Partners In Health Articleshttps://www.pih.org UGHE Student Studies Soil-Related Disease Afflicting Farmers https://www.pih.org//article/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.”

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Tue, 23 Apr 2019 14:33:33 -0400 https://www.pih.org//article/ughe-student-studies-soil-related-disease-afflicting-farmers
Major Milestones in PIH History https://www.pih.org//article/major-milestones-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.


1983

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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1987

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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1990

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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1994

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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1998

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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2003

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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2004

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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2005

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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2006

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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2007

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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2009

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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2010

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

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2010

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

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2010

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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2011

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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2012

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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2013

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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2014

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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2015

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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2018

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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2019

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 https://www.pih.org//article/major-milestones-pih-history
PIH TB Leader Urges Faster Rollout of New Treatments https://www.pih.org//article/pih-tb-leader-urges-faster-rollout-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.

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Thu, 18 Apr 2019 14:45:17 -0400 https://www.pih.org//article/pih-tb-leader-urges-faster-rollout-new-treatments
PIH Leader Addresses UN on Women, Girls’ Situation in Haiti https://www.pih.org//article/pih-leader-addresses-un-women-girls-situation-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.

 

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Thu, 04 Apr 2019 11:45:33 -0400 https://www.pih.org//article/pih-leader-addresses-un-women-girls-situation-haiti
Dr. Marta Lado: From Ebola Fighter to PIH-er https://www.pih.org//article/dr-marta-lado-ebola-fighter-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.

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Mon, 01 Apr 2019 22:30:12 -0400 https://www.pih.org//article/dr-marta-lado-ebola-fighter-pih-er
Dr. Michelle Morse: Leading a New Generation of Global Health Clinicians https://www.pih.org//article/pih-doctor-helps-train-the-next-generation-of-haitian-physicians 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.

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Mon, 01 Apr 2019 16:57:40 -0400 https://www.pih.org//article/pih-doctor-helps-train-the-next-generation-of-haitian-physicians
Dr. Joia Mukherjee: PIH's Global Health Warrior https://www.pih.org//article/dr-joia-mukherjee-pihs-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.

Book
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.

Rally
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.

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Mon, 01 Apr 2019 15:27:20 -0400 https://www.pih.org//article/dr-joia-mukherjee-pihs-global-health-warrior
Graciela Cadet: Inspiring Nurse Leader in Haiti https://www.pih.org//article/graciela-cadet-inspiring-nurse-leader-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.

 

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Mon, 01 Apr 2019 14:29:16 -0400 https://www.pih.org//article/graciela-cadet-inspiring-nurse-leader-haiti
Working in Global Health: Karim Llaro on 20 Years as a TB Nurse in Peru https://www.pih.org//article/working-global-health-karim-llaro-20-years-tb-nurse-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.

 

 

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Fri, 22 Mar 2019 18:18:13 -0400 https://www.pih.org//article/working-global-health-karim-llaro-20-years-tb-nurse-peru
Farewell to the Grave: Bobby’s Battle with Multidrug-Resistant TB https://www.pih.org//article/farewell-grave-bobbys-battle-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). 

 

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Fri, 22 Mar 2019 11:58:54 -0400 https://www.pih.org//article/farewell-grave-bobbys-battle-multidrug-resistant-tb
“Out of Breath” Provides Inside Look of North Korea’s Battle Against TB https://www.pih.org//article/out-breath-provides-inside-look-north-koreas-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

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Thu, 21 Mar 2019 13:55:07 -0400 https://www.pih.org//article/out-breath-provides-inside-look-north-koreas-battle-against-tb
Innovation: Contraception Program Empowers Women in Haiti https://www.pih.org//article/innovation-contraception-program-empowers-women-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.

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Tue, 19 Mar 2019 18:08:00 -0400 https://www.pih.org//article/innovation-contraception-program-empowers-women-haiti
The Evolution of Cancer Care in Haiti https://www.pih.org//article/evolution-cancer-care-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.

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Tue, 19 Mar 2019 11:06:02 -0400 https://www.pih.org//article/evolution-cancer-care-haiti
Celebrating Six Years of Accomplishments at University Hospital in Haiti https://www.pih.org//article/celebrating-six-years-accomplishments-university-hospital-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 https://www.pih.org//article/celebrating-six-years-accomplishments-university-hospital-haiti
Lancet Global Health Article Proposes Path to Universal Health Coverage https://www.pih.org//article/lancet-global-health-article-proposes-path-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. 

 

 

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Fri, 15 Mar 2019 10:13:51 -0400 https://www.pih.org//article/lancet-global-health-article-proposes-path-universal-health-coverage
Floods Kill Dozens, Leave Thousands Homeless in Malawi https://www.pih.org//article/floods-kill-dozens-leave-thousands-homeless-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.

 

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Tue, 12 Mar 2019 10:31:19 -0400 https://www.pih.org//article/floods-kill-dozens-leave-thousands-homeless-malawi
In Mexico, A Traditional Midwife and Teenage Mom Share Special Bond https://www.pih.org//article/mexico-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.

 

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Wed, 06 Mar 2019 13:46:37 -0500 https://www.pih.org//article/mexico-traditional-midwife-and-teenage-mom-share-special-bond
Blessings Henry, Neno's Feminist Future Doctor https://www.pih.org//article/blessings-henry-nenos-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.”

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Mon, 04 Mar 2019 15:44:17 -0500 https://www.pih.org//article/blessings-henry-nenos-feminist-future-doctor
Public Defender: Benson Chabwera Dedicated to Neno Community https://www.pih.org//article/public-defender-benson-chabwera-dedicated-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.”

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Fri, 01 Mar 2019 13:00:00 -0500 https://www.pih.org//article/public-defender-benson-chabwera-dedicated-neno-community
Haiti Facing Severe Shortages, ‘New Normal’ Following Weeks of Unrest https://www.pih.org//article/haiti-facing-severe-shortages-new-normal-following-weeks-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. 

 

 

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Fri, 01 Mar 2019 10:13:52 -0500 https://www.pih.org//article/haiti-facing-severe-shortages-new-normal-following-weeks-unrest
Research: Clinic Visits, Diagnoses Increase When Patients Access Free Care in Malawi https://www.pih.org//article/research-clinic-visits-diagnoses-increase-when-patients-access-free-care-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.

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Tue, 26 Feb 2019 14:25:05 -0500 https://www.pih.org//article/research-clinic-visits-diagnoses-increase-when-patients-access-free-care-malawi
Rising Star 'Kankwanzi' a Masonry Role Model on UGHE Site https://www.pih.org//article/rising-star-kankwanzi-masonry-role-model-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

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Tue, 26 Feb 2019 11:19:22 -0500 https://www.pih.org//article/rising-star-kankwanzi-masonry-role-model-ughe-site
UGHE Alumni Spotlight: Irene Murungi https://www.pih.org//article/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. 


 

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Mon, 25 Feb 2019 16:41:55 -0500 https://www.pih.org//article/ughe-alumni-spotlight-irene-murungi
PIH Staff: ‘Haiti Under Siege’ as Medical Crisis Intensifies https://www.pih.org//article/pih-staff-haiti-under-siege-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.

 

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Thu, 21 Feb 2019 15:32:26 -0500 https://www.pih.org//article/pih-staff-haiti-under-siege-medical-crisis-intensifies
Working in Global Health: Gabriela Sarriera on Grassroots Activism https://www.pih.org//article/working-global-health-gabriela-sarriera-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.

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Wed, 20 Feb 2019 21:37:27 -0500 https://www.pih.org//article/working-global-health-gabriela-sarriera-grassroots-activism
PIH Staff Safe, Facilities Open But Struggling During Unrest in Haiti https://www.pih.org//article/pih-staff-safe-facilities-open-struggling-during-unrest-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.

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Fri, 15 Feb 2019 12:53:38 -0500 https://www.pih.org//article/pih-staff-safe-facilities-open-struggling-during-unrest-haiti
UGHE Alumni Spotlight: Benjamin Ndayambaje https://www.pih.org//article/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.

