Partners In Health Articleshttps://www.pih.org PIH Director: “Staggering” Losses in Sierra Leone Flooding https://www.pih.org//article/pih-director-staggering-losses-sierra-leone-flooding Partners In Health’s top official in Sierra Leone described “staggering” losses Tuesday among PIH family and friends in Freetown, where rescue work was ongoing after devastating floods and mudslides killed hundreds a day earlier.

Just before dawn Monday, while most of the city slept or prepared for work, uncommonly heavy rainfall caused hillsides to give way in southern neighborhoods of Freetown, the nation’s capital. Mud roared down unstable slopes, killed at least 300 people, and left at least 1,000 homeless. Rescuers were continuing to search through debris into Tuesday evening.

Numerous family members of PIH staff are among the dead.

“There have been staggering losses among some of our staff members,” said Jon Lascher, executive director at PIH Sierra Leone.

One PIH employee lost eight members of his family, Lascher said. Another lost five. A third lost his sister.

“And the list goes on,” Lascher said in a Skype conversation Tuesday.

His comments reflect the massive tragedy in Freetown, where many residents lost entire families and homes. Reuters called the mudslides one of the deadliest natural disasters in Africa in recent years.

© Partners In Health

Sierra Leone’s Ministry of Health, army, and more were leading the response from a downtown command center, using logistics and communications systems originally set up for the Ebola epidemic. Lascher and Sierra Leone native Dr. Bailor Barrie, medical director at PIH’s Wellbody Clinic, were involved and assessing how PIH could help.

They said the response’s first priority was managing the overwhelming number of bodies arriving at morgues. Finding shelter for people who lost their homes also was a high priority. Lascher said many of the displaced were camped at National Stadium, a roofless soccer stadium.

PIH has also been focused on taking care of its staff.

“We spent much of yesterday trying to provide support to those we know who lost family members and homes,” Lascher said. “Early today, I went to visit one of our staff members whose house was destroyed and what I noticed in the mud were pots and pans and clothes and stuffed animals—everything that people owned, washed away.”

While the larger response takes shape, PIH also is helping arrange funerals and counselling.

“I think the next few days, as more people are recovered, is going to be a difficult time,” Lascher said. “You hear sirens from ambulances passing much more frequently than normal, and you know those ambulances are unlikely to be carrying the sick.”

© Partners In Health
Rescue and recovery workers, wearing coveralls reminiscent of those needed by Ebola burial teams as recently as last year, cross Freetown on Wilkinson Road near Congo Cross on Tuesday.

 

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Wed, 16 Aug 2017 10:30:52 -0400 https://www.pih.org//article/pih-director-staggering-losses-sierra-leone-flooding
Fodei Daboh: A Sierra Leonean Healing His Town https://www.pih.org//article/fodei-daboh-sierra-leonean-healing-his-town One Stone’s response wasn’t exactly a surprise. In up-country Sierra Leone, in the central chiefdoms of Kono District, the man with the rapper-inspired nickname was a known member of a young gang that tried, a bit too aggressively, to wash cars on the red-dirt avenues outside the gaping diamond mines. “He was a rude guy,” recalls Fodei Daboh.

Still, no one expected One Stone* to explode quite like he did. After being diagnosed with HIV, One Stone left the clinic, threw away the free anti-retroviral medicine, and gathered up his posse. They surrounded the house of a local health worker and shouted obscenities at her loud and long, as if she was somehow responsible for his illness.

Daboh, Partners In Health’s community health worker manager in Sierra Leone, took over. Since 2010, he has worked with PIH and its precursor in Kono, Wellbody Alliance. He currently manages a large staff, including 101 community health workers who support and advise patients during treatment and accompany them to the facility when they need care. One of those community health workers was the woman One Stone had yelled at.

“He’s just such a boss,” says Mara Kardas-Nelson, director of community based programs at PIH Sierra Leone. “You walk through the back streets of Koidu on a Saturday morning and everyone greets him. He stops to say ‘What’s up,’ ask how a person’s health is, ask about their goats, make little business deals. He knows everyone, is an integral part of the community.” And by all accounts, he goes the extra mile to make sure patients get what they need. He wasn’t a fan of One Stone’s bad behavior, but he also wasn’t about to let the man kill himself.

After asking around a bit, Daboh found the car washers and sat down with One Stone. “They were having beers, so I went to the bar and bought two bottles of beer and came back and gave him one,” Daboh recalls.

It seemed to ease tensions, and provided an entré into the clique. Every few days for more than a month, he hung out with One Stone, often buying him a beer but never bringing up his HIV diagnosis.

“Then, one day, I spent the whole day with him,” says Daboh. “And I realized, he has really, really accepted me.”

Daboh finally entreated One Stone to get help: “I said, ‘One Stone, you are my brother. Before you die young, before it’s too late, I want to take you to a hospital.’” It worked. The slow accumulation of trust allowed them to take the first steps toward treatment together. Today, a year later, One Stone is not only healthy, but a friend to PIH and Daboh.

© Partners In Health
PIH community health worker Mohamed Lamin Jarrah (center), one of over 100 staff members reporting to Daboh, walks with an HIV patient (left) in Koidu city, Sierra Leone, in September 2016. (Photo by Jon Lascher / Partners In Health)

Only some of the 800 HIV and tuberculosis patients that Daboh’s team of community health workers support are as demanding, but the anecdote is illustrative nonetheless. Every health worker strives to meet the unique needs of each patient. And Daboh—personally, expertly—has invested similar time, energy, and sympathy toward hundreds of patients, from a baby abandoned at the clinic to a grandmother who needs help going to the bathroom.

“Daboh understands how to communicate with his community,” says Storm Portner, who co-managed the program with Daboh and is now a medical student. “He understands what people are going through better than I ever could.”

That empathy wasn’t easily won. Daboh was born in Sierra Leone’s Bo District in 1972 and dreamed of being a lawyer. Beginning in 1990, he moved from school to school to stay ahead of the spreading civil war, ultimately fleeing Freetown when the violence finally caught up to him there. In neighboring Monrovia, Liberia, his sister, gainfully employed, paid his university tuition fees until that country’s civil war engulfed them, and he went from budding law student to homeless man in a bullet-riddled city. “It was not easy,” he says.

Allen Peal, the son of the Liberian ambassador to America, who had seen Daboh around and liked him, gave him a chance to manage a one-truck shipping enterprise. Daboh quickly proved his worth and was invited to work as a clerk on a rubber plantation, where he again excelled. Some four years later, he supervised 1,000 rubber harvesters.

© Partners In Health
A Liberian rubber estate not unlike the one where Daboh worked as a supervisor. (Photo by Rebecca E. Rollins / Partners In Health)

With an aging mother in need of care, he returned to Kono, Sierra Leone, in 2004, and used his savings to set up a small mining operation. It wasn’t a bad bet. Kono was then one of the most valuable and productive diamond mining regions in the world. Alas, his 10 employees found no diamonds, and he ran out of money. He looked for work for two years, without success.

“I became a street guy again,” says Daboh. “People started pointing fingers. ‘A rich man can become a painter,’ that is the saying.”

In 2007, things started to look up when a former headmaster offered him a job as a teacher, but the sunny forecast didn’t last. “I started getting sick—continuous, continuous, on and off, on and off,” he says. Weight loss. Fatigue. A chronic headache. He persisted as a teacher, but with hospitals and clinics in the area offering few, shoddy, or no advanced tests for illnesses like HIV or TB, Daboh treated himself with whatever medicine seemed right. He was 37 years old. He had been rich and homeless, safe and caught in crossfire, and healthy and perilously sick. And he had yet to give up. 

He also proved a natural leader. Convinced his symptoms spelled HIV, he joined a nationwide support group called NETHIPS, the Network of HIV Positives in Sierra Leone. He learned about the disease, became a district coordinator, and supported the organization’s expansion, helping them win a grant from a partnership with the World Health Organization.

When Wellbody Alliance, which is now a part of PIH, began the community health worker program in Kono in 2010, it immediately hired him as a community health worker. And that’s when he secured for himself yet another chance at a stable, long life. “On the day of the TB training,” recalls Daboh, “the guy knew how to teach so well, after he had explained the signs and symptoms, I stood up and said, 'I know my problem.'” With help, he managed to finally get a TB test, which confirmed that yes, he had had TB all along.

Daboh is cured now, and his community health worker program is seen as a model for the nation, with government officials, including the Minister of Health, visiting the district. The program supports patients across Kono, which has a population of just over half a million people, and sports impressive results: patients attached to a community health worker are 50 percent more likely to stay in care and demonstrate higher CD4 rates, a measure of immune response.

“At the beginning, maybe a person says things just to get the job of community health worker,” says Daboh. “But as time goes—one month, two month—you see that person’s attitude starts improving and every day you see their commitment increasing. Because the more a person comes across patients, the more they will get committed.”

Of course the increasing commitment might not have to do with patients. It could be that people become more and more committed to helping the sick and vulnerable the more time they spend with Daboh.

*Name has been changed.

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Fri, 11 Aug 2017 12:35:21 -0400 https://www.pih.org//article/fodei-daboh-sierra-leonean-healing-his-town
CASITA Program Helps At-Risk Children Excel in Peru https://www.pih.org//article/casita-program-helps-risk-children-excel-peru Life in a house with three children under 5 is, to say the least, chaotic. Analy Cipriano spends most days cooking, cleaning, doing laundry, and keeping a watchful eye on her babies in the cramped slums of Carabayllo, north of Lima, Peru. Money is tight, and spare time practically non-existent.

Yet when staff from Socios En Salud, as Partners In Health is known locally, came by with formula for her infant daughter, Ashley Minaya, and mentioned a free child development group, Cipriano was interested. Although nearly 6 months old, her baby still couldn’t sit up without support and seemed lethargic. The young mother decided to give it a try.

Every Wednesday for three months, Cipriano brought Ashley to the nearby health post in Punchauca, where PIH staff led early childhood education sessions for her and seven other mothers and their children. They sang songs, played games, read books, and practiced activities that encouraged age-appropriate language and motor skills. Each week, they were given tasks to practice at home and report on later in class.

Our children are able to learn more than we know.

Cipriano saw Ashley excel with the extra attention. Her baby learned to sit and started crawling. She was more animated and began saying little words here and there. She understood and followed instructions around the house. And she played by herself with toys they’d learn to make from recycled materials.

“I didn’t see my other kids do the same,” Cipriano said, crediting the PIH sessions for the difference. “Our children are able to learn more than we know.”

Cipriano’s experience wasn’t unique. Among the 180 families enrolled from 2013 to 2016 in PIH’s pilot program, called Proyecto CASITA, 85 percent of children at risk for developmental delays showed marked improvement, said Maribel Muňoz, leader of Proyecto CASITA. This was true regardless of whether families participated in individual, home-based interventions or group sessions like the one Cipriano and her daughter attended.

The results proved so strong, in fact, that PIH earned a grant from Grand Challenges Canada to vastly expand the program to reach 3,000 children between the ages of 6 months to 24 months in and around Carabayllo. The work will be accomplished over a three-year span, which started in May 2016, with the help of partners in the municipality of Carabayllo, the Ministry of Health, and the Korean International Cooperation Agency.

To meet the expansion’s ambitious goals for recruiting more families, PIH trained an additional 30 community health workers. The workers have diligently knocked on doors throughout the district to identify young children at risk of developmental delays.

CASITA participants, Miguelito and his mother, Mariela
Mariela holds her son, Miguelito, who has developmental delays related to microcephaly. The two participate weekly in Project CASITA sessions.
Photo by William Castro Rodríguez / Partners In Health

Sadly, they don’t have trouble finding candidates.

Carabayllo’s extreme poverty means families often face tough choices and live under constant stress. Malnutrition, domestic violence, teen pregnancy, and chronic illness are among their many daily challenges. PIH found, for example, that at least 70 percent of women enrolled in the CASITA pilot suffered some form of depression or stress, often related to spousal abuse. Such environments are toxic for children who, like sponges, soak up and internalize household tension.

Those families who qualify for CASITA are invited to attend three months of group sessions, hosted in community centers or any one of nine health posts or clinics throughout the district. Community health workers run the sessions and divvy up activities so that caregivers practice skills related to their children’s specific developmental delays.

Activities are both fun and focused. To hone fine motor skills, families make a game of picking up lentils from the floor. To strengthen tiny abs and backs, they sit supported while grabbing for toys just out of reach. And to practice speech, they read books and repeat words together.

Victoriano Meza and his son, Jake, play during a CASITA session.
Victoriano Meza and his son, Jake, practice fine motor skills during a CASITA session. Photo by Jorge Flores / Partners In Health

Beyond group sessions, PIH provides support to families through food baskets, mental health services, and assistance in applying for national identification cards, which give them access to a range of services—including subsidized health care—provided by the government.

Muňoz is encouraged by the progress these select Carabayllo children have made over a short span of time. “They are breaking down paradigms in our country,” she said, by growing up well-fed, well-educated, and in healthy home environments. “These children can be reference points for future kids. We are betting that what we do today isn’t for today. You have to see it as an investment in the future.”

Mothers and their children celebrate graduation from the CASITA program.
Mothers and their children celebrate graduation from the CASITA program outside PIH's offices in Lima. Photo by Jorge Flores / Partners In Health

 

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Fri, 28 Jul 2017 09:44:28 -0400 https://www.pih.org//article/casita-program-helps-risk-children-excel-peru
Iconic Hospital in Malawi to Expand https://www.pih.org//article/iconic-hospital-in-malawi-to-expand One of the first patients Dr. Emily Wroe met in Malawi, the slender nation bordered by Tanzania to the north and Mozambique to the south, was a pregnant mother with severe rheumatic heart disease. “Normally a patient in her condition can’t climb a flight of stairs,” says the Partners In Health clinical director for the country. “This woman, Nimiya, she walked seven hours to the clinic.”

Soon Wroe and fellow PIH staff will be able to help more women fiercely determined to get better. With donors’ support, PIH and the Ministry of Health will break ground on an outpatient clinic at Neno District Hospital this fall. The new single-story building will sit next to the main facility and will include smartly designed check-in areas, consultation spaces, and exam and treatment rooms. Thousands of sick people, who now sometimes face long queues, will be diagnosed and started on treatment for a variety of illnesses—in a single visit. “It’s so exciting to be able to match health service and infrastructure design, and meet such a tremendous community need,” says Wroe. “It makes care much more accessible.”

The new clinic adds to services that Ministry of Health clinician Grant Gonani already calls “awesome.” In 2007, the government of Malawi invited Partners In Health to work in Neno, a rugged district of hills, maize and potato fields, and weak health care. Most pressingly, local farmers, earning less than $1 per day, were suffering some of the worst rates of HIV on the continent. Roughly 1 in 7 adults in the district were infected.

PIH dove in head-first. Staff constructed health centers; hired and trained hundreds of people in the community as health workers; and built Neno District Hospital as the centerpiece of a revitalized health system. HIV survival rates in the district skyrocketed, becoming the highest in the country, with 90 percent of patients alive one year after starting treatment. The hospital grew busy, despite the fact that for many, the easiest route to it still involves a long walk and fording a river.

The outpatient clinic is a logical next step. People with more routine health needs, and those needing emergency care, will be treated at the facility. They will check in, have their medical records pulled, get tested for common conditions such as HIV and hypertension, be offered family planning, and be treated for everything that’s troubling them—be it HIV or epilepsy, hypertension or diabetes—as they would in the United States, for example.

Astoundingly, the clinic will also be seen as pioneering. Research suggests that Neno District is one of those rare places where patients can have most of their chronic health conditions taken care of in a single visit. In most health care facilities in sub-Saharan Africa, if you come for HIV treatment, for example, you must return later for a diabetes exam.

To doctors who treat women who’ve walked for hours to make an appointment, that, of course, doesn’t sit well. “We’re doing ‘innovative’ stuff,” says Wroe, of the new outpatient clinic, “but actually, most of it is bloody obvious.”

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Tue, 25 Jul 2017 10:57:59 -0400 https://www.pih.org//article/iconic-hospital-in-malawi-to-expand
PIH Hosts First Cross-Site Lab Training https://www.pih.org//article/pih-hosts-first-cross-site-lab-training It was a logistical and technical feat that had never been pulled off in Partners In Health’s 30-year history. Eleven staff members from eight PIH sites around the world arrived in Toulouse, France, for a week’s worth of training on everything from standard operating procedures to complex diagnostic exams for tuberculosis, HIV, and chronic myeloid leukemia.

PIH Director of Labs Daniel Orozco saw the week’s sessions as an opportunity for technicians to meet face-to-face, share their expertise and strengthen lab skills, and create a network of support they can use in the future to troubleshoot particularly tough cases.

The training, which was co-funded by the TB Care II project and made possible through the United States Agency for International Development, was split into two focus areas: basic laboratory procedures and an intensive course on GeneXpert—a rapid molecular test created by Cepheid Inc., headquartered in Toulouse, that is used to diagnose and monitor the treatment of a range of diseases.

PIH supports more than 20 laboratories across eight sites. Some are home to more basic diagnostic capacity; others are designed to specifically focus on a single disease, such as TB. While a handful of laboratories, such as those in Sierra Leone, opened in 2015, others have been around for decades, such as those in Haiti. Laboratory expertise and technology equally vary across sites, depending on whether staff are catering to a small clinic or a large referral hospital.

Orozco, a microbiologist by training, and his team designed the March training so that the first two days focused on lab practices and strategies. They discussed the importance of standardizing procedures across sites, the logistics behind purchasing and distributing supplies, and which tests should be available at each level of the health care system—from local clinics on up to specialty hospitals.

 

Claudine Nolte (clockwise, from left), quality management officer at University Hospital in Haiti, Moise Michel, a biomedical engineer at University Hospital, Roger Calderon, lab manager in Peru, and Zhanel Zhantuarova, a lab quality officer in Kazakhstan, practice basic maintenance on the GeneXpert, an instrument used to diagnose and monitor a variety of diseases at PIH laboratories.

The following three days were a deep dive on GeneXpert, at least one of which is available at each attendee’s sites. Staff practiced pipetting samples and running tests through the instrument for diseases such as TB, HIV, and chronic myeloid leukemia. They learned how to interpret results and error messages. And they worked on troubleshooting problems and general instrument maintenance.

“The information that I got here is of high value, because I’ll be able to use it when I get home,” said Mokenyakenya Matoko, laboratory head at PIH Lesotho, where TB infection rates are among the highest in the world. “Understanding how to best use this instrument is really going to benefit our patients.”

GeneXpert, a cube-shaped instrument the size of a home office printer, has revolutionized the whole diagnostic experience for patients living in poor countries, like the ones where PIH works. Patients wait hours, not weeks, to discover whether they have TB. If they do, they also learn whether their strain is multidrug-resistant—and particularly difficult to treat. Such rapid, accurate information allows clinicians to get patients on the correct medications and avoid further transmission.

