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

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

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

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

What drove you to become a nurse?

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

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

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

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

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

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

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

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

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

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

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

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

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

What attracted you to PIH’s work?

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

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

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

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

What are you most proud of having accomplished so far?

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

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

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

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

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

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

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

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

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

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

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

Tell us about your life outside of work.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

One of many firsts for this year’s class.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

Read the full NPR piece here.

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

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

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

A new hepatitis B clinic

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

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

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

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

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

Screen, treat, monitor, repeat

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

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

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

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

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

Preventing transmission of hepatitis B

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

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

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


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

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

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

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

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

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

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

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

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

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

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

Personal stories emerged from the study.

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

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

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

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

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

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

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

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

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

Listen to the full podcast episode, here.



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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

When asked about Mkango, POSER officer Edwin Kambanga smiled.

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

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

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

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

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

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

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

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

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

Joint Ebola statement by Farmer and Davis

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

A new model for safe birth

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

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

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

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

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

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

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

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

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

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

Partnership throughout pregnancy

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

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

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

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

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

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

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

Read the story as first published on Verve Up.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

“He was afraid,” Florinda agreed.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

PIH’s advocacy for the family has continued.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Chemotherapy in Sierra Leone

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

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

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

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

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

Cancer care in Rwanda

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

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

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

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

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

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

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

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

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

Full recovery  

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

If only it was that simple.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Read Lascher’s full article here.

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

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

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

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

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

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

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

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

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

For more information and media inquiries, contact Eric Hansen at

For a printable PDF of this release, click here.  

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

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

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

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

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

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

A "normal" pregnancy

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

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

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

Roblero’s pregnancy initially progressed well. 

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

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

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

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

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

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

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

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

A new kind of maternal care

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

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

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

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

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

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

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

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

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

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

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

"Here we are, thanks to all of you"

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

PIH’s support for the self-help groups extends beyond mental health care. In conjunction with PIH’s Program on Social and Economic Rights, or POSER, group members receive training in agriculture and other income-generating activities, along with material donations such as potato seeds, fertilizer, irrigation pumps, fungicide, and livestock. 

Claver Mugenzi (Photo by Nina Sreshta / Partners In Health)

In Mugenzi’s community of Kivuye, the self-help group started a livestock project and used their collective savings to buy rabbits, chickens, and 12 sheep, which they distributed among members. PIH donated an additional 20 sheep for the group. Members who didn’t get a sheep in the initial round will get the first newborn lambs.

Mugenzi is realizing his potential, as well.

“I have really improved now,” he said. “Even in local government, I have some responsibility. Even in my church, I am among the leaders. Stigma has been reduced. Before, I was not able to do anything, and my knowledge was like zero percent. I was not among the church leaders. No one was caring for me, or thinking I could be a leader.”

Sifa Dorcas, PIH’s social and community support coordinator in Burera District, said changing those perceptions at the self-help groups began with education, and awareness.

“The first task was to help people understand mental illness,” she said. “If you know the illness you have, then you can make a plan, and follow up in the medical system…As the main objective was to improve people's health and promote their reintegration into communities, we emphasized the role of family members and caregivers in treatment, and ultimately, in fighting stigma.”

Dorcas has led mental health outreach efforts in Burera District for years, visiting people in their homes, health centers, and communities. She and Dr. Nina Sreshta, Harvard University’s Dr. Mario Pagenel Fellow in Global Mental Health Delivery, visited six self-help groups in January and February to assess their growth and impacts. Dorcas said development of the groups started slowly, but has grown to include strong economic components built through collaboration and shared resources.  

“By working with nurses and social workers at health centers, we mobilized patients and families,” Dorcas said. “Most groups started saving by contributing 100 Rwandan francs ($0.11 U.S.) every month. Many groups have increased their savings, and some groups have members contributing up to 1000 RWF ($1.10 U.S.) each, every month.” 

