Partners In Health Articles 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
Research: Strong Health System Key to Growth in Post-Genocide Rwanda Five years ago in The Lancet, Dr. Agnes Binagwaho, Dr. Paul Farmer, and more than 60 co-authors described how treatment for HIV in Rwanda became a catalyst, and foundation, for revitalizing the country’s health system in the aftermath of the devastating genocide against the Tutsis in 1994.

This spring, as Rwanda marks 25 years since the genocide with the country's annual period of remembrance and memorials, known as kwibuka, the health system itself has become a foundation for socioeconomic support and empowerment, and a vital piece of the country’s renewal.

“Everything that is done in Rwanda is in the framework of poverty reduction and economic development,” Binagwaho said in March. “Our Vision 2020, and a strategy to implement that vision, is an economic development and poverty reduction strategy.”

Binagwaho is vice chancellor of the University of Global Health Equity, a growing, dynamic institution in rural northern Rwanda, so close to Volcanoes National Park that the extinct Mount Muhabura looms over campus. Farmer is co-founder and chief strategist of Partners In Health, which strengthens health systems in 10 countries around the world and began working in Rwanda in 2005. PIH is known locally as Inshuti Mu Buzima.

The 2014 Lancet study examined Rwanda’s health system at the 20-year mark and emphasized how Vision 2020, Rwanda’s national development plan launched in 2000, is inextricably intertwined with health care for all. 

“The idea was to move from the disaster of the mid-1990s towards becoming a middle-income country by 2020. The plan invokes the principles of inclusive, people-centered development and social cohesion. Central to this vision was health equity,” their 2014 study states. “Prosperity would not be possible without substantial investments in public health and health-care delivery.”

Five years after that publication, Binagwaho said socioeconomic support and empowerment remain huge pillars of Rwanda’s health system. 

The University of Global Health Equity, for example, is a PIH initiative that launched in 2015, inaugurated its Butaro campus in January, and is preparing to begin its new, six-and-a-half-year medical program this summer. With strong support from the national government, the university—which is creating local jobs in food services, security, campus support and more—is one embodiment of how Rwanda is working to lift up its citizens and improve livelihoods.

Dr. Agnes Binagwaho at the University of Global Health Equity in January 2019
Dr. Agnes Binagwaho speaks at the campus inauguration for the University of Global Health Equity in Butaro, northern Rwanda, in January. (Photo by illume creative studio)
Support staff on the University of Global Health Equity campus
Support staff on the University of Global Health Equity campus in northern Rwanda, in March. The university is creating local jobs in food services, security, campus support, and more, for residents of the surrounding Butaro community. (Photo by Mike Lawrence/PIH)

Other examples are a rice-farming program in the Rwinkwavu area of Eastern Province, for parents of children suffering malnutrition; a model village program that is building new, government-funded villages for impoverished communities across the country, including near the university; and an economic cooperative program that helps neighbors and co-workers pool their resources to create small businesses.

Binagwaho is a former Rwanda Minister of Health, and remains deeply connected with the government’s direction. She said that together, Rwanda’s national strategies for education, health, agriculture, and economic support have contributed to lifting more than 1.6 million Rwandans out of abject poverty over the past 25 years.

But she also noted that about 17 percent of Rwandans still remain there. A similar contrast can be found in life expectancy. While that statistic has increased from 33 years in 1990 to 68 years in 2018, Binagwaho said much work remains. Life expectancy globally was 72 years as of 2016, according to the World Health Organization.

“People still are not living to the full potential of humans,” Binagwaho said. “We have a lot of improvement to do.”

Rwanda’s next national census is in 2020, the same year targeted by the Vision 2020 development plan. That means a reckoning is around the corner. She added:  “We are waiting to see where the country stands now.”

Whatever the census reveals, the Lancet study five years ago and the continued work since then make clear that Rwanda already has come a long way since the national trauma that is now a quarter-century old.

Over 100 days in the spring of 1994, the genocide against the Tutsis led to the deaths of 1 million people—nearly 20 percent of the country’s population at the time—and displaced millions more. 

Whether survivor, perpetrator, or member of the diaspora, no Rwandan emerged unaffected,” Binagwaho and Farmer wrote in 2014.

The genocide reduced the country’s health system to rubble. The 2014 study describes the disaster starkly:

  • An estimated 250,000 women were raped, “and thus did HIV become a weapon of war.”
  • One of the 20th-century's largest cholera epidemics exploded in refugee camps along Rwanda's western border.
  • Fewer than one in four children were fully vaccinated against measles and polio in 1994.
  • Rwanda's under-5 mortality rate that year was the highest in the world, and life expectancy at birth would remain the lowest anywhere through the next few years.
  • Tuberculosis control programs, weak before the genocide, were in complete disarray, and many patients received only intermittent therapy for years afterward.


“Moreover, most health workers had either been killed or fled the country; many who remained had been complicit in the genocide, and trust in physicians and nurses was frayed,” the authors continued. Destruction of health facilities and the collapse of supply chains for drugs and consumables handicapped the country for years. Capacity to respond to the new crisis of mental health trauma was as strapped as capacity to respond to the trauma usually attended by surgical teams: Rwanda boasted neither psychiatrists nor trauma surgeons.”

Gilbert Rwigema, chief operating officer for PIH in Rwanda, said in March that even before the genocide, health infrastructure in Rwanda was very limited. There was just one central hospital—in the capital, Kigali—where patients from around the country were referred if complications arose in their treatment.  

“The few health facilities in 1994 were almost totally destroyed during the genocide, so the country had to rebuild,” Rwigema said. “Rwanda had to start almost from scratch.”

Now, he said, there are eight national referral and teaching hospitals around the country, four provincial hospitals, 36 district hospitals, and more than 400 health centers—with plans for an even more localized layer of care. Rwigema said there are plans for more than 2,000 health posts in Rwanda, which will provide access to services in even the most remote communities, served largely by community health workers.

As the 2014 study noted, though: “Major challenges to continued improvements in health care delivery in Rwanda remain, with significant implications for sustained economic development. Most notably, 44 to 47 percent of children were chronically malnourished in 2010.”

A national campaign begun in 2013 to reduce that percentage has given rise to agricultural incentive programs across the country. Similar programs are working to address non-communicable diseases, such as cancer, mental illness, injuries, and neonatal disorders, which together have accounted for more than half of Rwanda’s disease burden in recent years.

Rwigema has significant experience in Rwanda’s work to improve mental health care. He began working with PIH more than five years ago, as the program director for the northern Burera District. While there, he helped start the district’s mental health program, teaching families that mental health is a disease like any other and could be vastly helped with treatment.

“We fought that kind of stigma through campaigns, through education, through programs, also social support,” he said. “That work continues.”

The same could be said for many areas of Rwanda’s renewal, and for its people who will always be dealing with pain.

“The trauma of what happened 25 years ago will never heal completely—it is a trauma,” Binagwaho said. “People have been hurt in their heart, their bones. We still need accompaniment.”

Staff for PIH in Rwanda walk to the home of a patient in Burera District, in September 2016
Jean Bosco Bigirimana (left), oncology program coordinator for PIH in Rwanda, and a community health worker walk to the home of a patient in Burera District in September 2016. (Photo by Cecille Joan Avila/PIH)

PIH helps provide that accompaniment through economic and social assistance programs, which for the past four years have provided support in various forms to residents in Burera, Kayonza, and Kirehe districts. Thousands of families have benefited from economic development initiatives, new homes, and help with health insurance, education, and food security.

Binagwaho said sustained economic growth and empowerment, across all income levels, will be instrumental in helping the country and Rwandans move forward—a goal that PIH and the government share.

“At the 25th anniversary of the genocide, it’s good to recognize that the equity agenda that is a pillar of PIH is also a pillar of the strategy of the government of Rwanda since 1994,” she said. “It’s not PIH that brought it. It was already there.

“That is not just words,” she added. “It is a matter of doing. It is a matter of implementing.”

Mon, 06 May 2019 11:23:49 -0400
Expert Moms Helping Parents Raise Healthy Babies in Rwanda Diane Uwingeneye knew during pregnancy that her belly was unusually large. At four months, people said she looked six months along. It was her first pregnancy, and she thought she was simply having a big baby, or carrying a lot of fluid.

An ultrasound showed a healthy, growing fetus. But when she went into labor two months early in May 2018, she and her husband, Anastase Niyonsaba, rushed in an ambulance to Kirehe District Hospital, about an hour’s ride from their home in eastern Rwanda.

At the hands of trained clinicians, Uwingeneye safely gave birth to a daughter, who they named Pamela. When the placenta didn’t follow, though, the delivery team re-checked the 29-year-old mother. To their surprise, the couple learned a second baby soon would be coming—and it was in a dangerous, horizontal position.  

Nurses and Dr. Sadoscar Hakizimana, the hospital’s only OB-GYN surgeon, quickly prepped Uwingeneye for a cesarean section. Less than 15 minutes later, Pamela had a twin sister, Nelly. The ultrasound earlier in Uwingeneye’s pregnancy had not revealed her.

“That was something unexpected,” Niyonsaba said in March, 10 months after that surprising day, holding a happy, sleepy Nelly in his arms. “But we are happy that we have twins.”

Uwingeneye’s health and the twins’ safe births are a testament to the dedicated staff at Kirehe District Hospital (KDH). The hospital is supported by Partners In Health, known in Rwanda as Inshuti Mu Buzima.

The care the parents received only began with their children’s birth—the twins’ healthy development in the year since has been empowered by a vital program called Expert Moms. The program is embedded in the hospital’s maternity ward, neonatal care unit, and Pediatric Development Clinic. It's designed to meet two rapidly growing needs: better outreach and education for new parents, and better support and care for babies born with complications.

Babies born prematurely, with low birth weights or with feeding difficulties often are underserved, particularly in poor countries. Without adequate support, breastfeeding difficulties can lead to nutrition and health problems—even death—that otherwise would be preventable.

Rwanda’s Ministry of Health, supported by PIH, is addressing this gap with a multi-faceted, multi-year approach to strengthening care for newborns and mothers with complicated childbirths, or difficulty breastfeeding. Expert Moms are a key part of that program, and help train new mothers in breastfeeding techniques, assessing health risks for their newborns, and other parenting skills.

Faisi Uwitomze and Nadine Nirere, Expert Moms at Kirehe District Hospital
Faisi Uwitonze (left) and Nadine Nirere, Expert Moms at Kirehe District Hospital, help new mothers learn breastfeeding techniques, health assessments and other parenting skills. Both said helping parents raise healthier babies is incredibly rewarding, in a region with a booming population and dire need for maternal and child health support.  

Nadine Nirere, 31, and Faisi Uwitonze, 28, are the two Expert Moms at KDH. The hospital serves nearly 400,000 people in a rural, agricultural region near Rwanda’s borders with Tanzania and Burundi. Uwitonze received prenatal care herself at KDH, delivered her youngest son there, and received vital care after childbirth. Nirere is a nurse originally trained in Burundi.

In their full-time, paid employment as Expert Moms—PIH hired both women last August—Nirere and Uwitonze receive additional training from PIH staff and pass their knowledge on to other new mothers with complicated births, through regular follow-ups, visits in the neonatal ward and education sessions.

“I want to help other mothers receive the same training and support I did,” Uwitonze said.

Uwingeneye, and her twin daughters Pamela and Nelly, are living examples of that support.

Both girls had very low birth weights. Pamela weighed less than 3 pounds (about 1.3 kilograms) and Nelly was even lighter, at about 1.2 kg. Before they could leave the hospital, they needed to reach at least 4 pounds (1.8 kg) and show steady growth. Uwingeneye also needed to rest and heal, while she and her husband learned how to care for their tiny twins.

Uwingeneye stayed at KDH for two months after her twins were born. She and Niyonsaba learned about the Expert Moms program and pediatric clinics during that time, and have been consistent visitors since. Instruction and support from the Expert Moms, a social worker in the clinic, and pediatric development nurses all have helped Pamela and Nelly grow to the happy, smiling, and chubby babies they now are, a year later.

Pamela and Nelly celebrated their first birthday May 1—a milestone their parents marked with joy.

“A year ago, you were not expected to be alive,” Niyonsaba wrote, on a photo of the girls that he made into a card for their birthday. “Now you are growing up.”

Staff at the pediatric clinic have witnessed that growth. The clinics are held at health facilities across Kirehe and the nearby Rwinkwavu area, in Kayonza District. Infants born preterm, with low birth weights, or other complications receive medical, nutritional and developmental care—in the critical early years of life—through regular visits to the clinics, which are supported by PIH.  

Pediatric nurse Mathieu Nemerimana said the clinics benefit 1,500 children in Kirehe and Rwinkwavu, with structured follow-ups designed to improve infants’ long-term health, physical growth and developmental outcomes.

“We want them to reach their full potential of development,” he said. “When we see young children improving—that’s my favorite part (of the job). When they have issues, and they come back and they are growing, they are improving, they are active.”

Pediatric nurse Silas Havugarurema examines 9-month-old Hazard Habwipano at Kirehe District Hospital
Pediatric nurse Silas Havugarurema does a routine checkup with 9-month-old Hazard Habwipano at Kirehe District Hospital in March, with Hazard's mother, Claire Uzamukunda. Hazard suffered complications related to asphyxia when he was born, and has received followup care with Havugarurema and other clinicians at the hospital's Pediatric Development Clinic.
Pediatric nurse Mathieu Nemerimana and the new Pediatric Development Clinic building
Pediatric nurse Mathieu Nemerimana, shown here in March, said this new building for the Pediatric Development Clinic soon will provide much more space, privacy, and services at Kirehe District Hospital, where the clinic currently is held in a single, crowded room. 

One such clinic was on a March morning at KDH. The clinic is held in a single room at the hospital, and while a new building is under construction, the setup makes for a crowded setting. Mothers sat on a large rug with their infants on their laps or playing close by, as Expert Moms Nirere and Uwitonze led an educational session about premature births and how to help malnourished babies gain weight and grow healthy.

“There are many things mothers don’t know about breastfeeding, and sometimes that can lead to weight loss,” Nirere explained.

It was a Tuesday, which meant the clinic was specifically for parents of premature babies. Clinics on different days support children with developmental disabilities, or other growth challenges.

Jeannette Muhanyana, a 38-year-old subsistence farmer, also was in attendance, with her 2-year-old son, Olivier Manishimwe. She said the care she and Olivier have received has been invaluable. Olivier was her sixth child, and her first delivered by C-section. She has been visiting the pediatric development clinic with him regularly for the past two years, while receiving additional PIH support including food packages and financial help for costs of traveling to and from the hospital.

Muhanyana said the clinic also provides a circle of friends. 

“Most of the moms meet here, and we continue to communicate,” she said. “We go to visit each other, and help if each other’s children are sick.”

Jeannette Mukhanyana, Olivier and pediatric nurse Mathieu Nemerimana at Kirehe District Hospital
Jeannette Muhanyana holds her 2-year-old son, Olivier Manishimwe, while talking with pediatric nurse Mathieu Nemerimana at Kirehe District Hospital. Muhanyana said when Olivier was born prematurely, she "did not think he would be alive" today. She's been bringing him to the hospital's Pediatric Development Clinic regularly since his birth, and has received food and financial support in addition to care and education.

The need for parental support in Kirehe is enormous.

The district includes the Mahama Refugee Camp, which opened in 2015 and is home to more than 60,000 people fleeing political and ethnic conflict in Burundi. While the camp has two health centers, complicated cases are referred to KDH. Because of the camp and other factors, Kirehe’s population has been booming in recent years—and, correspondingly, so have hospital births.

Hakizimana said the hospital had 3,366 deliveries in 2017. But as of March, they were seeing “around 30 to 40 a day.” If that trend continues, it would translate to about 13,000 babies a year—a fourfold increase from just two years ago. 

Nirere and Uwitonze hope more Expert Moms like themselves will receive training and join the team at KDH. The two women work every weekday and rotate weekend shifts, but that is not enough for the need. 

“There are so many mothers,” Nirere said.

As if on cue, Dr. Mylene Irakoze walked out of the neonatology ward, greeted the two Expert Moms, and stated their value frankly:  “We need them every day.”


Fri, 03 May 2019 10:48:56 -0400
PIH Leader Urges Global Support, Financing for Universal Health Care at UN Following an all-day hearing on universal health coverage at the United Nations, Dr. Joia Mukherjee, chief medical officer for Partners In Health, earned hearty applause from fellow attendees following her impromptu call for wealthy nations to pay their fair share in supporting the right to health for all.

Mukherjee was among 600 representatives of health organizations and civil society from around the world who gathered at UN headquarters in New York City on Monday to urge that the global universal health coverage, or UHC, movement adopt six “key asks,” including international political support, regulation and legislation, partnership with nongovernmental organizations, and financial backing, among others. Their requests were meant to inform the political declaration that will guide the UN’s High Level Meeting on UHC in September.

Mukherjee’s rallying cry about global financial support for UHC was welcomed by the majority of those in attendance. 

“We must stand in clear opposition to the commercialization of care promoted by those who see UHC primarily about financial protection or insurance,” she said. “Study after study has shown that any fees or copayments increase inequity.”

Global action and financial support are imperative, Mukherjee added, given the long history of extraction of natural and human resources from countries in the Global South, following “the legacy of the dehumanizing history of colonization and imperialism.

“If we are to learn from the tragic mistakes of the past, we must clearly outline the collective global responsibility for protecting, respecting and fulfilling the human right to health,” she said. “This includes committing global resources to close the gap between what countries can mobilize domestically and what is truly required for high-quality health care for all in low- and middle-income countries.”

For Mukherjee’s full UN statement, listen below:


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Wed, 01 May 2019 16:40:23 -0400
UGHE Student Studies Soil-Related Disease Afflicting Farmers Home to five of the eight volcanoes in the Virunga Mountains, the northern Rwanda district of Musanze hosts thousands of tourists each year. Musanze's location in the foothills of Volcanoes National Park is generating booms in business, tourism, and agriculture, but the rich, fertile land is also the source of one of the region’s neglected tropical diseases: podoconiosis.

Like many neglected tropical diseases (NTDs), podoconiosis is a disease of scarcity and often affects the most remote and poor communities. It’s characterized by severe swelling of the feet and legs and is caused by long-term, barefoot exposure to volcanic soils rich in silicamaking Musanze’s geography highly conducive to the endemic disease.

Individuals with podoconiosis may suffer such extreme swelling that their feet and legs become disfigured. The disease, which is not widely understood, is often stigmatizing for those who develop it.

Four million people across 32 countries, mostly in tropical climates, are believed to have podoconiosis. In Rwanda alone, it is believed to affect about 69 of every 100,000 people. Until recently, though, the prevalence of the diseaseand how to diagnose and treat ithad been relatively undocumented.