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Wed, 13 Feb 2019 14:50:59 -0500 https://www.pih.org//article/ughe-alumni-spotlight-benjamin-ndayambaje
UGHE Alumni Spotlight: Titus K. Koikoi https://www.pih.org//article/ughe-alumni-spotlight-titus-k-koikoi Titus K. Koikoi is a program director for global health nonprofit Population Services International, in his home country of Liberia. In 2016-17, he was one of 25 health care leaders to complete the inaugural Executive Education course through the Global Health Delivery Leadership Program (GHDLP), at the University of Global Health Equity in northern Rwanda. The GHDLP was designed to equip trainees with management and leadership skills, and explore a range of replicable innovations in global health delivery. After an intensive two-week session on campus, participants completed a six-month project implementation period, with guidance and support from a mentor. 

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

I grew up in a small town of about 3,000 people, called Fissebu, in Lofa County, northern Liberia. Both of my parents were teachers, so we lived in staff quarters on the campus of the Zorzor Rural Teachers Training Institute (ZRTTI), where my father had been working, primarily training other teachers. We had electricity and pipe-borne water in our homes on the ZRTTI campus, and I could clearly see the disparity between marginally poor people and those who could afford basic social services. The campus is located about a mile away from the town. Fissebu is still there today, and is pretty rural. People live in huts and mud houses, with a few concrete houses. There are a few hand-pumps for water, plus a lot of hand-dug wells. Most of the town’s residents use a small creek for washing clothes and bathing. Most people use the forest for defecation. The town has one clinic and two senior secondary schools, and a computer training institute was recently opened about two miles from the heart of town. The basic means of survival for people in Fissebu is subsistence farming.

Can you give a brief overview of your professional background?

I’ve worked in global health programs and project management for more than eight years. My work has usually focused on grant management; health systems strengthening; capacity building; service delivery; data management and usage; community engagement and advocacy; government and civil society coordination; and water, sanitation, and hygiene (WASH). I’ve managed budgets of up to US$9.5 million, and currently work as program director for Population Services International (PSI) in Liberia, where we implement the USAID-funded Partnership for Advancing Community-based Services (PACS), and a Global Fund HIV project focusing on key populations. I have a master’s degree in public health and have worked as a public health professional for more than 10 years. 

What inspired you to apply to the GHDLP?

GHDLP’s program curriculum was very interesting. I could clearly see how participating in the program would allow me to apply my program management skills to real-life situations and learning. I saw that the program was modeled to bring together experts from diverse backgrounds and expertise, to discuss challenges and find ways to make implementation/service delivery better and more efficient. UGHE’s interest in rethinking health service delivery, so that the ultimate goal is quality service delivery to the beneficiaries, stood out for me. I was fascinated by such a unique training model.  

Can you describe your experience at the intensive, on-campus portion of the GHDLP course? 

My time at the GHDLP program was rewarding. I had a mix of both rural and urban experiences. I expanded my professional network and used the opportunity to discuss practical solutions around the many global health challenges we’re currently facing. I learned about innovative ways in which lessons from program implementation can enhance learning in the classroom. 

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

UGHE has begun a movement that seeks to encourage everyone involved with global health delivery to begin rethinking health care and looking into more efficient delivery models. This was the most valuable thing for me. I also enjoyed the case studies. While the case studies touched on very pivotal global health issues and highlighted smart solutions in some cases, they were also an eye-opener to demonstrate that some of the problems in global health have been there forever, and because we continue to do business as usual, those problems are still there. There is more than sufficient evidence to justify the need to innovate, rethink and be more efficient.

Please explain what types of mentorship you received. 

My team from Liberia developed a breakthrough project, and after the training in Kigali, we received mentorship in implementation, follow-up, mobilizing resources, writing reports and presenting the project. A team of experts from UGHE’s core faculty provided the mentorship remotely.  

Can you give an example of a time you used something you learned at UGHE in your workplace at PSI?

I was able to immediately set up an efficient feedback system on my return to work at PSI. Feedback can mean different things to different people. Most often, we feel feedback should only be negative, or should only flow from supervisors to their staff. I learned a different way of providing feedback while at UGHE, and I was able to utilize this learning appropriately. Feedback can be both negative and positive; feedback should flow from supervisors to their staff, and vice versa. This is one way to build a more transparent workplace and maintain a highly motivated and confident workforce. 

How has PSI benefited from your participation in the GHDLP program?

I returned from the GHDLP training course in December 2016, re-energized and with a lot of great new ideas. I’ve been able to transfer new skills and techniques to other managers, and I’ve shared various learning tools and materials with other colleagues for their professional growth. Overall, the GHDLP experience helped me contribute more and better to the awesome work PSI does in Liberia. I’m happy to have had the opportunity. 

Titus K. Koikoi
Titus K. Koikoi said he wakes up "every day remembering that service to humanity is the proudest engagement ever, and that health is an integral component of a more just, safe and better society." (Photo courtesy of Titus K. Koikoi)

What inspires you to work in global health?

I’m passionate about service to mankind. I get inspired every day knowing that the decisions I make, the actions I take, and the networks that I build, support and join, all go toward ensuring that a child somewhere receives timely vaccinations, a sex worker is tested for HIV, someone living with HIV is enrolled in care and treatment, someone in a village is treated for malaria, children learn in safe and healthy environments, people in villages have access to safe and clean water, and more. 

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

I wake up every day remembering that service to humanity is the proudest engagement ever, and that health is an integral component of a more just, safe and better society. I feel humbled that my work in global health gives me an opportunity to plan and manage service delivery for my fellow Liberians, and by extension, the world’s population in general. I feel challenged on a daily basis to give back to society, and to be a critical voice that advocates for access to health by all. I feel challenged and encouraged to contribute to local and global health care policies that ultimately affect health care and service delivery at the very peripheral level, and for the common person. 
There are manpower challenges in global health, and that is one reason why there’s a need for training more global health leaders. As a result of this challenge, I’ve seen little or no impact come out of huge health care investments over time. My home country is an example. It will take a great deal of innovation and rethinking, using models like the one developed by UGHE, to change the current paradigm. There are also huge disparities in terms of wealth distribution and access to care, and poorer people continue to feel the pinch of expensive health care across the globe, while the rich can afford to pay for foreign health care services. This must end now!

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

My hope is to see a more robust, efficient and resilient health care delivery system not only in Liberia, but also in countries where health service delivery to people in need is still a huge challenge. I hope my work always allows me to add my voice and hands to efforts that ensure under-served and under-privileged populations have frequent access to health care services. This remains one of the most critical things to supporting global security, fostering economic growth and maintaining political stability. 

What advice would you give to young global health professionals?

UGHE is an ideal platform for improving the skills and expertise of young global health professionals. Take up a course as soon as possible! While we all strive to prioritize efforts in global health and make the world a better place, we must now begin to innovate and rethink health care delivery. We cannot continue to do business as usual and expect different results. UGHE has practical solutions through the programs they’ve designed. I would recommend all young global health leaders and professionals apply to UGHE today. 

Read more from Koikoi in a 2017 interview with UGHE, here.

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Wed, 13 Feb 2019 14:19:09 -0500 https://www.pih.org//article/ughe-alumni-spotlight-titus-k-koikoi
UGHE Alumni Spotlight: Dr. Grace Dugan https://www.pih.org//article/ughe-alumni-spotlight-dr-grace-dugan Dr. Grace Dugan is an Australia native who graduated with UGHE’s Class of 2018. She earned her master’s of science in global health delivery while working for Partners In Health, known in Rwanda as Inshuti Mu Buzima, in the pediatric oncology ward at the Butaro Cancer Center of Excellence in northern Rwanda. 

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

I grew up near Warwick in Queensland, Australia. This is a rural, farming area two hours away from a big city (Brisbane). My main aspiration throughout my school years was to be a novelist, though I did have an interest in social justice and formed an Amnesty International club at my high school. A school careers counselor actually sent me to a rural health careers workshop that was aimed at encouraging rural students into medicine, nursing and allied health. She thought it would be a good fit for me because I had good marks in sciences and it would be a way to do good in the community, but I was completely uninterested. I just wanted to write books.

Can you give a brief overview of your professional background? What were you doing before you began attending UGHE, and what inspired you to apply to the university?