Like the Kivuye group, the self-help group at Rwerere Health Center has used its shared savings to buy livestock. Rwerere is about 25 miles west of Kivuye. One sheep in the area costs about 30,000 RWF, or about $33. The Rwerere group bought 21 of them, and PIH donated 20 more. Members use the manure for natural fertilizer, and sell lambs in local markets for extra income. Building on success from that project, the group then bought 13 chickens, and with a loan were able to rent a small coop for them. Members plan to sell eggs to generate additional income for the self-help group. 

As of February, the 17 self-help groups in Burera District had saved nearly 375,000 RWF, or more than $400, with an additional 930,000 RWF—more than $1,000—available for loans to members. Some families have used the money to buy health insurance or rent land for farming.

Sreshta said the visible, tangible successes for people living with mental illness—people who neighbors previously had shunned—can have a dynamic impact on perceptions.

“People with mental illness everywhere, not just in Rwanda, are vulnerable to social stigmatization and isolation,” Sreshta said. “These groups are very inspiring to see. Members develop camaraderie and a sense of agency by supporting each other and intentionally saving money for particular goals. Members talk about how these groups have reduced their feelings of isolation and hopelessness, and have contributed to boosting their confidence and resilience.”

Emmanuel Hakizuwera
Emmanuel Hakizuwera used his land as collateral for a bank loan that enabled his self-group to buy livestock. Photo by Nina Sreshta / Partners In Health 
Emmanuel Hakizuwera feeds a cow at his home
Emmanuel Hakizuwera feeds a cow that he bought for his family, as part of a shared loan with his self-help group for people with mental illness and their families. Hakizuwera said he wanted to "show that we love each other and it is easy to provide and to share.” Photo by Nina Sreshta / Partners In Health

The groups also are strengthening local support networks.

Emmanuel Hakizuwera, a member of the self-help group at Kirambo Health Center, took a bank loan in his name to help the group buy cows, using his own land as collateral. Kirambo is just a few miles west of Rwerere. Hakizuwera and his wife decided to help the Kirambo group because of their daughter, who suffers from epilepsy. He said the self-help group has provided not only education about mental health, but also a better understanding of the importance of treatment, medicine, and follow-up appointments for their daughter. Her condition has improved significantly during Hakizuwera’s participation in the group, and as she receives regular checkups at the health center. 

Hakizuwera and his wife have improved their finances with the purchase of a cow for his family, as part of the loan to the group. They get natural fertilizer for their fields and milk for their children. The group also is growing potatoes on the land Hakizuwera used as collateral.

He said applying for the loan was about more than money.

“My neighbor asked why I chose to offer land and my documents for the loan,” Hakizuwera said. “I wanted to show my neighbors and the community that there is no need to discriminate, including against people with mental illness. I wanted to also show that we love each other and it is easy to provide and to share.” 

Thu, 23 May 2019 11:07:14 -0400
Research: Study Validates Use of Depression Screening Tool in Rural Mexico Widely used screening tools proved highly effective in identifying patients suffering from depression in rural communities in Chiapas, the poorest state in Mexico, according to a study conducted by clinicians and volunteers working with Compañeros En Salud, as Partners In Health is known locally. 

The 2014 study was the first time such tools, known in the mental health field as the PHQ-2 and the PHQ-9, had been used in a rural, marginalized community in Mexico, and indicates how powerful these brief screening tools can be for identifying and diagnosing common mental disorders.

“The study demonstrated that these were valid tools and brought to surface the urgency of mental health issues arising from social and economic factors in rural Mexico,” says Dr. Jafet Arrieta, the former director of operations for PIH in Mexico and principal investigator on the study.

What Arrieta and her team found was shocking. Nearly 26 percent of residents surveyed were diagnosed with depression, compared to 7 percent across Mexico and 4 percent globally. This news is particularly alarming considering Chiapas has only one psychiatrist for every 200,000 people—far below Mexico’s overall average, according to the World Health Organization. 

