal investigator on the study.

What Arrieta and her team found was shocking. Nearly 26 percent of residents surveyed were diagnosed with depression, compared to 7 percent across Mexico and 4 percent globally. This news is particularly alarming considering Chiapas has only one psychiatrist for every 200,000 people—far below Mexico’s overall average, according to the World Health Organization. 

Arrieta and her co-authors published their findings in the Journal of Clinical Psychology in 2017, following six months of research conducted in 2014 as part of her master’s degree program in Global Health and Social Medicine at Harvard Medical School. 

By the time of Arrieta’s study, PIH had already been using the screening tools as part of its mental health program, which was launched in 2012 and integrated into the activities run by doctors completing their social service year, in partnership with Mexico’s Ministry of Health. Medical students went door-to-door to talk to residents about depression, and used the PHQ-2 for screening and then, if necessary, a PHQ-9 for basic diagnosis. Those residents who received a high PHQ-9 score were referred to a nearby clinic for further diagnosis and treatment.

Arrieta wanted to prove the effectiveness of this strategy in rural Mexico, and so wrapped the work into her graduate degree studies. To conduct the research, she recruited seven medical students to visit 152 households in the Fraylesca region in the community of Laguna del Cofre, a five-hour drive from Tuxtla Gutiérrez, the capital of Chiapas. 

“This was a mix of research looking to better understand the experience of people in Chiapas living with and seeking care for depression, and to assess this diagnostic screening instrument for depression,” says Arrieta. 

The results complemented similar PIH findings in rural primary care clinics in Haiti, Liberia, and Rwanda, highlighting the importance of investing in community-based mental health screening, diagnosis, and treatment. 

In Mexico specifically, doctors across 10 PIH-supported clinics have incorporated the PHQ-9 as a depression screening and follow-up tool used during check-ups. As a result, they have learned that an enormous number of their female patients have lived with, or continue to live with, domestic violence in their homes.

mental health home visit in rural Mexico
Yadira Roblero and Magdalena Gutiérrez, community health workers with PIH in Mexico, make a mental health home visit in Laguna Del Cofre. Photo by Aaron Levenson / Partners In Health

Maria* was one of the first patients who benefited from community-based screening for depression. She wasn’t able to finish primary school, was married by age 20, and widowed by 27—just six months after a car accident killed her two siblings. She felt devastated and was forced to raise seven children on her own in the coffee-growing community of Laguna del Cofre. Then her 14-year-old son, Ramon*, had a seizure and began exhibiting psychotic behavior.  

As Ramon grew more violent, Maria searched everywhere for answers—first with a number of traditional healers and then a physician, who incorrectly diagnosed her son with a brain tumor. Heartbroken and exhausted, she started experiencing headaches and body aches, then persistent vomiting. 

“The situation is common,” Arrieta says. “Mental health disorders go untreated and when other symptoms appear individuals look for some supernatural explanation. That creates a cycle of normalization of their mental health issue.” Without local access to mental health care, patients are left with few options to help understand the origin of new behaviors.

Eventually, Ramon was diagnosed with schizophrenia at the age of 20 and put on a costly treatment plan. To pay for his care, Maria left her other children with extended family to look for work in Tuxtla Gutiérrez. But the money she earned still wasn’t enough, and Ramon was forced to stop treatment. 

Maria coped by taking four naps a day, while doctors dismissed her symptoms as stress. She felt powerless; she now knew the source of Ramon’s suffering, but could do nothing to help him. She couldn’t afford the costly medication he required, much less find it on a regular basis. She had no immediate family to share the responsibility of caring for her son. Hopeless and without any other option, she resorted to chaining up Ramon to prevent him from hurting himself and others. 

When PIH brought mental health services to Laguna del Cofre in 2012, Maria met with the local doctor, who had received basic training in how to properly screen and treat patients for a variety of mental disorders. Ramon was unchained, placed on medication to treat his schizophrenia, and received regular checkups to ensure his recovery remained on track. 

What resulted was nothing less than a transformation. Ramon stabilized and was soon well enough to return to work on the family coffee plantation. 

“’I was very grateful, because no other doctor had helped us before,” Maria told Arrieta at the time of her study. “It was as if he had pulled us out of a quagmire.” 