This pervasive gap in knowledge and reliable information galvanized Dr. Ursin Bayisenge, a student in the University of Global Health Equity’s (UGHE) Master of Science in Global Health Delivery program, to learn more. UGHE is an initiative of Partners In Health and located in Butaro, just 27 miles east of Musanze.

“I hadn’t heard of the term ‘podoconiosis’ until I started working at RBC,” said Bayisenge, who also is an NTD researcher at Rwanda Biomedical Centre in the country's capital, Kigali. “One of the first cases I worked on was a country-wide geographical mapping of the disease. This research proved that podoconiosis was prevalent in all 30 districts of Rwanda, but few people knew about it.

“I was shocked that so many people could be impacted,” he continued, “and yet clinicians and health professionals don’t understand it.” 

Podoconiosis, a form of elephantiasis, is a chronic condition that often leaves people unable to walk. It's most prominent among Musanze’s subsistence farmers and others with routine exposure to soil. Prevention of podoconiosis includes protective footwear, but most subsistence families can’t afford to buy shoes. Informed medical professionals can diagnose podoconiosis without a test, and while no official treatment exists, symptoms can be alleviated through ointments, bandages, proper hygiene, and appropriate footwear. However, a lack of information about the disease—for medical professionals as well as patients—prevents proper diagnosis and access to care and treatment.

For Bayisenge, the decision to further investigate podoconiosis for his master’s capstone project at UGHE was easy. But he knew that a comprehensive assessment and subsequent intervention for podoconiosis control would require a different approach.

Each year, 12.6 million deaths worldwide are attributed to unhealthy environments, including soil. As part of a “systems” orientation to health, UGHE’s curriculum includes an approach known as One Health, which examines the complex links among humans, animals, and the environment. One Health brings a holistic approach to addressing the burden of disease, by broadening the perspective of specialists.

Applying this approach and building on the information collected through the RBC, Bayisenge used his practicum project to design and implement a knowledge, attitude, and practices—or KAP—survey on podoconiosis in Musanze, one of the Rwandan districts where the disease is most prominent. While clinicians play an important role in diagnosis, he knew that to better assess the community’s knowledge of the disease, his sample population would also have to include community health workers and environmentalists.

“Rwanda has a large workforce of community health workers who provide care and treatment at a patient’s house and have personal connections with remote community members,” explained Bayisenge. “Additionally, subsistence farmers frequently interact with the agriculture industry.

“Assessing both of these group’s KAP around podoconiosis is crucial to developing interventions that control the disease,” he added. “If well trained, community health workers and environmentalists could complement medical care by respectively managing and participating in prevention efforts of podoconiosis at the community level.”

UGHE students discuss challenges to global health
Left to right, UGHE graduate students Arlene Nishimwe, Egide Abahuje, Ursin Bayisenge, and Theodomir Sebazungu discuss coursework at the university in January 2018. Photo courtesy of Danny Kamanzi

Bayisenge’s research yielded expected responses. Of those who participated, very few people had heard of podoconiosis. Many, however, recognized the disease after being shown an image of its characteristics. Those who indicated meeting or treating an individual with podoconiosis acknowledged the patient’s intense isolation.

What Bayisenge hadn’t anticipated was respondents’ enthusiasm to be part of a solution. Respondents were eager to help support future prevention and management interventions.

By creating a baseline for understanding local knowledge about podoconiosis and attitudes toward people affected, Bayisenge hopes his study will raise awareness of the disease in Rwanda, thereby decreasing stigmatization and removing barriers to care.

“If people understand podoconiosis, they will not only give more support to those affected, but will help prevent it in those who are not yet affected.”

Tue, 23 Apr 2019 14:33:33 -0400
Major Milestones in PIH History .tlMenuItemEdit{ display:none !important; } .tlFourDotsButton{ display:none; } .inlineImgL{ float:left; width:45%; margin:0 27px 7px 0; } .inlineImgR{ float:right; width:45%; margin:0 0 7px 27px; } .stt{ /* clear:both;*/ display:inline; margin-bottom:5px; } #tl{ display:block; } .mobile-only{ display:none; } .clear{ clear:both; } /* Mobile */ @media screen and (max-width:768px){ .mobile-only{ display:block; } .inlineImgL{ float:none; width:100%; margin:5px 0; } .inlineImgR{ float:none; width:100%; margin:5px 0; } #tl{ display:none !important; } .stt{ display:none; } }

Three decades ago, Partners In Health was formed to support the work begun in a small, rural community called Cange in Haiti’s Central Plateau. From there, it expanded across the country, then on to Peru and Russia, across Africa, and on to Mexico and the Navajo Nation.

Through it all, PIH has kept patient care at the center of its work and fought for health care as a human right—both within individual countries and the halls where global health policy is created.

In the timeline below, read how PIH has grown, innovated, and pushed the boundaries of global health to ensure that every single person has access to high-quality care.


Paul Farmer and Ophelia Dahl begin operating a community clinic to provide free health care to the people of Cange, a small, rural village in Haiti.

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Dr. Paul Farmer, Ophelia Dahl, Dr. Jim Kim, Todd McCormack, and Thomas J. White found Partners In Health to support work providing health care to poor patients in Haiti.

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PIH launches the HIV Equity Initiative, which provides antiretroviral therapy to HIV-positive patients in Haiti. Our example helps later inspire major organizations like the Global Fund, PEPFAR, and the World Health Organization to fund the fight against HIV in rich and poor countries alike.

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PIH expands to Peru and begins supporting the government in battling an unchecked epidemic of multidrug-resistant tuberculosis. Our community-based MDR-TB treatment program sees an 80 percent cure rate, inspiring the World Health Organization to revise its treatment recommendations.

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PIH expands to Russia and begins supporting the government in fighting tuberculosis and multidrug-resistant tuberculosis epidemics, first in prisons and then throughout the community of Tomsk.

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Tracy Kidder publishes Mountains Beyond Mountains, a book tracing the lives of PIH founders and our work in Haiti, Peru, and Russia.

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PIH co-founds OpenMRS, an open source electronic medical records software tailored for use in developing countries. Today, organizations and governments in 64 countries use OpenMRS.

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PIH expands to Rwanda and partners with the government to bring high-quality health care to three of the country’s poorest regions. This includes oncology care at the Butaro Cancer Center of Excellence, which we open in 2012 to provide accessible, lifesaving cancer treatment to patients from Rwanda and east Africa.

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PIH expands to Lesotho and begins supporting the government’s response to the HIV epidemic. We soon broaden our scope to treat tuberculosis, improve maternal health care, and, in 2014, become the government’s primary technical advisor on its National Health Reform, which is bringing the country closer to universal health coverage.

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PIH expands to Malawi and begins collaborating with the government to provide comprehensive primary care to the rural poor. We build a brand new community hospital and two health centers that offer same-day consultation and care—including maternal health care and treatment for HIV, hypertension, malnutrition, and mental illness.

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PIH expands to the Navajo Nation and establishes local partnerships to help improve community health and support community health representatives. In 2015, we help launch the Fruits and Vegetables Prescription program, which provides families—most of whom live a three-plus-hour drive away from a grocery store—free access to fresh, local produce.

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PIH expands to Kazakhstan to support the government’s fight against multidrug-resistant tuberculosis.

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When a catastrophic 7.0-magnitude earthquake strikes Haiti, PIH provides lifesaving health care and social support to earthquake survivors.

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Our global mental health care program launches, providing high-quality, culturally sound treatment for common and severe mental illnesses, from depression to schizophrenia.

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PIH expands to Mexico and begins collaborating with the government to help train new doctors, revitalize rural clinics, and maintain a force of community health workers, who specialize in areas like maternal health, depression, and diabetes.

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After cholera is introduced to Haiti following the 2010 earthquake, PIH conducts a cholera vaccination campaign that protects 50,000 people against the deadly disease. The campaign’s success inspires the World Health Organization to establish a global stockpile of oral cholera vaccine.

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PIH opens University Hospital in Mirebalais, Haiti, a 300-bed teaching hospital that provides advanced, high-quality care and offers specialized residency programs to train the next generation of clinicians.

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Responding to history’s largest Ebola outbreak, PIH expands to Sierra Leone and Liberia to help end the epidemic and to support the government in strengthening the countries’ weak health systems.

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PIH begins leading a partnership called endTB, which expands global access to new treatments for multidrug-resistant tuberculosis and conducts clinical trials to find shorter, less toxic, more effective drug regimens across multiple countries.

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The first cohort of PIH global nurse leaders completes our inaugural Nightingale Fellowship, a program designed for nurse leaders to make system-wide impacts to improve patient care.

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In Rwanda, PIH inaugurates the permanent campus of the University of Global Health Equity, which we founded in 2015. The university trains new generations of global health leaders by offering a graduate degree in global health delivery and, beginning this year, dual degrees in medicine and surgery to students from around the world.

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Mon, 22 Apr 2019 16:02:38 -0400
PIH TB Leader Urges Faster Rollout of New Treatments Dr. KJ Seung, who has been fighting tuberculosis with Partners In Health since 2001, urged the World Health Organization and national governments to quickly implement new treatment plans for the deadly infectious disease, in an op-ed published Wednesday in The Lancet Global Health and co-authored by Dr. Cathy Hewison of Médecins Sans Frontières.

“The choice is clear: by choosing to implement the new regimens under operational research conditions, national tuberculosis programs will bring the benefits of scientific advancement to patients who need them and generate important evidence that will benefit other patients worldwide,” Seung and Hewison write.

TB is the world’s deadliest infectious disease, killing an estimated 1.6 million people worldwide per year. The disease’s multidrug-resistant strain, known as MDR-TB, is especially severe, and traditionally has required long, grueling treatment regimens. But recently, studies involving new TB drugs—the first of their kind in more than 40 years—are proving effective. Evidence now suggests that regimens that involve only oral drugs, rather than injections that have led to some of the harshest side effects for patients, are now possible. 

Seung and Hewison write that the WHO’s newly revised guidelines for MDR-TB treatment—supporting shorter regimens with only oral drugs—are a crucial step in the right direction.

“These new recommendations, if implemented, are expected to have a huge impact globally, increasing access of patients with multidrug-resistant tuberculosis to more effective and safer drug regimens that avoid debilitating side effects, such as permanent hearing loss,” the authors write.

They question, though, the WHO’s recommendation that new, shorter regimens only be fully rolled out after clinical trials are concluded—which, in some cases, could mean after 2022. Seung and Hewison urge, instead, that the regimens be used more widely in national treatment programs now.

“We believe that such research should be prospective and longitudinal in nature, supported by external funding, and analyzed with a single set of internationally accepted, systematically applied outcome definitions. Ideally, protocols would be harmonized across sites, allowing for data to be pooled easily,” the authors write.If done this way, and rigorously analyzed, operational research of new shorter regimens in realistic field conditions can complement the trial experience.”

Seung is a co-leader of the endTB project, a consortium that includes PIH, Médecins Sans Frontières and Interactive Research and Development, and is funded by Unitaid. Seung also is an assistant professor at Harvard Medical School and an associate physician at Brigham and Women’s Hospital. Hewison is a TB advisor for Médecins Sans Frontières.

Read their full article here.

Thu, 18 Apr 2019 14:45:17 -0400
Women’s Philanthropy for Women’s Health In early April, Partners In Health hosted two events centered on the role of women in the fight for global health equity. The morning following the inaugural Evening for Equity event, which featured TED-style talks from women leaders across the organization, PIH hosted a panel conversation titled “Women’s Philanthropy for Women’s Health,” during which attendees celebrated women’s increasing involvement in philanthropy and discussed a vision for its impact on women’s health globally.

Dr. Joia Mukherjee, PIH’s chief medical officer, addressed an audience of 50 philanthropists about why and how to support global health equity on behalf of women. Mukherjee described the historical injustices that have led to, for instance, women in Sierra Leone facing a 1 in 17 lifetime risk of dying during pregnancy or childbirth—compared to the 1 in 3,800 lifetime risk of women in the United States. Yet she shared that there are known ways to combat these inequities in women’s health, and just as many ways to support organizations like PIH that are leading this vital work.

Three panelists and a moderator discussed these ways to lend support, highlighting the following themes about philanthropy:

• If you don’t know where to start your philanthropic journey, engage with organizations fighting the injustices you feel most strongly about.

• It is critical to empower nonprofits to listen to the people they seek to serve.

• Philanthropy is an ever-evolving process, but must always remain rooted in education and collaboration.

• Philanthropy doesn’t only entail one-time donations; it also involves long-term partnership, creative and tax-wise giving, and legacy planning.

• One of the most effective gifts to PIH is sharing the work with friends, family, and other networks via email and social media.

Thu, 04 Apr 2019 13:23:02 -0400
PIH Leader Addresses UN on Women, Girls’ Situation in Haiti Loune Viaud, executive director of Zanmi Lasante, as Partners In Health is known in Haiti, urged members of the UN Security Council to support more equitable health care options for women and girls in Haiti, to help end sexual and gender-based violence, and to ensure increased participation of women in the political and public sector.

Viaud addressed the Security Council at the UN headquarters in New York City on Wednesday, April 3. She is the first Haitian woman representing civil society to brief the council and presented alongside Michelle Bachelet, the UN High Commissioner for Human Rights, and Jean-Pierre Lacroix, UN Under-Secretary-General for Peace Operations. Much of the day's discussion revolved around the UN's peacekeeping mission in Haiti and plans to remove troops this October.

Below, read excerpts from Viaud’s speech and watch a video with her full comments.

“Over the last 30 years, Haiti has been through significant challenges, including the devastating 2010 earthquake and cholera outbreak from which we continue to recover. We have also seen a number of positive changes in my country: Roads exist where they never had before, access to health services increased, and we are seeing better partnerships between local organizations and their foreign counterparts on health and education.

Yet, much more remains to be completed. The UN promised to right Haiti’s wrongs in 2014, four years after the cholera outbreak began and we hold you to this promise.” 

On addressing inequality:

“Today, women in Haiti face barriers to achieving basic access to services, education and healthcare. For example, Haiti has one of the highest maternal mortality rates in the world: 359 women die for every 100,000 live births in Haiti. 

Watching a woman die because she reached us too late; seeing families devastated after losing a mother, a wife, or a daughter in childbirth are images one cannot forget. They haunt me, and they should haunt all of us. Childbirth should not be a death sentence in Haiti.  

Cancer is another issue that primarily affects women in Haiti 75 percent of our patients are women. In partnership with the Haitian Ministry of Health, Zanmi Lasante has provided free cancer care to patients across the country for almost 20 years. Today, I am friends with Roselene Jean, our first cancer patient. Without the care we provided, she would no longer be with us. 

Mr. President, members of the Security Council, no woman should die in Haiti because of lack of access to obstetric care or cancer. 

Lack of access to women’s health care poses one of the greatest challenges to development in Haiti. Reinforcing the relationship between sustainable development and peace and security should therefore be central to the way the Council addresses the situation in Haiti and is fundamental to placing my country on the path to peace and stability.” 

On sexual and gender-based violence:

“The difficult work to end sexual- and gender-based violence in Haiti remains a silent fight. It is a topic no one wants to discuss, yet it can change a young woman’s life forever. Over 40 percent of all sexual assault victims in Haiti are under the age of 25, with many that we serve below the age of 15. I speak on behalf of all survivors of sexual and gender-based violence, when I say to you, Impunity for violence against women and girls in Haiti must end.  

We need not only a comprehensive law on gender-based violence, we must also educate Haitians to respect women and girls and shift the harmful social norms that cause the violence in the first place. The Security Council and the United Nations Mission for Justice Support in Haiti should work with the Haitian government to advance the adoption of the draft Penal Code, and ensure the definition of sexual assault under the code is based on consent. This would bring the Penal Code further in line with international legal standards and ensure access to justice for survivors. 

As service providers, we know the critical importance of medical care for survivors; we also know that throughout the country, these services are insufficient. Survivors of gender-based violence need timely and comprehensive care to address the risks of sexually transmitted diseases, including HIV as well as unwanted pregnancies. This means psychosocial support, medical intervention, and fair and safe access to the justice system.”

On women’s political participation:  

“Haiti is a small country full of larger-than-life women. These women have helped their communities and families flourish despite the most dire and tragic of conditions. These communities and families sacrifice everything for their children’s education and survival. Yet, girls have limited role models or advocates in Haiti’s halls of power. For a better future for our mothers, sisters, cousins, and daughters, we must support women’s participation in public and political life at all levels, and advocate for better laws, affordable health care, education, and justice.”

Viaud wrapped up her comments with a series of requests to Security Council members, including in building the capacity of local organizations to ensure high-quality, gender-sensitive services for survivors of sexual- and gender-based violence; funding to address women and girls’ urgent humanitarian needs; creating greater legal protections for women and girls; and ensuring women’s participation in future parliamentary elections.

Watch Viaud’s full speech HERE.

UN Security Council
UN Security Council members gather for a discussion on women and girls' rights in Haiti in anticipation of the withdrawal of peacekeeping troops this October.


Thu, 04 Apr 2019 11:45:33 -0400
Dr. Marta Lado: From Ebola Fighter to PIH-er Dr. Marta Lado is an infectious disease specialist and the chief medical officer of Partners In Health in Sierra Leone. She was among four speakers at PIH's inaugural Evening for Equity on April 2 at the John F. Kennedy Presidential Library and Museum, where she spoke about her experience fighting Ebola in Sierra Leone and how she decided to stay to help build the public health system. Watch a video of her talk HERE.

This story was originally published on October 4, 2018.

Best known among Partners In Health colleagues for her love of exclamation marks and good cheese, Dr. Marta Lado, chief medical officer in Sierra Leone, bursts with energy. The 39-year-old infectious disease specialist from the small town of La Coruna, Spain, completed her medical training in Madrid and then worked in a number of roles across Africa and Asia. Her compassionate spirit led her to Sierra Leone during the height of the Ebola epidemic in 2014, where she helped set up and operate one of the first treatment units in the country. In 2016, at a time when most medical professionals were withdrawing their support, Lado stayed put and soon joined PIH.

Most of Lado’s work now involves collaborating with the Ministry of Health to rebuild and sustain Sierra Leone’s public health system. Still, she can’t quite escape her connection to Ebola. Last month, she published a book, Ebola Virus Disease, that provides an overview on the management of the deadly infectious disease, details historical outbreaks, and shares expertise gained while working in treatment units in Sierra Leone. And this month, she is taking a brief leave to help a World Health Organization team fight the latest outbreak, this time along the border of Uganda and the Democratic Republic of Congo.

We sat down with Lado to discuss what drew her to Sierra Leone in 2014, her experiences working with the Ministry of Health, and patients for whom she wishes she could have done more.