Arrieta and her co-authors published their findings in the Journal of Clinical Psychology in 2017, following six months of research conducted in 2014 as part of her master’s degree program in Global Health and Social Medicine at Harvard Medical School. 

By the time of Arrieta’s study, PIH had already been using the screening tools as part of its mental health program, which was launched in 2012 and integrated into the activities run by doctors completing their social service year, in partnership with Mexico’s Ministry of Health. Medical students went door-to-door to talk to residents about depression, and used the PHQ-2 for screening and then, if necessary, a PHQ-9 for basic diagnosis. Those residents who received a high PHQ-9 score were referred to a nearby clinic for further diagnosis and treatment.

Arrieta wanted to prove the effectiveness of this strategy in rural Mexico, and so wrapped the work into her graduate degree studies. To conduct the research, she recruited seven medical students to visit 152 households in the Fraylesca region in the community of Laguna del Cofre, a five-hour drive from Tuxtla Gutiérrez, the capital of Chiapas. 

“This was a mix of research looking to better understand the experience of people in Chiapas living with and seeking care for depression, and to assess this diagnostic screening instrument for depression,” says Arrieta. 

The results complemented similar PIH findings in rural primary care clinics in Haiti, Liberia, and Rwanda, highlighting the importance of investing in community-based mental health screening, diagnosis, and treatment. 

In Mexico specifically, doctors across 10 PIH-supported clinics have incorporated the PHQ-9 as a depression screening and follow-up tool used during check-ups. As a result, they have learned that an enormous number of their female patients have lived with, or continue to live with, domestic violence in their homes.

mental health home visit in rural Mexico
Yadira Roblero and Magdalena Gutiérrez, community health workers with PIH in Mexico, make a mental health home visit in Laguna Del Cofre. Photo by Aaron Levenson / Partners In Health

Maria* was one of the first patients who benefited from community-based screening for depression. She wasn’t able to finish primary school, was married by age 20, and widowed by 27—just six months after a car accident killed her two siblings. She felt devastated and was forced to raise seven children on her own in the coffee-growing community of Laguna del Cofre. Then her 14-year-old son, Ramon*, had a seizure and began exhibiting psychotic behavior.  

As Ramon grew more violent, Maria searched everywhere for answers—first with a number of traditional healers and then a physician, who incorrectly diagnosed her son with a brain tumor. Heartbroken and exhausted, she started experiencing headaches and body aches, then persistent vomiting. 

“The situation is common,” Arrieta says. “Mental health disorders go untreated and when other symptoms appear individuals look for some supernatural explanation. That creates a cycle of normalization of their mental health issue.” Without local access to mental health care, patients are left with few options to help understand the origin of new behaviors.

Eventually, Ramon was diagnosed with schizophrenia at the age of 20 and put on a costly treatment plan. To pay for his care, Maria left her other children with extended family to look for work in Tuxtla Gutiérrez. But the money she earned still wasn’t enough, and Ramon was forced to stop treatment. 

Maria coped by taking four naps a day, while doctors dismissed her symptoms as stress. She felt powerless; she now knew the source of Ramon’s suffering, but could do nothing to help him. She couldn’t afford the costly medication he required, much less find it on a regular basis. She had no immediate family to share the responsibility of caring for her son. Hopeless and without any other option, she resorted to chaining up Ramon to prevent him from hurting himself and others. 

When PIH brought mental health services to Laguna del Cofre in 2012, Maria met with the local doctor, who had received basic training in how to properly screen and treat patients for a variety of mental disorders. Ramon was unchained, placed on medication to treat his schizophrenia, and received regular checkups to ensure his recovery remained on track. 

What resulted was nothing less than a transformation. Ramon stabilized and was soon well enough to return to work on the family coffee plantation. 

“’I was very grateful, because no other doctor had helped us before,” Maria told Arrieta at the time of her study. “It was as if he had pulled us out of a quagmire.” 