I’m a medical doctor and I had been working in Australia and New Zealand for 3.5 years before getting a job in global health. When I applied for a spot at UGHE I was working in Papua New Guinea in multidrug-resistant tuberculosis (MDR-TB), which was an extremely challenging but deeply rewarding and, without exaggeration, life-changing experience. I had basically jumped ship from the normal career pathway for Australian doctors and figured out that I wanted to work in global health forever, but had no idea what to do next. Just before going to Papua New Guinea, I discovered Paul Farmer’s books and read most of them, so that led me to PIH and then to UGHE. At the time I applied I was in a bad patch in my job, and I wanted something to look forward to in the future. I didn’t expect to get in, and when I did get in I at first decided to ask for a deferment because I felt really bad about leaving my patients. But when I told my wonderful boss, Stenard Hiarsihri, he gave me his blessing and encouragement, and I decided to go.

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

It’s a diverse program, which I really liked. We started with a semester that essentially was about the history and politics of global health, then we did research methods, then management, and a practicum. We also had shorter courses in political economy, leadership, and management and communications, which were all great. Everyone is working full time, and I was very lucky to be offered at job at Partners In Health, known in Rwanda as Inshuti Mu Buzima, where I worked in pediatric oncology at Butaro Hospital in northern Rwanda. I based my practicum on one of the huge challenges we faced at Butaro: how best to treat acute lymphoblastic leukemia, which is a common childhood cancer with very challenging treatment. In high-income countries, it is almost always curable, but the treatment is complicated, lengthy and with potentially fatal side effects, so finding the best way to treat it is not easy.

Dr. Grace Dugan participates in a class at UGHE
Dr. Grace Dugan participates in a master class at the University of Global Health Equity. (Photo by Amani Hatangimana / for UGHE)

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

I don’t have a favorite class, there was so much of it that was so wonderful. We were lucky to have a great faculty with an amazing array of practical experience. There were some challenges for our cohort, but I always felt so supported, encouraged and valued. It was so great to be in an institution which shared my values, and it made me feel like the sky’s the limit for what we could accomplish.

How did UGHE prepare you to work in global health? What have you been doing post-graduation?

I was already working in global health prior to and throughout the course, but in largely clinical roles. The master’s of science in global health delivery program gave me more confidence to take on managerial and leadership positions, and to potentially start my own project. A month after graduation, I was working in the Marshall Islands in the central Pacific Ocean, in an ambitious project which involved screening 22,000 people for TB and leprosy, as well as treating 4,500 people for latent TB. The project was led by a CDC doctor, Dick Brostrom, who has been a real leader in working to give TB patients in the Pacific access to high-quality treatment. It was a real privilege to work with him.

What inspires you to work in global health? What are the biggest rewards of working in global health, and the biggest challenges? 

I think of the work as an expression of solidarity with some of the world’s most vulnerable people. I find it inspiring to work with others who share a sense of the injustice of how global resources are distributed. It’s also wonderful as a doctor to be able to relieve suffering, though to be able to relieve it you first have to be able see it, and seeing it can be overwhelming. I’ve met doctors from rich countries who’ve told me they couldn’t cope with what they witnessed in poor countries, and didn’t want to work in those environments. For me, I remind myself that incredible suffering is taking place whether I’m witnessing it or not, so I may as well try to lend a hand.

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

One of my goals is to return to working in Papua New Guinea, where things are really terrible in terms of health care. When I was working there I noticed a sense of fatalism and a desire to blame the people or the culture for their health problems, but in my experience, patients sacrificed an enormous amount to receive treatment and it was possible to accomplish a lot.

Dr. Grace Dugan checks a patient in the pediatric ward at Butaro District Hospital.
Dr. Grace Dugan examines Frank Mugisha (pseudonym), then 6, in March 2017 in the pediatric ward at Butaro District Hospital. Frank had just completed 30 months of treatment for acute lymphoblastic leukemia. (Photo by Cecille Joan Avila / Partners In Health)

What advice would you give to young global health professionals?

UGHE students come from very different backgrounds, and I can only really give advice to those who are like me and come from high-income countries. Working in global health usually involves poor job security and you may want to do unpaid work, as well, so it’s helpful to avoid debt if you can, either from study or from a mortgage. It can be socially isolating so it’s important to look after your friendships, with people who support you and who understand your drive. There are a lot of people who like to complain about how difficult the work is, and that’s not a productive discussion to be having all the time. I get a lot of strength from staying in touch with friends in Papua New Guinea, Rwanda, Peru and the Marshall Islands, who all are really passionate about improving the health of their people.

It’s also good to remember that a lot of people who would really like to do this work are unable to because of other responsibilities, or because they don’t have the skills or the opportunity, so if you want to and you can, then you probably should. It doesn’t matter if it doesn’t lead to anything else or advance your career, the point is to do the work that needs to be done. And if you do one job and find that it didn’t work out, like you didn’t agree with the values of the organization or you didn’t feel you were accomplishing anything, don’t give up. With a bit of reflection and research, you might figure out what you’re hoping to achieve and find the right way to do that.

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Wed, 13 Feb 2019 13:26:20 -0500 https://www.pih.org//article/ughe-alumni-spotlight-dr-grace-dugan
Surgery, New Home Empower Young Mother in Malawi https://www.pih.org//article/surgery-new-home-empower-young-mother-malawi Wearing a “Feeling Lucky” T-shirt as she held her children close, Rose Kapeni* gently opened the front door of her new home and leaned forward to look inside. 

She smiled, and sighed in happiness and relief. Then she walked in to check out her new surroundings—with an excited group of friends and supporters right behind her. 

The joyous home-handover ceremony for Kapeni and her three children was filled with singing, dancing and laughter Feb. 7 in Neno District, Malawi, where friends, community members, and Partners In Health staff gathered to formally present and open the newly built home. The ceremony culminated a long period of illness and recovery for Kapeni, and showed how community-based health care can help provide healing that is far more than physical. 

“I’m beyond grateful that I was found and supported during this very difficult time,” Kapeni said. “I hope and pray PIH can continue to do this work, as there are many others in the community who are struggling.”

Kapeni, 25, went through more than her share of struggles.

A longtime HIV patient, she began suffering severe health problems in June 2016, when a persistent skin condition became debilitating. Her attempts to have surgery for the condition at Queen Elizabeth Central Hospital in Blantyre, Malawi’s second-largest city, failed. Twice, she was unable to have surgery because the surgeon wasn't there; a third time, the hospital did not have blood available in case she needed a transfusion. Travel to the hospital was long and difficult. 

Because of her condition and associated stigma, Kapeni’s husband left her and much of her family abandoned her. As money ran short, Kapeni almost gave up on having the surgery. 

When staff with PIH—known locally as Abwenzi Pa Za Umoyo—visited her home last September, they found Kapeni bedridden, essentially unable to move. 

The PIH clinical officer visited Kapeni to find out why she was missing follow-up appointments for HIV. Kapeni had been dedicated to antiretroviral therapy (ART) since 2014, so it was concerning that she was not taking her medication, and was missing checkups. 

The clinical officer discovered that Kapeni was no longer able to leave her home due to the skin condition, which by that time she had been living with for more than four years. Her HIV viral load was very high. She and her children lived in a small, crumbling structure with no solid walls, an incomplete thatched roof, and very limited food. Her condition made it painful for Kapeni to sit, or even to move. Motorbike rides to visit health facilities had become too painful. 

Rose Kapeni's former home
When PIH clinical staff visited Rose Kapeni in September, they found her bedridden in this unstable home, suffering from a debilitating skin condition and struggling to care for her children. (Photo by Mark Chalamanda / Partners In Health)

PIH’s clinical HIV team quickly mobilized, along with community health workers and the program on social and economic rights, or POSER, which addresses social and economic causes of poor health. The close coordination between all those teams ensured Kapeni quickly got comprehensive care, and soon resumed her ART. 

POSER staff provided a large bag of maize, along with emergency financial support for her hospital stay. POSER also coordinated transportation to Neno District Hospital, where, at the end of September, PIH’s medical director and a visiting surgeon successfully conducted Kapeni’s long-awaited surgery, fixing her condition. Her community health worker, Ida Simion, cared for Kapeni’s three children while she was hospitalized. 

Recovering at the Neno hospital last fall, Kapeni explained that throughout her ordeal, her only strength had come from her children: her son, 9, and two daughters, 6 and 2. All three children are HIV-negative. Kapeni knew she had to be there for them, so she persevered through the pain and stigma. 

“Problems come to anyone in life, and you just have to stay strong,” she said. 