Where did you get your drive to work in countries like Sierra Leone?

My dad comes from a family of farmers who lived in a really poor, rural part of Spain. He was incredibly fortunate when someone offered to pay for his studies, which allowed him to train as a doctor. Because of this, a duty has always been instilled in me to help others if I can. In my view, no one deserves what they’re born with, it should be shared wherever possible.

What’s the best part of your job?

I feel useful. My job makes a difference to others around me, whether that’s through treating someone in the clinic or teaching and mentorship of junior medics.

Of course, I have rollercoaster days with huge ups and downs, but I’ve been here for five years now. What I see is a completely different story to when I arrived. That’s what gets me out of bed in the morning.

An Ebola survivors' tree, adorned with ribbons tied on by survivors as they were discharged from the clinic.
The Ebola survivors' tree in front of the Maforki treatment unit, now weathered and worn, marks the passage of time since the outbreak ended. (Photo by Aubrey Davis / Partners In Health)

You played a prominent role in controlling the spread of Ebola in Sierra Leone. What do you feel you did well at that time?

I stayed. I showed commitment. That has definitely helped show the Ministry of Health that I’m serious about working together now.

On the whole though, I’m not proud of what happened during Ebola. Nobody had the resources to adequately treat anyone, and thousands died needlessly. Often I felt like I was only making a horrific death more dignified.

That’s an incredibly honest answer. Do you feel you could have done anything differently?

For a long time, the international medical community denied it was an alarm situation. Normally it’s possible to contain infectious diseases like Ebola, because they mostly affect villages. This was different, though. Cases reached cities and went out of control. The first patient in Sierra Leone was identified at the end of May 2014. Within six weeks, the disease had spread all over the country.

Sometimes I’ll sit and think about it. Perhaps I should have anticipated its scale of terror sooner and pushed harder for the Ministry’s attention. And internationally too. Everyone just fled. It felt like no one was listening.

What was your day-to-day role during that period?

No one had a clue how Ebola spread or how to properly identify a patient. There were no guidelines whatsoever apart from some developed in 1997, which I followed like my bible. I worked with the Ministry to set up the National Task Force, a group that met weekly to review new Ebola cases and develop guidelines.

Over that period, we collected all sorts of information, like: How should we disinfect patients’ beds? What kind of protective clothing should medical staff wear? How should we dispose of waste? Should we use chlorine, or is soap and water enough? My book expands on this information, highlighting all of the Ebola symptoms and guidelines we identified.

Health workers in protective garments at work in an Ebola Treatment Unit (ETU) during the 2014 crisis.
A view inside the Port Loko Ebola Treatment Unit in November 2014, at the height of the epidemic. (Photo by Jon Lascher / Partners In Health)

Patients must have felt so angry about what was happening to them at that time. 

Sierra Leoneans have an amazing ability to just accept that things are bad for them. They can’t picture what a high standard of care is like, so they never expect it. It’s really heart-breaking.

If a disease like Ebola threatened Sierra Leone again, would we be prepared to combat it?

Yes. Definitely. Our prevention control is better and, most importantly, there has been a shift in mindset among health care workers. Juniors are coming in with a real thirst to make a difference.

But we’re still in trouble. It’s not just about health care; it’s also about society. The basics still need to be addressed: poor hygiene, crowded housing, bad water systems, no gloves in hospitals—the list goes on.  

What do you most cherish and need to do your job well?

Staff. We need more expertise here, especially through local hires. We can’t always fill positions with international placements. We should be working with the Ministry to recruit local clinicians who can support the longevity of health care in Sierra Leone.

Great steps are being made already. Last year, PIH got approval from West African College for the first medical training course here in Sierra Leone. We’ve since been able to establish a teaching suite at Koidu Government Hospital in Kono.

If you could snap your fingers and change one thing about health care in Sierra Leone, what would it be?

Make health care free for everyone. Even if it didn’t work properly at first, or ever, it would change a really damaging mindset that Sierra Leoneans currently have around health care. They’ve had too many disappointing experiences of spending money they don’t have, only to receive terrible medical care. People just don’t think to go to the hospital if they get sick. 

Are there any patients who stick in your memory most?

It’s all the stupid deaths. If we’d had the very basics, that person wouldn’t have died. They’re the ones who stay with me.

What advice would you give to someone starting out in a similar line of work?

Doing this kind of work, in a culture often different to your own, requires maturity, good training, and a willingness to adapt to situations respectfully.

I’ve often found there’s no right or wrong way to do something. There’s just a way, and it’s important to be flexible to that. Making assumptions on things will disengage colleagues and stunt change. I’m learning that every day.

Mon, 01 Apr 2019 22:30:12 -0400
Dr. Michelle Morse: Leading a New Generation of Global Health Clinicians Dr. Michelle Morse is Partners In Health's former deputy chief medical officer and founding co-director of Equal Health. She was among four speakers at PIH's inaugural Evening for Equity on April 2 at the John F. Kennedy Presidential Library and Museum, where she spoke about how history and societal structures influence the provision of health care, and explore the new generation of global health clinicians. Watch a video of her talk HERE.

This story was originally published on January 27, 2014.

Dr. Michelle Morse splits her time seeing patients in Boston and Haiti, working two jobs that each could easily exceed full-time.

But she doesn’t think of herself as remarkable.

Morse, Partners In Health’s deputy medical director for Haiti, believes such global health work should be the norm for American doctors. Like many physicians who commit part of their time to service at PIH, she believes U.S. academic institutions have a responsibility to train health care professionals in poor countries.

“Physicians who choose to work internationally are idolized for their sacrifices and selflessness, but these physicians should not be exalted, nor considered exceptional,” Morse wrote in her application to the global health equity residency at Brigham and Women’s Hospital, a partner of PIH. “International medical work should become the rule.”

Since completing her residency in global health in 2012, Morse has become an attending physician at Brigham and Women’s Hospital, providing hands-on clinical training and mentorship to residents, just as she received from more senior doctors when she was a doctor in training.

In her role with PIH, Morse has helped establish innovative residency programs for young Haitian doctors, in an effort to improve the quality of care in Haiti. When not seeing patients at the Brigham, she’s in Haiti, providing instruction to Haitian residents at University Hospital in Mirebalais, the teaching hospital PIH built in partnership with the Haitian Ministry of Health after the 2010 earthquake.

When PIH co-founder Dr. Paul Farmer began his career in global health at Harvard Medical School and the Brigham, just a handful of his classmates were interested in working internationally. His constant travel between Haiti and Boston earned him the nickname “Paul Foreigner” to his classmates, as Tracy Kidder wrote in Mountains Beyond Mountains.

But today, interest in global medicine is more common, and many medical schools and residency programs offer rotations for students to gain experience seeing patients in poor countries. At Brigham and Women’s Hospital, where Morse works, the global health equity residency prepares young doctors for careers in global health. Still, global health isn’t yet the norm, and what physicians do once they’ve become involved is still a subject of debate, one that Morse hopes to influence.

Confronting an unequal world

Morse is a 32-year-old internist with a warm smile and an easygoing demeanor that wins her trust with patients. She grew up in west Philadelphia, where poverty and violence are epidemic, and saw how social inequalities allowed some people to thrive and caused untimely deaths in others.

“I really felt that it was my responsibility as someone who was educated and had opportunities to make sure that I fought to establish equity instead of inequity,” Morse said.

Her early interest was in domestic health disparities among poor, marginalized people in the United States. In medical school at the University of Pennsylvania, she had her first exposure to global health when she worked in a pediatric clinic in Guatemala. She saw how a lack of public health infrastructure, including access to clean water and sanitation, caused needless diarrheal death in children. She saw simple interventions—such as medications to treat parasites—help young patients.

Morse took a year off from medical school to conduct research on tuberculosis in Botswana. It reaffirmed her interest in global health and showed her that making a difference would require even more of her time and energy.

“I came to understand why weeks or months scattered throughout my career in a non-specific poor country are simply not enough of a commitment,” she said. “I only began to understand Botswana’s specific challenges—and formulate workable interventions—at the end of my year there.”

One day in Botswana she was looking into residency programs that offered global health training and found the global health equity residency at the Brigham.

“I’ll never forget that day,” she said. “I knew I had to do it.”

From world-class to resource-poor

As a global health equity resident with the Brigham in 2009, Morse got to see PIH’s work in Haiti firsthand. She participated in mobile clinics, visited patients in their homes, and saw HIV and tuberculosis patients on rounds at community hospitals.

“I absolutely fell in love with Haiti,” Morse said. “Because I had studied French, I was able to connect with people in a great way.”

The 2010 earthquake destroyed much of Haiti’s already-weak medical infrastructure, including the national medical school and nursing school. It emboldened her commitment to improving Haiti’s health system.

As part of her residency training, Morse worked several months per year in the PIH-supported hospital in Lascahobas, a rural community in the impoverished Central Plateau.

She was surprised to find she had more formal training than all of her Haitian colleagues, both doctors and nurses. In the U.S., a resident is considered a doctor in training, and surrounded by more senior physicians.

The Haitian health care team also worked without diagnostic and treatment equipment considered standard in American hospitals, such as electrocardiogram (EKG) tests to examine a patient’s heart.

Having come from a family of educators—both her mother and grandmother were teachers—Morse began to reflect on the role of education and training in providing quality care. Working with a Haitian colleague, Dr. Pierre Paul, she began to focus on medical education at University Hospital, which was in the final stages of construction.

The hospital promised to deliver the necessary infrastructure—space, electricity, diagnostics, and medical equipment, such as medical gas and operating rooms—for high-quality, complex care. But staffing the facility with trained health professionals would be the next challenge.

In the U.S., teaching hospitals play as important a role as medical schools in educating doctors and nurses to deliver care, ensuring there are enough trained health professionals to meet the needs of the population.

University Hospital was designed to provide similar training, both through continuous educational activities and through new medical residencies, helping to fill a critical gap in trained doctors and nurses. In Haiti, only about half of doctors have any residency training at all. In the U.S., it’s unheard of for a doctor not to have completed a residency.

“You don’t learn how to be a doctor in medical school,” Morse said. “It’s during residency that you dive in and begin to understand what it’s all about.”

Morse and Paul researched residency opportunities for Haitian physicians to determine needs and tapped local and foreign experts to put together curricula. University Hospital’s inaugural residencies would include pediatrics, general surgery, and internal medicine—Morse’s specialty. After a year of planning, the first class of residents began their three to five years of training in fall 2013, and subsequent classes will enroll each year.

After they complete their residency training, Morse hopes some will choose to stay at University Hospital, teaching the next classes of residents, as she has done. Others aspire to bring their advanced training to rural areas of Haiti, where care is out of reach for most people.

Between Boston and Haiti

Today, Morse teaches residents in two disparate places—Haiti and Boston—in facilities that are more similar than you might expect.

One fall day in Boston, she was doing rounds at the Brigham’s Faulkner Hospital, seeing patients with problems that included mental illness and drug dependency. One 92-year-old patient with high blood pressure was feeling better and eager to get home to her yoga and enormous appetite for reading. In Haiti, Morse’s patients are more likely to suffer from heart failure, tuberculosis, and other infectious diseases, and many don’t survive to old age.

At the Brigham, Morse often works up to 70 hours a week. In Haiti, she says, it’s even more. But Morse has found that each position makes her better at the other. And straddling academics and service helps her understand the role of academic institutions like Brigham and Women’s can play in the field of global health.

“I think the two jobs are absolutely synergistic,” Morse said. “I want to help academic institutions understand their responsibility toward the global health community and achieving global health equity.”

From her initial interest in health disparities in her west Philadelphia community, Morse has come to take on disparities globally. And she hasn’t let the problem of whether to work domestically or internationally hamper her commitment to universal access to health care. (Learn more about how to start a career in global health).

“The most important piece is to engage. Whether you do that locally or globally is secondary,” she said.

Mon, 01 Apr 2019 16:57:40 -0400
Dr. Joia Mukherjee: PIH's Global Health Warrior Dr. Joia Mukherjee is chief medical officer of Partners In Health. She was among four speakers at PIH's inaugural Evening for Equity on April 2 at the John F. Kennedy Presidential Library and Museum, where she spoke about her evolution as a doctor working in global health, and how we can work together to achieve universal health coverage. Watch a video of her talk HERE.

This story was originally published on December 8, 2017.

Dr. Joia Mukherjee doesn’t have much free time on her hands. In her words, she has “a day job, a night job, and a weekend job.” So when a representative from Oxford University Press asked if she would write an undergraduate textbook on global health, she inwardly scoffed, then politely declined.

But Mukherjee, Partners In Health’s chief medical officer and associate professor in the Department of Global Health and Social Medicine at Harvard Medical School, understands that “no” is never a final answer. She has heard the word plenty of times as an unabashed rabble-rouser who advocates for—and delivers—quality health care for the poor. So when the Oxford representative stubbornly persisted, she reconsidered.

The result is “An Introduction to Global Health Delivery: Practice, Equity, Human Rights,” a 14-chapter textbook published in November by Oxford University Press. Within 376 pages, Mukherjee outlines the history of the global health movement; talks about the staff, stuff, space, and systems necessary to provide high-quality health care (PIH’s mantra); and emphasizes the role that advocacy plays in building a larger community of globally minded citizens.

Photo by Zack DeClerck / Partners In Health

Mukherjee decided to write the book, she said, because she’s seen too many young people get excited about global health and begin courses on topics such as epidemiology and statistics, but then gradually feel removed from what first attracted them to the field: the idea of making the world more just. She remains convinced of the need to keep students interested and engaged, and wrote her book with that goal firmly in mind.

“We need a much, much bigger army of people raising their voices” about how health is a human right, she said.

Mukherjee, who is also an associate professor in the Division of Global Health Equity at Brigham and Women’s Hospital, sat down recently to talk about her book, the U.S.’s current health care battle, and the first steps toward pursuing a career in global health.

What do you hope this book will clarify for students interested in global health?

My main goal for writing the book is really to have young people understand that implementing global health projects together with people in affected countries is an act of solidarity and social justice. Global health ought to be about the delivery of care, not just prevention of disease. It’s about addressing the entire burden of disease, not just what’s easy or contagious. It really needs to address the social determinants, and understand why they are so unequal. You need a human rights approach, which involves civil society, engagement, and activism, but also involves supporting the public sector, because the guarantor of human rights is the government.

What is the difference between public health and global health?

If you have a vaccination program that has a 90 percent vaccination rate, public health would say, “Great, success!” But what global health ought to do is say, “Wow! Who are those 10 percent of kids who are not vaccinated, and why?” Those are the kids who are heads of households, whose parents have schizophrenia, who are starving. Those are the kids who live too far [from the clinic]. So that last 10 percent, that is the equity mission that ought to be baked into the human rights approach.

When I was a young person and in public health school, it really was about, “How do you get the biggest bang for your buck?” Not, “How do you question the number of bucks that you have?” That’s the difference really. Do you start from accepting $5 per capita? Or do you say, “We need to have people have good health care,” and then fight for the money?

That’s what the AIDS epidemic taught us. The whole time the global AIDS pandemic was just felling people left and right, and the public health community was saying, “prevention.” Meanwhile, we had the drugs for the global pandemic. I want to differentiate ourselves as people who want health equity and health justice, which means delivery of care. It doesn’t mean no prevention; it means prevention, treatment, and care.

Lima Prison
Mukherjee (center left) and Dr. KJ Seung (center back), co-leader of the endTB project, tour a prison in Lima, Peru, where there is a high incidence of multidrug-resistant tuberculosis. (Photo by William Castro Rodríguez / Partners In Health)

What other lessons can we learn from HIV activists in pushing for health care for all?

For me, the biggest lesson was that advocacy works. Then you have to unpack, what is advocacy? From a Partners In Health standpoint, we lead with service. That’s our sweet spot. We can show that it’s possible—whether it’s a cholera vaccine, MDR-TB treatment, hepatitis C treatment, cancer care. We give the movement for the right to health examples of success.

The second part is that the people who ought to lead the charge are local. Haitians teaching Haitians, and Rwandans working on research. Building capacity means building true intellectual capacity.

How has people’s view of universal health care changed here in the United States in recent years?

I gave a talk in 2014 on Boston Common about health care as a human right. There were 30 people there. It was tragic to me then that, in the richest country in the world, people don’t even think of health as a human right. Well, I’ll tell you, that has changed. This is when we have to realize we’re winning. If you have a rally for health as a human right, now, you can get 100 people, 200 people, 1,000 people, 4,000 people. Now, everyone is saying health is a human right. Even politicians are saying health is a human right—and not just U.S. Senator Bernie Sanders. We have actually captured some momentum here, despite the challenges that lie ahead.

Some people in the United States criticize PIH’s mission and ask why we advocate for quality health care abroad, when people are suffering here. How do you respond?

Human beings to me are not more or less human depending on the nation state in which they were born. I want everyone to have access to health care. I know this from my own experience as a mother—what the difference was for my son, versus the son of a poor mother who was cleaning the basement at the Brigham and Women’s Hospital. She worried she would lose her job, that she didn’t have enough time off. Social forces, the conditions of our birth, should not be a life-and-death dilemma for anyone, anywhere.

There’s another important thing we can learn from the AIDS activist movement: The people who fought for accelerated scientific trials for AIDS and treatment access in the United States, they didn’t stop fighting. They didn’t say, “We have AIDS. Now we have treatment, so we can relax.” They kept fighting and said, “This is a human right; this is about all humanity.” Americans and Europeans fought in solidarity with their brothers and sisters from Africa, Asia, and Latin America. Their voices were better and louder together.

Mukherjee speaks in February outside the Massachusetts State House in Boston at a rally supporting access to health care for all in the United States. (Photo by Jon Lascher / Partners In Health)   

We often talk about the social determinants of health—the social, economic, and political context of each patient. Why is that link important to understand?

In medical school, I was taught about any variety of genetic mutations that cause disease. We were taught about different behaviors, like smoking, as the cause of disease. But the thing that actually determines whether you live or die in the United States, the one factor that’s most important, is zip code. How is it that we teach about health care and don’t address the elephant in the room, which is zip code?

It’s at our own peril that we look only at the biomedical model of illness, and not at what we call the biosocial model—meaning political, economic, and historic linkages with health. You can’t look at malnutrition in Haiti and not understand land tenure. Most poor Haitians do not own land; they’re sharecroppers. How can you understand the AIDS epidemic in South Africa if you don’t understand apartheid and how it tore families apart? I say in the book that you have to really walk with people, have a deep understanding, and read broadly to really get what’s going on.

Could you share some lessons learned from patients over the years?

I dedicate the book to a couple of patients whose lives were lost in the nihilistic public health paradigm I was taught as a student. One was a little girl who was starving and sick. I weighed her when I was a medical student, gave her mother education about the food groups, and sent her home. She died. I’m quite sure that her mother knew exactly what to feed her. She didn’t have food.