Maria’s story echoed that of many other patients Arrieta and her team came across throughout their study. Thanks to access to a quick screening tool, families dealing with mental illness finally had a name for what plagued their loved ones. That diagnosis came accompanied by regular medication and the support of trained, compassionate clinicians who held their best interests in mind. Suddenly, patients who had suffered for years—sometimes decades—could participate in daily activities and enjoy much fuller, healthier lives.

“We are trying to break the stigma of mental illness by demonstrating that with appropriate care people can get better and be reincorporated into their communities,” says Arrieta. “It’s important to educate rural villages about symptoms of depression in response to life’s triggers in order to stop the notion of being crazy, and that sadness is something that can’t be cured.” 

*Names have been changed for privacy.

Thu, 23 May 2019 07:50:10 -0400
Malawi Flood Relief Raising Homes, Hope Amid ‘Too Much Misfortune’ As Partners In Health continues relief efforts in southern Malawi following devastating downpours earlier this year, personal stories are emerging that show not only the flooding’s severe impact on families and communities, but also the vital support that, in weeks since, has provided hope, helped people rebuild their homes, and sustained livelihoods.

Stories like Maliko Sadzu’s. The 60-year-old described the loss of his home in tearful conversations with PIH teams, and framed the March flooding as the climactic result of three months of near-constant rain. This year’s unusually heavy deluge began in January and relentlessly weakened buildings and infrastructure across Malawi’s mountainous Neno District.

PIH, known locally as Abwenzi Pa Za Umoyo, supports two hospitals and 12 health centers in Neno, serving more than 165,000 people. The impoverished region is served by a network of steep, rocky, dirt roads that can become impassable when rains are heavy. Washed-out bridges can also force unexpected detours, increasing residents’ barriers to health care and services. 

PIH teams have dealt with those roads and other challenges while providing relief efforts after the disastrous floods, working closely with national and local government to bring emergency supplies and support to more than 1,000 people in Neno. Thousands of subsistence farmers in the district lost all or part of their homes, as the months of rainfall culminated with 84 straight hours of downpours in early March, overflowing rivers and watersheds. Relief packages have included food, materials for cooking and for repairing homes, financial support, and even temporary, one-room shelters that are designed for expansion so families can build more as they’re able.

Lines of people waiting for supplies stretch long at a flood relief event
Lines of people stretch around supplies gathered at a distribution event for flood relief in Neno District. 

For many, work to rebuild and recover has only just begun, and wounds—mental and physical—are still raw.

Sadzu said he and his wife Lucia, 50, were sitting by a sheltered cooking fire behind their house in the Neno village of M’mola, as the heavy rains fell on an evening in early March.

“Suddenly, we heard a strange noise like a small quake, as if something heavy had fallen,” he said. The noise quickly was followed by a cry from one of their eight children.

Amayooo ndikufa ine!” their 18-year-old yelled in Chichewa, the local language. “Mother, I am dying!”

The parents rushed to the front of the house and saw that several walls had crumbled, with rubble falling near their 18-year-old, who was sick and had not gone to school that day. The teenager was unhurt, to their relief. But that night, as the family slept, additional walls collapsed around them. What remained of their kitchen was lost to flooding and rain the next day.

With no place to live and no food, Sadzu was left to wonder how he could build a new house, feed his family, and continue sending their children to school.

“This is too much misfortune!” he said, sobbing openly as he recalled that day. “We have seen strange things this year, a house destroyed by rain and almost killing my child?”

The season's heaviest rains in Neno were related to Cyclone Idai, which struck southeastern Africa in early March. The cyclone killed an estimated 1,000 people across Mozambique, Zimbabwe, and Malawi; affected 1 million; and forced hundreds of thousands from their homes. In Malawi alone, the flooding killed 60 people and displaced nearly 90,000 others across 15 of the country’s southern districts.