Maria’s story echoed that of many other patients Arrieta and her team came across throughout their study. Thanks to access to a quick screening tool, families dealing with mental illness finally had a name for what plagued their loved ones. That diagnosis came accompanied by regular medication and the support of trained, compassionate clinicians who held their best interests in mind. Suddenly, patients who had suffered for years—sometimes decades—could participate in daily activities and enjoy much fuller, healthier lives.

“We are trying to break the stigma of mental illness by demonstrating that with appropriate care people can get better and be reincorporated into their communities,” says Arrieta. “It’s important to educate rural villages about symptoms of depression in response to life’s triggers in order to stop the notion of being crazy, and that sadness is something that can’t be cured.” 

*Names have been changed for privacy.

Thu, 23 May 2019 07:50:10 -0400
Malawi Flood Relief Raising Homes, Hope Amid ‘Too Much Misfortune’ As Partners In Health continues relief efforts in southern Malawi following devastating downpours earlier this year, personal stories are emerging that show not only the flooding’s severe impact on families and communities, but also the vital support that, in weeks since, has provided hope, helped people rebuild their homes, and sustained livelihoods.

Stories like Maliko Sadzu’s. The 60-year-old described the loss of his home in tearful conversations with PIH teams, and framed the March flooding as the climactic result of three months of near-constant rain. This year’s unusually heavy deluge began in January and relentlessly weakened buildings and infrastructure across Malawi’s mountainous Neno District.

PIH, known locally as Abwenzi Pa Za Umoyo, supports two hospitals and 12 health centers in Neno, serving more than 165,000 people. The impoverished region is served by a network of steep, rocky, dirt roads that can become impassable when rains are heavy. Washed-out bridges can also force unexpected detours, increasing residents’ barriers to health care and services. 

PIH teams have dealt with those roads and other challenges while providing relief efforts after the disastrous floods, working closely with national and local government to bring emergency supplies and support to more than 1,000 people in Neno. Thousands of subsistence farmers in the district lost all or part of their homes, as the months of rainfall culminated with 84 straight hours of downpours in early March, overflowing rivers and watersheds. Relief packages have included food, materials for cooking and for repairing homes, financial support, and even temporary, one-room shelters that are designed for expansion so families can build more as they’re able.

Lines of people waiting for supplies stretch long at a flood relief event
Lines of people stretch around supplies gathered at a distribution event for flood relief in Neno District. 

For many, work to rebuild and recover has only just begun, and wounds—mental and physical—are still raw.

Sadzu said he and his wife Lucia, 50, were sitting by a sheltered cooking fire behind their house in the Neno village of M’mola, as the heavy rains fell on an evening in early March.

“Suddenly, we heard a strange noise like a small quake, as if something heavy had fallen,” he said. The noise quickly was followed by a cry from one of their eight children.

Amayooo ndikufa ine!” their 18-year-old yelled in Chichewa, the local language. “Mother, I am dying!”

The parents rushed to the front of the house and saw that several walls had crumbled, with rubble falling near their 18-year-old, who was sick and had not gone to school that day. The teenager was unhurt, to their relief. But that night, as the family slept, additional walls collapsed around them. What remained of their kitchen was lost to flooding and rain the next day.

With no place to live and no food, Sadzu was left to wonder how he could build a new house, feed his family, and continue sending their children to school.

“This is too much misfortune!” he said, sobbing openly as he recalled that day. “We have seen strange things this year, a house destroyed by rain and almost killing my child?”

The season's heaviest rains in Neno were related to Cyclone Idai, which struck southeastern Africa in early March. The cyclone killed an estimated 1,000 people across Mozambique, Zimbabwe, and Malawi; affected 1 million; and forced hundreds of thousands from their homes. In Malawi alone, the flooding killed 60 people and displaced nearly 90,000 others across 15 of the country’s southern districts.

Just days after the storm system subsided, members of the local village development committee and Neno’s disaster response team visited Sadzu’s family, along with PIH community health worker Mary Velvet. PIH and government partners provided the family with beans, nuts, more than 100 pounds of corn, a liter of cooking oil, a 20-liter plastic bucket for water, a roll of plastic sheeting to help with temporary shelter, and more. The family also received 2,000 Malawian kwacha ($2.75), for transportation costs to haul items to their home. 

Sadzu thanked all of them, knowing his family now had a path forward. A rising number of Neno residents now share that hope.

Like Sadzu, Martha Julias lost her home in the village of M’mola. Also like Sadzu, she received a visit from Velvet and government partners after the storm, and was given much of the same items as Sadzu’s family. 