With a week’s work behind them, lab staff were energized to share what they’d learned. “I will train my colleagues, and I will share everything that we have seen with them,” said Robert Gakumba, who heads the lab at Rwinkwavu Hospital in Rwanda.

Several people said their perspective had shifted after hearing the challenges faced by other PIH colleagues. Yearning for the latest diagnostic equipment was not the same thing as struggling to maintain a reliable source of electricity. They appreciated the opportunity to swap stories and advice, and vowed to stay in touch. Since the training, Orozco and his team built a database to track GeneXpert operations to ensure trainees continue to communicate.

“I’m really happy to have had the opportunity to share our experiences,” said Roger Calderon, lab director at PIH in Peru.

Matoko agreed. “We need each other in terms of sharing documents, experiences, and technologies,” he said. “This was really helpful; I’m looking forward to the next one.”

And so is the Boston-based lab team, which continues to ramp up the program by adding more GeneXpert machines to sites, providing software updates, and finding funds to expand the menu of tests available.  

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Mon, 10 Jul 2017 14:09:37 -0400 https://www.pih.org//article/pih-hosts-first-cross-site-lab-training
Harvard Study: Vitamin A Helps Protect Against TB https://www.pih.org//article/harvard-study-vitamin-a-helps-protect-against-tuberculosis Tuberculosis is the most deadly infectious disease in the world, killing 1.8 million people in 2015 alone, yet little is known about why exposure to the airborne disease sickens some people and not others.

Harvard researchers think diet may be key to TB transmission. According to an article published in Clinical Infectious Diseases in May, people with low levels of vitamin A were at least 10 times more likely to develop TB after exposure to the disease than those with higher levels. Increasing consumption of vitamin A—found in carrots, sweet potatoes, dairy, meat, and supplements—could be a powerful tool in disease prevention.

Dr. Megan Murray, the Ronda Stryker and William Johnston Professor of Global Health at Harvard Medical School, and her team of investigators discovered this link as part of an epidemiological study of TB among people living in Carabayllo and surrounding districts north of Lima, Peru. Staff from Socios En Salud, as Partners In Health is known locally, were essential for recruitment, patient follow-through, and blood sample collection and analysis of the 12,000 participants over five years.

We spoke with Murray, PIH’s director of research, about the surprise findings, why adolescents with low vitamin A levels are particularly at risk, and what the vitamin A link means for TB prevention.

How did your team arrive at this discovery?*

Households in Carabayllo were recruited when somebody developed TB, so we knew that we were looking at a population that was relatively high risk. Among the 12,000 household contacts, about half had given a blood sample. We checked to see if people had undiagnosed TB at the time that we drew their blood. Then we followed people for infection, and then for disease. With TB, those are different. Lots of people were already infected. About half of the people who weren’t, became infected within the next 12 months—probably because of exposure. About 2 percent of the people developed active TB. We took those cases and matched them to people who were just like them in terms of age, gender, and other factors, but who hadn’t developed TB. Then we compared their vitamin A levels, and they were really different.

Were you surprised by that difference?

We were just stunned. We were actually interested in vitamin D. People had been speculating for many years that low vitamin D is associated with TB risk, based on a seasonal pattern. The argument is that the disease starts to progress in the summer and takes five or six months to manifest. We were following that up, but then we had some data from a previous study that Dr. Molly Franke, an assistant professor at Harvard Medical School, had done in kids that showed that fruits and vegetables, in a case-controlled study, were protective against TB. We thought, ‘Well, let’s throw in some fruits and vegetables that seem to be associated with various vitamins.’

We were just stunned.

It turns out that vitamin A is only minimally associated with fruits and vegetables; it’s actually more in dairy and meat. When we got this result—that contacts with low levels of vitamin A were at greater risk for developing active TB, we were like, “Whoa, that can’t be right.” We looked for every possible reason why it might not be right, but we do think it is right.

The 10-fold factor is striking. Can you put that in context?

It’s huge. The strongest risk factor that we know is between smoking and lung cancer. That’s a 20-fold risk. It’s not a great example, because it’s so extreme that it’s way out of the normal ballpark. When you think about something like smoking and heart disease, you know it’s a very strong link. A ton of the heart disease in the world is caused by smoking. But it only doubles the risk. As epidemiologists and public health people, we’re interested in odds that are as low as 1.1, which is a 10 percent increased risk. We’re talking here about 10 times or 20 times the risk.

Vitamin A-deficient adolescents had up to 20 times the risk of developing TB. Any idea why?

We know that TB rates are higher in that age group than in any other age group. As kids move into puberty, from 10 to 20 years old, they’re at enormously high risk. We don’t really know why that is.

Adolescent health is not something that is well studied, especially around immunity. We do know that there’s some infectious diseases that are much worse in adolescence. Because of the growth spurt, they have very different metabolic demands and processes.

Vitamin A deficiency is prevalent among 30 percent of the population in low- to middle-income countries. Why is this?

I’m assuming it’s because of diet. If you think about it, it’s in dairy, meat, and fish. These aren’t very common in our diet. And the poorer the country, the less vitamin A you’re going to get.

To support these recent findings, your team is now helping design a study to test vitamin A supplementation among guinea pigs exposed to TB. How far along are you, and do you see anything promising?

Our collaborators at the University of Colorado—Fort Collins set up a nice guinea pig model in diabetes. They can make guinea pigs diabetic and then see what happens with TB. One of the questions we’ve been asking is, ‘What effect do drugs routinely used for diabetes have on TB?’ They’re on to some very interesting stuff suggesting that some of the anti-diabetes drugs could be useful in controlling TB, regardless of whether you’re diabetic or not.

When we learned this about vitamin A, I asked them if they could set up a similar project. They designed it, and we are waiting minute-by-minute for NIH funding. We’ll be ready the minute they say, “Go!”

So how long will it be before we test a vitamin A intervention in humans?

We can try it today, because this is something we know is good for people. We don’t need animal results to proceed with a trial here. We know that people who are vitamin A deficient should be given vitamin A, regardless of their TB risk. The trial that we’re envisioning is really about whether people at risk for TB should be screened for vitamin A. If they were low, we would treat it.

What do you hope will come about as a result of this publication?

I’ve had people say, ‘Why bother with a clinical trial? Let’s just give everyone vitamin A.’ I agree with that to some degree. In the U.S., we don’t recommend people who are not vitamin A deficient to take it. People take enormous doses of vitamins, and they can actually take too much vitamin A. To get people on board and to have TB programs start thinking this is a good approach, having some evidence that it’s useful is going to be good.

The poorer the country, the less vitamin A you’re going to get.

If you live in the U.S. and somebody in the household has TB, you get screened by the public health department. They come and do a skin test for TB and, if you have it, you get six to nine months of a preventive drug. We’d like to do that in lower resource settings. But some countries say, ‘Our TB burden is just too high. We can’t give half our population these drugs.’

The nice thing about vitamin A is that it’s good for other things besides TB. There’s a lot of interesting research going on right now on the relationship of vitamin A and general immunity.

*This interview has been edited and condensed.

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Tue, 27 Jun 2017 15:34:28 -0400 https://www.pih.org//article/harvard-study-vitamin-a-helps-protect-against-tuberculosis
Mortarboards Away! Liberia Graduates Next-Level Nurses https://www.pih.org//article/mortarboards-away-liberia-graduates-next-level-nurses In far southeast Liberia on May 31, families packed into grand, high-ceilinged St. Theresa Cathedral. “No matter what comes my way, no matter how I cry,” a gospel choir led the crowd in singing, “one thing I know that is definitely in my heart, my tomorrow must be greater than today.” A speech from the dais echoed the themes of persistence and optimism, urging the guests of honor to continue to “go to bed smarter than you woke up.” Soon after, Tubman University, a Partners In Health-supported public university, graduated the first class in a groundbreaking nursing program.

When the 15 students enrolled two years earlier, they had already earned Associate Degrees in Nursing and passed the national board exams. Some had been caring for patients in hospitals, health centers, or clinics for a decade. With the launch of the Tubman University program, they had returned to learn even more skills, participating in the first RN-to-BSN program anywhere in the country outside of the capital Monrovia. They attended classes every weekday, studying subjects such as nursing theory, and conducted research on effective nurse-patient communication, for example. Now they’re ready to become nurse leaders, managers, and teachers, or pursue master’s degrees in rare-but-essential specialties like pediatrics.

Minnie Horace, a PIH nurse clinical lead and one of the program instructors, points to a tangible feeling of momentum. In 2015, PIH helped Tubman’s first class pass its RN exams. Since then, PIH has helped modernize nearby J.J. Dossen Hospital and expand Pleebo Health Center. The RN-to-BSN program is just the latest to stoke enthusiasm about the future of health care in Maryland County.

Of course even the graduates who have pledged to serve the county will be tempted to leave, travel 18 hours north, and find work in Monrovia, where pay can be better. Sixty percent of all trained health staff in Maryland County are paid by donor organizations or, astonishingly, volunteer in hopes of one day earning a salary. So the graduation is both cause for huge celebration, and a reminder that much work remains for any organization hoping to keep up with the dogged, unrelenting progress of local nurses and students.

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Mon, 26 Jun 2017 16:18:34 -0400 https://www.pih.org//article/mortarboards-away-liberia-graduates-next-level-nurses
Urgent: Contact U.S. Senators About Health Care Bill https://www.pih.org//article/calling-u.s.-senators-about-the-health-care-bill1 The Better Care Reconciliation Act violates our right to health, and with the secret way it was crafted, it also violates our right to a fair deliberative process. As the Senate takes up debate, we remain committed to fighting for the right to health care for all.

There are so many ways that this bill violates PIH's core principles of making a preferential option for the poor. The bill threatens to:

1. Gut Medicare
2. Give tax cuts for the wealthy
3. Eliminate government subsidies for insurance
4. Remove protections for those with a pre-existing conditions
5. Defund Planned Parenthood

We must defeat this bill.  Use the suggested script below and call the senators listed at the bottom of this page. Thank you!

SUGGESTED SCRIPT:
First, speak with the front desk person, “Hello, my name is ____________________ I am an American citizen (or a citizen of the state of the senator you are calling)."

If you are asked where you are from you can say either “I am not comfortable giving my address” or “I am an American citizen and this bill affects all of us.”

"I vote, I am involved in organizing. I am calling to register that I am AGAINST both the AHCA and the Senate’s bill to repeal and replace ACA.  I (or a loved one) have _____________a medical condition that requires on going care and medications. What I (or a loved one) need to stay healthy is UNDER THREAT because the  proposed senate bill (Better Care Reconciliation Act- BCRA) will cut subsidies for insurance, will result in far higher premiums for insurance, and will not protect me (or my loved one) because of this “pre-existing condition.” I believe that all of these cuts and restrictions are  being put in place to provide tax cuts for extremely wealthy people. This is unjust and violates the social contract of our society.  Also, I am enraged by the fact that this bill was crafted without any public hearings and done in secret. This violates our rights to a free and open process."

"I would like to speak to the health aid of Senator ___________________ to register my opinion on this terribly dangerous and deeply unfair bill."

IF THE HEALTH AID ANSWERS, repeat the personal story above.

"Thank you for your time, I appreciate the ability to register my strong opposition to this Senate’s bill to repeal the ACA and replace it with something that will result in tens of thousands of deaths and loss of health insurance coverage for more than 23 million people."

SENATORS TO CONTACT:

ARIZONA: Sen. Jeff Flake (R)
Legislative Assistant Helen Heiden • helen_heiden@flake.senate.gov • 202 224 4521

ARKANSAS: Sen. Thomas Cotton (R)
Abigail Welborn, Legislative Assistant • abigail_welborn@cotton.senate.gov • 202-224-2353

ALASKA: Sen. Murkowski, (R)
HELP Cmte Legislative Aide Morgan_Griffin@murkowski.senate.gov • 202 224 6665
Legislative Director Garrett_Boyle@murkowski.senate.gov • 202 224 6665

COLORADO: Sen. Cory Gardner (R)
Legislative Director Curtis Swager • curtis_swager@gardner.senate.gov • 202-224-5941
Ali Toal, Legislative Assistant • Alison_toal@gardner.senate.gov • 202-224-5941

LOUISIANA: Sen. Bill Cassidy (R)
Senior Health Policy Adviser Matt Gallivan *matthew_gallivan@cassidy.senate.gov • 202-224-5824
Research Analyst Davis Mills • David_Mills@cassidy.senate.gov • 202-224-5824

MAINE: Sen. Susan Collins (R)
Legislative Assistant Elizabeth Allen • elizabeth_allen@aging.senate.gov • 202 224 2523

OHIO: Sen. Rob Portman (R)
Legislative Assistant Sarah Schmidt • sarah_schmidt@portman.senate.gov • 202-224-3353

NEVADA: Sen Dean Heller (R)
Legislative Assistant Rachel Green • Rachel_Green@heller.senate.gov • 202 224 6244

WEST VIRGINIA: Sen. Shelley Moore Capito (R)
Legislative Assistant Dana Richter • dana_richter@capito.senate.gov • 202-224-6472
Legislative Correspondent Mike Fischer • Mike_Fischer@capito.senate.gov • (202) 228-1395

 

ADDITIONAL SENATORS TO CONTACT:

ARIZONA: Sen. John McCain (R)
Legislative Assistant David Benne • david_bennet@mccain.senate.gov • 202-224-2235

ALABAMA: Sen. Luther Strange (R)
Legislative Correspondent Maria Olson • maria_olson@strange.senate.gov • 202-224-4124

ALABAMA: Sen. Richard Shelby (R)
Legislative Assistant Clay Armentrout • clay_armentrout@shelby.senate.gov • 202-224-4124

FLORIDA: Sen. Marco Rubio (R)
Legislative Assistant Ansley Rhyne • Ansley_rhyne@rubio.senate.gov • 202-224-3041

NORTH CAROLINA: Sen. Richard Burr (R)
Health Policy Director Angela Wiles • Angela_wiles@burr.senate.gov • 202-224-3154

PENNSYLVANIA: Sen. Patrick Toomey (R)
Legislative Assistant Theo Merkel • Theodore_merkel@toomey.senate.gov • 202-224-4254

WISCONSIN: Sen. Ronald Johnson (R)
Legislative Director Sean Riley • sean_riley@johnson.senate.gov • 202-224-5323

TEXAS: Sen. Ted Cruz (R)
Legislative Counsel Joel Heimbach • joel_heimbach@cruz.senate.gov • 202-224-5922

UTAH: Sen. Michael Lee (R)
Legislative Director Christy Woodruff • Christy_woodruff@lee.senate.gov • 202-224-5444
Legislative Assistant Andy Reuss & Leslie Ford • andy_reuss@lee.senate.govleslie_ford@lee.senate.gov •  202-224-5444

NEBRASKA: Sen. Ben Sasse (R)
Legislative Assistant Jessica Smith • jessica_smith@sasse.senate.gov • 202-224-4224

SOUTH CAROLINA: Sen. Lindsey Graham (R)
Legislative Aide Nick Myers • Nick_myers@lgraham.senate.gov • 202-224-5972

IOWA: Sen. Chuck Grassley (R)
Director of Health Policy Karen Summar • Karen_Summar@grassley.senate.gov • 202-224-3744

IOWA: Sen. Joni Ernst (R)
Legislative Assistant Andrea Hechavarria • Andrea_hechavarria@ernst.senate.gov • 202-224-3254

ARKANSAS: Sen. John Boozman (R)
Legislative Assistant Jennifer Humphrey • Jennifer_Humphrey@boozman.senate.gov • 202-224-4843

TENNESSEE: Sen. Robert Corker (R)
Health Care Policy Adviser Arne Owens • Arne_Owens@corker.senate.gov • 202-224-3344

TENNESSEE: Sen. Lamar Alexander (R)
Chief of Staff David Cleary • David_Cleary@help.senate.gov • 202-224-4944
Director of Operations Misty Marshall • Misty_Marshall@alexander.senate.gov •  202-224-4944

 

 

 

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Mon, 26 Jun 2017 11:12:57 -0400 https://www.pih.org//article/calling-u.s.-senators-about-the-health-care-bill1
Community Health Worker Program Expands in Chiapas https://www.pih.org//article/community-health-worker-program-expands-in-chiapas Dr. Rodrigo Bazúa didn’t have to think long to come up with examples of how new community health workers were making a difference throughout rural Chiapas, Mexico. There was Aracely in Letrero who, he believes, prevented a maternal death by convincing her neighbor to give birth at the hospital in Jaltenango. Then there’s Maribel in Plan de la Libertad, who helped get a patient’s diabetes and hypertension under control. And the list went on.

The women are among 33 new community health workers, or acompaňantes, recruited and trained over the past year to work in Letrero, Monterrey, Salvador Urbina, and Capitán. The expansion means that all 10 communities supported by Compaňeros En Salud, as Partners In Health is known locally, now have workers to support patients suffering from chronic illnesses, such as diabetes, hypertension, and depression. A select few focus on improving nutrition and maternal health.

“The relationships patients have with their doctor is short,” says Bazúa, a community programs coordinator for PIH in Mexico. “Control of chronic diseases is for the long term. It really depends on a strong relationship with the community health worker.”

PIH’s acompaňantes serve as bridges between the local clinic and the surrounding community. They are trusted neighbors who have been carefully recruited, trained, and supported by supervisors and local clinicians. They visit patients in their homes, interact with their families, and come to understand patients’ physical, emotional, and social situations—all of which come into play in maintaining good health. They become their patients’ strongest advocates and, quite often, their good friends.

“The tasks that community health workers contribute are tasks that doctors simply cannot do,” says Daniel Palazuelos, chief strategist for PIH in Mexico. “It’s not that these tasks are too complex or un-learnable, but community health workers have something doctors do not have: time, and a position in the community that can build a fundamentally different therapeutic relationship.”

Bazúa and Dr. Mariana Montaño, who shared the position of community programs coordinator up until March 2017, led the most recent expansion. After carefully examining the acompaňante program, they focused on elements that weren’t working perfectly, and coupled their analysis with a community health worker survey. The overarching lessons were that, before PIH recruited more workers, it needed to give supervisors fewer patients and provide them with better training and support.  

The tasks that community health workers contribute are tasks that doctors simply cannot do.

The doctors designed a supervisor curriculum that focused on leadership, professionalism, and conflict resolution. The idea wasn’t to shame supervisors, but to understand what difficulties they faced and discuss how to overcome those obstacles.

Last spring, they began testing their new approach. Monterrey, one of the most remote villages from PIH’s base in Jaltenango, began recruiting and training new community health workers in April. Three months later, it was Salvador Urbina, then Letrero in September, and finally Capitán in January.