After four weeks in the hospital, Kapeni returned to her home in Tiyese Village and, finally, began the long process of starting anew. 

Her vitality was evident in December, when Kapeni buzzed with energy while visiting PIH’s main office in Neno. She laughed as she talked with staff, joking and carrying herself with a renewed confidence. 

She and her children now have an additional source of strength.

Rose Kapeni and her children at their new home, February 2019 in Neno
Rose Kapeni, center and holding her three children, receives the key to her new home during a joyous ceremony Feb. 7 in Neno District, Malawi. The ceremony and new home, funded by a private donor, culminated a long, grueling period of illness, recovery and resilience for Kapeni and her children. (Photo by Elise Mann / for Partners In Health)

The POSER team worked with the community and Kapeni’s family to buy land for a new home. POSER had built 109 homes in Neno District since PIH’s arrival in 2007, and it was clear that the 110th could be for Kapeni, if funding could be found. Thankfully, a private donor provided money for the permanent, two-bedroom home for Kapeni and her children. 

John Living Munthali, infrastructure manager for PIH in Malawi, said construction of the home started in December and took six weeks. Crews molded bricks right on the site, nestled in a small community in Neno's Matandani area.

“We believe that treatment alone is not enough,” said Victor Kanyema, POSER program manager. “Working in collaboration with clinical teams, we make life better for all the people we serve in Neno.”

*Name changed

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Tue, 12 Feb 2019 11:10:31 -0500 https://www.pih.org//article/surgery-new-home-empower-young-mother-malawi
Eliminating TB, One Van at a Time https://www.pih.org//article/eliminating-tb-one-van-time The imminent launch of two vans equipped with state-of-the-art technology to test for tuberculosis (TB) and multidrug-resistant tuberculosis (MDR-TB) marks a major milestone for PIH’s and Peru’s fight against TB, the leading infectious killer of adults in the world. Within coming weeks, these trucks will enable PIH to carry out a new screening program called TB Móvil, which will search for, diagnose, and refer TB and MDR-TB cases in the three northernmost districts of Peru’s capital, Lima.

TB Móvil is one of various strategies that comprise a new ‘TB Elimination’ campaign, led by a coalition of PIH and partner organizations in northern Lima, which aims to rapidly drive down TB rates. It is the first time PIH is launching such a campaign. The TB Móvil component focuses on bringing testing closer to where people live, in order to search for and promptly treat TB and MDR-TB. The goal in 2019 is for the vans to drive through northern Lima and offer 100,000 people a free, fast way to be tested for the disease and gain access to treatment.

Once inside the truck, volunteers will receive a chest X-ray and—if necessary—a sputum test, the results of which are delivered in mere minutes thanks to advanced automated radiography and GeneXpert machines—two technologies that would otherwise be unavailable to poor patients. A clinician will evaluate the results and, if they test positive for TB, connect them to public health centers for a quick start to lifesaving treatment.

By actively searching for patients and bringing rapid testing, PIH, community organizations, and Peru’s Ministry of Health will ensure that more TB and MDR-TB patients receive early treatment. In so doing, we will halt the spread of the disease and save more lives, now and into the future.

PIH Co-founder Dr. Paul Farmer was in Peru in December to celebrate the program’s first steps. “I marvel at how much the Peru team has accomplished over the past 23 years,” he said. “Seeing former patients who two decades were so sick and are now flourishing, and seeing nurses and health workers and lab techs still working with compassion and conviction after years—these are the best gifts we could ask for, especially in front of these new tools. This novel community screening program is a symbol of shared commitment to do more to address one of the world’s most trenchant public health dilemmas.”

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Fri, 08 Feb 2019 12:35:36 -0500 https://www.pih.org//article/eliminating-tb-one-van-time
'It Felt Like the End of the Road': Bizinde Elyse Reflects on Beating Cancer in Rural Rwanda https://www.pih.org//article/it-felt-end-road-bizinde-elyse-reflects-beating-cancer-rural-rwanda One morning in July 2014, Bizinde Elyse noticed that his right knee was painful and swollen. 

A native of Nyamasheke District in Rwanda’s Western Province, Elyse brushed it off, assuming he had played football too roughly with friends at school and the swelling soon would go down. To his alarm, his knee kept swelling over the next few days, while becoming itchy and hot to the touch. His parents grew concerned and urged him to go to the nearest health center. He was about 20 years old at the time. 

At the health center, clinicians could not immediately diagnose the swelling’s cause. They gave Elyse some medicine and told him to come back in a few weeks. But his condition continued to worsen, as the swelling increased considerably and he became feverish. Elyse quickly went back to the health center, well before the few weeks were up, but clinicians again could not give conclusive results. They referred Elyse to the district hospital, which promptly referred him to University Teaching Hospital of Butare, in southern Rwanda. Butare is more than 100 miles—or three-plus hours, by car—from his home district. 

Doctors at the teaching hospital diagnosed Elyse with rhabdomyosarcoma, an aggressive and highly malignant form of cancer in skeletal muscle cells. 

Elyse remembers feeling shell-shocked. 

“I had always heard of cancer affecting other people, and I never thought I would ever be one of those people,” he said. “It felt like the end of the road for me. I was even more sad because my parents took it very hard. My mother was very distraught. I hated seeing her that way and it added to my own sadness.”  

Fortunately, doctors told him that since they had discovered the cancer in its early stages, it was still operable. They recommended a swift course of action, beginning with amputation to stop the cancer from spreading. Surgeons amputated Elyse's right leg in early 2015. Following that surgery, doctors transferred Elyse to Butaro District Hospital in northern Rwanda, for chemotherapy. The Butaro hospital and its Cancer Center of Excellence are supported by Partners In Health, known in Rwanda as Inshuti Mu Buzima. 

Elyse said the compassion of Butaro staff was as important to his full recovery as the treatment.        

“Everyone was really kind to me. It made me feel less lonely, as I had made the journey from Nyamasheke to Burera (District) alone, without my parents,” he said. “My treatment, lodging, and meals were all covered by Partners in Health. I would also get transportation from where I was staying to the cancer center, for treatment, and had access to counseling services, which I received regularly.” 

Partners In Health also provided Elyse with a prosthetic leg, so he could transition from using crutches. 

Today, Elyse is 25 years old, healthy and cancer-free. He decided to move to Butaro permanently to make checkups easier, and now runs a small variety shop near the cancer center. He sells everything from airtime data and mobile money transfers to small snacks and everyday items. 

Bizinde Elyse helps customers at his stall in March 2017
Bizinde Elyse, who had one of his legs amputated as part of his treatment for cancer found in his knee, has become a healthy, familiar face in the Butaro community in northern Rwanda. Here, he helps customers at his small stand in March 2017. (Cecille Joan Avila / Partners In Health)

His customers range from caregivers to first-time visitors to the Butaro hospital. He speaks gently as he serves his customers, and has become a beloved, familiar member of the community.

“If you could have asked me two years ago what I would be doing now, I would not even have told you—I would’ve assumed I’d be dead,” Elyse said. “Now, I am an entrepreneur and am contributing to my community and my country.”  

Elyse added that he is incredibly grateful for his recovery and new outlook on life. He also is able to think about his future. In 2017, Elyse graduated from high school, earning second-class honors in math, biology and chemistry. He said he hopes to be a doctor one day, so he can help people in the same way he was helped.

“I would like to thank everyone who helped me get better, from the doctors, nurses and care providers at Butaro, and the government of Rwanda, to Partners in Health, who covered the cost of my medication and also supported me with a prosthetic leg,” he said. “I have been able to go back to my normal life because of their intervention and support.”
 

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Fri, 08 Feb 2019 11:12:23 -0500 https://www.pih.org//article/it-felt-end-road-bizinde-elyse-reflects-beating-cancer-rural-rwanda
Op-ed Urges New Focus on ‘Crushing Burden’ for Poorest Billion https://www.pih.org//article/op-ed-urges-new-focus-crushing-burden-poorest-billion The director of Partners In Health’s NCD Synergies program is calling for a dramatically overhauled approach to cancer, heart disease, mental illness, and other non-communicable diseases, saying in a Bangkok Post op-ed that detection and treatment have “largely failed to reflect the experience” of the world’s poorest, jeopardizing efforts to achieve universal health coverage and leaving countless people without care. 