Similarly, I took care of AIDS patients before there was antiretroviral treatment in Peru—patients who, in the era of treatment in a second-world country, died for lack of medicines. I treated them for resistant TB without antiretroviral therapy, and they died.

I think about those patients for whom the conventional wisdom was modern medical care is just too expensive, and I always contrast that with my own experience with my son. He had cancer and very extensive surgery. It was extremely expensive, and he’s a very healthy 11-year-old boy now. And I think, if he has that access, why is it that I couldn’t give food to that little girl? What is wrong with the world? That is what I think about a lot. And that’s why I ended up finally agreeing to write this book. Because I thought, “We need more people to care. We need more people to make these problems their own problems.”

What advice would you provide students interested in pursuing global health?

Get close to poor people in your own country. Much of my earliest work was being a Big Sister, working in a shelter for victims of domestic violence, working in a soup kitchen—and talking to people. Learning to listen and to learn from the experiences and lives of poor people. That is the most important thing, because that proximity to suffering allows you, even as a person with privilege, to develop humility and deeper engagement with the problems.

That’s step one. Step two is trying to inform yourself about the causes. Be inquisitive about the why, the history.

Any experience you can have abroad that you can be of service to people is going to be important, even if it is extremely basic. You don’t have to go as an expert. I’m not a religious person, but I liken it to washing the feet of the poor. Just be present. Listen. Be humble. That way you see if you like this work. Is it for you? Is this what you want to be, you want to do?

Take risks early. It’s easy to get all wrapped up into how much money you owe. But you’re still from a rich country. You will pay back your debt eventually. Take volunteer jobs, and before you have a family. Those are the things that really transform who you are and will open the door for other opportunities.

If I have a job open on my clinical team somewhere in the world, I’m much more likely to take somebody who’s worked abroad than somebody who has 15 degrees. Don’t keep adding degrees because you don’t know what you want to do. Get out there and do it. And if your parents question it, they can talk to me.

Mon, 01 Apr 2019 15:27:20 -0400
Graciela Cadet: Inspiring Nurse Leader in Haiti Graciela Cadet is the deputy chief nursing officer and nurse manager of the ICU at University Hospital in Mirebalais, Haiti. She was among four speakers at PIH's inaugural Evening for Equity on April 2 at the John F. Kennedy Presidential Library and Museum, where she spoke about why she decided to become a nurse in Haiti, and how she uses her role to inspire and mentor fellow clinicians. Watch a video of her talk HERE.

This story about the Nightingale Fellows, which include Cadet, was originally published on June 20, 2018.

Emmanuel Dushimimana said doctors and staff in northern Rwanda were finding it so difficult to keep children with cancer in follow-up care, and to maintain vital connections, that he knew a solution had to be found. 

“We sat down and said, ‘What can we do? How can we educate caregivers?’” recalled Dushimimana, director of nursing and midwifery at Butaro District Hospital.

His answer was a training program that began in September 2017, teaching nine nurses new and better ways to inform children and their families about the effects of chemotherapy, long-term care, and more. With new informational booklets that provided resources and emphasized the importance of maintaining follow-up treatment, Dushimimana said, he began to see more children staying involved with long-term care through the Butaro Cancer Center of Excellence, part of the Partners In Health-supported medical campus in the rural, hilly region near the country's northern border with Uganda. 

“We have seen that the program is very successful,” Dushimimana said.

His was one of four presentations displayed June 14 at the PIH office in Boston, as part of a graduation ceremony for the first PIH Nightingale Fellows. The yearlong fellowship program began in May 2017 and included online instruction and webinars, monthly conference calls, mentorship from veteran nursing leaders, and individual leadership projects, such as Dushimimana’s training and outreach program.

The PIH Nightingale Fellowship was designed to provide support and training for nurses in senior or executive leadership positions, and ultimately to improve patient care. The program focuses on areas including health information systems, evaluation and supervision, quality assurance, resource management, and more.

Graduating alongside Dushimimana were fellows Angeline Charles, operating room nurse manager at University Hospital in Mirebalais, Haïti; Viola Karanja, director of nursing for PIH in Liberia; and Graciela Cadet, nurse manager in University Hospital’s intensive care unit.

The graduation drew a crowd of colleagues, friends, and supporters. Cory McMahon, PIH director of nursing, began the ceremony by pointing out that the fellows completed the program on top of their full-time jobs providing care in challenging circumstances.

“These fellows here are really paving the way for global nursing leadership,” McMahon said, before addressing the graduates directly. “Every day I’m inspired by each and every one of you.”

One of the fellows completed the program while also adding to her family. Cadet gave birth to her daughter, Meghan, in November—meaning she joined many Nightingale meetings via Skype or phone. Cadet, who also is a flight nurse on the Haiti Air Ambulance team, focused her leadership project on standardizing “code carts”—the rolling, multi-drawered containers of medical supplies and information—used in the ICU at University Hospital.

Cadet said improving code carts proved so beneficial, often in unexpected ways, that her team plans to replicate the model elsewhere in the hospital.

Charles Poster
Angeline Charles talks about her leadership project with Major Gifts Coordinator Ancito Etienne and other colleagues at PIH's Boston office in June.
Emmanuel Dushimimana
Emmanuel Dushimimana explains his leadership project to Supply Chain Analyst Ritza Cornet, while Dr. Anatole Manzi, director of clinical practice and quality improvement, looks on.
Viola Karanja presents her poster
Viola Karanja talks about her leadership project, before the graduation ceremony for the first group of PIH Nightingale Fellows. 
Graciela Cadet presents her poster
Graciela Cadet drew an attentive crowd of colleagues while presenting her leadership project.

Charles’ project had a similar goal of improving efficiencies at University Hospital—specifically, in her case, with the operating room.

“When the operating room was opened, there was no schedule in place,” Charles said.

That meant the operating room could get started late, which left patients unsure when their procedure would occur and be left waiting, in a facility that sees 16-20 operations a day. The facility also was seeing an unacceptably high number of cancellations—a number that now is dropping significantly, thanks to Charles’ scheduling project.

“The fellowship has helped me learn how to make new changes that improve our systems,” Charles said.

Karanja focused her project on empowering and expanding roles for nurse supervisors at PIH sites in Liberia. The need was so great, she said, that one of the biggest lessons was to scale back the project and break it up into phases.

“I think we got too excited—we did a lot of things at the same time,” she said. “This project will continue—it’s not going to end.”

Karanja said one of the most beneficial things about her project was seeing her team take proactive roles in improving nursing systems at the PIH-supported J.J. Dossen Hospital in Liberia.

“Everybody had buy-in,” she said. 

Dr. Paul Farmer, PIH co-founder and chief strategist, said all four graduates were leaders before they began the fellowship. He praised their ability, and the ability of nurses everywhere, to help whoever walks through their doors, to listen, and to ensure that everyone has a voice in the provision of medical care. 

“I just want to applaud you for being willing to use that voice for others. Particularly patients who are facing disease and poverty. Injury and poverty. War and poverty,” Farmer said. “I’m always going to be in your fan club.”

That fan club was strongly represented at the graduation, which included a video montage of fellows’ colleagues and family members, congratulating them on the achievement. A surprise appearance in the video by Dushimimana’s two sons—Nshuti, 5, and Munezero, 3—made him tear up with happiness.   

Dr. Sheila Davis, PIH chief of clinical operations and chief nursing officer, said the fellowship provided a way to illuminate and enhance the invaluable leadership of PIH’s nurses.

“We couldn’t have chosen a better group to be our inaugural leaders,” Davis said. “The future is so bright for all of us because of you and your commitment.”

Paul, Cory, Sheila, Marc
From left to right: Dr. Paul Farmer, PIH co-founder and chief strategist; Cory McMahon, PIH director of nursing; Dr. Sheila Davis, PIH chief of clinical operations and chief nursing officer; and Marc Julmisse, PIH deputy chief nursing officer and chief nursing officer at University Hospital in Mirebalais, Haïti, enjoy videos of the fellows’ colleagues and family members congratulating them on their graduation.


Mon, 01 Apr 2019 14:29:16 -0400
Working in Global Health: Karim Llaro on 20 Years as a TB Nurse in Peru Karim Llaro is a nurse who has worked with Socios En Salud, as Partners In Health is known in Peru, for more than 20 years. She began in the late 1990s as a field nurse, administering tuberculosis treatments to patients in their homes. She then became the TB program coordinator for northern Lima, the capital of Peru, before transitioning two years later to TB program coordinator for central Lima. Since 2008, she has been the TB program coordinator for Global Fund-supported work. Below, she reflects on how she came to work with Socios En Salud, and what she’s learned over two decades of providing care to some of Peru’s most vulnerable TB patients.

I finished my nursing degree in early 1997. Then I began my internship, which helped me decide if I would like to work in clinics and hospitals or within the community. Meanwhile, a colleague told me that there was a job posting looking for people to make home visits to patients living with drug-resistant tuberculosis around Carabayllo District. It was an excellent opportunity, was close to my home, and I felt I would be able to learn a lot.

When I began at Socios En Salud, I wasn’t afraid of getting sick because I knew the risks involved with working with TB patients; however, my older daughter just had turned one, and my family was very afraid of that possibility. Even so, I kept going because I had fallen in love with the work.

My work at Socios En Salud included visiting patients, bringing them medicine, tending to the harmful side effects that the drugs could bring, filling out reports for doctors, and—above all else—accompanying patients along the difficult journey they had to travel.

Every day was a challenge. Our objective was to not allow a single patient to die of TB. For that to happen, there had to be not only a nurse, but also a psychologist and social worker. The patients’ problems were not just clinical, but also emotional and, especially, financial. However, just my presence was enough for them to feel calmer and have more hope.

Many times, I was the shield against the patient’s family members, who didn’t understand that the patient was going through difficult times and secondary effects from the medications they took daily, such as drowsiness, fatigue, lack of sexual appetite, and hallucinations. There were very talkative and thankful patients, as well as reserved and quiet ones; however, I could tell that they each waited for me each day with anticipation and happiness.

Some patients used to call me a guardian angel, because I had more faith than they did that they would find a cure. The majority of patients lived in remote and dangerous slums. Yet, when I finished giving them their medication, they would accompany me to the door and warn their neighbors that they better not do anything to me, because I was their angel.

There was not a single day that was the same. At Socios En Salud, every day was different despite the fact that we knew what was awaiting us. This was a very enriching experience for me. I learned to value life and that every person deserves high-quality, comprehensive care.



Fri, 22 Mar 2019 18:18:13 -0400
Farewell to the Grave: Bobby’s Battle with Multidrug-Resistant TB In January 2018, Bobby Togar arrived at Liberia’s national tuberculosis annex in the capital of Monrovia for the second time in his life. The 42-year-old thought he was going there to die. He couldn’t eat, and could barely draw the breath to talk. With a body mass index of 10—half what it should be, his legs appeared as thin and spindly as knitting needles. As he was carried into the ward, his family went home to build his coffin. 

“Bobby was just skin and bone,” said Dr. Daniel Duré, Partners In Health’s TB clinical mentor at the time. “When I saw him, I thought of the skeletons we used to study bones in medical school. It was like having a living skeleton in front of me.” He had treated many hundreds of TB patients in resource-limited settings, but Togar was among the sickest he’d ever seen. 

The team at the TB annex—made up of Ministry of Health physician assistants and nurses, with support from PIH—was distraught. Togar had been discharged from the TB annex three years earlier, having been admitted for TB following repeated misdiagnoses: everything from typhoid, to “African sun,” to witchcraft. He had since returned home to Rivercess County in eastern Liberia, but a common cocktail of factors had conspired to prevent him returning to the capital for his medication refills. Among them were stigma—pervasive in Liberia, given the widespread lack of access to information about TB—and distance. Rivercess is a four-hour drive from the capital, along rough, easily waterlogged roads that can be unaffordable to travel for those relying on public transportation.

And so Togar had stayed in Rivercess, where he worked as an English literature teacher at an elementary school, doggedly pushing through his pain to inspire his students. He worked until he could barely breathe, unaware that TB was tightening its grasp on his lungs. When he arrived back at the annex, they were severely damaged, with TB’s telltale white lesions throughout both, like heavy clouds eclipsing the sun.

Dr. Maxo Luma, director of the TB program for PIH in Liberia, alongside the Ministry of Health, swiftly arranged a Gene Xpert test, a molecular diagnostic tool that detects the DNA in TB bacteria. The Haitian infectious disease practitioner, who arrived in Liberia in 2015, used the tool to arrive at Togar’s new diagnosis: multidrug-resistant tuberculosis, or MDR-TB, an especially hard-to-treat variant that kills about 230,000 people globally each year, according to the World Health Organization. 

Liberia is among the top 30 countries with the highest total number of TB cases, and the top 10 for its TB incidence rate of new yearly cases, at around 300 people living with the disease per 100,000, reports the WHO. Because of pervasive health inequalities and lack of access to care, the country is particularly prone to MDR-TB cases, especially in the wake of the Ebola outbreak of 2014, which further fractured the already weak health system. In the close-knit communities where many Liberians live, airborne infectious diseases like TB spread rapidly. Duré said he treated one patient whose home was a bathroom that she shared with nine other people.

When PIH began partnering with Liberia’s Ministry of Health in 2015 to roll out a comprehensive TB program, the cure rate for the deadly disease was 28 percent. Clinical staff are now working to reverse that, deploying resources and training to help TB patients buck the trend and complete their treatment regimens. It is challenging work for all involved. Patients grapple with debilitating stigma and grueling side effects that include hearing loss and depression. Meanwhile, clinicians are hampered by the lack of supplies and medicines, as well as funding to provide universal health coverage and treatment country-wide. Considering these constraints, they have only reached about 50 percent of known MDR-TB cases in Liberia.

PIH has seen success, though, in its partnership with the Ministry of Health to transform the TB annex, with its once-leaky roof, into a freshly painted, dignified space of care and support. It’s a place where psychosocial officers see patients regularly, where PIH staff frequently go above and beyond the call of duty by finding adolescent mentors for teenage patients, or tracking down extra food for those in need. After all, “medicine is not only about treating patients, it’s about treating humans,” said Duré.

Togar began a 20-month treatment regimen, beginning with a painful eight months of daily injections. Because his BMI was so low, clinicians were careful to find the right dose to maximize his chances of survival, and so the early phase of his treatment lasted longer than expected. 

According to Duré, despite the myriad clinical challenges and lack of resources, the biggest hurdle to Togar’s success was something fundamentally human.  “Bobby didn’t believe he could survive. He said to me, ‘Doc, why are you doing all this for me when you know I will die?’” The doctor looked him in the eye and told him the truth. “I said, ‘I am not God, but from my knowledge, this is not your time and you will survive.’”

How did he know? Years earlier, in Haiti’s Central Plateau, Duré had treated a patient with an even more advanced case of MDR-TB than Togar. And that patient had survived. The doctor remembered his approach back then, and prescribed similar supportive care for Togar. First on his list was something simple but, at the time, unimaginable: a walk outside. 

“Let’s go outside to see the sun,” Duré suggested. Togar looked at him, incredulous. “He couldn’t walk, so I told him to put my hand on his shoulder.” At first that, too, seemed absurd. “He was afraid to do that because he felt he was cursed, and he wasn’t used to interacting with doctors in that way,” he recalled. “So I took his hand and placed it on my shoulder and I said, ‘I’m a human just like you.’” 

That day they walked just two steps together, but they might as well have scaled a mountain. Togar’s outlook transformed. As he started to believe in the possibility of survival, his natural charisma returned. He began to charm the nurses, making seemingly extravagant requests for food that he still wasn’t physically able to eat: fufu, a Liberian cassava paste, and delicious, hard-to-make soups.

The nurses were doubtful of Togar’s survival, but Duré remained confident. Togar had turned an emotional corner. “Patient care is a two-way collaborative process,” he said. “Every TB patient requires a different recipe, and I could only help Bobby when he could tell me how to help him.” 

As Togar regained his weight and spirit, his natural leadership skills began to shine through. In the run-up to his first TB diagnosis, he had been poised to become the superintendent of Rivercess County—an eminent appointment that was derailed by his illness. But as his health improved, he was elected by other patients to another important position: chairman of the MDR-TB ward, or chief motivator. “Bobby told everyone, ‘If I can make it, all of you can make it. It’s not magic, it’s because I took my treatment,’” said Luma, calling him “a born leader.” 

Togar didn’t only motivate his fellow patients. The physician assistants and nurses who ran the TB annex before PIH arrived have also learned from him. “Before we came, they didn’t have any true mentors, so any time they saw patients as sick as Bobby, they would lose hope,” said Duré. “From him they have learned never to give up.” 

In July 2018, six months after one of the most deadly bacteria on earth brought Togar to his knees, he was standing tall again. PIH and Ministry of Health staff were by his side, cheering him on, when he walked out of the TB annex, a place he thought he would leave in a coffin. As he has successfully completed the intensive phase of his treatment, he now comes regularly for follow-up visits and close monitoring with the overall TB team. Togar continues to serve as chairman and counselor of the MDR-TB ward, plumbing the depths of his story to serve others. “If Bobby tells them the treatment works, they believe him,” said Luma. “He’s a superstar.” 

That’s true in more ways than one. During the Liberian civil war, Togar had become adept at tailoring while living as a refugee in neighboring Cote d’Ivoire. With widespread recognition as a talented designer, he has now opened a boutique in Monrovia. There he makes beautiful clothes and purses in Liberia’s traditional lappa cloth—vibrant patterns, yellow stripes, and, in one of his most popular designs, an inky blue sky decorated with golden rising suns.

Although Togar is on the mend, he has had trouble remaining financially stable throughout his illness. And so, PIH continues to accompany him on his journey in a different way. This week, he received the gift of an industrial fabric printer that can create more than 800 lappa designs. On World TB Day, Togar plans to bring some of them to the TB annex, where he’ll take to the mic, using his talent and his breath—something he believed he had lost—to inspire other patients with an excerpt from his book-in-progress: Farewell to the Grave

The staff at the annex are proud. “When he told me the title, I had to hide my face because I thought I was going to cry,” said Duré. “It’s so powerful.”

Bobby's tailor shop
Togar stitches together fabric for a dress inside his tailor shop during a visit with Dr. Maxo Luma (standing in doorway). 


Fri, 22 Mar 2019 11:58:54 -0400
“Out of Breath” Provides Inside Look of North Korea’s Battle Against TB Dr. KJ Seung has been fighting tuberculosis with Partners In Health since 2001 and is a co-leader of the Expand New Drugs for TB partnership, known as “endTB.” Seung is also an assistant professor at Harvard Medical School and an associate physician at Brigham and Women’s Hospital. He has been visiting North Korea since 2009 with the Eugene Bell Foundation to deliver lifesaving treatment and fight the country's devastating epidemic of multidrug-resistant TB, or MDR-TB, a severe strain of the world’s deadliest infectious disease.  