Staff spoke with pasantes, or first-year doctors supported by PIH, in each community to assess how many patients could use a community health worker. Typically, these patients suffer from diabetes, hypertension, alcohol abuse, depression, epilepsy, or schizophrenia. Nearly all need social support. But PIH also included on the list malnourished children and pregnant women, especially those considered at risk—such as teenagers or women with histories of complicated pregnancies.

Once they knew how many community health workers they had to recruit, the pasante and PIH staff hosted meetings in each village to explain the program. Attendees, mostly women, asked questions and decided whether it was a good idea for their community. Staff then interviewed volunteer candidates and made their final selections.

The recruits completed a four-week training, half of which focused on chronic disease and the other half on mental health. Veteran community health workers helped conduct these trainings, another PIH first, and were on hand to answer questions. “This has been an enriching experience for both sides,” says Montaño. “It represents a unique opportunity for social connection.”

Dr. Fátima Rodríguez (center), coordinator of PIH’s mental health program in Mexico, leads a training for new community health workers Vilga Vázquez (seated, from left), Celmira López, and Ernestina López in Capitán, Mexico. Photo by Mary Schaad / Partners In Health

Once training was complete, pasantes paired workers with patients. The relationships are far from obligatory; patients have the final say about whether they need, and want, such assistance. Usually, they do. Still, PIH staff say, it can be awkward convincing an octogenarian, who may have known a community health worker from the time she was in diapers, to entrust her health and well-being to someone without a medical degree. Over time and repeated visits, trust builds between the two.

Workers visit new patients once a week for six months to ensure they are taking their medication and have their sugar levels or blood pressure under control. That frequency changes over time, depending on the patient’s health. Meanwhile, PIH staff closely supervise the recruits, dropping by the community for several days each month to provide guidance and “follow them like a shadow,” Bazúa says. Program staff also conduct monthly trainings to continue the workers’ education and provide a forum to troubleshoot difficult cases.

Bazúa and Montaño say it has been difficult to determine whether workers provide “successful” home visits. They are now developing ways to measure that qualitatively and collect data on basic services provided with each visit. Whatever they discover will help inform how PIH can further improve and expand the program.

 

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Wed, 14 Jun 2017 13:38:41 -0400 https://www.pih.org//article/community-health-worker-program-expands-in-chiapas
This Week: CNN's Dr. Sanjay Gupta Interviews Dr. Paul Farmer https://www.pih.org//article/cnn-interviews-dr.-paul-farmer We’re pleased to announce that Partners In Health will be featured this week in a special CNN multimedia series called “Champions for Change.”

CNN Chief Medical Correspondent Dr. Sanjay Gupta visited Haiti last month to interview Dr. Paul Farmer and profile the work of our staff at University Hospital in Mirebalais. The CNN team spent three days in Haiti, documenting the impact of our efforts in the country’s central region.

In an online essay about the man who inspired him, Gupta writes, “My personal attitudes toward charity and altruism, in part, have been shaped by wanting to live up to the ideals Farmer has shown me, because if pure altruism really does exist in humans, it probably looks a lot like him.”

"Champions for Change” will feature other individuals and organizations, but the segments featuring Dr. Farmer and PIH will air on CNN and CNNgo at these dates and times:

• Wednesday, June 14: 8 a.m. EST
• Thursday, June 15: 9 p.m. EST
• Saturday, June 17: 3 p.m. EST
• Saturday, June 17: 9 p.m. EST (a one-hour show featuring highlights from the series)

Watch the full segment from CNN below: 

 

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Wed, 14 Jun 2017 12:05:45 -0400 https://www.pih.org//article/cnn-interviews-dr.-paul-farmer
Three Clinicians Bring Pioneering Mental Health Services to Liberia https://www.pih.org//article/three-clinicians-bring-pioneering-mental-health-services-to-remote-villages A village healer warned that if she crossed the river, then bad things would happen, but in Regina’s* youth there was no need to worry. She grew up, helped around the house, and married. She visited her husband’s parents on the far bank, but Regina’s family performed the right rituals and no misfortune befell her. Then, one day, Regina again climbed into a canoe and floated across the turgid brown water of the Cavalla. This time the rituals didn’t help.

When nurse and Partners In Health Mental Health Coordinator Garmai Cyrus visited the Buah District of southeast Liberia last year, Regina had been hallucinating for two decades, picking through trash and sleeping in the streets. Her family blamed the river.

Cyrus patiently earned their and Regina’s trust and, months after she first arrived, was able to diagnose Regina with schizophrenia. Much to the relief of all, an anti-psychotic medication proved effective. Regina now lives at home with her family. She’s clean, well-dressed, and easy to chat with. “You wouldn’t believe her transformation,” says Cyrus.

Such are the small miracles that PIH’s three-person mental health team helps perform in Liberia. Across 5,000 sparsely populated square miles of the southeast, Program Manager Bethuel Nyachieng’a, Coordinator Willis “Archie” Yansine, and Cyrus meet mentally ill people where they are, both geographically and spiritually, and do their best to help.

It’s a big job. The three have mentored and offered refresher courses for government mental health clinicians, the majority of whom received a few weeks of training years ago. They have publicized mental health issues, including via radio programs, and established ways to refer patients to specialists. And with their government colleagues, they have treated and followed-up with roughly 1,000 people suffering conditions including epilepsy, psychosis, and depression. “Building mental health in the southeast is very hard,” says Yansine. “It’s just now that people are getting to know about mental health.”

But with each accurate diagnosis, the PIHers are changing that. In one region last year, 166 patients had been diagnosed with epilepsy—ten times as many cases as substance abuse, which is typically far more common. “Everyone was ‘epilepsy, epilepsy, epilepsy,’” recalls Cyrus.

Partly from his previous work in Somalia and Kenya, Nyachieng’a knew that epilepsy’s seizures, tremors, and other symptoms can easily be confused with other conditions. So before changing any treatments, he and local clinicians took another, more thorough pass at diagnosis. The correct number suffering epilepsy proved to be 46, while the others suffered from depression, psychosis, and other ailments. Once accurately diagnosed, patients were placed on more effective treatments.

The team also makes uncommon improvements by venturing beyond hospital grounds. In Harper, one of the major cities in the southeast, Nyachieng’a performed a survey of homeless people, including two former child soldiers who lived on the streets and carried toy guns. All in all, some 43 faced mental health challenges. Nyachieng’a helped stabilize their lives by bringing them rice, reuniting them with their families, or putting them in the care of a nearby Catholic church. Then he treated or followed-up on virtually all of them.

“In the areas you need to reach by canoe, the big challenge is that patients are not seen as patients; they’re seen as possessed by demons,” says Nyachieng’a. But here, too, the team has turned challenges into opportunities. Yansine, for example, joined forces with herbalists and traditional healers. He met them, shared some basic information, and offered to provide the healers with the medical expertise and medication needed for them to expel the demons. “We developed a rapport,” he says. “Now they will call me about the aggressive patients and I will do an assessment and give them the treatment.”

All of this and more have made a big difference in whole communities, but it’s only from faraway that you’d call the changes something as impersonal as “progress.”

Cyrus, for example, grew close with Regina, and found herself learning some very real, very non-allegorical details about Regina’s life before she “ran crazy,” as her family said. Regina lost two children during birth. Her husband abandoned her. And when she crossed the river that portentous day in the 1990s, it wasn’t to taunt fate or the village healer. Regina was fleeing civil war for a refugee camp in Ivory Coast. Mid-stream, a nearby boat capsized, killing friends and relatives. Whatever mythic powers might or might not have been at play, Regina experienced a lot of psychological trauma and had no experts to turn to.

“It’s hard for me to express the feelings,” says Cyrus, “but I am so grateful to be able to work with Regina and other patients.”


*Name has been changed.

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Tue, 30 May 2017 15:24:39 -0400 https://www.pih.org//article/three-clinicians-bring-pioneering-mental-health-services-to-remote-villages
After Hurricane Matthew: PIH's Impact in the South https://www.pih.org//article/after-hurricane-matthew-pihs-impact-in-the-south Six months ago, Hurricane Matthew plowed across the southern tip of Haiti, leveling houses, sweeping away crops and livestock, and killing approximately 100 people in early October last year.

Many residents have since rebuilt homes from scattered debris and replanted fields in the wake of the powerful Category 4 storm. Yet 175,000 people remain without reliable housing and at least 1.5 million—or nearly 40 percent of the population living in the southwest peninsula—lack regular access to food, according to the United Nations Office for the Coordination of Humanitarian Affairs.

It has been a trying time, and Zanmi Lasante, as Partners In Health is known locally, has been in the hardest-hit southern states since the beginning. At the Ministry of Health’s request, PIH collaborated with officials in Sud and Grand d’Anse departments to support Immaculate Conception Hospital in Les Cayes, the sole public referral hospital for 1.5 million people. Staff also shored up cholera treatment centers and supported the government’s cholera vaccination campaign, which reached nearly 800,000 people.

Immaculate Conception Hospital was pummeled by the hurricane’s torrential rains and 145 mph winds. PIH hired contractors to repair damaged roofs across much of the hospital, including the maternity and pediatric wards. Plumbing and electrical structures were repaired. A new generator was installed to ensure near round-the-clock power, and a chlorine machine is now in place to help decontaminate the wards and maintain sanitation. The internal medicine ward, emergency room, and post-op area are now being renovated and may be ready by July.

Before the hurricane, the hospital contained only a quarter of the supplies it needed. PIH stocked the facility with essential medicines and helped develop a three-month reserve of supplies to meet future demand. Staff also ensured a nearby warehouse received the medical supplies necessary to back up other public clinics in the region.

In February, medical residents from University Hospital in Mirebalais provided emergency preparedness training to clinicians at the Les Cayes hospital, paying particular attention to how to triage patients and deliver urgent care.

These basic steps had a major impact. Immaculate Conception Hospital served 25,200 patients from last October through this March, an average of 4,200 patients each month—a huge accomplishment for a hospital that was flooded, dilapidated, and understaffed at the time of the hurricane.

Flooding at Immaculate Conception Hospital in Les Cayes. Photo by Rebecca E. Rollins / Partners In Health

A building near Immaculate Concpetion Hospital that was badly damaged by Hurricane Matthew. Photo by Aliesha J. Porcena / Partners In Health


PIH anticipated a spike in cholera cases following the hurricane and, unfortunately, its fears were confirmed. Staff prepared the cholera treatment center near Immaculate Conception Hospital and 10 PIH-supported centers in the Central Plateau and lower Artibonite by renovating water, sanitation, and electrical systems and buying necessary equipment, such as ambulances to transport the sickest patients to and from the centers. More staff was hired. And 380 community health workers began a six-month training to identify symptoms of the deadly diarrheal disease and help patients get access to care.

Many storm survivors carry a heavy mental and emotional burden after losing their homes, livelihoods, and friends and family members. PIH collaborated with other nonprofits, such as Handicap International and International Medical Corps, to recruit three social workers and four psychologists, who provided counseling to clinicians and community members. Twenty community health workers were also trained to identify symptoms of mental illness and given materials so they could support and refer neighbors to Immaculate Conception Hospital. 

The preparation paid off. PIH treated 1,682 patients at cholera treatment centers between October 2016 and March 2017. Meanwhile, the organization worked with the Haitian Ministry of Health to help vaccinate nearly 800,000 Haitians against cholera in the south, 60,000 of whom received their dose at Immaculate Conception Hospital.

PIH has been wrapping up efforts in the south following its six-month commitment, and staff are now returning to Port-au-Prince and Mirebalais. But they are connecting with local partners, such as St. Boniface Haiti Foundation in nearby Fond-des-Blancs, to ensure the Les Cayes hospital will continue to be supported during the long recovery ahead. 

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Thu, 11 May 2017 09:52:41 -0400 https://www.pih.org//article/after-hurricane-matthew-pihs-impact-in-the-south
New Birth Waiting Homes to Welcome Expectant Mothers in Sierra Leone https://www.pih.org//article/new-waiting-homes-to-welcome-expectant-mothers-in-sierra-leone Others are bigger. Elsewhere they’re more plentiful. But it’s tough to beat the understated dignity of the new birth waiting homes that Partners In Health opened in eastern Sierra Leone last week.

The three white houses sit on a hill at the quiet edge of the city of Koidu. Four beds in each bright, airy building will welcome a total of 12 expectant mothers at a time. Shaded porches will provide a place to rest. At the back is a small examination room where nurses can perform daily checkups. In a covered outdoor kitchen nearby, a cook will prepare breakfast, lunch, and dinner. While other waiting homes ask mothers to pay their own way or work off the cost of meals and accommodations by washing dishes, the PIH waiting home offers everything for free. Best of all, the home sits just a stone’s throw from Wellbody Clinic, where there hasn’t been a single maternal death in two years.

In Sierra Leone, half of all women give birth at home, and many die or lose children after suffering complications that could have been addressed at a well-equipped health clinic staffed by trained personnel. The national maternal mortality rate, 1,100 per 100,000, is one of the highest in the world. The hope is that women will come to the homes ahead of their due dates, when nothing is an emergency, and then give birth in the clinic. During the soft opening this spring and summer, the home will welcome patients from the three nearby areas with the highest maternal mortality, per the advice of local health officials. They’ll then reach out to more distant regions and welcome any mother likely to have a tricky birth.

There’s no guarantee the community will take up the offer. Birth waiting homes have been around since at least the 1970s, and there have been plenty of misfires. In Ghana, an early attempt at a waiting home in an abandoned ward of a hospital attracted just one mother, and she stayed only for a night. (Feedback cited the “desolate” setting.) Mozambique’s early homes lacked local political support and failed to take off. In Indonesia, expectant mothers were asked to pay dearly for small, thatched-roof huts attached to the houses of male strangers. Needless to say, the women declined.

Waiting homes are improving on the whole, however, and are en route to being everywhere from Cuba to Mongolia. A free maternal waiting home in Malawi virtually eliminated maternal mortality in the area. At an expansive complex in Zimbabwe, up to 100 women are checked in at any time. They say the days are a rare respite from domestic responsibilities and often sing, especially while relaxing together at night.

The home in Sierra Leone is still a ways from being that established. But clinic staff have reason to be optimistic. PIH’s commitment to offer not just adequate but great health care has resulted in a half dozen successful waiting homes around the world—in Mexico, Malawi, and Lesotho. And in Sierra Leone, though the home itself is low-key and dignified, the team's PR approach is direct. They recently appeared for an hour on a talk show on the local public radio station, FM 90.2. After answering caller questions, they concluded with, “Let us encourage the women in our lives to come stay at the birth waiting home to have a safe birth!”

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Fri, 05 May 2017 16:27:06 -0400 https://www.pih.org//article/new-waiting-homes-to-welcome-expectant-mothers-in-sierra-leone
Working in Global Health: Katie Kralievits https://www.pih.org//article/working-in-global-health-katie-kralievits I grew up with a close connection to Haiti. My maternal grandparents lived in Port-au-Prince for many years, and several of my family members were born there. In the late 1950s—in part due to political instability—my family fled Haiti for Miami, Florida, but continued to speak Haitian Creole and maintain close contact with their friends back in Port-au-Prince. This influence continued for decades, and I was raised to have a deep appreciation for the Haitian people and culture. I learned about Partners In Health while in graduate school and, prior to joining the organization, supported it mainly because of its work in Haiti.

As an undergraduate at the University of Notre Dame, I didn’t have a clear academic focus. I intended to major in chemistry and decided, at the mature age of 17, to pursue medical school. However, in my first two years of college, I realized I much preferred calculus and Spanish to chemistry, and switched my major to mathematics, while still considering a career in medicine.

To buttress potential medical school applications, I shadowed physicians, worked in a research lab, and conducted literature reviews for a physician in Miami, but I wasn’t invested in any one topic, nor was I particularly committed to pursuing medicine. During my senior year, I was fortunate to secure a clinical research job in Miami, but with graduation less than a month away, I was told that the position’s funding was eliminated. Plan A went out the window. While I was stressed to be jobless, I was also relieved since I knew my interests lay elsewhere.

I turned to my advisor, who suggested a Master of Science in Global Health degree at Notre Dame. After learning more about the program and the potential opportunities it offered, I applied and was admitted.

Within weeks of starting, I realized how little I knew about global health. The program provided an excellent introduction to this emerging field, while allowing me to discover career opportunities that suited my interests and strengths. Over the course of the year, I conducted a thesis research project, which culminated with two months of “field experience” in Peru. While I had traveled abroad many times before—mostly to Greece, where my father is from, and around Europe—this was the first time I’d worked and lived in a low-resource setting. And while my research project seemed elementary at the time—and even more so a few years later—it gave me the opportunity to gain work experience abroad.

The greatest benefit of the academic program was the opportunity to connect with and learn from leaders in the field, including representatives from the World Health Organization, the U.S. Centers for Disease Control, Catholic Relief Services, and others. During the semester, I met Dr. John Meara, who was then chairing the Lancet Commission on Global Surgery. He spoke about the Program in Global Surgery and Social Change at Harvard Medical School and the Lancet Commission’s goal of improving access to surgical care in low-resource settings. His research, which was heavily quantitative, was interesting to me, and I asked if I could help. Dr. Meara started sending me introductory papers on the topic, and I was assigned a small project to work on for the Commission.

I was grateful for even a chance to work for an organization I admired so much.

Finding a job in global health after graduation was next to impossible. That year, I applied to at least 30 entry- to mid-level jobs. I was finally offered a one-year research associate position with a widely-recognized Catholic international aid organization in Lusaka, Zambia. I was nervous, yet excited, and figured this would be another good opportunity to gain additional field experience.

In summer 2014, I moved to Lusaka, where I received a warm welcome from my Zambian and American colleagues alike. After a few months, however, I had accomplished very little. I quickly realized the challenges of working for a massive U.S.-based organization—each decision required half a dozen steps to receive approval from headquarters. Most importantly, I felt disconnected from the work we were doing. Patients and recipients of our services were termed “beneficiaries,” and there was minimal regard for their opinions on how we could better serve them and their communities.

Similarly, being an expat in this part of Africa was often uncomfortable. While I can’t complain about my accommodations nor about the friendships I made, unapologetic segregation in the workplace was the norm. I distinctly remember the organization’s leadership urging me to “be careful” when spending time with my Zambian friends, who were far more accomplished young professionals than me. 

During my tenure in Zambia, a catastrophe was wreaking havoc on the other side of the continent: the Ebola epidemic. Though thousands of miles away, I closely followed its development, and it was during this time that I rediscovered PIH’s work. I was impressed by its rapid response to this emergency and its prioritization of patient care. When reading the website one evening, I stumbled on the employment page and saw a posting for a research assistant. I was thrilled, as it was the only posting for which I was qualified on paper. I submitted my application that night and waited—for four months.