Just days after the storm system subsided, members of the local village development committee and Neno’s disaster response team visited Sadzu’s family, along with PIH community health worker Mary Velvet. PIH and government partners provided the family with beans, nuts, more than 100 pounds of corn, a liter of cooking oil, a 20-liter plastic bucket for water, a roll of plastic sheeting to help with temporary shelter, and more. The family also received 2,000 Malawian kwacha ($2.75), for transportation costs to haul items to their home. 

Sadzu thanked all of them, knowing his family now had a path forward. A rising number of Neno residents now share that hope.

Like Sadzu, Martha Julias lost her home in the village of M’mola. Also like Sadzu, she received a visit from Velvet and government partners after the storm, and was given much of the same items as Sadzu’s family. 

For Julias, 19, the items helped her support her brother, a 21-year-old living with epilepsy. Julias previously lived with their parents in Blantyre, the largest city in southern Malawi, but moved to Neno in 2018 to help her brother. Velvet visited frequently and accompanied him to monthly checkups, but until Julias’ arrival, he did not have full-time care.

Julias’ presence might have saved her brother’s life during the rains. They both were outside in their garden at about 9 a.m. on a March day, when three walls of the house fell down—shattering windowpanes, damaging their metal roof, and revealing how the extended downpours had eroded their home’s foundation. 

“Imagine if he had been inside the house. What could have happened?” Julias said.

Julias said the emergency support they received gives them hope, and will help them restart their lives in weeks and months to come.

Dr. Luckson Dullie and Roda Biziwelo at a flood relief event in Neno District
Dr. Luckson Dullie, executive director of Partners In Health in Malawi, comforts Roda Biziwelo, who supports six people and lost her home to heavy rains earlier this year. 

Roda Biziwelo, a 65-year-old widow, also has to rebuild. She lives in the Neno village of Nyakoko with her 25-year-old daughter, who has cerebral palsy, and her five grandchildren. 

Biziwelo lost her home during the rains. She, her daughter, and the grandchildren now are living in a makeshift, thatch-roof shelter. Despite assistance from PIH and partners, she remains anxious about her family’s future. She expects to harvest only two bags of corn this year, not nearly enough to last until the next harvest season.

Her struggles are indicative of the tough months that lie ahead for many Neno residents, and for Malawians across the country. The flooding destroyed many fields and crops just as they were maturing, meaning risks of severe food shortages loom.

The flooding and destruction of homes and property in Neno District and across southern Malawi have been devastating, especially with Cyclone Idai coming at the end of the growing season when families cannot replant,” said Dr. Emilia Connolly, chief medical officer for Partners In Health in Malawi. “We are so fortunate, with the response from our request for fundraising, to be able to support our community where we live and work to strengthen the health care system through food, household, and infrastructure support.”

To help PIH continue providing emergency assistance to Malawi families and communities in need of food, mosquito nets, supplies to rebuild homes, and more, please consider donating here.

Tue, 21 May 2019 16:10:03 -0400
Ebola Survivor Fights Odds and Expands Her Family Mariama Kamara felt suddenly unwell upon coming home to her daughter and grandson one evening in August 2016. After walking the familiar dusty road home from the diamond mine where the 43-year-old worked in Sierra Leone’s Kono District, she sat down in the kitchen with a worsening headache and nausea. The terrifying realization came to her as she listened to her family’s playful evening chatter—her symptoms pointed to Ebola.

Sitting slumped at the kitchen table, Kamara questioned how her daughter and adopted grandchild, Hawa and Ibrihim Kamara, would cope if she wasn’t there for them, and wondered about the treatment they would likely receive when neighbors heard they were an “Ebola family.” It occurred to her that many other mothers, like her, must have faced similar turmoil before being taken away by ambulances, as was increasingly the case in her village. In a flash of panic, she considered taking her family with her to the hospital, reasoning that perhaps they would be safer by her side rather than left to face these hardships alone.