For Julias, 19, the items helped her support her brother, a 21-year-old living with epilepsy. Julias previously lived with their parents in Blantyre, the largest city in southern Malawi, but moved to Neno in 2018 to help her brother. Velvet visited frequently and accompanied him to monthly checkups, but until Julias’ arrival, he did not have full-time care.

Julias’ presence might have saved her brother’s life during the rains. They both were outside in their garden at about 9 a.m. on a March day, when three walls of the house fell down—shattering windowpanes, damaging their metal roof, and revealing how the extended downpours had eroded their home’s foundation. 

“Imagine if he had been inside the house. What could have happened?” Julias said.

Julias said the emergency support they received gives them hope, and will help them restart their lives in weeks and months to come.

Dr. Luckson Dullie and Roda Biziwelo at a flood relief event in Neno District
Dr. Luckson Dullie, executive director of Partners In Health in Malawi, comforts Roda Biziwelo, who supports six people and lost her home to heavy rains earlier this year. 

Roda Biziwelo, a 65-year-old widow, also has to rebuild. She lives in the Neno village of Nyakoko with her 25-year-old daughter, who has cerebral palsy, and her five grandchildren. 

Biziwelo lost her home during the rains. She, her daughter, and the grandchildren now are living in a makeshift, thatch-roof shelter. Despite assistance from PIH and partners, she remains anxious about her family’s future. She expects to harvest only two bags of corn this year, not nearly enough to last until the next harvest season.

Her struggles are indicative of the tough months that lie ahead for many Neno residents, and for Malawians across the country. The flooding destroyed many fields and crops just as they were maturing, meaning risks of severe food shortages loom.

The flooding and destruction of homes and property in Neno District and across southern Malawi have been devastating, especially with Cyclone Idai coming at the end of the growing season when families cannot replant,” said Dr. Emilia Connolly, chief medical officer for Partners In Health in Malawi. “We are so fortunate, with the response from our request for fundraising, to be able to support our community where we live and work to strengthen the health care system through food, household, and infrastructure support.”

To help PIH continue providing emergency assistance to Malawi families and communities in need of food, mosquito nets, supplies to rebuild homes, and more, please consider donating here.

Tue, 21 May 2019 16:10:03 -0400
Ebola Survivor Fights Odds and Expands Her Family Mariama Kamara felt suddenly unwell upon coming home to her daughter and grandson one evening in August 2016. After walking the familiar dusty road home from the diamond mine where the 43-year-old worked in Sierra Leone’s Kono District, she sat down in the kitchen with a worsening headache and nausea. The terrifying realization came to her as she listened to her family’s playful evening chatter—her symptoms pointed to Ebola.

Sitting slumped at the kitchen table, Kamara questioned how her daughter and adopted grandchild, Hawa and Ibrihim Kamara, would cope if she wasn’t there for them, and wondered about the treatment they would likely receive when neighbors heard they were an “Ebola family.” It occurred to her that many other mothers, like her, must have faced similar turmoil before being taken away by ambulances, as was increasingly the case in her village. In a flash of panic, she considered taking her family with her to the hospital, reasoning that perhaps they would be safer by her side rather than left to face these hardships alone.

In the fall of 2014, Partners In Health was invited by the Sierra Leonean government to help respond to the Ebola epidemic, including the provision of care in Kono District. Over that time, around 800 people from the district were placed under isolation, many of whom were parents or caregivers of young children, according to PIH records. More than half of them, or 454 people, were identified as Ebola-positive. And a large number counted among the staggering 3,955 deaths across Sierra Leone, during what would amount to the world’s largest epidemic of its kind.

When mothers and fathers were taken away, their infants relied on the care of generous neighbors and extended family. If that wasn’t an option, they were taken to the Observational Interim Care Center, a UNICEF-funded service that provided food and support to children of Ebola patients. By the end of the epidemic, 5,666 children across the country had lost a parent as a result of Ebola.

Surviving Ebola

But Kamara didn’t want to think about this that night, while she sat hunched in her chair. Still, her conviction in her family’s resilience grew as the hours passed. She was a keen boxer, regularly participating in local female boxing competitions, and had taught Hawa how to box from an early age. Her favorite motto, “Train hard, fight easy,” was one she had instilled in her daughter. And this fighting spirit, she felt certain, would translate into the strength Hawa needed to guide Ibrihim through life, whether she returned to them or not.