When I received a phone interview, I was grateful for even a chance to work for an organization I admired so much. Though a fraction of the size of my then employer, I knew PIH’s work was different. The organization seeks to provide quality health care to those living in abject poverty. Rather than reaching the most patients for the least amount of resources—a priority, I quickly learned, for many organizations—its goal is to raise the standard of services for those without access to health care.

I left Zambia a few months before my term was complete and have been working with PIH for two years. Every day I am inspired by the work being done by my colleagues in Boston and in the 10 countries where we work.

My job as a research assistant is multifaceted, and I have the privilege of working with an incredibly collaborative team. On any given day, we coordinate and support the research for Dr. Farmer’s writing commitments, from articles to op-eds to textbook chapters, and prepare materials for events, including lectures and classes. This provides me with the opportunity to learn from and work with Dr. Farmer and his academic colleagues, who are leading experts in their fields.

This role has also taught me the meaning of accompaniment, one of PIH’s core values. I often travel with Dr. Farmer and experience firsthand the complexities and daily demands of his life as a physician, professor, and public figure. Though the hours can be unpredictable, I am always in awe of Dr. Farmer’s ability to juggle dozens of commitments, while never failing to maintain constant follow-up on his patients—whether in Haiti or Rwanda or Boston—his students, and his colleagues from around the world.

I also have the chance to meet young and enthusiastic students interested in pursuing a career in global health. I often receive similar questions, and I continue to offer the same advice:

  1. Do something that interests you. As an undergraduate and graduate student, I wasn’t particularly interested in going to medical school. And that’s okay. Global health is about much more than providing medical care abroad—something I didn’t understand before I pursued my master’s degree and worked in Peru and Zambia, and now with PIH. There is room for everyone interested in this work, so I encourage students to pursue their interests and direct them toward a career of serving others.
  2. Get “field experience.” I say this in quotes, because the field can mean rural Africa or a marginalized neighborhood in one’s own hometown. It’s imperative to spend time understanding the experiences—and suffering—of others to better serve those in most need.
  3. Aim low. This may seem like bad advice, but when I was applying for jobs as a graduate student, I was looking for opportunities for which I was totally unqualified. I often hear young (and often inexperienced) students express concern about pursuing an entry-level job, or one with administrative duties. After encouraging them to get involved in any way possible, I gently remind them that if they are committed to this work, no task is too small.

In my two years with PIH, I’ve learned just that: No task is too small. And that’s because the mission of the organization continues to motivate me every day and in every aspect of my role. 

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Thu, 04 May 2017 10:15:26 -0400 https://www.pih.org//article/working-in-global-health-katie-kralievits
Medical Aid and Food to Thousands of Peru Flood Victims https://www.pih.org//article/medical-aid-food-provided-to-3200-flood-victims-in-peru One month has passed since devastating floods and mudslides swept Peru’s coastline and communities north of the capital of Lima, killing 113 people and destroying the homes of an estimated 700,000 people.

The powerful rainy season storms, sparked by an El Niño in the neighboring Pacific Ocean, cut power and access to clean drinking water in the region. Roads and bridges crumbled, leaving remote farming villages isolated for days.

Volunteers and staff from Socios En Salud, as Partners In Health is known locally, responded immediately to the disaster. Every day since March 20, 50 medical brigades over the past month pushed throughout the Carabayllo District, PIH’s headquarters north of Lima, and beyond to deliver emergency aid and medication to more than 3,200 people, distribute 500-plus baskets of food, and tend to the mental health needs of nearly 200 patients.

Each new day was an opportunity to make a difference for those most in need—for people like *Jazmín, *Carlos, and Celeste.

Like many residents of Santa Rosa del Huaico, Jazmín just wanted to cross the swollen Huaycoloro River, which had wiped away her family’s home days earlier. Following her family and friends, the 6-year-old tried to pick a path along mounds of bags and trash that had accumulated midstream, but she slipped and fell. Her hands sunk deep into the muck, and a shard of broken glass sliced her left wrist.

Luckily, a PIH medical brigade had been established nearby. Her mother took her to one of the pop-up tents, where a volunteer doctor cleaned her wound, stitched her back together, and bandaged her wrist. All the while, Jazmín smiled and bravely sat through the ordeal. She never cried or complained, just chatted calmly with her doctor.                                                                                     

*Jazmín hugs Carmen Contreras, director of intervention programs in Peru, after receiving care at a medical tent. (Photo courtesy of Socios En Salud)

Miles away in Chocas, *Carlos was coming to terms with his own loss. The mudslides destroyed his home, including important documents and all the clothing he wasn’t wearing. He and his family were left without electricity or running water.

The floods seemed an unfair blow to Carlos, who had already suffered for three years with a debilitating injury. A terrible accident had left part of the 40-year-old’s left leg and foot paralyzed, and it was difficult for him to get around before the storms. Now it was nearly impossible.

In early April, a PIH medical brigade found Carlos outside his makeshift home erected from a tarp and a bedsheet. Staff taught him physical therapy exercises and massage techniques to improve his range of motion. His recuperation is slow, but steady, and he receives visits from volunteers who provide him counseling as he faces the long road ahead.

*Carlos (center) sits outside his makeshift home while PIH staff and volunteers examine his left leg. (Photo courtesy of Socios En Salud)

A week into the flooding, a PIH medical brigade visited the village of Las Brisas, where the Chillón River had swallowed more than 150 families’ homes. Flor Pérez, 19, and her 1-month-old baby, Celeste, were among those who had seen their houses swept away in the rushing waters.

Dr. Leonid Lecca, executive director of PIH in Peru, visited the mother and her infant, who had been born prematurely and underweight, in a neighbor’s home. He noticed that the baby was badly dehydrated and had a swollen abdomen. Staff escorted the family to a nearby health center. And Daniela Puma, a nurse working with PIH, began visiting the family regularly to ensure they had diapers and other medical supplies.

Two weeks after that first visit, Celeste was healthy and stable. A recent checkup even revealed she’s well within the average range of length and weight for an infant her age.

Flor Pérez (left) smiles at her newborn daughter, Celeste, who has recovered from dehydration and gained weight. (Photo by William Castro Rodriguez / Socios En Salud)

*Names have been changed to protect privacy.

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Thu, 27 Apr 2017 12:18:11 -0400 https://www.pih.org//article/medical-aid-food-provided-to-3200-flood-victims-in-peru
Study Brings Relief to Rwandans with Hepatitis C https://www.pih.org//article/study-brings-relief-to-rwandans-with-hepatitis-c1 Dr. Shumbusho gazes intently at her patients from behind narrow glasses, her gray wisps of hair pulled back into a bun, and listens to them describe the challenges of their deteriorating health. They have come to Rwanda Military Hospital from across the country, seeking answers about hepatitis C, an illness that causes ongoing damage to their livers.

Some didn't know they had the disease until recently. Others did but haven’t been able to do anything about it, because treatment has long been difficult to access. Hepatitis C drugs are expensive, don’t always work, and come with severe side effects. But if the disease is left untreated, up to 20 percent of these individuals will develop liver cirrhosis. Up to five percent of them will die of liver cirrhosis or liver cancer.

The good news is that the latest hepatitis C drug, approved in 2014, is almost 100 percent effective and carries only typical side effects you’d see on any drug label. The bad news is it was originally priced at more than $1,000 per pill, which is taken every day for 12 weeks.

Paying this price isn’t an option for Shumbusho’s patients, whose annual income is less than $700 a year. But in this hospital, there are closets full of the medication because these patients are part of a clinical study Shumbusho and her colleagues are leading to understand who contracts hepatitis C and how they respond to treatment.

“The true burden and impact of hepatitis C in sub-Saharan Africa has never been quantified,” explains Dr. Neil Gupta, a former chief medical officer for Partners In Health in Rwanda and a principal investigator of the study. Nobody really knows how many people have the disease in Rwanda, especially in rural areas, he says, but the government estimates as many as 55,000 have advanced hepatitis C. Why the prevalence is so high and how people contract it is unclear.

That’s why Rwanda Military Hospital, the University of Rwanda, the Rwanda Biomedical Center, Stanford University, Brigham and Women’s Hospital, and Partners In Health established the study, which will identify and treat 300 participants over two years. Most of them are subsistence farmers and rural residents who otherwise would have no way of being treated.

Shumbusho has seen patients every day since February. They arrive—many of them after very long journeys—get their bloodwork done, and receive the medication. Then fatigue shifts to relief. For many, it’s the first time they’ve received treatment for an illness that has plagued them for decades.

Their gratitude spurs Shumbusho on. “It’s very motivating.”

Study Coordinator Alphonsine Imanishimwe counsels a new patient through her first dose of medication. Photo by Neil Gupta / Partners In Health

Patients come back every month for three months so Shumbusho can monitor their progress. She’ll keep track of their weight, hear how they’re coping with the daily medication, monitor any side effects, and log these details for the study.

By late 2017, Shumbusho, Gupta, and their colleagues will not only have a sense of why the disease is so prevalent and among whom, but they’ll also provide recommendations for improving treatment policies around it, such as how many blood tests patients should receive and how often they should see their doctors.

Rwanda Military Hospital will be further set up to handle hepatitis C in the future. It will have a pharmacy stocked with drugs, clinicians trained in the specifics of the disease, and a new machine for diagnosing hepatitis C.

And they’ll have hard evidence that treatment with the right drugs is a surefire solution. Gupta hopes the study will get more attention on the topic and stimulate research. “We need more work like this,” he says.

Most importantly, the study will cure hundreds of very sick people. For Gupta, access to treatment is the main goal. “The drugs are extremely effective and are not reaching the majority of people who need them,” he says. “Our ultimate objective would be to use this experience to demonstrate and advocate for access to this treatment for millions of others in resource-poor settings globally."

Gupta and other authors recently published a baseline study for hepatitis C treatment in Rwanda.

J.M.V. Halleluia is a laboratory technician working on the study. Photo by Aaron Levenson / Partners In Health

 

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Thu, 27 Apr 2017 09:22:14 -0400 https://www.pih.org//article/study-brings-relief-to-rwandans-with-hepatitis-c1
Stevenson's Story: Starvation in Central Haiti https://www.pih.org//article/stevensons-story-starvation-in-central-haiti He felt impossibly light. At 6-months-old, Stevenson Louis should have been a pudgy, smiling, playful infant. He should have been sitting on his own, or close to it. Instead, he was as weightless as a newborn cradled in my arms. His dark chocolate eyes stared up at me vacantly, his face expressionless and somber. I wanted nothing more than to make him smile. But I doubt he’s done that much in his short, difficult life.

His mother, Manise Darius, handed me Stevenson as soon as she walked into the malnutrition clinic in Boucan Carré, Haiti. We’d met the day before during a home visit. Still, I’m not sure why the 26-year-old mother entrusted me with her son. Maybe her arms needed a break following the long walk from her house to the clinic. Or maybe she’d read my mind and knew how much I missed holding my own son, whom I’d left—fat and happy—back in Boston only days before.

The view behind Darius's home. Photo by Cecille Joan Avila / Partners In Health

I traveled to Haiti in November to report on the malnutrition program run by Zanmi Lasante, as Partners In Health is known in Haiti. As part of the trip, I and several PIH colleagues made home visits to families enrolled in the program, observed care at two malnutrition clinics, and had a tour of the Nourimanba production facility, where PIH produces a nutrient-rich peanut paste fed to malnourished children at 12 health facilities throughout the Central Plateau and lower Artibonite.

On our first reporting day, we visited three families in and around Boucan Carré. Darius was the second mother we met, and by far the worst off. Although her 2-year-old daughter, Ferlanda Louis, was the only one of her children enrolled in the malnutrition program, it was clear Stevenson would benefit as well. Ms. Esther Mahotiere, a nutrition program coordinator, and Ms. Asmine Pierre, lead nurse of the clinic’s malnutrition program, encouraged her to come to the clinic to have them checked out.

Esther Mahotiere, the nutrition program coordinator, stirs a tub of Nourimanba before feeding a patient at the malnutrition clinic in Boucan Carré. Photo by Cecille Joan Avila / Partners In Health

That was easier said than done. Darius lived several miles outside of Boucan Carré, had three other children at home, and her husband was rarely home because he—like many men in the area—worked hours away in Port-au-Prince. She didn’t have enough money to feed her family on a daily basis, much less pay for a motorcycle ride into town.

So when Darius arrived in the clinic that Tuesday morning with little Ferlanda hugging her right leg and Stevenson on her left hip, I couldn’t help but smile. She’d made it. She’d come. She was trying, despite all the odds stacked against her.

Assessing starvation

 

 

Mahotiere (above image) measures the height of a boy visiting the malnutrition clinic. Darius (below image) holds Stevenson while a nurse gauges his upper arm circumference, which helps determine the degree to which he is malnourished. Photo by Cecille Joan Avila / Partners In Health

After handing me Stevenson, Darius and her daughter found a spot on the wooden benches inside the packed clinic. Ferlanda had on the same purple and green princess gown she’d worn the day before and was slowly nibbling the periphery of a wafer cookie. It was one of the treats packed into the bag of food we delivered to her family’s home less than 24 hours ago. Darius handed another package of wafers to the toddler sitting beside them. The boy clutched it in his hand, content just holding the rare treasure.

It was barely 9:30 a.m., and the air already hung heavy and stale in the clinic. Mahotiere, Pierre, and two nursing students tended to the flow of women and men who’d come with children in various stages of starvation. That’s a harsh word—starvation. But there’s really no substitute that can adequately describe what happens to a fragile, growing body when it receives one meal a day—if even that—over an extended period of time.

When children don’t get enough to eat, they fail to gain weight and height at a proper pace. Their hair becomes brittle and turns a coppery hue. They’re more likely to get sick and have a harder time healing. Severe acutely malnourished children may develop a condition called marasmus, in which an overall nutritional deficiency causes them to waste away and look more like human skeletons than rough-and-tumble toddlers. They could also develop kwashiorkor when deprived of protein. Their hands, feet, face, and even scrotum can become painfully swollen. Their bellies distend like overinflated balloons.

Roughly 1 in 5 children are starving in Haiti, and twice as many are stunted.

These are the physical signs of starvation, but there are also mental repercussions that are equally alarming. Children’s brains fail to develop at a proper pace, making it more difficult for them to learn and concentrate. All of these factors combine to set children severely behind their peers—potentially for the rest of their lives.

It was the first visit for some children visiting the Boucan Carré clinic that day. For others, it was one in a series of weekly or bimonthly visits, all depending on whether they were severely or moderately malnourished. Nurses measured the children’s height, weight, and upper arm circumference—which provide clues to the degree an infant or toddler is malnourished—and jotted the numbers down in their charts. Then each child and guardian sat down with a nurse for an individual consultation and were sent off with a fresh supply of Nourimanba.

Roughly 1 in 5 children are starving in Haiti, and twice as many are stunted. Not all of them receive the care they need, but some do make it to PIH clinics and get enrolled in a malnutrition program. In Boucan Carré, an average of 127 patients visited the clinic every month and nearly 700 patients enrolled last year alone. That was just a fraction of the 9,000 children suffering from malnutrition whom PIH helped at its clinics and hospitals across the country in 2016.

Mahotiere tries to grab Stevenson’s attention, while Ferlanda nods off to sleep behind him in front of the family’s two-room home. Photo by Cecille Joan Avila / Partners In Health

 

Patient by patient

I’d been holding Stevenson for half an hour when I realized I’d have to let him go to do my job. I tried one last time to make him smile by tweaking his cheeks, then swaying side-to-side as if he were my tiny dance partner. His face remained unchanged, his eyes still locked with mine. Other mothers watched and smiled softly to themselves. Reluctantly, I handed him—slender and warm—back to his mother.

Mahotiere, a kind and no-nonsense nurse, sat at a wooden desk behind a wall of manila folders. She searched through the pile, called out a name, and waited for the child and guardian to take a seat on the plastic chair beside her.

Jelciné Marie Lourde and her 18-month-old son, Ocléne Davensky, took their turn. In the two months since he was enrolled, Ocléne had gained 4 pounds and weighed nearly 18 pounds. According to the Centers for Disease Control, an average boy his age should be 27 pounds, yet the fact that he was gaining weight was a positive sign.

As she chatted with the boy’s mother, Mahotiere opened a jar of Nourimanba, dipped in a wooden tongue depressor, gave the thick slurry a swirl, and scooped a small dollop out for Ocléne to taste. Clearly, he was a fan. His mouth opened wide to accept the peanut paste.

Youseline Benjamin sat down next. She seemed older than the rest, but it was hard to judge ages when, uniformly, every child looked younger than what their chart read. She, shockingly, was 11. She had been enrolled on August 30, 2016, weighing just 38 pounds. Other girls her age should be at least twice that size. It hit me that my 8-year-old daughter, who is average for her age, weighs 60 pounds.

Youseline Benjamin, 11, sits for her consultation with Mahotiere. Photo by Cecille Joan Avila / Partners In Health

Since enrolling in the malnutrition program, Youseline has gained 9 pounds. Her only complaint that morning was of a mild rash on her belly. Mahotiere examined her and jotted down a prescription to fill at the nearby pharmacy.

A slight stir rose in the room around a mother perched on the front bench. She was holding her daughter gingerly over her lap. The toddler’s shirt slid up to reveal what looked like white and yellow scales where there should have been brown skin. Pierre asked the mother what had happened, and learned that the little girl had fallen backward into an open fire. By the look of the girl’s skin, the accident had happened days—if not weeks—ago. The nurse sent mother and daughter to urgent care with instructions to have clinicians tend to the severe burn.  

Meanwhile, Claudia Louis and her 2-year-old son, Kendy Michel, took a seat alongside Mahotiere. Kendy had just been enrolled the week before, but he had already developed a taste for Nourimanba. The nurse checked his temperature and gave him a sample of the peanut paste.

Kendy couldn’t get enough. His jaw unhinged as wide as a baby bird’s with each helping. Then, while his mother gathered up their things, he continued shoveling the paste into his mouth from one of two tubs they took home. He cried pitifully when his mother finally closed the jar, shushing him apologetically as she scooped him into her arms.

Kendy Michel, 2, sits on his mother’s lap and shovels Nourimanba into his mouth. Photo by Cecille Joan Avila / Partners In Health

My colleagues and I couldn’t get enough of Kendy. He attacked his tub of Nourimanba with such zeal that it was hard not to love him. He stood out from the other children, who sat lethargic and moon-eyed as they waited their turn in the crowded clinic. Each child made me think of my own three back home. I realized that the first thing I wanted to do when I returned was to cook a meal for my children, watch them clean their plates, then repeat the process endlessly.