Seung prominently appears in the 2018 documentary "Out of Breath," which chronicles the foundation’s efforts to treat MDR-TB in North Korea. BBC World News will air the documentary four times on the weekend coinciding with World TB Day, which falls on March 24. "Out of Breath" can also be viewed on Amazon Prime and You Tube

Below, Seung discusses the film, how it intersects with endTB, and what he hopes viewers will learn about the global fight against TB.

How was this documentary created? 

"Out of Breath" is a documentary film about the work of the Eugene Bell Foundation, an NGO that has been working on MDR-TB in North Korea for several years now. The director, Hein Seok, accompanied the foundation on four separate visits into North Korea over two years. It's very uncommon to have footage like this from inside of North Korea. There are some amazing interviews with patients and North Korean doctors. In my opinion, there is nothing comparable in film, TV, or print media.  

Have you visited North Korea since "Out of Breath" was filmed? What’s the latest update on the country's MDR-TB epidemic?  

The film was shot several years ago, so there have been some new developments since then. We've been working really hard to introduce drugs like bedaquiline and delamanid, the first new TB drugs developed in over 40 years. North Korea is 1 of the 17 countries in endTB, which also includes Médecins Sans Frontières and Interactive Research and Development. These drugs are quite expensive, but with support from Unitaid, we have been able to treat some of the most complicated and highly resistant MDR-TB patients in North Korea. The drugs seem to be quite effective, so I'm hoping this will eventually improve cure rates for all MDR-TB patients that we treat. While the film doesn't show these newer activities, it still accurately depicts the environment and work that the Eugene Bell Foundation is doing in North Korea. The patients are horribly sick, and the conditions are very difficult.  

North Korea has been in the media spotlight lately, as President Donald J. Trump recently met with North Korean leader Kim Jong Un to discuss denuclearization, sanctions, and other topics. Does that media attention affect efforts to deliver health care, such as desperately needed MDR-TB treatment? Is the media overlooking critical issues facing North Korea and its people? 

I think one of the things that people will realize when they watch this film is that North Koreans are not robots like they are normally portrayed on TV or in print. Yes, there is a crazy amount of media focus on North Korea nowadays, but you can learn much more about the country by watching "Out of Breath." Global health is always going to be intertwined with politics, no matter what country you are working in, but one of the main reasons why PIH and the Eugene Bell Foundation have been successful in North Korea is that we find a way to treat the patients, despite the politics. In the end, the patient comes first. That approach works in North Korea, just like it works in other PIH countries.  

As the global health community recognizes World TB Day on March 24, what issues surrounding the disease and its treatment are most on your mind? 

One of the things that I think that "Out of Breath" does extremely well is depict the impact that TB has on patients and their families. It’s really hard for people living in the United States or Europe, where TB has become just another curable infectious disease, to understand how frightening TB is to people living in low-resource countries. This is a disease that ravages whole families, slowly and painfully. The North Korean scenes in "Out of Breath" are hard to believe for most people, but PIH-ers who work with TB patients in other countries will find them very familiar. So I hope that is one thing people will learn from this documentary: We still have a long way to go to end TB.  

Out of Breath

Thu, 21 Mar 2019 13:55:07 -0400
Innovation: Contraception Program Empowers Women in Haiti More training for nurses and greater access to family planning services has resulted in significantly more new mothers leaving a Haiti hospital with long-term contraception, a fact that could lead to safer pregnancies and fewer maternal deaths.

A recent Partners In Health study found that over just three months at the PIH-supported University Hospital at Mirebalais, in Haiti’s Central Plateau, increasing contraceptive education for nurses and providing new mothers with more family planning access and options led to “a great improvement in the percentage of women who had delivered in the maternity ward accepting a long-acting contraception method,” such as the Jadelle implant, which can be left in  a patient’s upper arm for five years.

The rate of women discharged from the hospital with long-acting contraception has risen from 5 percent to 20 percent as a result, according to the study, published in December by The British Medical Journal.

That’s good news in Haiti--especially on the Central Plateau, where the fertility rate is nearly five children per mother. Previous studies have shown that the more pregnancies a woman has, the greater her risk for complication or death, especially in countries with limited resources. 

Across Haiti, about 360 mothers die out of every 100,000 live births, a high maternal mortality rate compared to 14 deaths per 100,000 in the United States, and 39 deaths per 100,000 in Cuba, according to World Bank data.

Empowering women with more options to plan their pregnancies, and control their health overall, can help turn that tide.  

“There’s a direct link between family planning and maternal mortality,” said Meredith Casella Jean-Baptiste, a co-author of the study and the women’s health coordinator for Zanmi Lasante, as PIH is known in Haiti. “Maternal mortality can be reduced by up to 44 percent when women have access to family planning methods and by up to 60 percent when all their contraceptive needs are met.”

University Hospital is a 300-bed teaching facility that serves a population of about 189,000. In its maternity ward, about 375 women give birth per month.

Prior to the study, the hospital didn’t have protocols for contraceptive education and family planning services for new mothers, said Jean-Baptiste, who is also a midwife. The majority of women waited six weeks after delivery before coming back to the hospital for family planning, if they were able to come back at all, and education was sparse.

“We wanted to give women options before they left the hospital,” Jean-Baptiste said.

That effort pushed forward in early 2016 when the World Health Organization changed its eligibility criteria for some long-acting contraceptive implants, saying the benefits outweighed the risks for women immediately after delivery and while breastfeeding. The change increased access to implants, such as the Jadelle, and spurred University Hospital’s training and education study.

“That really opened the door for us for exploring how we could best put that in place here,” Jean-Baptiste said. “There had been a number of barriers for women trying to access that kind of family planning.”

Beginning in March 2016, University Hospital staff implemented standard protocols for contraceptive education and expanded training for nearly 30 staff members, including nurses, midwives, and residents in the internal medicine ward. The idea was to ensure that every woman, regardless of whether or not she was a mother, could access family planning methods during her hospital visit.

Stephanie Louis, a study co-author and midwife who has worked at University Hospital since 2013, said staff are now more focused on patient awareness of family planning options in the maternity ward, as well as in pediatrics and internal medicine.

Patients “feel a sense of pride, as if it gives them a new direction in their lives,” Louis said, once staff have addressed their questions about long-lasting contraception.

“New moms, in particular young mothers who accept a long-term family planning method, are always thrilled to make a decision such as this,” she added. “They say it will allow them to have more time for themselves and other members of the family, or simply allow them to finish their education [for those who are still in school].”

The study’s authors believed that this approach can be replicated in other institutions throughout Haiti, and beyond, to impact high maternal mortality rates.

Jadelle implant insertion
Bruny finishes inserting the Jadelle in Dorcius's arm, then later performs the same procedure for the patient's sister.

For its part, PIH supports 12 hospitals and clinics in some of the poorest, most remote regions of Haiti. Jean-Baptiste said all of those facilities now conduct outreach about family planning services, visiting homes, churches, community centers, and other public gathering places to raise awareness and access.

“Opening up access to women in their own communities helps them feel comfortable to ask questions and choose a family planning method,” she said.

Staff also reach out to older women who could be influential in their communities, added Jean-Baptiste, and help address taboos and misinformation about family planning.

The most common concern Jean-Baptiste hears about the Jadelle, is whether women will be able to have it removed, in case they want to have another child before five years are up. The answer is “yes,” but clinicians counsel women before the implant’s removal to make sure they have all the information they need.

“Family planning is a choice, and our role is to fulfill the needs of each individual woman’s choices—whether she wants to keep the method in place, or remove it,” said Jean-Baptiste. She added that less than 10 percent of women choose to remove it before the five-year mark.  

Jean-Baptiste said having choices empowers women and fundamentally changes how they approach family planning.  

“We really try to do as much education as we can around the different types of methods we offer in the hospital,” Jean-Baptiste said. “Education, of course, is the most important factor in terms of what a woman chooses and what she decides is best for herself and her family.

Read the full publication here.

Tue, 19 Mar 2019 18:08:00 -0400
The Evolution of Cancer Care in Haiti */ /*-->*/

Cancer does not discriminate by income or place of birth. Globally, 9.6 million people die each year from cancer, yet 70 percent of cancer deaths occur in the world's poorest places. This is true greatly because only 5 percent of cancer treatment is available in low- and middle-income countries.

Partners In Health does not believe cancer care is a luxury. Staff working with Zanmi Lasante, as PIH is known in Haiti, began treating patients for cancer in Cange in the early 2000s. Oncology services have steadily grown since then. Last year alone, more than 570 patients were treated at University Hospital in Mirebalais for a variety of forms of the disease, ranging from breast cancer to lymphoma.

View the timeline below to see major moments in PIH's evolution of cancer care in Haiti. Shaded boxes indicate links to more in-depth stories about our oncology patients and program.

Building in Cange, Haiti to commemorate 2011 event: PIH begins a breast cancer clinic at Hópital Bon Sauveur in Cange.Oncology services move from Cange to University Hospital in Mirebalais, a 300-bed teaching facility that opened in March of that year. Isemelie Bazard is the first breast cancer patient to undergo surgery there, and she remains healthy to this day.In May 2013, Isemelie Bazard was the first patient to undergo surgery at University Hospital in Mirebalais—and is among a growing number of breast cancer survivors in Haiti.Martha Cassemond, PIH’s first chronic myelogenous leukemia patient, completes 10 years of treatment and is doing well. She has since had a healthy son.Martha Cassemond was diagnosed with a rare form of leukemia when she was 12 and has been on lifesaving medication for the past 13 years, thanks to the care and support of Partners In Health in HaitiAn oncology rotation is added to University Hospital’s medical residency program.”University Hospital launches a weekly multidisciplinary clinic between oncology and surgery to encourage collaboration on the removal of cancerous tumors.  The pathology lab at the Stephen Robert and Pilar Crespi Robert Regional Reference Laboratory opens on University Hospital’s campus, allowing for quicker, local cancer diagnoses.Cancer patients used to wait 90 days for a diagnosis. Now it’s 20, thanks to new pathology services in Mirebalais Regional Reference Laboratory.More than 9,000 women are screened for cervical cancer through OB/GYN services across PIH’s 12 hospitals and clinics, including University Hospital. The oncology department moves into the Roselene Jean Bosquet Center, a newly renovated space within University Hospital that better accommodates high demand for services. Project ECHO is launched, in which colleagues from around the world use teleconferencing to share clinical knowledge.


Tue, 19 Mar 2019 11:06:02 -0400
Celebrating Six Years of Accomplishments at University Hospital in Haiti .tlMenuItemEdit{ display:none !important; } .tlFourDotsButton{ display:none; } .inlineImgL{ float:left; width:45%; margin:0 27px 7px 0; } .inlineImgR{ float:right; width:45%; margin:0 0 7px 27px; } .stt{ /* clear:both;*/ display:inline; margin-bottom:5px; } #tl{ display:block; } .mobile-only{ display:none; } .clear{ clear:both; } /* Mobile */ @media screen and (max-width:768px){ .mobile-only{ display:block; } .inlineImgL{ float:none; width:100%; margin:5px 0; } .inlineImgR{ float:none; width:100%; margin:5px 0; } #tl{ display:none !important; } .stt{ display:none; } }

Six years have passed since University Hospital in Mirebalais opened its doors and began transforming health care for more than one million people across Haiti's Central Plateau. Since March 2013, thousands of patients have had access to specialized care provided by clinicians working with Zanmi Lasante, as Partners In Health is known locally.

University Hospital has also been home to a growing medical education program, which has graduated 89 residents from a variety of specialties, including emergency medicine, surgery, and pediatrics, to add to the growing health care workforce in Haiti.

For a deeper dive into University Hospital's many accomplishments, check out the below image, a bird’s eye view of the campus. Hover over various sections to learn more about how hospital staff save lives every day by providing high-quality care to all patients, regardless of their income.




A Safe Haven for Mothers and Babies

When University Hospital opened in 2013, staff frequently saw full-term pregnant women sleeping overnight on cement sidewalks waiting for labor to begin. Many of them lived far from care and wanted to be near the hospital as their due date approached. Mothers of babies in the neonatal intensive care unit also slept outside to be available for feedings. These everyday scenes were a testament to the mothers’ determination to receive high-quality care for themselves and their newborns. They also were the inspiration for Kay Manmito, the maternal waiting home PIH built on the grounds of University Hospital.

Kay Manmito, or “Mother’s Home” in Haitian Creole, hosts women with complicated pregnancies and mothers of premature and NICU infants, guaranteeing them a facility-based birth and providing them with free prenatal care, meals, psychosocial support, and health education. In 2018, Kay Manmito housed more than 400 women so that they could receive the lifesaving, dignified care they needed, from blood pressure monitoring to C-sections. These patients were among the 12 women, on average, who delivered each day in the neighboring hospital’s maternity ward. For expectant mothers like Natacha Jean Paul, whose risky pregnancy brought her to the facility, “the care found here is priceless.”



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Training Haiti’s Next Generation of Clinicians

Brain drain has long stymied Haiti’s health care system. Doctors and nurses have historically had few options for specialized training within the country, and 80 percent of those who do train in Haiti leave within five years of graduation to practice abroad. The few clinicians with specialized training who remain in Haiti typically work in the capital of Port-au-Prince, far from where most patients—particularly the rural poor—can access care.

Medical education is integral to University Hospital, which was built as a teaching facility where Haitian clinicians could train in advanced specialties. Since opening, the hospital has begun offering residency programs in pediatrics, surgery, obstetrics and gynecology, neurology, nurse anesthesiology, and family, internal, and emergency medicine. To date, 89 clinicians have graduated from these programs, including the family medicine residency at PIH-supported St. Nicholas Hospital in St. Marc. Nearly 80 percent have chosen to work in rural areas of Haiti and 58 percent work at PIH-supported facilities, strengthening local health systems and caring for the most vulnerable patients.

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Cancer Care for All

Cancer affects people around the world proportionately, yet access to treatment is disproportionate, as lifesaving chemotherapy and surgeries are often unavailable or inaccessible in poor countries. University Hospital’s oncology department is changing this reality. There, patients from across Haiti receive the diagnoses, specialized care, and psychosocial support they need to survive.

Last year, University Hospital provided cancer treatment to more than 570 patients, the majority of them women with breast cancer. Cita Cherie* is one such patient: She has been receiving palliative chemotherapy for an advanced stage of breast cancer since the hospital opened. “If it were not for the Mirebalais hospital, I would not be alive today,” Cherie says. “I get all my medication for free, and when I come to the hospital, the doctors take really good care of me. They welcome me and they really value me.”

*Name has been changed at patient’s request.

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A Lifesaving Laboratory

The Stephen Robert and Pilar Crespi Robert Regional Reference Laboratory, which PIH opened in 2016 across from University Hospital, has transformed health care for more than 1 million people. The 15,800-square-foot facility contains a clinical lab, a pathology lab, and Biosafety Level 2 and 3 laboratories, allowing staff to quickly and confidently diagnose and monitor infectious diseases and noncommunicable diseases like cancer. Highly trained technicians use advanced tools to improve the quality and timeliness of diagnostic services, meaning more patients receive better care in less time.

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Rehab for the Body, Mind, and Spirit

The Center of Excellence in Rehab and Education is the first public facility of its kind in Haiti. Here, patients from all walks of life come for outpatient physical therapy sessions, and a select few remain for extended stays to recover from trauma. They are stroke survivors and amputees, accident victims and people living with various forms of disability. They come for physical transformation, and often leave with a mental and emotional lift as well.

Staff and patients interact in one of the most pleasant spaces on the University Hospital campus. The L-shaped facility fills with natural light and bright tile mosaics decorate the walls, some with Haitian proverbs worked into the design. One, appropriately, says: “Piti piti zwazonich li,” or “Little by little the bird builds its nest.”

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A Hub of Activity

University Hospital’s emergency department buzzes with activity. The suite of rooms rarely has an opening in its 21 beds, and two rows of chairs regularly fill with awaiting patients.

There are the typical emergencies, from broken bones and lacerations to heart attacks and motorcycle accidents. But there are just as many patients who come following acute episodes spurred from chronic illnesses, such as diabetes and heart failure.

The emergency department is often the first stop for University Hospital patients, who come from across the country at all times of day. They are greeted by seasoned clinicians and medical residents on rotation through the ward. Ten emergency medicine residents have graduated from the program since its launch in 2013.

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A Cut Above the Rest

University Hospital is home to six state-of-the-art operating rooms, tucked away in the heart of the facility. In 2018 alone, surgeons performed 1,400 lifesaving cesarean sections and 800 other women's health-related procedures, such as hysterectomies.

The operating theater hosts routine surgeries, such as appendectomies and the removal of tumors. It has also hosted teams of international surgeons who, in collaboration with PIH clinicians, have conducted cleft palate repairs and—most impressive of all—the separation of conjoined twins.

So far, 19 surgical residents have entered University Hospital’s medical education program, four of whom formed the first graduating class last fall.

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Always a Full House

In the pre-dawn hours, dozens of patients begin arriving at University Hospital’s main entrance to await their turn for high-quality care, at little or no cost. Last year, clinicians conducted nearly 277,000 outpatient visits and admitted close to 6,000 patients, many of whom had traveled hours to be seen by the facility’s top-notch doctors and nurses.

Once patients have registered and had their vitals taken, they sit in one of several waiting rooms for their name to be called. They come for consultations with maternal and mental health, dental services and radiology, oncology and chronic diseases. Those who are admitted may end up in a number of departments, such as labor and delivery, pediatrics, or isolation—should they be diagnosed with an infectious disease, such as multidrug-resistant tuberculosis.

Regardless of why they come, they will receive care within specialties that would otherwise be out of reach for the rural poor across Haiti.

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Tue, 19 Mar 2019 11:03:04 -0400
Lancet Global Health Article Proposes Path to Universal Health Coverage Authors of a groundbreaking piece published Thursday in The Lancet Global Health argue that universal health coverage, or UHC, is achievable when local health officials are given the proper tools to estimate their communities’ burden of disease and then use that information to determine the level of staffing, supplies, and infrastructure needed to provide high-quality care for everyone in need in their community.

The article, titled “A Practical Approach to Universal Health Coverage,” offers an alternative perspective, a complete reversal from what has been common practice in global health circles. Currently, national ministries of health interested in achieving UHC are told by the ministry of finance that they have a certain designated budget for health and are expected to work from that to see what is possible for their populations. The limited funds often only cover basic services such as vaccines and vitamins, but rarely more complex care for patients, say, diagnosed with cancer,  tuberculosis, or even a complicated pregnancy.