“NCDs have long been a crushing burden for children and young adults living in extreme poverty in rural Sub-Saharan Africa and South Asia: hundreds of thousands will die each year before the age of 40 from an NCD,” Dr. Gene Bukhman writes in the Wednesday op-ed, co-authored with Dr. Gina Agiostratidou of the Helmsley Charitable Trust. 

“In addition, the out-of-pocket expenses necessary for treatment can be catastrophic for families already living on next to nothing,” they continue. “And that's if these conditions are diagnosed at all, which is far from guaranteed.” 

Bukhman helped launch NCD Synergies in 2013, and in 2016 became a co-chair of the Lancet Commission on Reframing NCDs and Injuries for the Poorest Billion. Agiostratidou is the director of Helmsley’s Type 1 Diabetes Program. Their op-ed coincides with the 2019 Prince Mahidol Award Conference, held this week in Thailand’s capital and focusing on the political economy of NCDs, which kill an estimated 41 million people a year globally. 

Despite that alarming rate, they write, “NCDs among the poorest billion have gone under the radar of the global health community,” particularly regarding young patients.

“Childhood conditions among the poorest billion, such as type 1 diabetes, rheumatic heart disease, or sickle cell anemia, often have genetic, infectious, or environmental determinants,” they write. “Because these NCDs are diverse and relatively uncommon, they have so far failed to garner needed health policy attention: they don't easily fit into a traditional public health agenda, structured around highly standardized approaches to preventing disease or minimizing risks. 

“Now is the time for that to change.”

Bukhman and Agiostratidou lay out a three-pronged approach to revamping NCD policies, including: a greater focus on the world’s poorest, research on integrating health care delivery for non-communicable diseases and injuries, and partnerships to boost financing and integrated solutions. 

Read the full op-ed, here.
 

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Fri, 01 Feb 2019 14:03:05 -0500 https://www.pih.org//article/op-ed-urges-new-focus-crushing-burden-poorest-billion
Dr. Binagwaho to POLITICO: UGHE Aims to “Radically Change Education” https://www.pih.org//article/dr-binagwaho-politico-ughe-aims-radically-change-education Dr. Agnes Binagwaho, vice chancellor of the University of Global Health Equity, recently told POLITICO that UGHE’s new campus in northern Rwanda reflects its “mission to radically change education” and build a 21st-century model for better health equity.  

“Our vision is a world where every individual no matter where they are, who they are and where they live can lead a healthy and productive life,” Binagwaho told the international politics and policy website, in a story published Sunday. “Our mission is to radically change education, health education, so that we impact the way health care is delivered around the world.”

Binagwaho was one of several UGHE and Partners In Health leaders quoted in the story, which followed Friday’s inauguration of the Butaro campus, UGHE’s first permanent home

The university is an initiative of PIH that was launched in 2015. Construction of the campus began a year later, with classes and part-time studies temporarily based in Rwanda’s capital, Kigali. 

Though UGHE is a private, nonprofit institution, the government of Rwanda has played an important role in its development. In addition to providing financial resources and donating the land for UGHE, the government is paving roads that link Butaro with Musanze and Kigali, and has increased access to water, electricity, and internet connectivity throughout the region.  

In addition to providing an overview of UGHE, its mission and the new campus, the POLITICO story also speaks with UGHE’s founding dean, Dr. Abebe Bekele, about his innovative approach to curriculum, and tells the story of UGHE alumni Crispin Gishoma and Arsène-Florent Hobabagabo, who graduated last May and now run a diabetes clinic in Kigali. 

Read POLITICO's full story here.
 

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Tue, 29 Jan 2019 10:10:06 -0500 https://www.pih.org//article/dr-binagwaho-politico-ughe-aims-radically-change-education
UGHE Campus Intertwined with Butaro Community https://www.pih.org//article/ughe-campus-intertwined-butaro-community Jean Claude Niyonzima laughed when asked about his average workday in recent weeks, as he helps prepare the University of Global Health Equity in northern Rwanda for the Jan. 25 inauguration of its new, permanent campus. 

“Oh, my goodness,” said Niyonzima, UGHE’s 29-year-old facilities manager. “I’m moving all day.”

His days start at 5 a.m. and quickly become a blur of contractor meetings, equipment and furniture orders, mechanical plans, and check-ups on everything from final coats of paint to ceiling fans. By the time he responds to the day’s last emails, it’s usually 10 p.m.  

Construction of the UGHE campus has transformed the surrounding community of Butaro over the past two years, in ways large and small. There now are streetlights. Vastly improved public infrastructure for electricity, potable water, and internet access. The first elevator in Burera District. A future paved road to the capital, Kigali, that will drastically reduce travel time for the 80-mile trip. Construction-related jobs for more than 1,500 people, with more than 90 percent of the workforce local, and more than 30 percent women. Many workers are learning new skills—such as masonry, welding, plumbing and landscaping—that could help with future employment. 

Like Anne Marie Nyiranshimiyimana. A mason on the campus project, Nyiranshimiyimana initially faced criticism—“They told me, ‘No woman builds, no woman climbs,’” she said—but she has since risen to the rank of master mason. She’s also become a source of inspiration for women and girls in her community. She’s known around Butaro by her nickname, Kankwanzi, which loosely translates to “rising star who refuses to conform to society’s expectations.”

Nyiranshimiyimana is one of many people on the construction crew who also worked on Butaro District Hospital, which opened in 2011 about two miles away. Nyiranshimiyimana began her masonry training on that project. Both the university and the hospital are initiatives of Partners In Health, a global health nonprofit that works in Rwanda through sister organization Inshuti Mu Buzima. The hospital and the UGHE campus sit atop scenic hillsides, visible to each other across a lush valley. The hospital is one of several teaching facilities that will collaborate with the university and provide hands-on training for students. 

The new campus will eventually span almost 250 acres and is home to six academic buildings, housing for 200 students and staff, a dining hall, administrative spaces, and more. Though UGHE is a private, nonprofit institution, the Government of Rwanda has played an important role in its development. In addition to providing financial resources and donating the land for UGHE, the Government of Rwanda is paving roads that link Butaro with Musanze and Kigali, and has increased access to water, electricity, and internet connectivity throughout the region.  

UGHE construction brought more than 1,500 jobs to the area
UGHE worked closely with the Burera District local government and community not only to hire and train local workers, but also to spur economic development by using Butaro-sourced goods and services whenever possible, including cement, sand, gravel, cured bricks, and more. (Photo by James Martin/CNET, for UGHE) 

These changes have had many impacts locally, but the greatest has been on the 115 households moved to make way for construction of the campus. Many families sold their land as part of the relocation process. All of them were compensated by the government. More than 40 households have moved to a new, government-constructed model village about a mile away, called Mulindi.

Niyonzima, the facilities manager, said the relocation process began with community meetings and explanations of the campus project, which has been universally welcomed by the community. That sounds somewhat unbelievable, but Niyonzima—who grew up in Rwinkwavu, in southeastern Rwanda, and has lived and worked in Butaro for more than six years—said residents quickly saw the benefits of the new university. 

”Where they were, they didn’t have potable water. They didn’t have electricity. They didn’t have a health center. They didn’t have a school or a nursery,” Niyonzima said. “The Government of Rwanda has committed to providing all of that.”

Additionally, he said, many Butaro residents are farmers, who now will have a new, growing market and customer base for their produce. 

Construction of the hospital, and IMB’s resulting strong reputation in the region, also paved the way for the community to welcome UGHE. 

“After hearing the university project was connected to IMB, they didn’t even really ask much more,” Niyonzima said. 

UGHE and the government collaborated to make the relocation process transparent and accessible. 
Guided by Rwandan land laws, UGHE worked with government officials to take a full inventory of land and property. Compensation was distributed before families moved. Families were given advance notice to move, and local leadership helped several families identify and buy land elsewhere in Burera District. 

When asked if any families opposed the relocation, Niyonzima answered unequivocally: “None of them. None.”  

The model village of Mulindi, completed in August 2017, is not unique in Rwanda. Every district in the country has at least one model village, funded and built by the government to connect rural communities to roads, schools, electricity, water, health posts, and markets. Mulindi eventually will house more than 200 families. 