Starting again

Sitting at a desk beside Mahotiere’s, Pierre started new files for Ferlanda and Stevenson as the children perched on their mother’s legs. Because Ferlanda had missed two appointments in a row, she was categorized as having “abandoned” the program. Darius explained that she had intended to come, but that Stevenson had been sick. She had no one else to rely on, so they had to stay home.

 

Ferlanda (above image) gets her turn on the scale. Darius (center, below image) balances Ferlanda and Stevenson on her lap while Asmine Pierre (left), lead nurse of the clinic’s malnutrition program, feeds the children Nourimanba. Photo by Cecille Joan Avila / Partners In Health

Most children graduate from the malnutrition program after completing three months of appointments and Nourimanba supplements. They gain weight and grow inches taller. They begin reaching major development milestones, such as sitting, crawling, walking, and talking. In other words, they begin to do what children their age are supposed to do.

Some don’t reach these milestones the first time around. Their mothers, like Darius, are peasant farmers who raise their own food and sell what they can in the market. Sometimes crops fail. Droughts strike. Floods wipe out fields. And husbands fail to send home what they’ve earned at jobs miles away in the city. That means there is very little money for anything, and families must make painful choices between food or transportation, clothes or medicine.

Outside her home, Darius holds a handful of the low-quality rice, typically used as chicken feed, that she buys and prepares for her children. Photo by Cecille Joan Avila / Partners In Health

So when parents or guardians don’t arrive for appointments at the malnutrition clinic, their absence is never mistaken for lack of love or compassion. They know their children are starving. Quite often, they are too.

PIH’s malnutrition staff understand this intimately. When families eventually return to the clinic, they don’t browbeat parents or guardians. They simply grab another intake form and start the process over. Again. And again. And again. For as many times as it takes to pull that child out of starvation and place them on the path to a healthy future.

I watched Pierre as she measured Stevenson’s upper arm, his dark eyes following solemnly her every move. I took in his brittle, rust-colored hair that Darius had tied into a neat sumo ponytail. I glanced at his spindly arms and legs that hung limply from a white onesie. And I wondered if he would make it. I couldn’t bear the thought of him not.

Pierre offered Ferlanda a taste of Nourimanba, which she licked delightfully from her lips. Then it was Stevenson’s turn. His delicate mouth opened and closed over the wooden tongue depressor. Then the faintest of smiles lit his face.

Darius holds Stevenson in the doorway of their home, made from mud, sticks, and corrugated metal. Photo by Cecille Joan Avila / Partners In Health

 

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Wed, 19 Apr 2017 11:31:46 -0400 https://www.pih.org//article/stevensons-story-starvation-in-central-haiti
TOGETHER, WE STAY https://www.pih.org//article/together-we-stay Infrastructure Manager Steve Mtewa watched as people streamed into Dambe Health Center on its opening day in Neno, Malawi, last year. He knows what people in his rural community face when they’re sick. Getting ill is possibly the worst challenge because reaching clinics is time-consuming and costly.

We treated 108 people that day, among them five patients with such severe hypertension they were at risk of stroke, four with suspected tuberculosis, and 47 who tested positive for malaria — and it wasn’t even malaria season.

This center will serve 30,000 people in and around Dambe; the staff at other facilities we built and renovated around the world this year will care for hundreds of thousands more. By investing in infrastructure, mobilizing equipment and medicine, and providing clinical expertise, we are prepared to respond to immediate and long-term crises.

New maternity waiting homes in Malawi, Haiti, Lesotho, and Mexico provide safe, clean places expectant mothers can stay before and after delivering their babies. When it comes to delivery, women have access to trained midwives and, if complications arise, they are referred to a nearby facility for lifesaving procedures.

We worked with the Ministry of Health to improve infrastructure and care at the National Tuberculosis Hospital in Monrovia. We also began improvements to Pleebo Health Clinic and a nearby referral facility, J.J. Dossen Memorial Hospital.

In Haiti, we opened the Stephen Robert and Pilar Crespi Robert Regional Laboratory, which sits next to University Hospital. The proximity means that oncology patients who previously waited three months to receive a diagnosis can now get one in three weeks.

In Rwanda, we began construction on a 250-acre campus for the University of Global Heath Equity. When complete, classrooms, administrative buildings, a library, and dorms will drape a picturesque hill in northern Burera District. Thousands of students and health professionals from around the world will learn not only how to treat patients, but how to build health systems — eventually enabling them to run the provision of health care in their home countries.

That is the goal that drives our work. Whether a new waiting home, refurbished hospital, or cutting-edge university, these investments are symbols of our long-term commitment to the communities we serve.

 

We Go. We Make House Calls. We Build Health Systems. We Stay.

See Partners In Health's full 2016 Annual Report.

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Tue, 11 Apr 2017 10:30:00 -0400 https://www.pih.org//article/together-we-stay
TOGETHER, WE BUILD HEALTH SYSTEMS https://www.pih.org//article/together-we-build-health-systems The baby boy arrived 14 weeks early and weighed less than 2 pounds. Thamar Julmiste, a nurse at St. Thérèse Hospital in Hinche, Haiti, immediately noticed he wasn’t breathing. Luckily, she and a colleague knew what to do. They performed CPR on the tiny newborn and were relieved to see his birdlike ribcage rise and fall on its own.

“People didn’t think he was going to live,” Julmiste recalled. But he did.

Julmiste followed what she and her colleagues learned during a training for nurses in neonatal intensive care. Two more groups of nurses from around the country have since studied the same theory and clinical skills in a free training at University Hospital in Mirebalais. They are the first among a growing group of neonatal and pediatric intensive care nurse specialists in Haiti.

Like Julmiste’s tiny patient, everyone deserves the best level of care. But that’s only possible when health professionals receive the best level of training.

Because strong health systems depend on strong “human systems,” we are intent on bringing the resources of leading medical institutions directly to the communities we serve, building each local workforce of health professionals according to the highest standard of care.

Besides trainings for nurses, our medical residency programs in Haiti continue to welcome new doctors every year in specialties such as surgery, emergency medicine, family medicine, and pediatrics. Last year alone, 37 residents enrolled in the programs. We’re also training nurses and community health workers in Liberia and elsewhere.

We’re expanding our non-clinical education as well. Last year, our first class of students at the University of Global Health Equity in Rwanda began their graduate degree in Global Health Delivery, which focuses on how to create national health care systems in developing countries. Lecturers from the Ministry of Health, Harvard Medical School, and other institutions taught students everything from epidemiology to budget management. Nearly 250 professionals from around the world have applied for 27 spots in the third class, which will start in September.

This is lasting work, made possible by compassionate, committed people like you. Thank you for giving your time and resources. Because of you, we are well-positioned to deliver high-quality global health training in some of the world’s poorest communities.

 

We Go. We Make House Calls. We Build Health Systems. We Stay.

See Partners In Health's full 2016 Annual Report.

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Tue, 11 Apr 2017 10:28:25 -0400 https://www.pih.org//article/together-we-build-health-systems
TOGETHER, WE MAKE HOUSE CALLS https://www.pih.org//article/together-we-make-house-calls Our efforts to tackle the Ebola virus in West Africa were among the most challenging in our history. When the number of new Ebola cases finally dropped in Sierra Leone, it was a welcome relief.

But soon we learned of a new problem facing Ebola survivors. An increasing number suffered from an eye disease called uveitis, an inflammation of the eye that, if left untreated, can lead to blindness.

Thousands of people had survived one of the worst epidemics in the world, only to face the loss of their vision.

We needed to find as many Ebola survivors as possible and screen them for uveitis. Roughly 100 of our community health workers, many of them Ebola survivors themselves, fanned out across the district in which we work to spread the word about uveitis and its risks.

Going house to house, they convinced neighbors and community members wary of doctors and hospitals to come to an eye clinic we had established with the Ministry of Health. In just one month, we screened 277 people and successfully treated 50 more for uveitis.

Based on our success, we worked with government and international partners to expand this work nationally. In June, we coordinated screenings and treatments for Ebola survivors across the country, in every district. Again, our community health workers proved vital in finding these survivors and getting them to treatment. Ultimately, we screened 3,058 Ebola survivors and treated 379 for uveitis.

These are the transformations we strive for, and see, daily. And it’s because of our community-based model that our care is successful. In our work around the world, we visit people in their homes to check vital signs, encourage them to take their medicine, and determine when they need more advanced care. Then we connect them with that care.

“People helping people. That’s what I do,” says Mohamed Lamin Jarrah, a community health worker in Kono District, Sierra Leone. “I have witnessed the darkest moments of my neighbor’s life, and I have seen the joy of relief in their eyes. There are thousands like me, willing to do the hardest work there is.”

You are an integral part of this work. With your partnership, we provide the kind of one-on-one care that heals and saves lives. As you accompany us, we accompany our patients.

 

We Go. We Make House Calls. We Build Health Systems. We Stay.

See Partners In Health's full 2016 Annual Report.

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Tue, 11 Apr 2017 10:20:41 -0400 https://www.pih.org//article/together-we-make-house-calls
TOGETHER, WE GO https://www.pih.org//article/together-we-go When Hurricane Matthew began lashing Haiti’s southwest corner last October, we — like many of you — knew the devastation would be profound. And indeed it was: 1,000 lives lost, 15,000 people displaced, and a sharp spike in the number of people needing health care — including those suffering from cholera.

Because of our long history in the country, we could respond immediately, partnering with local and national Haitian officials to support Les Cayes’ Immaculate Conception Hospital, the sole public facility for that region’s 1.5 million people. We repaired the roof and other structures damaged by the storm, purchased a generator that provides electricity 20 hours a day, and installed a chlorine machine that helps decontaminate and maintain sanitation in wards.

We also supported a nearby cholera treatment center by providing medications and supplies. Perhaps most significantly, we helped Haiti’s Ministry of Health in its vaccination campaign against cholera. In November, 729,000 people received a vaccination — which means mothers, fathers, and children are safe from a diarrheal disease that can kill within 24 hours.

That’s impact.

Partners In Health isn’t a disaster relief organization by conventional standards. But to most of our patients, we are that and more.

When a mother doesn’t have enough food for her malnourished child, that’s an emergency. When there is no doctor to treat a father with HIV, that’s an emergency. And when there are no medicines to fight a teenager’s cancerous tumor, that’s an emergency.

The disasters we see are generational, and that’s why your partnership is so vital. With your support this year, we’ve been able to continue solving complex, longstanding health challenges in ways that improve lives and communities.

We’re using new tools, for example, to battle an often deadly strain of tuberculosis. As collaborators in a project called endTB, we’re bringing the first new tuberculosis drugs developed in 50 years to patients in 14 countries — this year in Peru, Lesotho, and Kazakhstan.

We also began a new partnership with the Sicangu Lakota Nation, applying what we’ve learned in the Navajo Nation to help strengthen the health care system of this 27,000-member tribe in southern South Dakota.

Your help enables us to go where we’re needed. Together, we’re showing how comprehensive, sustainable health systems can transform lives all over the world.

 

We Go. We Make House Calls. We Build Health Systems. We Stay.

See Partners In Health's full 2016 Annual Report.

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Tue, 11 Apr 2017 10:16:54 -0400 https://www.pih.org//article/together-we-go
Pacifique Ntirenganya: A Passionate Global Health Leader https://www.pih.org//article/pacifique-ntirenganya-a-rising-star-in-global-health Wearing a white shirt and glasses, Remy Pacifique Ntirenganya smiled into a computer screen while calling a colleague in Boston over Skype. He moved around a room of colorful wall hangings, trying to get a better signal in a staff house outside Rwinkwavu Hospital, a public facility Partners In Health supports in Rwanda.

The call was squeezed between his evening jog and a visit to a warehouse to check medical supplies. Ntirenganya had begun his day there, checking the temperature of refrigerated medicines before moving on to draft materials for an upcoming workshop. All on a public holiday.

Working outside normal hours is typical of him. Ntirenganya manages PIH’s pharmacy program at Inshuti Mu Buzima, as PIH is known locally, which covers 15 pharmacies at clinics and other hospitals across the country.

The 31-year-old and his team developed the program over four years, also creating a system for monitoring and replenishing medical supplies across PIH’s three sites in Rwanda. Ntirenganya also published the first internationally recognized paper on medicine prescription patterns in PIH-supported hospitals, and mentored young pharmacists to follow in his footsteps—all while studying for a master’s degree in public health from the University of Rwanda.

“He’s just an extraordinary person to work with,” says Emmanuel Kamanzi, a PIH officer in Rwanda.

Expanding horizonsliterally

Ntirenganya grew up in a poor, rural area in eastern Rwanda, not far from Rwinkwavu Hospital. His widowed mother made sure he and his younger brother put their education first. The family sometimes had to skip meals to pay for school fees, but they were rewarded—the boys’ report cards were full of A’s.

“No one expected it,” laughed Ntirenganya.

By the time he took his national exams at 15, he was the top student in his home province of Kibungo, and he ranked sixth in the country for his age group.

Ntirenganya’s prize was a government-sponsored trip to Lausanne, Switzerland, where the International Olympic Committee invited young students from post-conflict countries to visit, meet students from Europe, and broaden their horizons.

“I had never even been to Kigali, [Rwanda’s] capital city,” he recalls. Ntirenganya passed through Geneva. He saw the Alps. These were things he read about in books, he said, but never imagined he’d see.

Ntirenganya continued to excel. In 2012, he won a fellowship with Global Health Corps, which places young professionals with global health nonprofits, and joined PIH as a supply chain analyst, keeping track of and ordering medical goods for PIH teams across Rwanda. He proved invaluable during a period in which PIH expanded its medical services to oncology and non-communicable diseases, which need predictable supply chains of medications. A year later, when PIH decided to create a larger pharmacy program, Ntirenganya became the manager.

It was a challenging project. Until then, individual clinical teams had ordered their own medical supplies, but Ntirenganya’s team took on the task of equipping the entire organization. This meant selecting every product—from freezers to IV bags. They projected quantities, assessed their supply chain, and managed the intricacies of a new budget. In doing so, they became integral to the functioning of PIH. Like spokes on a wheel, every clinical team at PIH relied on the pharmacy hub for its medications and equipment supplies, with Ntirenganya at the center.

Ntirenganya assists in a training session held in Rwinkwavu, Rwanda, in February 2015. Photo by Cecille Joan Avila / Partners In Health

From there, Ntirenganya’s team broadened its work even further: They teamed up with Rwanda’s Ministry of Health to revamp the dispensaries. Together the teams produced workshops, trainings, and presentations. Endless inventory lists were compiled, assessed, and then redrafted. Gradually they created robust pharmacy programs, which in turn enabled the clinics and hospitals to stock a reliable supply of medications.

With an accurate record of medical supplies, the teams learned that some drugs were in higher demand than expected, including those for noncommunicable diseases such as diabetes, hypertension, and asthma. A PIH grant enabled these drugs to be stocked throughout the three PIH-supported districts, which serve a population of 900,000.

But Ntirenganya’s greatest challenge was yet to come. In September 2014, PIH as an international organization was in the throes of the Ebola crisis in West Africa. Teams were strapped, and medical supplies were taking longer to reach Rwanda. The pressure was on him and his team to fill the gap.

Laura Gould, a PIH supply chain analyst in Boston who talked with him often, said Ntirenganya didn’t hesitate to get his hands dirty. He hauled boxes. He called vendors. He stayed at a PIH warehouse on weekends to make sure medicines kept cold in the event of power outages.

“It’s hard to say what he didn’t do,” she says.

When away from his supply closets and inventory lists, Ntirenganya is now among a small group of Rwandans venturing into academic research. He published his first paper in 2015, in the International Journal of Pharmacy. Working closely with colleagues at Rwanda’s Ministry of Health and Harvard Medical School, he dug through hospital medical records to discern clinicians’ prescribing habits.

They found that the volume and types of drugs given to patients were within the World Health Organization’s guidelines—a reassuring finding for PIH, which supports the hospitals. And it’s a model study that could be applied to more hospitals across Rwanda to help the government estimate cost and supply.

“Pacifique epitomizes the new generation of passionate and dedicated global health leaders that the world and Africa needs to tackle existing and emerging global health challenges,” says Dr. Alex G. Coutinho, executive director of PIH in Rwanda. “He is showing that pharmacy and supply chain are as important as laboratory diagnostics or clinical care in responding to health inequity or disease threats.”

On to Liberia

Ntirenganya’s workload isn’t getting any lighter. Last September he joined PIH’s team in Liberia, where his work supports a small hospital and a health center in the southernmost county. Liberia ranks 177th out of 188 countries in the U. N.’s 2015 Human Development Index. Thirty-five percent of the population lives in extreme poverty. Maternal mortality, which indicates the state of a country’s health system, is horrific. For every 90 or so children born alive, a woman dies from pregnancy-related complications.

The acting director of Liberia’s National Drug Service welcomed him. “He told me, ‘To be successful here, you need to perform miracles,’” laughs Ntirenganya.

He’s not worried. “Slowly, slowly, you can see change,” he says.

The hardest part about moving was leaving friends and family in Rwanda, especially a boy named Shema. Shema used to hang around the pharmacy warehouse and became friends with Ntirenganya, who saw something of himself in the 6-year-old. After talking to Shema’s parents, who are separated and struggling financially, Ntirenganya bought him shoes, clothes, and books. Then he enrolled Shema in school. Then he invited Shema to live in his home with his mother.

“There were so many people supporting me,” he says. He wants to do the same for Shema.

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Fri, 31 Mar 2017 15:35:36 -0400 https://www.pih.org//article/pacifique-ntirenganya-a-rising-star-in-global-health
UPDATED: Record Rainfall Slams Peru, Death Toll Rises https://www.pih.org//article/record-rainfall-slams-peru-death-toll-rises

A map of Carabayllo, a northern district of Lima where PIH has worked for the past 20 years. Hover over the dots for more information about PIH's work in the flood-affected region.

 

(Update as of March 29)

Since March 20, PIH staff and dozens of volunteers have provided medical attention and social services to more than 250 flood victims across 10 communities in Carabayllo, where the organization has worked for more than two decades. Residents arrive at mobile clinics with nail puncture wounds, cuts from broken glass, persistent coughs, and diarrhea following days of little access to clean drinking water. While teams distribute medication, they also give out food and bottled water.

Meanwhile, other PIH staff and volunteers go door-to-door searching for patients too overwhelmed to seek care and escort them to mobile clinics.


(Update as of March 23)-- Partners In Health in Peru established two mobile clinics yesterday in the Fujimori and Huarangal neighborhoods of Carabayllo, a slum on the northern outskirts of Lima. Staff offered basic medical attention to flood victims, most of whom arrived cold, exhausted, and badly bruised. Care was in such urgent demand that medical teams ran out of supplies. The crews returned today with more medicine, bandages, and other goods to the same locations. 