But The Lancet Global Health authors, among them Harvard Medical School professors and Partners In Health clinicians, advocates, and data experts, consider this short-sighted, and have developed an open-access tool they’ve used alongside district officials to help advance steadily toward UHC in remote, rural districts in countries such as Lesotho, Haiti, Malawi, and Liberia.

“This tool represents one pragmatic method to advocate for adequate resources to align inputs with the disease burden, rather than starting with the limitations of a truncated budget envelope,” write the authors, among them Dr. Paul Farmer, a PIH co-founder, Dr. Joia Mukherjee, PIH’s chief medical officer, and Robert Yates, project director of the UHC Policy Forum at Chatham House.

For poor countries, UHC has been an elusive goal, first initiated by national representatives and global health leaders in the Alma Ata Declaration of 1978 in Kazakhstan. Now decades later, at least 400 million people still lack access to basic health care. Several efforts have been made to forge a path toward universal coverage. Projection models, such as the World Health Organization’s OneHealth tool, have successfully helped countries plan and budget for care delivery nationally. But little has been developed to help district officials plan, implement, and monitor their path toward providing affordable and easily accessible high-quality care for all—the definition of UHC set forth by the United Nations in its Sustainable Development Goals for 2030.

PIH leaders saw this gap, and organically over the past 12 years gathered key players to the table to discuss this bottom-up approach of planning for care delivery and subsequently developed an open-source tool they could use hand-in-hand with district health managers.

Formally called the Universal Health Coverage Monitoring and Planning Tool, the interactive spreadsheet enables users to forecast how much additional staff, supplies, and infrastructure will be needed at any given health facility to be sure to reach 100 percent of the estimated burden of disease for that targeted community.

Dr. Jean Claude Mugunga, PIH’s associate director of monitoring, evaluation, and quality, and Adarsh Shah, a monitoring and evaluation analyst, led the tool’s development. They settled on Microsoft Excel because it’s cheap and popular, and therefore more likely to be used. With the help of some pro-bono work by a consultant, Nicholas Luzarraga, they had a shareable prototype up and running by the end of October 2018, in time for the Global Conference on Primary Health Care in Astana, Kazakhstan.

But as early as 2008, PIH was using an initial iteration of the tool when invited by the government of Lesotho to help decrease the rate of maternal mortality across seven rural clinics. Based on projections, PIH staff and their district colleagues estimated what they would need to ensure every expectant mother had access to at least four prenatal visits and delivered within clinics at the hands of trained clinicians. The results were impressive; facility-based births jumped from 12 percent to 56 percent from 2008 to 2010.

Based on that early success, the Lesotho government invited PIH to be its primary technical advisor in a sweeping National Health Reform across four districts, home to 70 health centers. Early analyses indicate substantial increases in service delivery from 2014 to 2017, including a 15-times increase in facility-based deliveries at health centers.

Lesotho is not the only country in which PIH has tested its UHC tool. Colleagues in Haiti, Liberia, and Malawi have also used it to help forecast burden of disease and advocate for increased funding and resources.

The Lancet Global Health authors know that a handful of countries using this tool does not equate to worldwide attainment of health for all. “True global success of UHC,” they argue, “can only be achieved if we have a clear and specific plan for implementation.”

This tool takes the world one step closer.

Mother and baby at Nkau, Lesotho
Nokhuthazile Tjamakile holds her daughter, Nosiphiwe, at Nkau Health Clinic in Lesotho, where she gave birth three months earlier. 



Fri, 15 Mar 2019 10:13:51 -0400
Floods Kill Dozens, Leave Thousands Homeless in Malawi Four days of unseasonably heavy rains have left 487,000 people in southern Malawi without homes and property, according to official reports. As families prepared for the end of the rainy season and the approach of the harvest, floods swept away acres of farmland, killed at least 30 people, and injured hundreds more. The numbers are expected to rise in the days ahead.

Neno District, where Partners In Health serves 165,000 people, was one of the districts affected. Some 3,500 subsistence farmers lost all or part of their homes, saw their food and possessions damaged or swept away, and suffered injuries as a foot of rainfall caused rivers to burst their banks. 

The president of Malawi, Arthur Peter Mutharika, declared a state of disaster on Friday, March 8. 

“It’s devastating,” says Dr. Emilia Connolly, chief medical officer of Abwenzi Pa Za Umoyo, as PIH is known in Malawi.

PIH staff are assessing the damage and pulling together a response. The two hospitals and 12 health centers that PIH supports weathered the storm and are providing care, yet evidence of the heavy rain’s destruction was clear. 

Throughout surrounding villages, entire walls of mud-brick, thatch-roofed houses collapsed in heaps. Families told PIH staff that they’d lost everything—sacks of maize, cooking pots, plates and utensils. Many have taken shelter in extended families’ and friends’ homes, even a nearby school.

“Everyone's moving in together,” says Connolly. “It's a strain on even those who didn't lose a home.”

While the situation is difficult now, families could face challenges for months. Many lost their crops just as they were maturing, too late to replant and recover what was lost. The Malawian government is mobilizing resources to help with emergency response, including sending essentials such as maize, beans, and rice to the flood zone.

But any such response may take days to reach remote, rural areas, such as Neno District. “It's still going to be quite dire for a lot of people,” says Dr. Luckson Dullie, executive director of PIH in Malawi.

Dullie and Connolly expect an increase in illnesses such as malaria and typhoid as families continue to live in crowded spaces over coming weeks and months with a significant amount of standing water from flooding.

As PIH staff scramble to support as many people as possible, they are also keeping their eyes on the horizon. Another storm, currently ranked Category 1, is approaching Madagascar, and expected to make landfall in Malawi on Thursday.

To help PIH provide emergency response to staff and residents in need of food, mosquito nets, and supplies to rebuild homes, please consider donating here.

PIH staff is working tirelessly to rebuild patients' homes, deploy mobile clinics to the worst-affected areas, and ensure families are safe, housed, and fed amid this disaster. Please, support these efforts with an emergency gift now >>

Donate now

Collapsed road in Malawi
This collapsed dirt road is less than three miles from the PIH-supported Dambe Health Center.


Tue, 12 Mar 2019 10:31:19 -0400
In Mexico, A Traditional Midwife and Teenage Mom Share Special Bond Margarita Perez Jimenez and Martha Domínguez López can both say their lives changed at the age of 14. For Jimenez, that was the year she began working as a traditional midwife in Chiapas, Mexico. For López, it was when she became a single mother.

The two women met around May 2017, when Jimenez was 67 years old and had delivered, she says, at least 5,000 babies, most of them within a mud brick, zinc-roofed shack behind her home in the rural town of Francisco Madero. López could have been among the women who delivered in these modest surroundings, not far from roaming chickens and a black-and-white kitten.

Except at 14, López was a particularly young expectant mother and, therefore, more likely to experience complications during delivery. It was with this in mind that Jimenez and López’s family turned to outside help.

After carrying her pregnancy to full term, López gave birth in Casa Materna, a maternal health center supported by Compañeros En Salud, as Partners In Health is known in Mexico. Since the facility opened in May 2017, nearly 150 women have given birth at the hands of doctors and OB/GYN nurses who staff the clinic 12 hours a day, seven days a week. Three times as many women have come for urgent care and exams in the past six months alone, after being referred from the neighboring Jaltenango Hospital.

Since the facility’s early days, PIH staff have seen an increase in the number of women choosing to come to the Casa for prenatal services and, when the time comes, to deliver. The trend is reassuring, especially in Chiapas, a state where the rate of maternal mortality is among the highest in Mexico—58 per 100,000 women.

Historically, expectant mothers living in the coffee-growing regions of the Sierra Madre visit a traditional midwife for their prenatal care and for help with labor and delivery. When pregnancies are normal and labor is uncomplicated, such a choice is low-risk. But it can be hard to predict whether labor will be complicated. When it becomes so unexpectedly, women and their newborns can be in grave danger, especially when the nearest hospital may be a three-hour drive over treacherous, mountainside roads.

PIH leadership in Mexico knew there had to be a better way to ensure expectant mothers had access to quality care. In late 2016, staff began recruiting and training 34 community health workers specialized in maternal care across the 10 communities PIH serves in rural Chiapas. These women each serve a handful of expectant mothers in their neighborhoods by answering their questions, counseling them on breastfeeding and nutrition, and accompanying them on prenatal visits at nearby PIH-supported public clinics.

When due dates approach, they help patients create a birth plan and advise them to travel in advance to Jaltenango, where they stay near the Casa Materna to await labor—receiving vouchers for meals and free lodging throughout their stay.

None of this is meant to undercut the role of traditional midwives. PIH-supported clinicians partner with these well-trusted women as valuable local resources and allies who can bridge the gap between custom and modern medicine. The organization provides them with birth kits—including sterile gloves and umbilical tape, gauze, and alcohol—and training on how to identify at-risk pregnancies. Midwives are encouraged to refer patients to the Casa Materna should complications arise, and to support them throughout labor and delivery at the facility.

Casa Materna care
Alma Rosa Valentin Martinez (center), an obstetrics nurse fulfilling her social service year with PIH in Mexico at Casa Materna, takes the blood pressure of Gloriena Elizabeth Roblero Mendoza, a 35-year-old mother pregnant with her fifth child. Her 4-year-old son, Angel Ronay Roblero Roblero, plays with a birthing ball throughout the exam.

This entire system of maternal health care was just getting in place in the spring of 2017, when López arrived at her aunt’s home in Francisco Madero. At 14, she was four months pregnant, abandoned by her partner, and fleeing her abusive father.

Her aunt, Atanacia Argeta Idalgo, lived on a small farm with her husband and four children a 10-minute walk from the center of town. She welcomed López and took her to see Jimenez, whose arthritic hands had delivered all of her children and had even ushered her into the world, 32 years ago.

Jimenez, a grandmotherly woman with silver-streaked hair and a weathered, round face, gently massaged López’s abdomen to feel the baby’s position. A girl, she said. But how could she be sure?

“The girls are soft; and the boys are hard,” Jimenez said matter-of-factly.

She knew what she was talking about. When Idalgo took her niece to Casa Materna for her routine six-month ultrasound to determine the baby’s sex, staff there confirmed the midwife’s assessment: girl.  

Every several weeks, López walked up the hill into town to visit Jimenez. The teenager grew to trust the midwife’s touch and warm presence. Her pregnancy, thankfully, had been easy—no major aches and pains. She’d had low blood pressure, but that seemed to have subsided over the course of the pregnancy.

So when her due date approached and her abdomen clenched at dawn with early contractions, López and her aunt headed first to Jimenez’s house. The midwife examined the young mother and determined that she still had hours to go, guessing the baby would arrive by early afternoon.  

But Idalgo hesitated returning home to wait, seeing her niece racked with pain. Instead, she drove her 15 minutes to the Casa Materna for a check-up. Staff there examined López and repeated the midwife’s prediction; the young mother still had hours to go and could continue laboring at home.

Idalgo knew López only felt comfortable with Jimenez by her side. Yet she worried that, given her niece’s age, serious complications could arise. The midwife had equal concerns.

So Idalgo talked to Casa Materna staff about the teen’s preference for Jimenez. Without flinching, the attending nurse said, “Well, if she has confidence in her, bring her along.”

That’s exactly what they did. Later on the morning of October 24, López’s labor had progressed and Jimenez thought it was time to return to the Casa Materna. The midwife, aunt, and young mother loaded into the car and sped back to Jaltenango. Staff welcomed them, and one of the nurses attended to their every need throughout their stay.

Around 2 p.m., with Casa Materna staff waiting in the wings, Jimenez helped López deliver a healthy, 7 lb. baby girl with a head full of hair.

“Thanks be to God, she didn’t suffer much,” Jimenez said of her patient.

Casa Materna staff congratulated the women, and informed Jimenez that she was the first traditional midwife to deliver her patient there. It was a major win—proving that local expertise can partner with modern medicine to bring quality maternal health care to women living in rural Chiapas.

Two weeks later, Jimenez sat in the shade of Idalgo’s patio, next to López and her yet-to-be-named infant daughter. The young mother, not one for words, glowed with pride.

Jimenez said Casa Materna staff had invited her to return with her patients. When asked if she would recommend the facility’s services to other women, Jimenez’s answer was easy: “Adelante!” And she would be right by their side.

Martha and her baby girl
Martha Domínguez López (right), 14, gently hands her newborn daughter to Jimenez while the two visit on the back patio of her aunt's home in Francisco Madero.


Wed, 06 Mar 2019 13:46:37 -0500
Blessings Henry, Neno's Feminist Future Doctor For Blessings Henry, a typical school day begins at 3 a.m.

The 17-year-old is in her last year of secondary school in Malawi’s Neno District, a rural region of rugged mountains and arid flatlands in the country’s south, near the border with Mozambique. Blessings uses her early mornings, as well as her evenings, to study before and after classes. These long days devoted to education are in pursuit of Blessings’ ultimate goal: going to medical school and returning home to Neno to work as a doctor.

Blessings wants to become a physician not only to care for patients—she also wants to inspire young women in her community.

“Very few people here have reached being a medical doctor,” she says, citing a fact that’s especially true of women. “I would like to work in Neno so that more girls from Neno have a role model to encourage them to go to school.”

Only 8 percent of men in Neno have completed secondary school, and the rate is even lower for women—just under 5 percent. In one of the poorest districts in one of the world’s poorest countries, most families aren’t able to pay the costs of their children’s education, from books and pencils to required school uniforms and examination fees. Most students—especially girls, due to poverty or early marriage—drop out.

Indeed, poverty nearly prevented Blessings from remaining in school. When her father unexpectedly died, Blessings’ mother and grandmother were left to care for her and her four younger siblings without any consistent income for food or other basic necessities, let alone the fees associated with secondary education. Determined to enable Blessings to stay in school, her mother contacted Abwenzi Pa Za Umoyo, as Partners In Health is known locally, for support.

PIH has been subsidizing Blessings’ education ever since, from seventh grade onwards. She’s one of nearly 150 secondary school students in Neno whose educations PIH helped fund in 2018 alone. Without this support, Blessings says, “I would not have been able to continue school. My family is so vulnerable, there is no way they would have been able to pay school fees or get scholastic materials.”

Blessings’ path to medical school is paved not only by her own hard work and PIH’s support, but also by her mother and grandmother’s commitment to her education. Though she is far from her family during school—she is a boarding student, and must walk at least three hours to get home for visits or breaks—she feels their encouragement echoed in a community of female students and teachers who help and inspire each other.

All of these women have shaped Blessings’ future plans, along with her steadfast belief in herself and other girls.

“It’s important that everyone, either male or female, be given an equal opportunity to attain education,” she says. “No matter how poor and vulnerable they are, all young women around the world should set their goals, be focused, and continue working hard.”

Mon, 04 Mar 2019 15:44:17 -0500
Public Defender: Benson Chabwera Dedicated to Neno Community Late in 2007, Benson Chabwera was hired as a security guard by Partners In Health, not long after PIH had begun its partnership with the Malawi government to strengthen the health system in Chabwera’s home district of Neno. 

Chabwera was in his late 20s at the time. He had been married to Vaida Zilozo for about four years and they had a 3-year-old daughter, with another baby on the way. Chabwera started on the night shift for PIH, known in local Chichewa as Abwenzi Pa Za Umoyo, or APZU.

About five months into the job, Chabwera got an additional opportunity. The National Statistical Office of Malawi wanted him to help with the country’s population and housing census, conducted once a decade. Because that work would be in the daytime, Chabwera reasoned, he could do it while continuing to work his PIH security shifts at night.

Sleep was not a factor in his reasoning.

“I slept on the weekends,” Chabwera recalled.  

The decision to take a grueling second job reflects a work ethic and drive that has propelled Chabwera through a series of achievements with PIH, and life, in the 10 years since. Now 37, Chabwera is one of the most well-known and well-liked faces around Neno District—and has transformed himself from a security guard with a high school education into a manager of more than 600 health workers, a graduate with advanced degrees, a pillar of local access to health care, and a strong advocate for PIH’s patient-first model and community-wide impacts.

Basimenye Nhlema, community health director for PIH in Malawi, described Chabwera as “completely hilarious and friendly,” and a compassionate, respectful supervisor. 

“Benson is a pure joy to be around, a ball of energy, always ready to move and work,” said Nhlema, who joined PIH two years ago. “From the time I have worked with Benson, I have found him to be quite committed, dependable, hands-on and considerate.”

Since 2013, Chabwera has been a community health worker (CHW) program officer, one of two for PIH in Neno District. He oversees nearly 100 senior CHWs and more than 500 CHWs, who go home-to-home in their communities to visit families, provide access to services and serve on the frontlines of health care delivery. 

CHWs are the foundation of PIH’s work in Malawi, and in the 10 countries where PIH works. In Malawi’s Neno District—a region so isolated that native Malawians will tell you, “If you’re not from Neno, you don’t know Neno”—PIH supports two hospitals and 12 health centers, working to reduce high rates of maternal deaths, HIV, malaria, malnutrition, and more. 

Henry Makungwa, CHW program manager for PIH in Malawi, said CHWs in Neno are selected in their communities, by their communities, to serve among their friends, family members and neighbors. More than 1,200 CHWs in total work across two Neno regions—upper and lower, or the district’s mountains and its flatlands.  

Chabwera’s position in upper Neno regularly takes him across rugged, mountainous terrain, where dirt roads are rock-filled and steep at best, and flooded or downright impassable at worst, depending on the season. 

His position also requires him to navigate complex interpersonal relationships, a challenge familiar to any manager of a large staff, anywhere. 

“We have an army of over 1,200 CHWs, so conflicts, issues and grievances are always on the table,” Nhlema said.

She said a particular situation stuck in her mind.

“I remember when I had just joined and we were deciding what to do with community health workers who did not meet the new selection criteria,” Nhlema said. “It was clear that based on the needs of the program, we had to lay off those CHWs who were unable to read and write, and I remember vividly the pain and emotional struggle that Benson went through to accept that decision. 

“I recall him trying very hard to negotiate other ways out for CHWs,” she continued. “I see this attribute in him a lot, where he shows tremendous concern for the welfare of CHWs. If I had to summarize his role in the organization, I would say he is a defender of CHWs and the work they do—and I find this totally reassuring.”

Benson Chabwera talks with a mental health patient's brother on a home visit
CHW program officer Benson Chabwera, left, and PIH driver Mataka Mizimbe, center, talk with Kenneth Kaombe at the Kaombe family's home in Neno District. Kenneth's brother, Moses Kaombe, has benefited from support by PIH's mental health team in Malawi, led by Mark Chalamanda, who joined this visit but is not shown. Chabwera's co-workers say his knowledge and understanding of Neno, his home district, helps him connect with people and families facing difficult health challenges.