Emmanuel Kamanzi, UGHE’s director of campus development, oversaw planning and construction of the campus, managing the more than a dozen contractors on site. The project actually brought him back to Rwanda, and Butaro--Kamanzi has worked for PIH and IMB in several capacities over the years, including as director of development for Butaro District Hospital during its construction almost a decade ago. Following that project, Kamanzi moved to the U.S. and worked in PIH’s Boston office, as program officer for Rwanda. But his familiarity with large-scale projects in Butaro made him a natural fit for development of the UGHE campus, so he moved back early in 2016--with a clear vision in mind, and work that won’t end with construction.   

“We wanted to design and build a campus that is inspirational, durable and easily accessible, while fostering a strong sense of community and high quality of life,” Kamanzi said. “We made sure that everyone involved understood these principles, and was aligned with them. Now that construction is complete, our major focus will be to make sure that the function follows the form we’ve achieved.”

UGHE's administration building
Wavy clouds form a scenic backdrop for UGHE's administration building, days before the landmark campus inauguration Jan. 25. (Photo by Emmanuel Kamanzi / UGHE)

Dr. Abebe Bekele, UGHE’s founding dean of health sciences, said families will be connected to the campus community—and vice versa. 

“The campus is going to be dependent on the community in Butaro—for food supplies, for services, for advice and safety, and most of all, to help us teach our students—so we will be creating an opportunity for the community to work with us,” Bekele said. “We are working on different programs that can engage Butaro residents. One is community-based education, where our students will directly learn from the community, and in turn help them while doing so.”

Bekele sees UGHE as a point of pride not just for the community, but for the region as a whole. 

“This is owned by Partners In Health,” Bekele said of the university. “But, truly speaking, the people who own this are the people of Rwanda and the people of Africa.”

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Thu, 24 Jan 2019 14:06:56 -0500 https://www.pih.org//article/ughe-campus-intertwined-butaro-community
Ophelia Dahl on Optimism in Difficult Times, for Boston's NPR Station https://www.pih.org//article/ophelia-dahl-optimism-difficult-times-bostons-npr-station Ophelia Dahl, a co-founder of Partners In Health and the board chair, reflected recently about the organization's early days in Haiti and on how deeply she and other co-founders wished to "make a dent in the extreme poverty faced by thousands of Haitians," in partnership with local colleagues. 

Some 30 years ago, their team built a clinic in rural Haiti that had a positive impact on countless lives. That clinic grew into a hospital, which served as a reference point for patients from across Haiti. Their work spurred a movement that leapt to Peru and Russia, expanded to Mexico, and also has taken root in the heart of Kazakhstan and five countries in Africa.

All of this was possible, Dahl says, because they chose optimism over apathy. Here's is the beginning of her essay, as published on WBUR's Cognoscenti, the opinion page for NPR's Boston-based affiliate:

"There’s a well-loved Haitian proverb I often turn to during challenging times: 'Piti piti, wazo fe nich li.' It translates to, 'Little by little, the bird makes its nest.' My friends and colleagues offer it up as words of consolation and hope when a challenge seems overwhelming. I bring it up now, as I often do during difficult times when so much seems uncertain, because it also reminds me of a specific moment from my first trip to Haiti in 1983 as an 18-year-old volunteer."

Read more here.

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Tue, 22 Jan 2019 10:58:28 -0500 https://www.pih.org//article/ophelia-dahl-optimism-difficult-times-bostons-npr-station
UGHE’s New Campus a Beacon for a Brighter Future https://www.pih.org//article/ughes-new-campus-beacon-brighter-future The University of Global Health Equity will be celebrating so much more than a new campus at its landmark Jan. 25 inauguration in northern Rwanda. 

When leaders from  the Government of Rwanda, Partners In Health, international academic institutions and other global health organizations gather at UGHE’s brand-new cluster of sparkling white buildings, surrounded by the Butaro region’s green hills, they’ll be celebrating an institution that is dedicated to improving health care services and delivery for underserved populations around the world. They’ll be celebrating UGHE’s innovative focus on equity and social determinants of health, which pairs education in human rights and social justice with rigorous, community-based medical training.

The university is an initiative of PIH that was launched in 2015 with catalytic funding from the Bill & Melinda Gates Foundation and the Cummings Foundation. Construction of the campus began a year later, with classes and part-time studies based in Rwanda’s capital, Kigali. The campus already is transforming infrastructure, accessibility, and employment—not to mention health services—in the Butaro community. Butaro District Hospital is just two miles away, across a valley, and will serve as one of multiple teaching hospitals for university students. The hospital and its cancer center are supported by Inshuti Mu Buzima, PIH’s sister organization in Rwanda.

Though UGHE is a private institution, the Government of Rwanda has played an important role in its development. In addition to providing financial resources and donating the land that UGHE is situated on, the Government of Rwanda has paved roads that link Butaro, Musanze, and Kigali, and increased access to water, electricity, and internet connectivity throughout the region.    

All of that synergy empowers UGHE with opportunity—for students, staff, and partners; for patients, communities, and countries. Opportunity for a brighter future, and for aspiring doctors who otherwise would not have the chance to pursue their dreams. For people who thought medical school would never be within their reach. For patients who thought high-quality care would never reach them, and who thought their disease was a death sentence. 

Dr. Agnes Binagwaho, UGHE’s vice chancellor, said the realization of UGHE’s vision will affect far more than academics, and far more than Rwanda alone.  

“Together we are assembling the building blocks of a university that will contribute to the transformation of health service delivery, through education, mentorship and research, in every corner of the globe,” she said. “This year, the University of Global Health Equity has progressed further and faster than any of us could have imagined.”

Construction on the UGHE campus in March 2018.
Construction progresses on the UGHE campus in March 2018. More than 1,000 workers joined the construction crew over the two-year building process. (Photo by Barb Kinney for UGHE)
Construction on the UGHE campus in March 2018.
Facilities Manager Jean Claude Niyonzima walks in March 2018 through one of the main academic buildings on UGHE's new campus in Butaro. (Photo by Barb Kinney for UGHE)

UGHE’s growth comes at a time of severe need for qualified healthcare workers across Africa. The WHO estimates the continent will have a shortage of more than 6 million healthcare workers by 2030. 

With that need firmly in mind, UGHE’s new campus will provide a permanent home for health sciences education grounded in the belief that health care is a human right. The university so far has graduated two classes of part-time students who earned master’s of science degrees in global health delivery, through a two-year program. Those students gathered in Kigali for several weeks each semester, with the remainder of their studies conducted remotely or on trips with classmates and staff. 

The 250-acre (100-hectare) campus is about 80 miles north of Kigali and, in the first phase of construction, includes housing for up to 200 students and staff, a dining hall and six academic buildings. The state-of-the-art academic buildings will include a clinical simulation center; a science laboratory; a 6,700-square-foot Information Commons, providing e-learning tools, tech support and a medical library; a configurable Studio Classroom, and more. 

The campus’ setting in rural Butaro directly reflects the university’s mission and values. 

“It’s no accident that our campus is not in an urban city-center,” said Dr. Paul Farmer,  co-founder and chief strategist at Partners In Health and global health department chair at Harvard Medical School. “We want our students to understand what it’s like to deliver care in rural settings, yes, but more importantly to look beyond what they can learn in the classroom and the clinic. Some of the key lessons learned in the delivery of equitable care have been learned right here in rural Rwanda, and some of these lessons are broadly applicable in cities and many disparate settings. 

“The students who study here will be encouraged to learn clinical skills while also learning how to think about the world beyond the hospital,” Dr. Farmer added. “If we’re ever going to see a world where every person, no matter who they are, receives quality health care, we need to transform the way we think about training our future leaders. Opening this beautiful, state-of-the-art campus in Butaro signals our commitment to improving care delivery not only in this region, but across the world.”

UGHE’s founding Dean of Health Sciences, Dr. Abebe Bekele, joined the university’s leadership in June. He is a highly regarded thoracic and general surgeon, former dean of the School of Medicine at Addis Ababa University in Ethiopia, and former CEO of Tikur Anbessa Hospital in Addis Ababa. 

Bekele will oversee the launch of UGHE’s first medical degree program, which will give students the opportunity to earn bachelor’s degrees in medicine and surgery, jointly known as MBBS, along with the master’s in global health delivery, over six and a half years of study. All together, the program will be known as the MBBS/MGHD dual degree. 