In coming days, PIH staff will continue to push north along the flooded Chillon River to reach Canta, a neighborhood 70 miles north severely affected by flooding.


(March 22)-- Torrential rains pummeled Peru over the past week, causing widespread flooding, devastating landslides, and massive destruction throughout the country. One of the most ferocious rainy seasons in decades has already dumped up to 10 times the normal amount of precipitation, hitting the west coast, including metropolitan Lima, particularly hard.

More than 70 people have died and 600,000 have seen their homes demolished or damaged, according to the United Nations. Entire villages have been swallowed by flood waters washing down from the Andes, sweeping away homes, livestock, and crops with frightening speed and intensity.

The devastation is far from over. Meteorologists predict that today’s rainfall will be unprecedented. And another four weeks remain of the rainy season, promising little relief.

The Peruvian government has declared a state of emergency in roughly half of the country and is coordinating rescue and relief efforts throughout Lima and other major cities. Yet urban slums and rural regions beyond the capital have largely been cut off from aid due to impassable roads and the collapse of hundreds of bridges.

Residents in Canta build a temporary bridge above raging flood waters. Video by Margot Aguilar / Partners In Health

 

Neighbors in Carabayllo clean debris from a flooded street. Photo courtesy of Socios En Salud

Staff from Socios En Salud, as Partners In Health is called locally, responded to the crisis in Carabayllo, a slum north of Lima where it has worked for the past 20 years, and in nearby villages that remain isolated. Executive Director Dr. Leonid Lecca traveled with a team on Monday to assess the damage. They visited with farmers who lost their homes, all their livestock, and their entire crops.

“I don’t think any of us knew the extent to which this was spiraling out of control,” says Jerome Galea, deputy director of PIH in Peru.

On Saturday, Lecca launched an online campaign to recruit professionals who could volunteer their services. “The response was swift,” Galea says. As of Tuesday, 2,600 nurses, doctors, psychologists, and social workers—among others—signed up for the cause.

PIH staff are working to coordinate their movements throughout Carabayllo and surrounding rural communities. Some will provide primary care out of PIH’s 12 health posts, which are doubling as collection and distribution points for donated goods. Bottled water, clothing, food, tarps, and first aid supplies are among items most in need.

Dr. Leonid Lecca (right), executive director of PIH in Peru, consults with a medical team about evacuating a patient in need of urgent care in Carabayllo. Photo by Brendan Eappen / Partners In Health

PIH volunteers treat injuries in Carabayllo. Photo by Brendan Eappen / Partners In Health

Meanwhile, PIH staff are reminding residents of the importance of maintaining hygiene. As flood waters mix with latrine waste, the risk of diarrheal and other infectious diseases spikes.

Potable water has been a rare commodity. The supply was cut for nearly one week to roughly 70 percent of Lima, a city of 10 million, after the water sanitation authority shut down a major treatment plant, fearing that an influx of debris-laden flood water would overwhelm filtration systems. Service was restored to some communities on Monday, and residents have been collecting what water they can from dripping faucets. The next water cut, Galea says, is literally only a mudslide away, and residents are storing water in anticipation.

Yet the rains also bring standing water, whether from flooding or open home storage containers, which poses other problems. It is fertile breeding ground for mosquitoes bearing infectious diseases such as dengue and Zika. As part of ongoing outreach efforts, PIH staff members are speaking to residents about proper water storage and distributing insect repellent.

These are still the disaster’s early days. PIH staff are anxious for what coming weeks will bring.

“This is big,” Galea says, “and it’s going to get worse.”

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Thu, 30 Mar 2017 11:30:11 -0400 https://www.pih.org//article/record-rainfall-slams-peru-death-toll-rises
Flood Survivors Receive Medical Attention in Peru https://www.pih.org//article/flood-survivors-receive-medical-attention-in-peru Heavy rains have subsided throughout most of Lima, Peru, during the tail end of one of the most destructive rainy seasons in decades. In the northern slum of Carabayllo, residents of the flooded Chillon River are beginning to return home. They find floors coated with mud, fields that resemble ponds, and no signs of their livestock. A shoulder-height line smudges the interior walls of homes that are still standing, a sad reminder of the water’s peak.

Staff from Socios En Salud, as Partners In Health is known locally, have been organizing brigades of medical volunteers and pushing north along the Chillon to remote communities where the government has yet to respond. They say residents seem dejected, broken, many on the edge of tears.

Since March 20, PIH staff and dozens of volunteers have provided medical attention and aid to more than 250 people across 10 communities in Carabayllo, where the organization has worked for more than two decades. Residents arrive at mobile clinics with nail puncture wounds, cuts from broken glass, persistent coughs, and diarrhea following days of little access to clean drinking water. While teams distribute medication, they also give out food and bottled water.

A view of flooded streets in Buena Vista, a neighborhood within Carabayllo where residents suffered extensive losses last week when the Chillon River spilled over its banks. Photo Courtesy of Socios En Salud

 

Lecca tends to a patient out of a mobile clinic in Buena Vista. Photo Courtesy of Socios En Salud

Meanwhile, other PIH staff and volunteers go door-to-door searching for patients too overwhelmed to seek care. That was how they discovered Maria Vergara. Her story sounded similar to those of her neighbors, yet that made it no less tragic.

Carmen Contreras, director of intervention projects, found Vergara while canvassing the neighborhood around a PIH mobile clinic. The 60-year-old and her husband, Julián, are peasant farmers who grow vegetables, potatoes, and fruit in Rinconada, a community neighboring the Chillon. Through tears, she told Contreras how the flooded river swept away nearly their entire crop.

 “She thanked God that her papayas were already ripe and that she would have a good harvest,” Contreras said. “With that money, she said she would buy a brace to help endure her back pain.”

Vergara suffers from a laundry list of ailments. She has diabetes and arthritis. Her back pain has been especially bad in recent days, but her health problems date back to age 2, when she broke her left shoulder. The accident immobilized her left hand, which she gingerly positions with her right whenever she needs to use both. Six years ago, she burnt herself badly when a cauldron of boiling water spilled while she was cooking, so she no longer trusts herself in the kitchen.

Medical volunteers working with PIH in Peru visit Vergara at her badly damaged home in Rinconada. Photo Courtesy of Socios En Salud

Dr. Leonid Lecca, executive director of PIH in Peru, examined Vergara on March 22 and had her evacuated to the closest hospital. Staff there ensured her diabetes was under control and gave her medicine for a persistent cough, then released her the next day. With nowhere else to go, the couple returned to their flood-damaged home. They sleep outside at night, in the midst of rainy season, afraid what remains of the roof will collapse on top of them.

“Julián only asks that we help her,” Contreras said, relaying the couple’s story. “At night, the river makes noises and they both cry and pray for Maria’s pains to go away.”

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Thu, 30 Mar 2017 09:41:42 -0400 https://www.pih.org//article/flood-survivors-receive-medical-attention-in-peru
New Drugs, New Hope to End TB in Peru https://www.pih.org//article/new-drugs-are-a-new-hope-against-tb-in-peru For the first time in 50 years, two new drugs are available to patients battling the most trenchant forms of tuberculosis. TB experts around the world, including those at Partners In Health, hope that Bedaquiline and Delamanid will deliver patients a quicker, less toxic cure than older drugs on the market.

They will soon see whether their hope is justified.

Through an effort called endTB, PIH and nongovernmental organizations Médecins sans Frontières and Interactive Research & Development are offering new treatment regimens that include Bedaquiline and Delamanid to more than 3,000 people. Patients will be selected from 15 of the most TB-plagued countries—including Peru, Lesotho, and Kazakhstan—over a four-year period. UNITAID is funding the global effort, which launched in April 2015.

In endTB’s first phase, patients diagnosed with multidrug-resistant tuberculosis (MDR-TB) take Bedaquiline and Delamanid as part of the typical two-year treatment plan sanctioned by the World Health Organization. In its nascent second phase, a separate group of patients will enter a clinical trial that tests the speed and efficacy of combining Bedaquiline and Delamanid with other drugs in six innovative treatment regimens. TB experts hope one of the regimens will yield a cure before six months.

So far, Georgia is the only country to have launched its clinical trial. Lesotho and Peru are close behind, having recently trained endTB staff and clinicians, according to Segundo R. Leon, co-investigator of the endTB clinical trial in Peru and director of research at Socios En Salud, as PIH is known locally. Below, Leon describes how MDR-TB is currently treated, how that may change in the future, and why he hopes the clinical trial will be a success.

Francisco (right), a patient with MDR-TB, is provided with treatment and emotional support by Yecela Rodríguez, a field technician in the endTB project, who is visiting his group home in Carabayllo, Peru. 

Treatment for drug-resistant TB is notoriously long. Can you explain what most patients typically go through?

Before these new drugs, patients used to go through regular treatment, which includes injections. Those daily injections take almost six to eight months, followed by pills for up to 16 months. It requires that the patient go to the hospital or health center or be hospitalized for long periods of time. That means it’s less feasible to treat a lot of patients.

The idea with this project is to move forward to new oral treatment, which can be delivered more easily to patients.

Why has it taken 50 years for new TB drugs to be developed?

In general, antibiotics development has been a very slow process. In the 20th and beginning of the 21st centuries, we had such a big amount of money in developing new medical diagnostics and treatments, but antibiotics were probably the least funded. These new drugs are a new hope.

How many people have started taking Delamanid and Bedaquiline so far in Peru?

The Ministry of Health currently has around 50 patients, but their goal is to reach 400. We are going to start recruitment soon for the clinical trial. Our intention is to treat at least 140 patients.

How are patients doing on the new drugs?

Most of the 50 patients have completed their six months of treatment with Bedaquiline and are now receiving the rest of their regular treatment for up to two years, based on their medical evaluation. Their adherence to the new drugs was excellent.

Have there been any adverse side effects?

We’re aware that the new drugs, especially Bedaquiline, caused some adverse events in patients with heart disease. One of the things we monitor very often is the patient’s cardiac rhythm. Also we see some side effects in combination with other drugs, like with drugs for HIV treatment. We are preparing our physicians and nurses to be aware of any adverse effects during the clinical trial. So far, we haven’t had any complications in the first group of 50 patients.

Packets of medication for endTB patients. 

Where are patients receiving care?

We have incorporated endTB inside every hospital we work with, including Hospital Nacional Sergio E. Bernales and Hospital Nacional Hipólito Unanue. In both, we have doctors recruited from the hospital, but we also have additional doctors who only work for the project we run. They will see the patients every day. They check their blood and look for any sign of adverse events.

Our nurses don’t work for the hospital. But since they are in contact with the hospital all the time, they are prepared for managing everything, even if the patient is at home. The patient can call the nurse and say, “OK, I’m not feeling good. This feeling is kind of rare. Can you come, or can I go to the hospital?”

How close are we to launching the clinical trial in Peru?

We expect to have everything ready in less than two months.

How are we finding these patients?

We go to every health center and look for the patients who have been diagnosed with TB and also have resistance to rifampicin or other TB drugs. Then we know they have MDR-TB and can recruit them to participate in the study.

Where do most of the patients come from?

This is only Lima. And even within Lima, it’s only certain parts of Lima—especially in the northern and eastern part, which are zones with a higher burden of TB.

Will we be able to find enough patients?

We’re not expecting problems with recruitment. We actually think there are a lot of patients out there with MDR-TB and are not diagnosed. We can help the health centers identify those patients faster than they do, because we collaborate by providing some of the drug sensitivity tests. One of our strengths is our experience recruiting and retaining patients in the community.

How will treatment within the clinical trial be conducted?

There will be six different combinations of drugs. The idea is to give the patients those different combinations for 70 weeks. Some of them will include Delamanid. Some of them will include Bedaquiline. And one includes both. The goal is to see which of those groups becomes TB-culture negative faster than the other. We don’t know yet in which week they will become negative. We expect it will happen after the sixth month.

What are you most excited about regarding this clinical trial?

People with TB, especially MDR-TB, used to fail the first line of treatment because they weren’t able to adhere to it. Some were infected with HIV. Others had to deal with structural factors. They are poor. They don’t have a job. They have a problem with transportation. Or they have family they are worried about and have to support, so treatment is not important to them. I’m very excited that they can take the pills to their homes and complete treatment easily instead of receiving shots.

The other part is that, after many years, we are introducing new drugs for an old disease. And we are trying to tackle a disease that affects the poorest people, those with the least access to health care. Both parts of endTB, the programmatic side and the clinical trial, will include patients affected by MDR-TB, so they will receive treatment for free.

Also, this trial will update nurses’ and doctors’ knowledge about how to treat TB. The government, through the Ministry of Health, is changing the guidelines for TB treatment to include these new drugs. Once those drugs are in the guidelines, it means everyone in the country can use them.

Diego (right), a patient with TB taking part in the endTB project, receives treatment from Yecela Rodríguez, a field technician at the Punchauca Health Center in Carabayllo, Peru. 

 

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Fri, 24 Mar 2017 15:10:04 -0400 https://www.pih.org//article/new-drugs-are-a-new-hope-against-tb-in-peru
Our Patients Will Die Without Foreign Aid https://www.pih.org//article/our-patients-will-die-without-foreign-aid Partners In Health is gravely concerned about deep and significant cuts in United States overseas development assistance in the budget proposed by President Donald J. Trump. As much of this aid is for health in some of the world’s poorest countries, these cuts will have a devastating impact on millions of people throughout the world. In short, people will die. Children will lose their parents. And whole communities, economies, and even nation states will be disrupted without the U.S.’s vital support of health programs in the developing world. 

In the last 15 years, through both Republican and Democratic administrations, the U.S. has led a historic and highly successful fight to combat AIDS, malaria, and tuberculosis. The efforts of the U.S. to support health in the developing world have been overwhelmingly bipartisan. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), initiated by President George W. Bush in 2003, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, financed 30 percent by the U.S. government, marked a new era in the global commitment to people-centered development. They are responsible for more than 17 million people receiving life-saving AIDS treatment and millions of new infections averted. These are people who now can work and support their families, gain education and skills, and live long, healthy lives.

For many people around the world, our foreign aid efforts are what make America great.

Thanks to PEPFAR and other pivotal U.S.-supported programs, the new millennium saw significant declines in child and maternal mortality and death from AIDS. The generosity and nobility of the United States has not gone unnoticed. In many fragile states around the world, these programs result in tremendous good will toward the American people. Many experts in foreign policy agree that humanitarian assistance is a critical pillar of U.S. efforts toward peace and security. For many people around the world, our foreign aid efforts are what make America great.

Yet, there is still so much work to do. Preventable causes take the lives of 16,000 children a day. These children need medicines, bed nets, and nutritional supplementation. Only about half of those with HIV are receiving life-saving treatment, even as new tools and treatments to end the HIV epidemic are being developed to build upon the gains of the last 15 years. The West African Ebola epidemic of 2014 claimed tens of thousands of lives. Currently, nimble financial mechanisms are being proposed to rapidly respond to threats like Ebola and bird flu.  

Nurse Dina Mofoka (center) speaks with a multidrug-resistant tuberculosis patient at Botšabelo Hospital in Maseru, Lesotho. Photo by Rebecca E. Rollins / Partners In Health

All of these critical health, development, and global security achievements are under threat, while much unfinished work in global health remains. If we allow the Trump administration and the Republican-led House and Senate to gut these programs in favor of military spending and tax cuts, people will die. Far from cutting U.S. overseas development assistance, it should be expanded if America is to remain a global leader in promoting health and development as part of our humanitarian and diplomatic values,

For 30 years, Partners In Health has been a global leader in the fight for health care for the world’s poorest people. Our efforts in both the provision of care and in shaping the international response to health and disease pandemics have increased access to health care around the world. Because of our long experience providing health care for the world’s poor, we know the impact such cuts will have. And they will be drastic.

The National Institutes of Health finance a significant portion of PIH’s work in places like Peru, where thousands of patients with multidrug-resistant tuberculosis have benefited from research on the most effective treatments for the life-threatening infectious disease. But President Trump’s proposed budget would gut NIH funding by nearly $6 billion—or 20 percent, leaving many patients without hope of a cure.

Because of AIDS advocates’ international coordination in support of continued U.S. funding, President Trump’s budget maintains current levels of funding for PEPFAR and the Global Fund. But there is no guarantee they will remain sacred within the budget passed by Congress in coming months. We must maintain pressure to support these critical initiatives that have saved millions of lives and resulted in enormous good will toward the American people.

Community health worker Lucrecia M. Sherman (left) visits the home of HIV patient Lucy Farr in Harper, Liberia. Farr fell critically ill when her HIV treatment became unavailable during the Ebola epidemic. She is doing better now under the care of PIH. Photo by Rebecca E. Rollins / Partners In Health

Slashing this aid would have an immediate and severe impact on governments PIH collaborates with in Rwanda, Malawi, and Lesotho, where we support each country’s national HIV program, serving more than 17,000 patients.

In Haiti alone, 12,000 patients diagnosed with HIV are on antiretroviral therapy, thanks to PEPFAR and the Global Fund. They would die or develop drug-resistance should their treatment be interrupted. HIV prevention and testing for more than 100,000 people would cease to exist. And 30,000 pregnant women would no longer be screened for HIV, leaving their newborns at risk of contracting the deadly virus.

We have never turned our back on communities fighting ill health and dire poverty.

Despite the protection of AIDS funding, other critical lifesaving programs to care for women and children are at risk because they lack a vocal constituency. The U.S. is also a major donor to family planning efforts. Cuts to this and the reinstatement of the Mexico City Rule will result in unwanted, and even dangerous, pregnancies—particularly among adolescents.

We have never turned our back on communities fighting ill health and dire poverty. We stay for the long haul and have been privileged to see the long-term, intergenerational impact of treating AIDS, saving a child, or preventing maternal death—impact that will be severely compromised if cuts to U.S. assistance occur.

We urge our supporters and all people who care about the health of the poor to call their representatives in Congress and encourage the U.S. government to remain a leader in global health. This leadership must be based on compassion, as well as strategic diplomacy. Trust us. For three decades, we’ve seen the power such a vital investment makes in people’s lives.

This statement was originally published on Medium by Dr. Joia Mukherjee, chief medical officer of Partners In Health.

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Fri, 17 Mar 2017 10:14:14 -0400 https://www.pih.org//article/our-patients-will-die-without-foreign-aid
10 Hens and Hope in Chiapas https://www.pih.org//article/10-hens-and-hope-in-chiapas Mud-splattered pickups were parked alongside a dirt road in Laguna del Cofre, Chiapas, a small town hugging the Sierra Madres in southern Mexico. Nearby, a group of women and curious children stood holding cardboard boxes. It was a cloudy morning two days after Christmas, and they were receiving a long-awaited gift. It wasn’t toys or clothes, nor candy canes or other sweets, but a package of 10 hens and a rooster.