In the fall of 2014, Partners In Health was invited by the Sierra Leonean government to help respond to the Ebola epidemic, including the provision of care in Kono District. Over that time, around 800 people from the district were placed under isolation, many of whom were parents or caregivers of young children, according to PIH records. More than half of them, or 454 people, were identified as Ebola-positive. And a large number counted among the staggering 3,955 deaths across Sierra Leone, during what would amount to the world’s largest epidemic of its kind.

When mothers and fathers were taken away, their infants relied on the care of generous neighbors and extended family. If that wasn’t an option, they were taken to the Observational Interim Care Center, a UNICEF-funded service that provided food and support to children of Ebola patients. By the end of the epidemic, 5,666 children across the country had lost a parent as a result of Ebola.

Surviving Ebola

But Kamara didn’t want to think about this that night, while she sat hunched in her chair. Still, her conviction in her family’s resilience grew as the hours passed. She was a keen boxer, regularly participating in local female boxing competitions, and had taught Hawa how to box from an early age. Her favorite motto, “Train hard, fight easy,” was one she had instilled in her daughter. And this fighting spirit, she felt certain, would translate into the strength Hawa needed to guide Ibrihim through life, whether she returned to them or not.

During the peak of the Ebola epidemic in Sierra Leone, communities were instructed to call an emergency line if they or others suspected Ebola’s tell-tale symptoms. Many patients, like Kamara, were taken into immediate isolation for 21-days. So after being rushed to PIH-supported Koidu Government Hospital, where she received an injection to stem the spread of the infection, she was taken by ambulance to an Ebola treatment center more than 70 miles away.

“There were six of us packed in. One man died on the way with blood and sickness coming out of him everywhere,” Kamara remembered. “I didn’t have a chance to say goodbye to my children, but my resilience was strong and I believed I would be back with them soon.”

Kamara was at the Ebola treatment center for almost five weeks, without any form of communication with her family.

“I cried for the whole month she was gone,” said Hawa, who was 24 at the time. “When people went there, they rarely came back.”

Hawa found out that her mother’s test result had come back Ebola-positive when a group of people working for the district health medical team came to her home and removed all of their belongings to be taken away and burned—a typical practice at the time, which left survivors completely destitute. Fortunately, she had already found a new home for her and Ibrihim, who was 4 at the time.

After weeks of worry, Kamara was one of the few to fight the terrifying odds and survive Ebola, returning home to her family in October 2016.

“When she came back it was night and she was sad,” Hawa remembered. “She didn’t want me to touch her, because she was worried about infection. But I wanted to hug her so badly.”

Committed to care

Upon her return, Kamara decided to support the children of those parents less fortunate than her. After being told she was no longer welcome at the local mine, due to unfounded suspicions that she was still infectious, she applied to become a caregiver at the center that supported children of Ebola patients. She worked there for more than a year cooking, cleaning, and “taking care of people’s children when they couldn’t.” All but one of the 30 children under her watchful care survived the epidemic.

Kamara also felt drawn to other survivors. She became part of a tight-knit group of friends who supported one another through regular bouts of illness—common during post-Ebola recovery—and intense societal stigma, which they experienced from community members on a daily basis. She had to carry her treatment center certificate wherever she went in case someone confronted her.

Ebola survivor Sierra Leone
Kamara is among 28 Ebola survivors PIH in Sierra Leone has employed in a range of different roles, such as in the Koidu Government Hospital laundry room.

Cognizant of societal stigma in the epidemic’s aftermath, PIH leadership vowed to employ Ebola survivors and their children whenever possible. Today, 28 Ebola survivors work for PIH in Sierra Leone, in a range of different roles. Kamara is a member of the launderette team at Koidu Government Hospital. And not far away, Hawa works with the social protection team, providing financial support to Kono’s most vulnerable patients.

“When I see patients, it reminds me of my past,” Hawa said. “My mum was in a lot of pain when she had Ebola.”