The first cohort of 30 students will begin the program in July, after the university receives accreditation by Rwandan and international governing standards. In 2025, those students could become the first graduates of UGHE’s comprehensive medical school.  

“By the time they graduate, they will be doctors, with a master’s of science degree in global health delivery,” Bekele said.

Construction progresses
Beautiful views abound on the UGHE campus, in the green hills of the rural Butaro region in northern Rwanda. Many buildings are adorned with geometric designs, in traditional Rwandan patterns known as imigongo. (Photo by Danny Kamanzi/UGHE)

They’ll undergo a unique course of study along the way. Butaro District Hospital will provide a clinical location that essentially is on-site, just a 15-minute walk from the UGHE campus. Lessons will be tailored to address the continent’s greatest burdens of disease and gaps in care.

“Our students will learn and think about research from day one,” Bekele said. “We will pay specific emphasis on health needs that the continent demands at the present moment—that is, emergency care and safe surgery and anesthesia.”

Bekele said graduating doctors “will be able to handle emergency care medicine in all settings, and to perform, at least, essential surgical procedures” in settings with limited resources. 

In their first year of study, UGHE medical students will be introduced to an education outside of medicine, to help them better understand the conditions, history and contextual realities of the patients they’ll serve. 

“We are an equity-based global university,” Bekele said. “A health professional who has no idea about human rights, gender, injustice—a health professional who does not understand the history and political economics of Africa,  a health professional who is not prepared in critical thinking and scientific reasoning— probably has no place in tomorrow’s Africa.”

Bekele emphasized that students will take advantage of the numerous health facilities supported by Inshuti Mu Buzima, for hands-on learning and experience in community-based education.

“We will teach the students at health posts, health centers and hospitals, as they develop through the six and a half years,” Bekele said. “Gone are the days when doctors are expected to only treat sick patients. The doctors of today need to connect with and understand the communities that they serve."

UGHE also offers Executive Education programs. The customized short courses are designed for global health executives and so far have included partnerships with the Global Fund to Fight AIDS, Tuberculosis and Malaria; George Washington University’s Health Workforce Institute; and Yale University’s Global Health Leadership Institute, among others. The courses focus on health system strengthening, leadership, management, strategic problem-solving and more.

A third pillar of UGHE education is One Health, a concept stressing the integration of human health, animal health and the environment. An advanced program in that discipline could be about a year away, but eventually will be one of UGHE’s “signature programs,” according to Bekele. 

“One Health is new to Africa,” Bekele said. “UGHE is strategically placed to play a pivotal role in representing One Health on the continent.”

The University of Global Health Equity's first class, of 24 students, graduates in May 2017 at a ceremony in Kigali. (Photo by Zacharias Abubeker for UGHE)
The University of Global Health Equity's first class, of 24 students, graduates in May 2017 at a ceremony in Kigali. (Photo by Zacharias Abubeker for UGHE)

Graduates of the MGHD program already are making impacts. UGHE’s alumni community includes 37 global health leaders, who now are working in public, private and nonprofit sectors. 

One of those leaders is Dieudonne Hakizimana, who graduated in 2017 as a member of UGHE’s first group of MGHD students. He came to UGHE with a master’s in epidemiology from the University of Rwanda and 10 years of experience in the health field, including four years at Inshuti Mu Buzima’s Rwinkwavu District Hospital in southeastern Rwanda. 

His studies at UGHE prepared him for a leadership role in global health, with training in management, health financing and more. He is now a teaching and learning officer at UGHE, where he’ll help students reach goals of their own. 

Applications to be among the next wave of UGHE students are coming from all over the world. UGHE received more than 300 applications across 26 countries in 2018, for the 24 spots in the current cohort that began studies in September.  

Bekele said offering classes online soon will help meet that global demand. 

Accepted students also get significant financial support from the university. All enrollees in UGHE’s global health delivery program get scholarships, which cover an average of 91 percent of the $54,000 charge for tuition, room and board. UGHE has awarded more than $1.8 million in financial aid so far.  

UGHE’s alumni community already is bringing lessons from the university into their professions, and communities. 

Titus K. Koikoi, a Liberian who is program director for global health nonprofit Population Services International, took an Executive Education course at UGHE, through the Global Health Delivery Leadership Program. He said the course continues to affect how he approaches his work in Liberia. 

“UGHE has begun a movement that seeks to encourage all involved with global health delivery to begin rethinking health care and looking into more efficient models for health services delivery,” he said. “I feel humbled that my work in global health gives me an opportunity to plan and manage service delivery for my fellow Liberians, and by extension, the world’s population in general. I feel challenged on a daily basis to give back to society, and to be a critical voice that advocates for access to health by all.”
 

UGHE's new campus greets a new dawn in January 2019, just days before students arrived.
UGHE's campus greets a new day in January 2019. Leaders from the university, the Government of Rwanda, Partners In Health and academic institutions around the world will gather on the campus Jan. 25 for a formal inauguration. (Photo by Emmanuel Kamanzi/UGHE)

 

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Fri, 18 Jan 2019 13:24:03 -0500 https://www.pih.org//article/ughes-new-campus-beacon-brighter-future
Make Social Justice Your New Year’s Resolution https://www.pih.org//article/make-social-justice-your-new-years-resolution Host a birthday fundraiser: Make your birthday meaningful by asking your friends and family to contribute to a Facebook Fundraiser for PIH! Start yours by signing into Facebook here.

Claim your sticker: Sign up here and we’ll send you a free “Health care is a human right” sticker to put on your laptop, water bottle, or notebook! It’s an easy way to spread the social justice message. Claim yours here.

Become a Paul’s Partner: Partner with PIH year-round by signing up for a monthly gift. Each month your donation will go towards helping communities in need around the world, from providing monthly HIV medications to supporting regular postnatal visits for new moms. Start your monthly gift here.

Post on social: Tell your friends and followers why you support the right to health care! Share a PIH post or make one of your own. Don’t forget to tag PIH in your post and we will share some of our favorites. And be sure you're following us on Facebook, Twitter, and Instagram.

Share the social justice story: Want to inspire your friends and family to get involved in social justice? Mountains Beyond Mountains is the perfect introduction to PIH’s work. If you’re looking for something new, here’s a list of some of our favorite inspirational books.

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Tue, 08 Jan 2019 12:33:22 -0500 https://www.pih.org//article/make-social-justice-your-new-years-resolution
Most-Read Stories of 2018 https://www.pih.org//article/most-read-stories-2018 Partners In Health is proud of what our friends and colleagues accomplish every day, in every community where we work. Each year is filled with new challenges and innovative solutions that help us deliver high-quality care in some of the poorest, most remote regions of the world.

We often share these stories of struggle and success on our website and social media. In case you missed them the first time around, we've compiled our top 10 stories from 2018. These are the people, places, and programs that caught your eye, from Lesotho, Sierra Leone, and Malawi to Haiti and the Navajo Nation.

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Kamohelo Phoofolo and her daughter

10. Safe Deliveries, Big Smiles at Lesotho Health Center

Kamohelo Phoofolo, 8 months old, was born safely at a facility revitalized by Lesotho's national health care reform, one of nearly 4,000 more safe childbirths in 2017 than in years prior. Read more.

Gladys, a Sierra Leonean midwife

9. Gladys: Trailblazer, Midwife, Feminist in Sierra Leone

Boyama "Gladys" Katingor, the head midwife at Wellbody Clinic in Kono, Sierra Leone, ensures every expectant mother receives the best possible care and advocates for her patients' both in and outside the clinic. Read more.

Malaria cases rise in Malawi

8. Malaria Cases Rising in Malawi as Peak Season Nears 

Flora Tigone worried when her infant son, Chisomo, suddenly became lethargic and feverish. A month ago, an older child had battled malaria. Fearing that was the case with Chisomo, Flora knew she had to act quickly. Read more.

First graduates of Nightingale Fellowship

7. Graduates "Paving the Way for Global Nursing Leadership"

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 first four fellows graduated from their yearlong program in June. Read more.

Dr. Marta Lado discusses her book on Ebola

6. Dr. Marta Lado on Ebola, and its Aftermath, in Sierra Leone

Dr. Marta Lado, chief medical officer for Partners In Health in Sierra Leone, talks about the lessons she learned while treating patients for Ebola, and why she stayed to help rebuild the public health system. Read more.