The birds are more than farm animals to these poor families. They are strutting, squawking bank accounts and edible assets that hold the promise of reversing their childrens' downward slide toward stunting and starvation.

The families received their chickens through a partnership between Compaňeros En Salud, as Partners In Health is known in Mexico, and Heifer International, an Arkansas-based nonprofit focused on ending hunger and poverty through sustainable agriculture and commerce. PIH helped identify families with malnourished children, while Heifer provided the hens whose eggs would add protein and essential calories into the families’ diet.

PIH and Heifer piloted the program in August 2014 with 65 families in Soledad and Matasano, two of the 10 communities in which PIH operates in the rural Sierra Madre of Chiapas. The collaboration was so successful that they decided last year to expand to two other communities: Laguna del Cofre and Salvador Urbina.

“From the data we have, it seems that the community with the biggest problem is Laguna del Cofre,” says Dr. Rodrigo Bazúa, the community program coordinator in Mexico, citing a malnutrition survey PIH conducted in 2015. “Fifty percent of the children were chronically malnourished.” Many showed signs of stunting, meaning their height and weight did not meet global benchmarks for their age.

Chronic malnutrition can affect a child’s entire life.

Children in Salvador Urbina weren’t much better. More than 30 percent showed signs of malnutrition. Sadly, these percentages are typical for the region. Mexico’s 2012 National Health Survey found that 44 percent of children in Chiapas suffer from chronic malnutrition—six times the national average.

Such high numbers ring alarm bells for Bazúa. “Chronic malnutrition can affect a child’s entire life,” he says. Children’s brains grow at a frenetic pace within their first years, from 20 percent to 95 percent full brain development by the time they turn 3. Such rapid change requires proper nutrition.

This knowledge fuels Bazúa and his team’s mission. Their first task was to locate families in each of the two communities who could benefit from “chicken packages.” PIH-supported doctors working in the Laguna del Cofre and Salvador Urbina clinics provided the names of children diagnosed with malnutrition who visited regularly, and added others under 5 who were at risk. Each family was approached about the program and asked if they wanted to participate. In the end, 45 families signed up in Laguna del Cofre, and another 27 in Salvador Urbina.

With that, the PIH and Heifer team got to work. Alejandro Domínguez, Heifer’s regional coordinator, organized efforts from afar, while program manager Gerardo Albores trained PIH community health workers on essential topics such as how to build chicken coops, administer vaccinations, and prepare concentrated feed. Over several months, the CHWs passed these lessons along to families receiving chickens. Once their coops were ready, families picked up their new flocks. The birds are now settling into their new homes and laying eggs, adding protein and calories to the children’s typical diet of rice, beans, and corn tortillas.

Eggs represent something beyond food to these families. Most people in the region are coffee farmers whose profits have been deeply affected by a fungus, called la roya, that has devastated crops for the past three years, leaving families strapped for cash. But ranchos, or farm-fresh eggs, sell for 5 pesos apiece. For a family living on 50 pesos, or $2.75, a day, 10 laying hens represent an entire additional income.

10 laying hens represent an entire additional income

Laguna del Cofre and Salvador Urbina families now wake to the sound of roosting hens and occasionally add a fried egg or two to their meals. PIH community health workers track such changes when they regularly visit families to record what a child has eaten over the past 24 hours, says Francisco Pablo, a nutrition technical supervisor. They also ensure children attend monthly appointments at a clinic PIH supports, where their weight and height is charted over time.

It’s too early to tell if the program has made a difference in Laguna del Cofre and Salvador Urbina. Yet PIH has seen progress in Soledad and Matasano, where the program began. Children whose families received chickens are no longer losing weight, compared to peers outside the program. Those at risk have not slipped into the danger zone.

Families in the nearby community of Buenos Aires are also benefitting from the abundance of hens in Soledad. As flocks have doubled there, families prepared a "chicken package" for their neighbors, who are likewise struggling to provide their growing children with enough protein and calories. "Passing on the gift" is all part of Heifer's long-term goal to multiply the number of children they help rise from the depths of malnutrition in Chiapas.

Women from Soledad give some of the chickens they have raised to neighboring families as part of a joint project between Heifer International and PIH in Mexico to reduce malnutrition in the rural communities of the Sierra Madre. Photo by Aaron Levenson / Partners In Health

 

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Wed, 08 Mar 2017 12:37:05 -0500 https://www.pih.org//article/10-hens-and-hope-in-chiapas
Ebola Patients Need Better Treatment https://www.pih.org//article/article-urges-better-treatment-for-ebola-patients-defends-superspreaders We need to provide better care for Ebola patients. That is the main point that physician-anthropologist Gene Richardson and co-authors, including Partners In Health Co-founder Dr. Paul Farmer, make in a recent comment in academic journal The Lancet Global Health. As obvious as the opinion might sound, it is contrarian, even rabble-rousing.

Richardson and his colleagues’ argument builds on a thought experiment. Imagine you are a West African in late 2014, the height of the Ebola epidemic. You’re feverish, vomiting, and headachy. Westerners are exhorting you to enter an Ebola treatment unit. What would you do?

You would probably do two things, the authors show. First, you would recognize that you might have nothing more than malaria, a largely non-fatal disease with the same symptoms as Ebola.

Then you would calculate your various odds of survival as best you could. (History provides us statistics to calculate the odds precisely.) To wit, if you have malaria, your chance of dying is .2 percent if you stay at home, and 16.1 percent if you get in one of those unsanitary ambulances and wait in a treatment unit’s messy triage area. If you have Ebola, your chance of dying is 70.8 percent at home and 64.3 percent at a treatment unit. Average your odds of survival according to where you go, instead of what mysterious disease you’re suffering from, and you have a 35.5 percent chance of dying if you stay at home, and a 40.2 percent chance of dying if you go for “treatment.”

In other words, a wise person in Sierra Leone, Guinea, or Liberia would ignore Western pleas. “You would be acting in your rational self-interest by staying at home,” the authors write, “not factoring in 1) rational desires to die at home rather than in (or in the queue in front of) a far-off tent; 2) rational fears that you might never see your family again; 3) rational responses to the pervasive messaging that Ebola has no cure” and so on.

The authors’ deconstruction of “rational” choices becomes controversial in context, however. Many in the global health community are not, and were not, eager to acknowledge the sagacity of people who avoided treatment units. A recent report by the World Health Organization provides an example. “All the modeling analyses show, as expected, that admitting patients to Ebola treatment centers and shortening the delay before hospitalization could have played a large part in slowing the increase and accelerating the decline in case incidence,” the report says.

Paragraph after paragraph focuses on corralling people and allowing the epidemic to burn itself out, while hardly mentioning the role of proper doctoring. It indulges in the “fetishisation of containment-through-isolation,” the Lancet authors write, instead of acknowledging the deadliness of treatment units.

And the line of thinking begets even worse ideas, the authors show. Rather than treating potential patients as people, global health experts see them as “superspreaders” or “vectors”—like creatures in a sci-fi movie. They label potential patients “‘unwilling to seek medical care,’” when such care is non-existent,” the Lancet authors write.

In just seven paragraphs, the authors extend their argument further—into history, anthropology, social theory, and more—but it all goes to underscore a single point: Don’t blame people, heal them. It’s good advice whether there’s an epidemic or not.

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Thu, 23 Feb 2017 16:44:46 -0500 https://www.pih.org//article/article-urges-better-treatment-for-ebola-patients-defends-superspreaders
Chasing a Cure for Melva in Peru https://www.pih.org//article/chasing-a-cure-for-melva-in-peru By all appearances, Melva Fernandez is a typical 7-year-old girl. She adores the Disney movie Frozen, loves dolls and video games, and is—occasionally—a bit naughty.

But unlike other children her age, Melva has battled a mysterious and difficult-to-treat form of tuberculosis for six years, and has already swallowed more medication than the average person will stomach over a lifetime.

Melva and her family have chased a cure from her rural home outside Cuzco, Peru, to the capital of Lima, then on to the United States and back. With support from Socios En Salud, as Partners In Health is known in Peru, the root of her problems—a rare immunological disorder—was finally diagnosed and is being treated successfully. Time will tell if more drastic measures are necessary. One thing remains true through it all: this little pony-tailed girl just wants to feel better.

A curious case of tuberculosis

Melva was 10 months old when an odd lump developed in her armpit. Her parents took her to a clinic near their home, where staff diagnosed her with tuberculosis and placed her on antibiotics. She seemed to get better but, within months, her symptoms reappeared.

So Melva got a second round of treatment. Again she improved, only to relapse several months later. Her TB started manifesting throughout her body, an odd symptom in pediatric patients already on medication, as her belly grew painfully distended and more lumps developed in her neck and armpits.

This cycle of recovery and relapse repeated for years until Melva landed at the National Institute of Children’s Health in Lima in 2013. Staff placed her on a powerful cocktail of medication to treat multidrug-resistant tuberculosis (MDR-TB). When those failed to have a lasting effect, they switched to a more potent regimen for extensively drug-resistant tuberculosis (XDR-TB), the worst form of the disease. Again, she got better only to relapse months later, despite the fact she never missed a dose.

Dr. Leonid Lecca, the executive director of PIH in Peru, was making his usual rounds at the children’s hospital when he met Melva and her father. This specialist in TB and his PIH colleagues had earned a reputation for helping local physicians tackle particularly tough cases in the past. Around 80 percent of the children they’ve accompanied through TB treatment have been cured.

A bone marrow transplant is still on the table.

Yet Melva’s case was exceptional. Lecca consulted with Dr. Hernán Del Castillo, the physician tending to the little girl, and both suspected something was interfering with her previous treatments. They conducted a series of genetic tests over several months to see if they could pinpoint a solution. And they found one.

Last January, doctors diagnosed Melva with an extremely rare disease that prevents her immune system from responding to the bacteria that causes TB. No matter how many times her doctors threw the best medicine available at her illness, her body would not be able to launch a proper defense.

That left her doctors with two options, neither one viable for a family of subsistence farmers living in poverty. They could place Melva on interferon-gamma, an artificial protein key to the immune system’s ability to fight against TB, and costs $14,000 each week. Or they could enter her in a medical study.

If they chose the interferon route, the drug would have to be imported from the United States and kept between 2 to 8 degrees Celsius to remain effective. Dr. Silvia Chiang, a specialist in pediatric TB consulting on Melva’s case, chatted with an infectious disease expert in Houston about the possibility of shipping interferon-gamma to Lima. “He said people ‘get nervous even transporting the drug across town,’” she recalled. Shipping it to Peru was a non-starter.

The second option was a long shot. There was an observational cohort study for people living with rare diseases that Chiang had heard about through contacts in the infectious disease world. If patients were willing to travel, they could receive free care at the National Institute of Allergy and Infectious Disease in Bethesda, MD.

PIH Co-founder Dr. Paul Farmer visits Melva and her father during their stay at the National Institute of Allergy and Infectious Disease in Bethesda, MD. Photo by Katherine Kralievits / Partners In Health


A long shot cure

By early May 2016, Lecca, Melva, and her father, Carlos Fernandez, were on a plane to the United States to begin her new treatment. It was the first time either the little girl or her father had left the country.

Chiang started visiting Melva and her father regularly at the NIH Clinical Care Center in Bethesda. She got a kick out of the feisty little girl and felt sympathy for her father, who worried about responsibilities back home and grew increasingly tired of living far from the rest of his family. Luckily, PIH had already thought ahead; the organization was helping his family with food, transportation, and education expenses back in Cusco until the father and daughter returned home.

During one of Chiang’s regular visits, she picked up an important clue about Melva’s case. Her father thought she got TB from her grandfather. But the researcher doubted that could be true, considering he had been cured long before his granddaughter was born.

So how did Melva contract the deadly infectious disease as an infant?

Chiang remembered that Melva’s swollen lymph node hadn’t been far from where nurses injected her with the bacille Calmette-Guerin (BCG) vaccine, an immunization against TB often given to infants in countries outside the United States. This vaccine contains active strains of Mycobacterium bovis, which causes tuberculosis in cattle and is a cousin of the more common Mycobacterium tuberculosis.

If PIH is dedicated to helping somebody, it’s not going to stop.

The TB expert, alongside the NIH team, wondered if Melva was battling multidrug-resistant BCG, and not what she’d been treated for up to that point, MDR-TB. Experts at the facility ran a battery of tests, results confirmed their hunch, and they switched out one of the antibiotics Melva took. Meanwhile, they kept her on interferon-gamma to help address her immunodeficiency.

It was a slow and painstaking process, but Melva began to come around. While she and her father remained for months in the hospital, Peruvian staff there heard about the girl’s case and came by to visit. Some even brought traditional dishes, such as lomo saltado or aji de gallina, as a way to fill the void left by homesickness.

By October, Melva tested negative for BCG. Her doctors weaned her off IV medication and switched her to pills, all in anticipation of her transition back home. Still, they were hesitant to claim victory.

“A bone marrow transplant is still on the table,” Chiang said. “There is not a lot of experience in the world with her specific immunological defect. Whenever we don’t have a lot of experience, we’re always very careful about when and if you make that decision.”

A hesitant homecoming

In December, Melva and her father flew back to Peru. It had been nearly eight months since Fernandez had seen his wife and two sons, and he seemed anxious about what he would find. He wanted to check on his fields, make overdue repairs to the house, and find work again—something he hadn’t been able to do while at Melva’s bedside.

For her part, Melva was returning to a home and family she barely remembered, having spent the past three years in hospitals. The last time she’d seen her mother was before her trip to the U.S., and she hadn’t recognized her.

They arrived home with a three-month supply of medication and a plan to visit Cuzco every month for checkups. The hope is that her treatment will continue to work, and that Melva won’t suffer another relapse.

Meanwhile, her doctors are hedging their bets. Chiang sent PIH staff in Lima swabs and instructions for how to take saliva samples from Melva’s older brother, Juan Carlos. Should the little girl require a bone marrow transplant, her doctors think he would be the most likely match. Melva is scheduled to travel back to the NIH facility in coming months for a checkup to see if the procedure will be necessary.

“If PIH is dedicated to helping somebody, it’s not going to stop,” Chiang said. “We will pull out all the stops.”

 

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Fri, 17 Feb 2017 11:18:21 -0500 https://www.pih.org//article/chasing-a-cure-for-melva-in-peru
Improving Care at the Most Remote Clinics in Liberia https://www.pih.org//article/improving-care-at-the-most-remote-clinics-in-liberia In southeast Liberia, a small Partners In Health team of nurse trainers has been driving to some of the most remote health clinics in the world. In trucks and on motorcycles they bounce for hours over rolling grassland, cross flooded rivers, and squeeze through cuts in massive fallen trees.

The four-wheeling isn’t for fun. The rugged commutes are to help increase the quality of health care at some two dozen small rural clinics. Starting in 2015, the Liberian Ministry of Health began rebuilding the country’s health system, which was devastated by the civil war that ended in 2003 and again by the Ebola epidemic of 2014 and 2015. The government is creating health care guidelines, training staff in hospitals, and much more. But improvements in the hard-to-reach rural clinics are a ways off yet. In the meantime, the handful of staff in these single-story cement buildings are often the first to see patients and the last to receive training.

A clinical mentor on the way to Juduken Clinic. Photo by Ezra Patrick Lugemwa / Partners In Health

So beginning in April 2016, PIH, along with local health officials, created a program called the Integrated Clinical Mentorship and Improvement Collaborative. The design of the program borrowed liberally from various models, including the program that PIH, Harvard Medical School, and Rwanda’s Ministry of Health invented to mentor rural nurses in Rwanda seven years ago, called MESH-QI. Taking a cue from the Liberian Ministry of Health’s nationwide priorities, the goal of the Collaborative was to boost services for mothers and children, and improve infection control for everyone, by sharpening up the skills of clinicians in these remote facilities.

“We want to build sustainable, country-driven, and evidence-based solutions,” says Anatole Manzi, PIH director of clinical practice and quality improvement.

For two months, PIH master coaches Nurse Gilbert Lekakeny Nkodedia and Nurse Irene Awino Ogongo each led three other nurses in rolling out the project. They measured the 19 clinics’ performance in eight areas key to preventing the spread of disease and improving the health of women and children. They gathered baseline data on how often nurses washed their hands during births, for example, and how many clinicians routinely tested pregnant women for syphilis.

Once the observation period was over, the fun began. “Traditionally, the solution is, ‘Let’s see how they are performing and have the directors correct them by writing you should do X instead of Y,’” says Manzi. Instead, the master coaches and other PIHers hosted county health officials, clinic staff, and community representatives in something like a design sprint.

The agenda was shared. Challenges were presented and agreed on. Sticky notes were deployed. And participants spent hours sharing possible root causes of poor staff performance and brainstorming potential solutions. An example? One of the causes of poor hygiene might be a lack of motivation. One of the solutions could be a talking faucet, a small stereo recording that plays at handwashing stations and reminds staff, in English and the local dialect, of the importance of scrubbing in.

The next day, they winnowed the list to the few ideas that seemed most promising. These solutions were a bit more conservative, including, for example, establishing a buffer stock of essential hand hygiene supplies. At the end of the second day, everyone dispersed to the county level office to review and share ideas that were to be tested, knowing that they would be able to refine or abandon them in subsequent sessions every two months.

Was all that really necessary? How difficult can it be to encourage clinicians to wash their hands?

Manzi answers with the story of Ignaz Semmelweis, a Hungarian doctor who practiced medicine in Vienna, Austria, in the 1840s, the dawn of modern medicine.

Many pregnancies in one maternity ward of the hospital where Semmelweis worked went well, while in another maternity ward, 1 in 5 expectant mothers died. Semmelweis wanted to find out why and used the technique of objective experimentation. He had women give birth on their sides instead of their backs (no effect). He rerouted a bell-ringing priest known to frighten women (also no effect). After months of trying out various theories, he finally arrived at the answer.

Doctors in the dangerous ward weren’t washing their hands. They were performing autopsies and heading straight to the delivery room, and the women were getting infected and dying of sepsis.

All should have been well from then on, but finding the answer proved to be only half the solution. Semmelweis lectured his peers on the importance of chlorine. He fought with powerful colleagues. He berated the stubborn. And he grew ever-crankier, suffered a mental breakdown, and died (of sepsis, likely contracted while having a wound treated in a hospital) a full three decades before most of the world would embrace his ideas about antiseptic.

“So when we talk about quality improvement and infection control in Liberia,” says Manzi, “we don’t want to be like Semmelweis.”

And they weren’t. Clinicians created solutions for themselves, such as a calendar with pictures of the best hand washers of the month. And patients contributed, for example, by proposing a patient-staff buddy system, in which each inspects the other’s hand washing.