Limiting people’s employment opportunities because of a lack of education—likely stemming from a lack of access and other ingrained societal factors—struck close to home for Chabwera. 

He said he had only a certificate of education, equivalent to a high school diploma in the U.S., when he first joined PIH in 2007.

“Initially, I did not know really anything about computers, like the difference between a laptop and a desktop,” he said. 

The stability of his job at PIH empowered Chabwera to pursue higher education on weekends. He and Makungwa traveled to the city of Blantyre every Friday for months, taking classes on Saturdays and Sundays before returning to Neno for the work week. 

They initially paid for their own food and transportation, while urging PIH to rent a house in Blantyre for employees attending school. PIH eventually agreed to the arrangement, which is still in place. 

“We were among the pioneers to advocate for support from the organization when we wanted to pursue higher education,” Chabwera said. “If you go to Blantyre, you will see that there still is a guest house. A lot of people have benefited from that house. A lot of people are still going to school.”

PIH’s investment has paid off for numerous staff members, including Chabwera. 

“Right now, as I am speaking, I have a certificate in accounting plus an advanced diploma in rural and community development—I don’t take that for granted,” Chabwera said. “It wouldn’t have been possible without PIH. It took me from point zero to maybe point 100.”

And he's still climbing. Nhlema said Chabwera is one of many PIH staff members, including several supervisors, who have signed up for an online course this spring through the University of Washington, called "Leadership and Management in Health." The 12-week course runs from April through June. 

"I believe this is a huge milestone and will propel him even further," Nhlema said.  

Over the years, Chabwera's responsibilities with PIH have grown with his education. 

Makungwa said when Chabwera joined the community health department in 2009—ending his tenure as a security guard—he was posted at Magaleta Health Center, where he supervised CHWs in that facility’s catchment area.  

“His interaction with the CHWs as well as the facility’s leadership was superb,” Makungwa said. “He cultivated a very good working environment with different stakeholders, including village chiefs, faith-based organizations and village health committees, just to mention a few.”

His strong performance at Magaleta earned Chabwera a transfer to the Neno District Health Office, in the central community known as the “Boma,” with a larger catchment area and greater number of CHWs. His commitment and hard work continued, leading to Chabwera’s promotion in 2013 to his current role of CHW program officer in upper Neno. 

Kelly Lue, who recently worked in mobile health and research for PIH in Malawi, said the depth of Chabwera’s experience was evident, for example, when members of PIH’s CHW team in Liberia visited Neno for a training event in March 2018.  

“Benson's encyclopedic knowledge of our CHW program was evident from the very beginning. Because of that knowledge and his warm, kind, and hilarious personality, he is an invaluable asset to the CHW team and to APZU,” Lue said. “On one outing, we visited a superstar CHW and Benson translated between her and the Liberia team, so they could ask her questions about her daily work. The conversation was filled with laughter and smiles. It was clear that Benson and the CHW had a great rapport.”

Walking around central Neno with Chabwera, it’s easy to see where that rapport comes from. He’s the kind of person who can’t walk very far without greeting friends and neighbors, and sharing a kind word or laughter with all of them. 

“His interactions—especially with community leaders and community members—are always mature and tactful,” Nhlema said. “Since he is originally from Neno, he understands the people and their communities, hence his ability to carefully maneuver through the cultural nuances of our catchment areas.”

CHW Program Officer Benson Chabwera leaves a home visit in Neno, Malawi, in September 2018
CHW Program Officer Benson Chabwera leaves a home visit in Neno, Malawi, in September 2018. Chabwera said working in his home district and improving the lives of fellow community members is what inspires him as part of PIH, where he's been on staff since 2007.

Chabwera’s parents moved to Neno from Mulanje District in 1981, the year Chabwera was born, in search of better land for cultivation. Neno has been Chabwera’s home ever since—and he’s continued his parents’ tradition of working the land. Over the years, he’s grown crops including corn; soybeans; Irish potatoes, known as mbatata; onions; tomatoes, and more. 

While Chabwera said he’s reduced his farming lately, because the revenue isn’t always strong, another kind of growth has continued all around him. A school, new homes, health facilities, better roads, and a larger market all have sprung up in Neno’s central Boma in recent years. 

Chabwera said the cause is clear. 

“All these structures you see, it is because of PIH,” he said, citing the local impacts of an influx of PIH staff; expansion of PIH-supported Neno District Hospital; more than 100 homes for impoverished local residents, built by PIH’s program on social and economic rights; and the development of jobs and infrastructure, related to all those factors.  

In addition to his wife and four daughters—of whom Chabwera is unfailingly proud—Neno also is home to Chabwera’s five siblings, and their children. Chabwera originally was the sixth child of eight. Two of his sisters have passed away. He now is doing all he can to support his extended family, along with his extended community. 

And when the once-a-decade census came around again last fall, adorning homes with chalk-written numbers in villages across Neno, Chabwera didn’t have time to participate.

“This is my home district,” Chabwera said. “Working with my fellow community members, providing support to my fellow brothers and sisters, being able to serve and improve people’s lives—that’s what inspires me.”

Fri, 01 Mar 2019 13:00:00 -0500
Haiti Facing Severe Shortages, ‘New Normal’ Following Weeks of Unrest Elizabeth Campa, senior health and policy advisor for Zanmi Lasante, as Partners In Health is known in Haiti, writes below how the organization is “entering a new normal for operations in Haiti, where a 12-day lockdown paralyzed the country, closing banks, schools, and businesses and halting all public transportation. Violence and unrest across the country resulted in 26 deaths and dozens of injuries, according to reports by UNICEF. 

During that time, PIH staff and clinicians maintained all 12 of its facilities open and operational, serving patients and working round-the-clock shifts to meet need.  

The most recent national crisis that began close to three weeks ago on February 7th, but dates back to the summer of 2018, is far from over. While the national protests that choked Haiti into 12 days of consecutive lockdown have declined to more localized events, the unknown of ‘what is next’ is on the minds of all Haitians. 

Zanmi Lasante maintained all its 12 facilities, opened, powered up, and receiving patients, while the challenges on the ground continued to make everyday activities more difficult. At University Hospital of Mirebalais, a 300-bed facility and one of the largest public hospitals in the country, a marked decline in women seeking services in labor and delivery is heavy on the minds of the team there. The last two weeks has documented a 30 percent decline in the area of maternal health.  Women are too afraid to reach our sites. Regularly 40 percent of women come to University Hospital from outside the direct service area. Now, PIH is seeing considerably fewer women from the capital of Port-au-Prince or other areas. Where are these women going for labor? We do not know.  

Our staff continue to face harassment and armed gangs that now control countless areas around the country. Yet, they still come to work; they still are there for our patients to ensure that if they do come in, we will be there for them no matter the obstacles. Staff morale has suffered, as they struggle to make every moment count when they get to communities to extend assistance to the Haitians patients too sick to travel for an appointment or to make it to our health facilities.  

Haitians have seen a 30 percent increase in inflation in the past weeks. A cup of rice that previously cost 40 cents is now almost doubled at 75 cents. While this may not seem like a lot for many, for a population where 85 percent of individuals live on less than $2 dollars a day, this is devastating.  

Fuel, while more readily available, is still being sold at close to five times the prices of January. Fuel is the lifeline for PIH’s facilities, as all depend heavily on generators to produce electricity that keeps facilities running. This price increase has had a major impact on a budget that had already been stretched to its limits. Tens of thousands of Haitians depend on PIH and its services in health care, water, and sanitation, and nutritional programming each day to ease their suffering. Knowing this, we need to make sure we have the vehicles and ambulances to get out to the communities and bring our services to them if they cannot come to us.  

We need to continue to provide food, water, and shelter to our patients and staff. We need to continue to provide hope to those who are sick by ensuring our facilities stay stocked and powered. PIH in Haiti may be entering a new normal when it comes to a country under siege, but we will continue with our mission no matter the obstacles placed in front of us. 

Maternal waiting home in Mirebalais
Expectant and new mothers gather for lunch at Kay Manmito, the maternal waiting home on the campus of University Hospital in Mirebalais. Photo by Cecille Joan Avila / Partners In Health

A PIH staff member in Haiti, who preferred to remain anonymous, wrote this account describing the recent lockdown and its impact on co-workers, patients, and loved ones: 

It saddens me to see my country in this deteriorating state. Every day is a guessing game of whether or not another violent protest will take place. The 12-day lockdown was a reality check of the ongoing socio-political and economic challenges Haiti has been enduring for the past 200 years.  

During the crisis, basic commodities such as drinking water, gas, and cooking fuel were hard to come by, resulting in people scrambling to obtain whatever they could in the markets. Panic and fear permeated the country when people understood the gravity of the situation. It also made me question how it must be for the approximately 60 percent of Haitians living in poverty who are unable to pay for basic staples, such as rice and beans, with the rapid devaluation of the Haitian gourde.  

I thought about all the patients Zanmi Lasanate serves across its 12 sites, and about the staff who were unable to arrive to sites due to roadblocks. I commend my co-workers who worked eight days or more straight to provide services to the patients who were courageous enough to cross barricades and burning tires.  

Although I understand where the protestors’ frustration derives from, violence is not the answer. In order for the country to move forward, we need our kids going to school. We need hospitals to remain open. And we need people to work. For the time being, things seem a bit calmer compared to earlier this month. However, people are still on guard, and tensions remain present. From experiences past, anything could happen in Haiti. So, as we say in Creole,Nap swiv,” or, “We will just wait and see. 



Fri, 01 Mar 2019 10:13:52 -0500
Research: Clinic Visits, Diagnoses Increase When Patients Access Free Care in Malawi A mother recently carried her feverish 3-year-old boy two hours into Dambe Health Center in the hills of the remote district of Neno in southern Malawi. She left with medication for his new diagnosis, one Malawians hear often: Malaria. They’d caught it early this time.

If the boy had been sick several years earlier, before the clinic’s opening, the scenario would have played out much differently. The mother might not have been able to take her son to the doctor in the first place. It would’ve taken her an entire day to walk to the nearest free care at Neno District Hospital and back home, and that’s if she could’ve afforded to miss a day’s labor. 

On average, Malawians live on just $586 a year, one of the lowest per capita incomes in sub-Saharan Africa. For the more than 170,000 people living in Neno, one of the poorest regions of the country, it’s even lower. 

“Mothers will often wait until a child has a seizure from cerebral malaria,” says Dr. Luckson Dullie, executive director of Abwenzi Pa Za Umoyo, as Partners In Health is known in Malawi. That’s because families must travel long distances to clinics and fear the potential cost of care. Yet Dullie knows that a child faces a 70 percent chance of death when care is delayed. 

Families shouldn’t have to debate whether they can afford to seek care for sick children. There is a better way, backed by common sense and solid research.

Research published by a team of PIH staff in Malawi and collaborators at the University of Warwick details how poor patients suffer when faced with long distances to care and the prospect of paying high user fees. Simply put, when health care is a morning’s walk away and care is free, exponentially more patients arrive at clinics and diagnoses rise for infectious diseases, such as malaria, HIV, and tuberculosis.

While Malawi has resisted international pressures and provided free public health care since 1964, about one-fourth of its health centers are operated privately and still charge user fees. In Neno there were four such centers when PIH began supporting the Ministry of Health in 2007. At that time, there was no district hospital, and the 10 health centers had fallen into disrepair. 

Over the past 12 years, PIH built Neno District Hospital, a community hospital, and two health centers, and revitalized two more centers. Clinicians have focused on reducing maternal deaths, treating severely malnourished children, and providing preventative care and treatment for HIV, tuberculosis, malaria, and noncommunicable diseases (NCDs). Meanwhile, staff have provided financial support to Neno’s most vulnerable patients by helping them access safe housing, pay for children’s school fees, and train for local jobs. 

Community health screening
Residents line up for a PIH-led community health screening, covering everything from malnutrition to diabetes, at the Kasupe Primary School in Lower Neno.

Since 2007, PIH-supported clinicians at health centers and the district hospital have tended to a steady flow of patients eager to access free services. As in other communities around the world where PIH works, patients arrive when facilities are staffed, well-stock with essential medicines, and provide reliable quality care.

Seeing these results, Dullie and his team realized they had a natural experiment in their backyard. They wanted to see whether their belief was true: that user fees discouraged patients from seeking services. If they analyzed historical data from the district health system, where some health centers have required fees and others haven’t, they knew they could test their hypothesis.

The team compared outpatient attendance and new diagnoses of HIV and malaria between July 2012 and October 2015 across health centers that charged fees and those that did not. Sure enough, there had been a 70 percent drop in attendance when patients were charged fees and a 50 percent reduction in HIV diagnoses in the district. When the fees were subsequently removed at these centers, the team documented a 350 percent increase in outpatient visits, and a case identification for malaria saw a similar increase. 

Dullie and his colleagues carefully chronicled how charging patient fees obstructed access to health care, particularly for sick children. The lack of affordable care has a way of proliferating the spread of disease, which in Neno and many poor settings includes HIV, malaria, and tuberculosis, putting especially infants and mothers at high risk of preventable death.

Following the paper’s publication three years ago, Dullie and his team worked with the Ministry of Health to remove user fees in three of four health care centers still charging the equivalent of a few dollars for each visit. The continued advocacy has resulted in the removal of user fees in all four of the privately operated facilities in Neno.

“Now, without user fees, patients can come in every time they have an issue,” he says. “Parents don’t wait too long and kids come in with less severe forms of illness.”

The study also helped Dullie and his team see a vast need for care in the remote, rural region of Dambe. They advocated for building a new health center to meet potential patient demand. And their work prevailed. 

In 2016, Dambe Health Center opened to great local fanfare and large crowds. Luckily, for the toddler with malaria and his mother who visited recently, it was ready to receive them with a cure.

Tue, 26 Feb 2019 14:25:05 -0500
Rising Star 'Kankwanzi' a Masonry Role Model on UGHE Site When Anne Marie Nyiranshimiyimana began working as a mason, she was met with staunch criticism.

“They told me, ‘No woman builds, no woman climbs.’ They told me, ‘Women can’t do a lot of things,’” Anne Marie said. 

Despite that resistance, Anne Marie persevered and became not only one of 200 female workers on the construction site for the new University of Global Health Equity campus, but also a dynamic presence, role model and mentor. Her work helped draw international attention to the northern Rwanda site in late January, when government officials, global health leaders, educators and dignitaries gathered to formally inaugurate the campus, in the community of Butaro, with a celebratory ribbon-cutting and weekend symposium.

The job wasn't Anne Marie's first in the area. She began her masonry training during construction of the Partners In Health-supported Butaro District Hospital, just across the valley from UGHE. The university also is an initiative of PIH, which is known locally as Inshuti Mu Buzima.    

Anne Marie's training and work experience has given her a passion for masonry. She's risen to the rank of master mason, while inspiring her peers along the way.

That growth was evident on the UGHE construction site. Using her knowledge to mentor and encourage others, Anne Marie quickly became a role model to women and girls in her community. Her nickname, Kankwanzi, loosely translates to “rising star that refuses to conform to society’s expectations.” That mentality is reflected by her success in encouraging females to go into masonry, a traditionally male-dominated industry. Despite a huge stigma in Rwanda around women who are employed as construction workers, Anne Marie continues to advocate for their increased involvement.

“[Women] bring great value to construction sites. They are better implementers, and more equipped to budget time and resources,” she said. “Hiring [women] supports the whole family.”

Before she developed her masonry skills, Anne Marie struggled to provide for her family. Having only been educated through primary school, she found it difficult to find a job. But equipped with a new skill set and income, her position has enabled her to buy health insurance and send her children to school.

Beyond having a ripple effect on her family and community at large, Anne Marie’s vocation also has given her an increased sense of identity and confidence.

“Women look up to [me] so much when they hear about me," she said. "They want to come work with Kankwanzi."

This story and photo originally appeared on the UGHE website, here

Tue, 26 Feb 2019 11:19:22 -0500
UGHE Alumni Spotlight: Irene Murungi Irene Murungi is a technical advisor for gender at The AIDS Support Organization (TASO) Uganda and the Uganda AIDS Commission. In 2018, she participated in the Global Health Delivery Leadership Program (GHLDP) 2.0 at the University of Global Health Equity in northern Rwanda. The intensive, six-month executive education course helps global health leaders address complex challenges in their fields, share experiences and strategies, and create solutions. The program includes a two-week residency on campus, six months of distance coaching to support the execution of a breakthrough project, and then a final, three-day reconvening in Rwanda, where country delegations present their projects. 

Can you share some of your reflections from your time in Rwanda, during GHDLP 2.0?

First, GHDLP 2.0 was great exposure. Getting to challenge myself and see what my peers from other countries were doing. Learning from them, and comparing with what is happening in my own country, helped me relate to what we were learning. 

Second, it was an opportunity to do an on-site check of my leadership skills and interpersonal skills, vis-a-vis what I thought I really had. So it was a time for me to really learn about myself, and to reflect on what I've been doing, how I've been doing it and how I can do it better. 

Third, it was a value addition. Because I believe that I really didn't remain the same after leaving Rwanda. Most importantly, I had an issue with trusting people—I think it's something on which I scored lowest when we were doing a personal assessment. But recently, I think I've really tried to pull through. Now, I give a benefit of the doubt in whatever I do. And I think it is improving my work relationships. 

How are you applying some of the skills you learned when you were in Rwanda, now that you're back home? 

One is on trust, which I've just talked about. Two is the fact that as we're making decisions at the leadership level, we'll always have to disagree. But I think, from Rwanda, I learned that even when I disagree, I should be able to offer solutions. 

What were some other things that you learned when you were in Rwanda?

I learned more about the different interventions that Rwanda as a country has taken up, compared to Uganda, where—in a closely related setting—we have the same challenges. But I realized and learned that, depending on how the government provides assistance, it can be really hard to deal with some of the so-called challenges now in our country. From the interactions we had in Rwanda, I realized that their success has had a lot to do with integrity—where there is zero corruption, because of the systems in place. 

I also appreciated the effectiveness of Rwanda’s community-based structure—that is, getting to the household, including for treatment of malaria, testing, and many health interventions. In Uganda, it's only counseling and referrals. Looking at our village health teams that are really not doing the same as their counterparts in Rwanda. I think I learned that there is need for community health workers to be self-driven, and for communities to do more to appreciate their contributions.

The idea of being self-driven—and not just looking up to an implementing partner to keep on pushing for results—really is key.

And then, also realizing how social determinants affect health outcomes. You find that children and wives have been abandoned. So you realize that gender issues are really affecting the systems put in place. Coming back to Uganda, I’ve started really looking at how best I can focus on changing the gender-interrelated challenges that affect successful implementation of the different projects at hand. 

Can you talk a little about your breakthrough project?