Teen HIV Club gathers in Malawi

5. Teens with HIV Find Support, Friendship at Malawi Club

On Saturdays in Neno District, Malawi, teens living with HIV can find friendship, games, snacks, HIV education and, most importantly, support. Read more.

Breast cancer survivors share stories in Haiti

4. Breast Cancer Survivors in Haiti Share Their Stories

In 2018 alone, PIH clinicians and staff in Haiti have been caring for 450 women diagnosed with breast cancer. Five survivors shared their stories in honor of Breast Cancer Awareness Month in October. Read more.

Single mother cares for kids, handles HIV

3. Single Mother in Malawi Caring for Kids, Handling HIV

Agnes Paulo's expression was somber as she held her infant son, Ulemu, in her lap. Paulo, 35, is a single mother and living with HIV. Her four older children are HIV-negative, but Ulemu had not yet been tested. Read more.

Mental health work expands across PIH

2. Mental Health Team Expanding Innovative, Pioneering Care

Dr. Giuseppe “Bepi” Raviola, PIH’s director of mental health, oversees a growing program that is caring for thousands of people in Haiti and Rwanda; developing safe houses for women with chronic mental illness in Peru; working to treat common mental disorders in communities across eight countries; and much more. We caught up with him for an eye-opening chat. Read more.

Eating well in the Navajo Nation

1. Eating Well: Grocery Program Takes Off in the Navajo Nation

Doctors give patients, usually mothers, “prescriptions,” or vouchers, for a month’s worth of free fruits and vegetables for their families. The mothers spend the vouchers at their local store. And PIH reimburses the stores for the cost of the produce as part of the Fruits and Vegetables Prescription Program, or FVRx. Read more.

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Fri, 21 Dec 2018 18:01:32 -0500 https://www.pih.org//article/most-read-stories-2018
PIH Staff Pick Inspiring Reads for 2019 https://www.pih.org//article/pih-staff-pick-inspiring-reads-2019 Many people discovered Partners In Health after reading "Mountains Beyond Mountains," Tracy Kidder's 2003 book that followed the trajectory of PIH's early days and chronicled the lives of the nonprofit's co-founders, Dr. Paul Farmer, Ophelia Dahl, and Dr. Jim Kim.

With inspiring reads in mind, we asked a selection of staff if they could recommend other social justice-minded books, either fact-based or fiction. Here's a short list of what they had to say:

“Nickel and Dimed: On (Not) Getting By in America”

Barbara Ehrenreich

I read this book when I was just out of college. The author effectively goes “undercover” in various jobs in America—as a Merry Maid cleaner, Walmart employee, etc.—disrobing herself of any social capital or safety nets that she had come to take for granted. 

She applied and survived without academic credentials, insurance, a savings account of any amount, or even a car. As a product of a white, scrappy middle-class family who ensured education for my siblings and myself, I had been raised thinking people who worked hard would excel, and those who didn’t lacked personal character. This book shattered that perspective, and informed how I would pursue my career. 

Professionally, I worked to ensure context-sensitive admissions to universities and thoughtful financial aid packages before turning to my current work at PIH. For both, I attempted to understand how institutionalized barriers prevented hard work alone from equating to similar outcomes for all—a strand that runs throughout Ehrenreich’s book. The book lingers with me still, 15 years later, as I explain to my young children that, for example, some people with multiple houses did not work hard for them, while other people who work incredibly hard—much harder than some wealthy people would ever need to—can barely make rent.  

—    Katie D. McDonnell, senior director of development


“No Ordinary Time: Franklin and Eleanor Roosevelt—The Home Front in World War II”

Doris Kearns Goodwin  

It’s a phenomenal book, looking at the years leading up to WWII, through the lens of Franklin and Eleanor’s relationship. Of note for global health enthusiasts, there are some great behind-the-scenes details around the founding of the United Nations. It’s a dense read, but endlessly fascinating and enlightening. 

—    Joan VanWassenhove-Paetzold, senior program development officer


“White Fragility: Why It’s So Hard for White People to Talk About Racism”

Robin DiAngelo

This book provides white folks with the skills to better accompany people of color in the fight for social justice, truly reflecting PIH’s fundamental value of accompaniment. 

The timing of this book could not be more important for white people in the U.S. As white Americans continue to struggle with how to engage one another and folks of color in difficult discussions about race, racism, and systematic oppression, DiAngelo provides a framework for white people to begin these conversations from an honest, open, and empathetic place. 

The author delivers a thought-provoking history about the construction of race in America and how that system functions to provide power and privilege for those born with white skin. Moving past the narrative of racism being confined to individual acts of hate and discrimination, DiAngelo allows the reader to understand how whiteness affords white people with untold and unseen benefits in American society. DiAngelo challenges fellow white folks to engage in the difficult work of dialogue, action, and accountability to deconstruct whiteness in America. She identifies the barriers that she and other white people use to shut down conversations about race, racism, and unearned privilege, while providing tools for creating authentic dialogue about these critical issues.

—    Jarrod Chin, director of diversity and inclusion


“Last Night I Dreamed Of Peace”

Dang Thùy Tram

“Last Night I Dreamed of Peace” is the wartime journal of a young Vietnamese doctor named Dang Thùy Tram. Her journal and life were taken by an American, but after decades, her writing returned to her family, and was recently made available for translation. 

Barely out of medical school, Dr. Thùy volunteered to set up a semi-mobile field hospital for National Liberation Front guerillas in the middle of the most intense fighting of the American war. Facing impossibility, this young doctor wrote of resilient hope. Her words are raw and clear as she describes saving some lives, failing to save others, and her intense battles with the love and hatred in her own soul. Dr. Dang Thùy Tram’s sentences astonish and inspire me every time I read them. 

—    Reilly Hay, donor support coordinator


"Cutting for Stone"

Abraham Verghese 
 
As a writer, I find “Cutting for Stone” inspiring because of the seamless way the author weaves together the story of identical twin brothers—born, interestingly, to an Indian nun and a British surgeon—with the weighty topics of civil war, racism, and inequity in health care. 
 
The story is largely told through the eyes of Marion, who grows up with his identical twin, Shiva, on the campus of Missing Hospital in Addis Ababa, Ethiopia. The boys, who are raised by adoptive doctors, wish to become physicians themselves, but their paths diverge sharply in adolescence. The rift is spurred by a single rash act that has lifelong repercussions for both twins, and brings to mind that old adage of how a butterfly flapping its wings in China causes ripples of changes on the other side of the world. 
 
A physician and writer himself, Verghese masterfully unravels his story, which at the core is about family, love, and the pain and joy wrapped into a single act of sacrifice. I would recommend this book to anyone looking for a good read, but especially to those social justice warriors frustrated by the way the world’s resources—food, housing, security, health care—are unfairly split between the haves and have-nots. 
 
Early on in the book, I came across the following passage and wondered if, secretly, Verghese was a Partners In Health supporter. Or at the very least, I thought, he must have drunk the PIH punch before penning this novel. It’s something Matron, the nun who runs Missing Hospital, says to Mr. Harris, whom she hopes will provide a significant donation to support her ailing facility:
 
“We aren’t even fighting disease. It’s poverty. Money for food, medicines…that helps. When we cannot cure or save a life, our patients can at least feel cared for. It should be a basic human right.”

—    Leslie Friday, interim direct of content

 

"Homegoing"

Yaa Gyasi

If you haven’t read Yaa Gyasi’s 2016 novel, "Homegoing," do yourself a favor and request a copy from your local library or bookstore immediately. While tragic, the novel unravels the tales of two sisters and weaves together the stories of each generation of their separated families, all tracing back to their ancestor, an Asante woman.

Starting in Ghana during the slave trade, the complex story features richly developed characters who span 250 years of history, and examines the implications of colonization and slavery. Each chapter acquaints the reader with a different descendant. Gyasi's tale is at once devastating and beautiful, and explores the ripple effects of violence and trauma, as well as family and love. It’s impossible to put down and will have you thinking about it for months.

- Elise Mann, Global Health Corps fellow, Malawi

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Thu, 20 Dec 2018 16:59:00 -0500 https://www.pih.org//article/pih-staff-pick-inspiring-reads-2019