Mother to all

True to her promise of supporting those left vulnerable by Ebola, Kamara adopted three children in the wake of the epidemic: Alusine and Alusane, now 16-year-old twin brothers, and Sara, now 13.

“It wasn’t a difficult choice for me,” Kamara said, having noticed how the three children struggled to receive the care they needed in their community. “My house is full of love.”  

Not to mention, quite busy. Kamara maintains a strict routine to keep her family in check. “I get up at 4 a.m. to do domestic work, go to work, and then I’m home by 4 p.m. to spend time with them,” she said.

Kamara stresses the importance of education, believing the surest way to motivate her children to work hard is through her own attendance of PIH’s literacy classes, which take place five days a week and have welcomed more than 80 students in Kono to date. “If I’d had this training before in my life, I think I would have found times a lot easier,” she said. “When I started, I couldn’t hold a pencil properly. But now I can write my name.”

Although not as strong physically as she once was at the peak of her boxing game, Kamara has gained mental perseverance through her recent trials. Hawa said her mother became noticeably “louder” following her illness, and that after hearing about PIH’s classes, nothing could stop her from signing up to receive the education she never had growing up.

Kamara’s family is about to get even larger as Hawa looks forward to the birth of her first child with Komba James Tongu, her husband and PIH's motorbike coordinator in Kono, at the end of the summer. Kamara surely takes this addition as a blessing and is prepared for the new adventure.  

“My mum did whatever it takes and took on any responsibility for me,” she said, “just like I do for my children now.”

Fri, 10 May 2019 15:12:28 -0400
Research: Strong Health System Key to Growth in Post-Genocide Rwanda Five years ago in The Lancet, Dr. Agnes Binagwaho, Dr. Paul Farmer, and more than 60 co-authors described how treatment for HIV in Rwanda became a catalyst, and foundation, for revitalizing the country’s health system in the aftermath of the devastating genocide against the Tutsis in 1994.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Muhanyana said the clinic also provides a circle of friends. 

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

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

The need for parental support in Kirehe is enormous.

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

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

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

“There are so many mothers,” Nirere said.

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


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

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

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

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

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

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

For Mukherjee’s full UN statement, listen below:


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Read their full article here.

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

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

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

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

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

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

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

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

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

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

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

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

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

On addressing inequality:

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

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

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

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

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

On sexual and gender-based violence:

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

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

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

On women’s political participation:  

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

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

Watch Viaud’s full speech HERE.

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


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

This story was originally published on October 4, 2018.

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

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

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

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

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

What’s the best part of your job?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Are there any patients who stick in your memory most?

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

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

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

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

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

This story was originally published on January 27, 2014.

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

But she doesn’t think of herself as remarkable.

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

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

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

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

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

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

Confronting an unequal world

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

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

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

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

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

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

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

From world-class to resource-poor

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

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

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

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

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

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

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

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

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

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

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

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

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

Between Boston and Haiti

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

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

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

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

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

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

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

This story was originally published on December 8, 2017.

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

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

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

Photo by Zack DeClerck / Partners In Health

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

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

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

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

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

What is the difference between public health and global health?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Everybody had buy-in,” she said. 

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

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

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

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

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

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


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

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

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

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

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

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

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

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



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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

How was this documentary created? 

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

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

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

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

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

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

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

Out of Breath

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Read the full publication here.

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

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

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

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

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


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

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

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

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




A Safe Haven for Mothers and Babies

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

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



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Training Haiti’s Next Generation of Clinicians

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

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

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Cancer Care for All

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

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

*Name has been changed at patient’s request.

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A Lifesaving Laboratory

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

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Rehab for the Body, Mind, and Spirit

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

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

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A Hub of Activity

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

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

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

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A Cut Above the Rest

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

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

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

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Always a Full House

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This tool takes the world one step closer.

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



Fri, 15 Mar 2019 10:13:51 -0400