During the peak of the Ebola epidemic in Sierra Leone, communities were instructed to call an emergency line if they or others suspected Ebola’s tell-tale symptoms. Many patients, like Kamara, were taken into immediate isolation for 21-days. So after being rushed to PIH-supported Koidu Government Hospital, where she received an injection to stem the spread of the infection, she was taken by ambulance to an Ebola treatment center more than 70 miles away.

“There were six of us packed in. One man died on the way with blood and sickness coming out of him everywhere,” Kamara remembered. “I didn’t have a chance to say goodbye to my children, but my resilience was strong and I believed I would be back with them soon.”

Kamara was at the Ebola treatment center for almost five weeks, without any form of communication with her family.

“I cried for the whole month she was gone,” said Hawa, who was 24 at the time. “When people went there, they rarely came back.”

Hawa found out that her mother’s test result had come back Ebola-positive when a group of people working for the district health medical team came to her home and removed all of their belongings to be taken away and burned—a typical practice at the time, which left survivors completely destitute. Fortunately, she had already found a new home for her and Ibrihim, who was 4 at the time.

After weeks of worry, Kamara was one of the few to fight the terrifying odds and survive Ebola, returning home to her family in October 2016.

“When she came back it was night and she was sad,” Hawa remembered. “She didn’t want me to touch her, because she was worried about infection. But I wanted to hug her so badly.”

Committed to care

Upon her return, Kamara decided to support the children of those parents less fortunate than her. After being told she was no longer welcome at the local mine, due to unfounded suspicions that she was still infectious, she applied to become a caregiver at the center that supported children of Ebola patients. She worked there for more than a year cooking, cleaning, and “taking care of people’s children when they couldn’t.” All but one of the 30 children under her watchful care survived the epidemic.

Kamara also felt drawn to other survivors. She became part of a tight-knit group of friends who supported one another through regular bouts of illness—common during post-Ebola recovery—and intense societal stigma, which they experienced from community members on a daily basis. She had to carry her treatment center certificate wherever she went in case someone confronted her.

Ebola survivor Sierra Leone
Kamara is among 28 Ebola survivors PIH in Sierra Leone has employed in a range of different roles, such as in the Koidu Government Hospital laundry room.

Cognizant of societal stigma in the epidemic’s aftermath, PIH leadership vowed to employ Ebola survivors and their children whenever possible. Today, 28 Ebola survivors work for PIH in Sierra Leone, in a range of different roles. Kamara is a member of the launderette team at Koidu Government Hospital. And not far away, Hawa works with the social protection team, providing financial support to Kono’s most vulnerable patients.

“When I see patients, it reminds me of my past,” Hawa said. “My mum was in a lot of pain when she had Ebola.”

Mother to all

True to her promise of supporting those left vulnerable by Ebola, Kamara adopted three children in the wake of the epidemic: Alusine and Alusane, now 16-year-old twin brothers, and Sara, now 13.

“It wasn’t a difficult choice for me,” Kamara said, having noticed how the three children struggled to receive the care they needed in their community. “My house is full of love.”  

Not to mention, quite busy. Kamara maintains a strict routine to keep her family in check. “I get up at 4 a.m. to do domestic work, go to work, and then I’m home by 4 p.m. to spend time with them,” she said.

Kamara stresses the importance of education, believing the surest way to motivate her children to work hard is through her own attendance of PIH’s literacy classes, which take place five days a week and have welcomed more than 80 students in Kono to date. “If I’d had this training before in my life, I think I would have found times a lot easier,” she said. “When I started, I couldn’t hold a pencil properly. But now I can write my name.”

Although not as strong physically as she once was at the peak of her boxing game, Kamara has gained mental perseverance through her recent trials. Hawa said her mother became noticeably “louder” following her illness, and that after hearing about PIH’s classes, nothing could stop her from signing up to receive the education she never had growing up.

Kamara’s family is about to get even larger as Hawa looks forward to the birth of her first child with Komba James Tongu, her husband and PIH's motorbike coordinator in Kono, at the end of the summer. Kamara surely takes this addition as a blessing and is prepared for the new adventure.  

“My mum did whatever it takes and took on any responsibility for me,” she said, “just like I do for my children now.”

Fri, 10 May 2019 15:12:28 -0400