Initially, when my colleague and I left Rwanda, our breakthrough project was looking at hearing loss among patients with multi-drug-resistant tuberculosis (MDR-TB). As we began the research for our project and consulted our mentor, we realized that we really needed to focus on defaulting; on the lost-to-follow-up patients on MDR (multi-drug-resistant) treatment.

So we changed our project, which now is focusing more drug-resistant TB patients who become lost to follow-up. We are focusing on the period from June 1, 2015, to June 1, 2018, to look at those who defaulted and what was the cause, as well as comparing with those that stayed in treatment—what was so special that kept them in treatment?

What have you learned in your research?

Our suspicion as we set out for the project was that there likely would be factors relating to finances, in terms of patients lost to follow up. While we found that financial factors can be involved, the majority of factors really are social problems. People who are feeling frustrated and take to drug or substance abuse, for example, such as alcohol and smoking habits.

We also realized that there are aspects of co-infection, such as HIV and TB. That can be associated with loss of immunity and other factors, relating to waiting times at hospitals and limited transportation, among others. 

We found those are really critical issues that are leading to MDR-TB patients becoming lost to follow up.

How has your UGHE advisor, Dr. Paul Pierre of Haiti, helped you through this process?

He has really been helpful. We had so many ambitions and we kind of had failed to zero down to what we really wanted to do. He helped us focus. He also provided technical assistance when we were developing the tools to submit for ethical review and approval. He gave us the guidance to help us prepare for that submission. He has really been supportive. 

Is there anything specific that you've learned from him, apart from mentorship and guidance?

I think, giving time to my mentees. Although he was busy, he made sure that he gave us time. There was a time when he had to go to Congo, but he made sure that at least if we could not do calls, that we could email, and we were exchanging emails every other day. And when he returned, he continued to support us. He made sure that we were on the same page. I learned that prioritizing my mentees is key, as I grow to be a mentor in the future.

Also, having a wide wealth of knowledge is vital. He is well-informed. I learned that every time I’m presenting something, I must have enough information to fully inform my discussions, rather than just citing hearsay or making sweeping statements. Those are just some of the lessons and attributes I learned from our mentor, Dr. Paul Pierre. 


Mon, 25 Feb 2019 16:41:55 -0500
PIH Staff: ‘Haiti Under Siege’ as Medical Crisis Intensifies Partners In Health leaders in Haiti say staff have been held at gunpoint at roadblocks and a PIH vehicle has been stolen by an armed gang as nurses and doctors face “overwhelming challenges” to reach health facilities, where fuel for generators and crucial medicines are running low in the second week of protests, violence and civil unrest across the island nation. 

All PIH sites remain open and operating during the crisis. 

Loune Viaud is executive director for Zanmi Lasante, as PIH is known in Haiti. She's working closely with teams on the ground and provided updates on the increasingly dire conditions Thursday. PIH supports 12 health facilities and hospitals across Haiti’s Central Plateau and lower Artibonite, serving more than 1.2 million people. Medical staff at those facilities have seen “dozens of gunshot victims” and patients with severe lacerations. 

Many PIH staff “have had to walk through barriers of burning tires and protesters, sometimes having rocks thrown at them, even being held at gunpoint” amid the protests, Viaud  said. 

“To avoid having our teams venture out of the facilities, we need to ensure that we have food, clean water and a shelter, to keep them safe. Additional security will need to be implemented at the facilities,” she said. 

The Hospital of the State University of Haiti, in the capital of Port-au-Prince, is Haiti’s largest public hospital and has been closed during the protests. Its closure means the PIH-supported, 300-bed University Hospital of Mirebalais, about 30 miles north of the capital, is Haiti’s only facility of its size currently operating. 

“We need to ensure that services for our operating rooms, maternity wards and emergency rooms are well staffed and supplied,” Viaud said. “In areas where we are able to get around the protests, reaching our patients remains a challenge, as there are only four working ambulances for the 12 sites.”

Viaud said PIH medical staff were “stopped by an armed gang” Wednesday in the lower Artibonite, where their PIH vehicle was stolen. None of the staff members were injured physically in the jarring incident.
At least eight people have died across Haiti since Feb. 7 in violent clashes between police and demonstrators, according to the Miami Herald. Schools, businesses, and public transportation have mostly remained closed in the wake of the political and economic crisis largely sparked by skyrocketing prices, a rapidly devalued currency, and chronic fuel shortages. Blockades prevent travel, and residents are reluctant to leave their homes.

Temporary reprieves in recent days have not enabled medical staff to catch up with shortages. 

“While there have been windows of opportunity to restock the shelves of our 12 health facilities and hospitals, fuel for generators continues to be a major challenge,” Viaud said. “And when we can secure fuel, it is often as much as six times the price of what it cost just a few weeks ago. At some sites where there is electricity, the grid has been down for days, placing an even heavier burden on generators that are already struggling.”

The crisis is not limited to the capital and large cities. 

“We continue to see a number of areas where we work—including Thomonde, Mirebalais, Verrettes and Petit Riviere—facing constant obstacles," she said. "This week, we have seen protests erupt along the border of the Dominican Republic and Haiti where we support a hospital at Belladere, one of the only facilities for miles in an area often forgotten by many donors and organizations.” 
Shortages of medicines are compounding the problem—as are concerns that many people needing care, especially pregnant women, may be unable to reach health facilities because of roadblocks and other obstacles.

“We’ve seen a decline in deliveries at our facilities, which is very concerning given that such a high population of Haitian women give birth at home, with no trained medical personnel,” Viaud said. “Roughly 30 percent of women in Haiti require emergency cesarean sections due to complications.”

To support our health facilities and emergency response in Haiti, DONATE HERE.


Thu, 21 Feb 2019 15:32:26 -0500
Working in Global Health: Gabriela Sarriera on Grassroots Activism Like many people, I first heard about Partners In Health when I was in college. I was a sophomore at the University of Vermont and a group of us had decided to attend the Unite for Sight Global Health and Innovation conference that’s hosted at Yale every spring. It’s the world’s largest global health conference that convenes professionals and students from more than 55 countries, and that year there happened to be a large number of speakers from PIH.

A year later, hard work coupled with serendipity led me to move to Rwanda. I was studying microbiology at the time with the long-term goal of attending medical school. Rwanda had achieved significant strides in the health sector despite the fact it is an impoverished country. Interested in understanding the global health field better, I reasoned it would be worthwhile to immerse myself there. With the support of UVM faculty, I took seven months to conduct research in Rwanda.

While there, I was working with Dr. Agnes Binagwaho, now vice chancellor of the University of Global Health Equity  and a senior lecturer on global health and social medicine at Harvard Medical School. I lived in the capital of Kigali at a staff house for Inshuti Mu Buzima, as PIH is known locally. The work I did with Dr. Binagwaho provided me a unique opportunity to better understand the Rwandan health system, and my housing provided me with insight into the non-profit realm. I learned that PIH wasn’t like other NGO’s; it didn’t seek to impose what it perceived Rwanda needed, and instead took the revolutionary approach of listening to the needs of the country first and then acting in accordance with those needs.

After returning to the United States and graduating, I took a job working for Dr. Joia Mukherjee, PIH’s chief medical officer. While I didn’t quite know what was next, I was certain that I wanted to work with PIH before embarking on my path through medical school. Joia was in the process of publishing her first book, An Introduction to Global Health Delivery: Practice, Equity, Human Rights, and I had the unique privilege of assisting at the 11th hour. It was while working with Joia that I was able to further understand how inequality contributed to poverty, racism, and health outcomes. I drew connections between what most impoverished countries faced, and the present condition in my home country of Puerto Rico.

As a native Puerto Rican, I was raised among stark dichotomies. Like many of the countries where PIH works, Puerto Rico has a history of colonization, exploitation, and imposition of neoliberalist principles. We have been another instrument in America’s toolbox for purposes of medical research, war weapons, cheap labor, tax havens, and the optimization of private markets. For further evidence of the systemic racism by the United States toward Puerto Rico, look no further than the U.S. response to Hurricane Maria in September 2017. 

The U.S. response to the hurricane’s devastation of my home country infuriated me. PIH doesn’t work in Puerto Rico, yet my colleagues helped me acquire more than 150 pounds worth of essentials, including food, portable solar-powered lights, batteries, and monetary donations, and I flew down one week after the hurricane hit. Research for Joia’s book sparked my interest in getting further involved in domestic issues, and inspired a sense of urgency to contribute to advancing policies that directly affected Puerto Ricans and other marginalized communities.

That sentiment followed me into my current role as the manager of PIH’s grassroots strategy through the Engage program. PIH Engage is directly informed by the work the organization does in the field and uses that example to demonstrate that providing access to health for everyone is possible and should be our moral imperative. We target elected officials and their staff at all levels of government and show them what is possible when funds are allocated correctly. We also partner with other amazing organizations, such as Act Up, Health Gap, and Housing Works, to amplify their messages in support of health care as a human right. Our work also includes supporting domestic legislation that seeks to advance the universal health coverage movement.

I work with incredibly inspiring and dedicated volunteer community organizers, ranging from high school and college students to late-career professionals, who have a deep desire to improve the present condition for marginalized people. The PIH Engage network understands what happens when health care is unavailable, and they educate their communities, organize teams, generate resources, and advocate for policies that further the health for all movement.

While in college, I was always aware I wanted to do more. I fixated on understanding problems at their root. I was deeply aware of what happened when people in power were not held accountable. Against advice from most people in my life, I moved to Rwanda and then decided to take a couple of years off from formal schooling. The result has been an invaluable education and a deep knowledge that there is more than one way to achieve your goals.

I’ve come to realize that what matters most to me is using the privilege geography has afforded me to amplify the voices of those who were not lucky enough to be born within select parts of the world. I’ve come to understand that health care can be a tool for social change. We must dismantle existing structures used to perpetuate injustices and focus on achieving equity. My plan, and personal honor, is to be among the thousands of individuals around the world working toward  that dismantling so that, together, we can build a better, more just health care system for all.

Wed, 20 Feb 2019 21:37:27 -0500
PIH Staff Safe, Facilities Open But Struggling During Unrest in Haiti Partners In Health staff and patients remain safe and health facilities open despite more than eight consecutive days of strikes and civil unrest that have broken out throughout the country.

The situation is growing ever more dire as food, clean water, and fuel for generators and ambulances become increasingly difficult to transport from the capital to PIH’s 12 clinics and hospitals across the Central Plateau and lower Artibonite. If the situation continues, bedside oxygen and medications will run short as well.

According to the Miami Herald, at least eight people have died since Feb. 7 in violent clashes between police and demonstrators. Schools, businesses, and public transportation have been shut down in the wake of the political and economic crisis, largely sparked by skyrocketing prices, a rapidly devalued currency, and chronic fuel shortages. Blockades prevent travel, and residents are reluctant to leave their homes.

Hospitals throughout the country have closed, including the Hospital of the State University of Haiti—the largest public hospital in the country, as staff do not arrive for shifts and supplies have become scarce. 

The unraveling situation has made it particularly difficult for staff with Zanmi Lasante, as PIH is known in Haiti, to get to and from facilities and transport supplies. And patients are being turned away at road blocks when seeking emergency and routine care.

To help us prepare for emergency response in Haiti, please DONATE HERE.

Fri, 15 Feb 2019 12:53:38 -0500
UGHE Alumni Spotlight: Benjamin Ndayambaje Benjamin Ndayambaje is a Rwandan who grew up in a refugee camp in Uganda. A trained veterinarian and former veterinary surgeon, he graduated in the University of Global Health Equity’s inaugural Class of 2017. While earning his master’s of science degree in global health delivery, he focused on one health, which involves the integration of health for people, animals and the planet. 

Can you describe where you grew up? What were your aspirations when you were younger?

I was born and grew up in Uganda, in a refugee camp. Life there wasn’t easy for people from foreign countries. There were long distances to school, or to a clinic for medical checkups and treatments. The scarcity of resources created bottlenecks for most refugees. Environmental and hygienic conditions were not good in the camp. As a child, I aspired to be a medical doctor to save lives—especially for those in need. 

As I grew up, my aspirations and interests changed, particularly as I spent time with my grandpa during school holidays. I enjoyed looking after my grandpa’s herd of cows. My grandpa taught me how to milk, and how to take care of young calves. He couldn’t treat some of their diseases, though, and we lost quite a number of cows to curable diseases. We couldn’t get enough milk for home consumption and selling. From that experience, I became determined to work hard and save our animals from diseases. My interest in saving animals for the benefit of people’s wellbeing has grown since then. I aspired to be a veterinarian to treat and protect animals from diseases. 

Can you give a brief overview of your professional background? What were you doing before you began attending UGHE?

I hold an undergraduate honors bachelor’s degree in veterinary medicine from the University of Rwanda. I am a registered veterinarian, and practiced for one year as a private veterinary surgeon. Early in 2013, I worked as a manager for the Institute of Livestock Research and Development (ILRD). I managed the Innovative Program for Enhancing Milk Production (IPEMP) in the Umutara region, to help address the multitude of challenges for farming communities in northeastern Rwanda, primarily through research and outreach activities.

Later in 2013, I was recruited as a junior faculty member in the department of veterinary medicine at the University of Rwanda. I co-founded a One Health Students Club, which was later named “Students’ One Health Innovative Club,” as a platform for university students from various disciplines to collaborate on the most pressing community challenges. In the same year, I acted as managing director of Hobas Ltd. With support from USAID and the Land O’Lakes dairy and agriculture company, Hobas trained 500 farmers in dairy-related enterprises, to improve milk production for both home consumption and surplus sales in Rwanda’s Eastern Province.

In 2014-15, I won a competitive fellowship with Global Health Corps, and was placed in a senior position with the food security and livelihoods program with Partners In Health, known in Rwanda as Inshuti Mu Buzima. Moreover, I joined an online learning initiative through Harvard University and took a course titled, “Improving Global Health: Focusing on Quality and Safety,” and earned a certificate upon completion.

What inspired you to apply to UGHE?

I strongly believe health is a human right! Since childhood, I’ve wanted to save animals to improve people’s health and wellbeing.  Life in the camp in Uganda, as the son of a refugee, and my Global Health Corps experience with Partners In Health inspired me to apply for UGHE. Moreover, the UGHE mission and vision were stepping stones for me to acquire more skills and knowledge to participate in the global health arena.

Can you describe your studies at UGHE? What did you focus on?

Studies at UGHE focused on shaping future global health leaders capable of identifying and defining global health pathologies, and knowing how to address them effectively and strategically. At UGHE I explored strategic problem-solving; experiential and hands-on learning; leadership and management training, focused on defining the role of global health leaders in addressing intertwined health challenges; and one health, which encourages multi- disciplinary collaboration to address health challenges facing humans, animals and the environment.

My focus was on one health. My capstone report focused on the use of pesticides and their effects on human, animal and environmental health in eastern Rwanda. Results of the study revealed the effects of improperly applied pesticides on humans, animals, and ecosystems. Moreover, the study recommended a multidisciplinary approach to address such health challenges, which are always multi-faceted in nature.

What was the most valuable thing you learned at UGHE? What was your favorite class?

The most valuable thing I learned at UGHE is that health is a human right, and global health is a complex web of challenges. Leadership plays a vital role in managing and strengthening health systems. 

Favorite classes: 
1.    Principles of Global Health (first class by Dr. Paul Farmer, PIH co-founder and chief strategist) 
2.    One Health (by Dr. Hellen Amuguni, of the Cummings School of Veterinary Medicine at Tufts University) 
3.    Leadership and management (by Cloe Liparini, senior advisor for leadership development programs)
How did UGHE prepare you to work in global health? What have you been doing post-graduation?

Global health challenges are multi-faceted, and thus require a holistic approach. UGHE prepared me to think systematically and strategically when approaching global health challenges. Biosocial analysis is paramount when addressing global health. Using human-centered design skills gained at UGHE, my current project is designed to address root causes of health challenges and meet the needs of a targeted group of people. 
Because the one health field encourages multi-disciplinary collaboration in addressing global health challenges, my project involves a diverse group of professionals.

Since graduation, I've taught at the University of Rwanda—applying global health tools acquired at UGHE—while working on global health projects. I'm now pursuing my PhD in applied ecology and one health, at the University of Nebraska's College of Agricultural Sciences and Natural Resources

Benjamin Ndayambaje at UGHE graduation in 2017
Benjamin Ndayambaje addresses his peers during commencement for UGHE's Class of 2017, in the master's of science in global health delivery program. (Photo by Zacharias Abubeker / for UGHE)

What inspires you to work in global health?

What inspires me most is giving back to my community, and giving a hand to the most in need. It always feels great. Helping people who need a hand, without expecting a reward or gain of any kind, give me peace of mind.  

What are the biggest rewards of working in global health? What are the biggest challenges?

The biggest reward is giving the voiceless a chance to speak up, by listening to them and helping them figure out better ways to move out of poverty and improve the health of themselves and their families.  

The biggest challenges include leadership and management, accountability, and humility among others in the global health arena. Also, understanding global health as an intertwined set of problems and learning how to approach them effectively. Collaborative efforts to solve challenges are still minimal at local, national and global scales. Experience with numerous global health threats—outbreaks, pandemics and epidemics—such as HIV, H1N1, Ebola,  and others, shows that collaboration, leadership and management all play a vital role in containing, preventing, predicting and fighting against these threats.

Furthermore, as Dr. Paul Farmer said: "The idea that some lives matter less is the root of all that's wrong with the world.” I strongly agree with him. We as global health leaders need to fight for global health equity, while promoting humility, advocating for the voiceless and making the world a better place for all human beings.

What do you hope to achieve through your career in global health? Why is this work important?

I hope to play a role in improving the health and well-being of many people, especially those in need. This will be done through advocating for the voiceless and poor families, and designing human-centered research and development projects (likely involving food security and livelihood), especially in the developing world. I envision becoming a global health leader as a researcher and consultant.

I was born in a refugee camp. My personal hardships and experiences have laid the ground for me to strive for progress, and make the world a better place for everyone. It’s not only rewarding, but also a great feeling and accomplishment to help those who can’t help themselves. I always aspire to make a difference in the lives of those in need, and give them hope for future. 

What advice would you give to young global health professionals?

The best advice I can give to young global health professionals is to work hard with humility, collaborate among themselves, and bring the best out of themselves by fighting for global health equity. 

Today, more than ever, we have the best global health experience and tools—such as technological knowhow, skills and knowledge—to address these challenges. We need global health leaders who are optimistic and not afraid to confront these challenges, with the mission of health for all and health care as a human right. 

Watch Ndayambaje explain his capstone project on pesticide safety for Rwandan rice farmers, in a UGHE video here.

Wed, 13 Feb 2019 14:50:59 -0500