How did it turn out? “Small ideas lead to great improvements,” says Manzi. An analysis in April will reveal year-end results, but between March and December 2016, at least, the improvements were dramatic.

The percent of clinicians who used a childbirth checklist and monitoring tool during deliveries, known as a partograph, increased from 24 to 71.

Testing pregnant women for syphilis increased from 0 to 24 percent.

The percent of women giving birth at clinics increased from 41 to 56.

Other results showed no improvement. And the percentage of women tested for HIV actually decreased 16 percent, due to some clinics’ difficulty in finding and paying for HIV test kits.  

Manzi and others are pleased with the improvements. The solutions that failed will be replaced by new ideas, which they will test and hopefully prove valuable.

“It’s a cycle,” says Manzi. “It’s a new way to accelerate and push. Most importantly, the clinicians feel like they own their health system. In my experience working with country teams to design and implement quality improvement interventions, the role of leadership has been critical. PIH/Liberia’s leaders played a critical role throughout this program. They are both leaders and key players—inspiring, informing, supporting, and acknowledging change agents as they generate creative ideas.”

And the number of clinicians who washed their hands correctly? It increased from 37 percent to 72 percent. If only Semmelweis had tried a “Handwashing Champion” calendar.

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Fri, 10 Feb 2017 15:44:16 -0500 https://www.pih.org//article/improving-care-at-the-most-remote-clinics-in-liberia
Sibo Tuyishimire: Top Student and Cancer Survivor https://www.pih.org//article/sibo-tuyishimire-top-rwandan-student-and-cancer-survivor Hillside School’s unique attraction is its working farm. The all-boys school in Marlborough, Massachusetts, aims to give students an appreciation for the environment and for hard work. For first-time visitors, a farm surrounded by classrooms can seem incongruous. But for prospective student Sibo Tuyishimire, it’s perfectly natural.

While touring the campus in December, the 15-year-old Rwandan strode confidently toward the farm’s grazing animals.

They all came screaming, explained Renee Di Prima Burns, Sibo’s foster mother. “When I say screaming, I’m not kidding,” she laughed. Honking geese, bleating sheep, ducks, and chickens rushed to their delighted newcomer.

“Sibo walked in there like he owned the place,” she said proudly.

The young man is used to the commotion of a farm, albeit a slightly different one. He grew up in a region of Rwanda that is as remote as they come, with no running water or electricity. He still lives in Rwanda most of the year, but returns to the U.S. during his school vacations in December and stays with Burns and her family in nearby Concord.

His double life is part of a remarkable story that has caught the attention of several U.S. private schools, including Hillside. In the last decade, Sibo has had a prolonged battle with cancer. He arrived in the United States in 2011, riddled with a second relapse of Hodgkin lymphoma. Since then, he not only recovered, but returned home to earn grades that placed him in the top 4 percent of Rwandan students.

“The schools wanted to be a part of his story,” said Burns.

Treating cancer in Rwanda

In 2005, Partners In Health and the Rwandan government began restoring Rwinkwavu Hospital, a dilapidated facility in rural eastern Rwanda. A year later, staff started treating children with cancer simply because there was nowhere else for them to go. Not a single oncologist practiced in the country and there was no national cancer program. Treatment just wasn’t an option for cancer patients unless they could afford private care abroad.

“This was needless suffering and death, and we knew we could do something about it,” said Dr. Sara Stulac, a pediatrician and PIH’s deputy chief medical officer.

She and other PIH staff managed to secure cancer medications from a private hospital in Rwanda. They also reached out to medical institutions in Boston. The Dana-Farber Cancer Institute, among others, supplied more chemotherapy, while Brigham and Women’s Hospital offered to biopsy samples. Stulac trained doctors and nurses in the basics of cancer care, including how to safely administer chemotherapy. With guidance from pediatric oncologists in the U.S., they designed individualized chemotherapy regimens over email. Rwinkwavu Hospital’s pediatric cancer ward was born.

It didn’t look like an oncology department you’d see in a Western hospital—sometimes IV bags dangled from coat hangers—but as Stulac says, they ensured every patient’s course of treatment was safe and effective.

In fact, it was lifesaving. As a couple of children emerged from the hospital cured from their tumors and illnesses, word got around, and a few cases in 2006 turned into a tide of children and their parents from all over Rwanda seeking care the following year. And the next.

When 5-year-old Sibo turned up with his mother in 2007, he was pale, thin, and in pain from a distended belly full of cancer. After a few months, he responded well to treatment and returned home. But later, he was back at Rwinkwavu and put through more rounds of chemotherapy and a trip to Uganda for radiation therapy.

Sibo’s condition worsened, and Stulac and her colleagues knew that his only hope of survival was a stem cell transplant. The procedure was not available in sub-Saharan Africa and prohibitively expensive elsewhere in the world. But Boston Children’s Hospital offered free care, and he was flown to the United States. Stulac emailed everyone she knew in search of a family to host Sibo, and the chain grew until it arrived in Burns’s inbox. Burns invited Sibo to join her, her husband, and their children in Concord. His treatment began immediately.

After another round of chemotherapy, it took about four weeks to do the transplant, explained Dr. Leslie Lehmann, the clinical director of the Pediatric Stem Cell Transplant Center at Dana-Farber Cancer Institute. The procedure went according to plan, but Sibo needed to remain in the U.S. for a year while he recovered. Before he left the hospital, his bed was inundated with visitors—friends and clinicians alike.

“He was incredibly popular,” said Lehmann. “The nurses loved him. He’s just got a great spirit.”

5,000 patients—and counting

Sibo’s case was among many that served as the impetus for developing a formal cancer program in Rwanda. PIH and Rwanda’s Ministry of Health were close to finishing construction of a new hospital in the north of the country. They decided that the hospital would house the country’s long-needed national cancer center. Butaro District Hospital opened in 2011, and its Cancer Center of Excellence opened the following year.

Rural East Africa had seen nothing like it. Besides chemotherapy and surgery, the center had its own pathology lab, social services, counseling, and palliative care. Staff could use specialized imaging equipment to collaborate with pathologists at the Dana-Farber Cancer Institute. Beds were surrounded on three sides by brightly painted walls and large glass windows overlooking Rwanda’s hills.

Cancer services have come a long way since Sibo first arrived on PIH’s doorstep. Teams of doctors and nurses have cared for about 5,000 patients since the center opened. Emergency flights to the U.S. are a thing of the past. There are no coat hangers holding IV bags.

Sibo’s sickness is also fading into history as he focuses on his education. After visiting Hillside and before returning to Rwanda in December, he took the SSAT test for secondary school admissions. He’ll likely hear from schools in March.

In the meantime, he continues at his current school in Rwanda, playing basketball and participating in the debate team. “I tried. I was scared,” he said about the test. “Math—I like it. It’s not very hard for me, but the language part was a bit difficult.”

His cancer formed no bitterness in him; he is a remarkable young man who takes everything in his stride. Whether sharing a single-room house with his mother and brother in Rwanda, or walking the annual tree lighting parade with Burns and his host family in Concord, he slips from one world to another with ease.

It’s not clear yet whether the ducks and chickens at Hillside get to see their friend again, but Burns is confident great things are in store.

“It’s destiny for him,” she said.

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Fri, 03 Feb 2017 15:27:30 -0500 https://www.pih.org//article/sibo-tuyishimire-top-rwandan-student-and-cancer-survivor
New Director Boosts Nourimanba Production in Haiti https://www.pih.org//article/new-factory-director-boosts-nourimanba-production-in-haiti On a humid morning in November, Guy-Thierry Nyam welcomed visitors to the Nourimanba Production Facility in Corporant, Haiti. Dressed in a red polo and blue jeans, the native Cameroonian and new factory director easily blended in with workers filing into the air-conditioned facility. He peered through a set of windows in the lobby’s adjoining conference room to see a handful of employees, dressed in white lab coats and hairnets, preparing for the day’s first batch of Nourimanba—the nutrient-rich peanut paste used to treat malnourished children at PIH clinics.

In Haiti, 1 in 5 children suffer from malnutrition. They may eat once a day, if their families have the means, and that meal usually consists of plain rice. Maybe a potato. Neither is enough for anyone to survive on nor contain the necessary nutrition, particularly for a child whose mental and physical capacity will be greatly stunted if they don’t have enough to eat within their first few years of life.

PIH is dedicated to addressing malnutrition and, thanks to its partners Abbott and the Abbott Fund, found a local, sustainable response by building the Nourimanba Production Facility four years ago. The Nourimanba produced here is distributed to PIH’s 12 clinics throughout the Central Plateau and lower Artibonite.

At each clinic, children are weighed, measured, examined, and—for those found severely or moderately malnourished—their families are given a supply of Nourimanba to take home. The enriched peanut paste is a food supplement, but it is treated like medicine. As it should be; it saves lives.

 Alice Regis and Marie Elizabeth Guerrier sort out damaged peanuts along the production line. Photo by Cecille Joan Avila / Partners In Health

When Nyam arrived in September, he was excited to further strengthen efficiency and production at the facility, and to work with a staff of energetic employees eager for his leadership and guidance. Their new director, who has the build of a linebacker and the patience of a schoolteacher, got to work immediately and scaled up production within the first few months.

Before joining Zanmi Lasante, as PIH is known in Haiti, Nyam worked in Cameroon for four years as a packing shift manager for Diageo, a multinational manufacturer of alcoholic beverages such as Johnny Walker whiskey. He logged another seven years as a production manager for Barry Callebaut, among the world’s largest chocolate and cocoa suppliers. Most recently, he was plant director at oil and gas producer Technoseal in the Republic of Congo before taking over the Nourimanba plant.

“I was happy to be coming back to my origins” in food production, he said. “That’s why I didn’t hesitate to join the facility here.”

Nyam led visitors out of the lobby and around the perimeter of the plant. He pointed to two generators (electricity is, at best, spotty in Haiti) and a water filtration system that feed the facility. At the back of the building was the entrance to the peanut warehouse. Inside, hundreds of bags of peanuts—all locally grown—were stacked atop wooden pallets.

That is their fuel for working here.

All the sacks are labeled by origin, variety, and date of arrival, he explained. Each sack is emptied into a machine that sorts out stones and other debris. If necessary, the peanuts are dried to ensure proper levels of humidity. Then the peanuts are dumped into a towering Dr. Seuss-like contraption that de-shells and drops them onto a conveyor belt. Four employees with eagle eyes and quick hands sort out “stressed” or damaged nuts. 

In other plants, machines would perform this seemingly tedious task. But job creation had been a central goal of the project from the beginning. And the factory has done just that. About 50 people work at the facility now, including six supervisors.

Once the sorting is completed, the peanuts are tested in the chemistry lab to check moisture and aflatoxin levels. Aflatoxin is a carcinogenic mold that can grow on peanuts, so the test ensures that only quality peanuts are used in production. Sourcing better peanuts is possible when farmers have the necessary tools to increase the quality of their peanuts, which includes being able to carefully store harvests.

Off a neighboring hallway, employees poured buckets of sorted peanuts into a roaster. The process decreases humidity, reduces contaminants, and develops the nuts’ aroma. The roasted and cooled peanuts are then ground and combined with a few other ingredients in an industrial-sized stainless steel mixer in the production room. In goes canola oil, powdered milk, vitamins and minerals (including vitamin A and iron), and sugar. Workers then fill and carefully apply a “Nourimanba” label on the 32-ounce containers. Each label includes a list of ingredients, production date, and batch number to ensure the container can be tracked.

Every child enrolled in PIH's malnutrition program returns home with a supply of Nourimanba, peanut paste enriched with essential vitamins and minerals. Photo by Cecille Joan Avila / Partners In Health

The air outside the production room was especially thick with the smell of sweet peanut butter. Nyam opened the door of a storage closet, where floor-to-ceiling shelves held cardboard boxes full of Nourimanba containers, which remain there until additional laboratory testing—performed in the onsite microbiology laboratory—rules out the presence of pathogens, such as Salmonella and E. coli, and confirms they are safe for consumption.

Timing is everything in the production of a perishable good. Most Nourimanba ingredients, including all the peanuts, are sourced in Haiti to support the local economy. But some ingredients, including canola oil and vitamin mix, cannot be reliably and cost-efficiently sourced locally, so the plant does import some supplies. Raw materials can take up to four months to import from the United States, and another two months just getting through the red tape at Haitian customs. Delays mean goods with a short shelf life, such as canola oil, have only six months before going bad.

To avoid stock-outs following such delays, Nyam made Gouby Dorzin, one of his supervisors, accountable for purchasing perishable ingredients. He also found suppliers in Haiti and the Dominican Republic as back-ups, should U.S. imports get stalled.

The factory produces about 200 kilograms of Nourimanba with each batch, and completes an average of five batches per day. Nyam hopes to increase daily production to seven batches and is looking for ways to speed up the process. “It’s not easy,” he says with a shy smile. “But it’s not impossible.”

The Nourimanba plant has been running eight hours a day, five days a week. It’s well on the way to meeting this year’s production goal of 120 metric tons. It has been so successful, in fact, that Nyam is offering other goods and services in the near future. He knows the plant can produce “spicy” peanut butter (popular in Haiti) and offer a range of pre-production services, such as peanut blanching, to fellow manufacturers (something the plant already does for at least one local company).

PIH staff would like to one day produce organic peanut butter that can be sold in the United States. Having someone like Nyam around makes that goal all the more attainable.

Ms. Esther Mahotiere, a nutrition program coordinator in Haiti, feeds Nourimanba to 8-month-old Wisline Sauvene at the malnutrition clinic in Boucan Carré. Photo by Cecille Joan Avila / Partners In Health

First, though, Nyam wants to ensure children are continuing to get the Nourimanba they need, when they need it. PIH-supported malnutrition clinics in Boucan Carré and Lascahobas prove he’s achieving that goal. Nurses proudly display medicine cabinets fully stocked with the nutritious medicine.

Back in the factory conference room, Nyam gazed at the bare walls over a cup of coffee and a sample of Nourimanba. (It was the first time he’d tasted the sweet, peanut-buttery concoction.) Someday, he’d like to see the blank space replaced by posters of children enjoying giant spoonfuls of Nourimanba—not so much for his own sake, but for that of his employees.

“They should be proud of their mission,” he said. “That is their fuel for working here.”

 

 

 

 

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Fri, 03 Feb 2017 10:29:27 -0500 https://www.pih.org//article/new-factory-director-boosts-nourimanba-production-in-haiti
Dr. Shyirambere: Cancer is No Longer a Death Sentence in Rwanda https://www.pih.org//article/dr.-cyprien-shyirambere-discusses-cancer-care-in-rural-rwanda Dr. Cyprien Shyirambere meets patients near the brink of death at the Butaro Cancer Center of Excellence in northern Rwanda. They and their families may have no idea why they’re sick; they just want a cure.

Shyirambere often helps them reach one. The pediatrician began working with Inshuti Mu Buzima, as Partners In Health is known in Rwanda, three years ago as the center’s oncology program associate director and has seen how basic services can save lives.

For World Cancer Day, Partners In Health spoke with Shyirambere about why he chose to study medicine, how cancer care has changed in his home country, and what challenges he faces treating the disease in one of the most remote regions of the world. This interview has been edited and condensed.

What inspired you to become a doctor?

I saw the scarcity of clinicians in the country, because people were not willing to do medicine. They wanted to do a quick program like information technology or finance in order to make money.

If you look in World Health Organization literature, you will see that Rwanda was one of the countries where the health workforce was significantly short. I wanted to train in medicine and give my contribution, so that Rwandan people could have more access to health care.

After completing my training, I was doing my rotation in different departments. While in pediatrics, I saw that children actually need more attention because they die so quickly if there’s no one to provide basic things, such as IV fluids and antibiotics. When they do get special attention, they show quick recovery. That is especially what inspired me to go into pediatrics.

What got you interested in oncology specifically?

It was not an easy decision. When you are training, you are told that cancer cannot be cured in poor places like Rwanda. Then I heard that there was a program in Rwanda where PIH was treating cancer.

I said, "Well, it’s time for Rwanda also to start something." So that’s how I joined the Cancer Center of Excellence in Rwanda.

What did cancer care look like in Rwanda when you started?

Before the Butaro Ambulatory Cancer Center opened in 2012, there was not much in the country. Chemotherapy was not available in public facilities. There is still no radiotherapy. Only a few people with financial means could afford cancer care in a private hospital in Kigali, the capital of Rwanda, or go abroad to places like India or China.

The majority of Rwandans had no access to cancer care. It was a death sentence in Rwanda. Telling someone, "You have cancer," was equal to saying, "You are going to die."

How has that changed since the Butaro center opened?

Now, people know that if you have cancer, you can get treatment—and not just in Butaro, but also in other referral hospitals.

We have had around 6,000 patients in five years. That’s around 1,200 every year. The top four cancers we see are women with breast cancer or cervical cancer, and children with acute lymphoblastic leukemia or Wilm’s tumor, which is a cancer of the kidney. There are also cancers of the blood, such as Hodgkin and non-Hodgkin lymphoma.

Shyirambere helps Wilson Ngamije* back into his jacket after a quick exam. Ngamije is at Butaro District Hospital to receive chemotherapy for Hodgkin lymphoma.

What stands out about cancer care at Butaro?

What makes our cancer center unique is the collaboration with other cancer centers in the United States. There is no oncologist here in Butaro. We have a physician. We have general nurses who have received training in oncology. And we have protocols that have been endorsed by the government—all of which we use to treat cancer. Academic cancer centers in the U.S. give us leadership mostly, and sometimes staff come here to give us on-site mentorship.

We believe that cancer can be treated without all the oncology facilities, but with people who are committed and with a strong health system. That’s what makes our cancer center unique—that motivation, that collaboration, that commitment.

As people become aware of the cancer center, the number of patients have increased from around Rwanda and outside the country. Almost 10 percent of the patients we see come from a neighboring country, mainly Burundi and Congo.

What are some of the challenges you face?

We see patients who arrive in late stages of cancer, and this impacts their prognosis. And of course, there are limitations in the capacity of our staff, in terms of training.

We also lack resources. This is basically a district hospital, so we don’t have all the facilities around us. We don’t have an intensive care unit or a CT scan machine, which is mandatory for staging cancer. We don’t have any radiotherapy machine in the country, so we refer our patients to Nairobi, Kenya, and it’s very expensive.

Another challenge is the social-economic situation of our patients. We need to subsidize their transport and their food, and this is becoming a burden to the hospital.

How are you meeting these challenges?

Increasing awareness in the community is one strategy we use to decrease the number of people who come with late presentation [of their cancer]. We work together with the Rwandan minister of health to increase awareness in the population for early detection. We use media, community health workers, and all means of communications so that people know that cancer exists, that it can be treated, and that some can be cured.

There is a plan to expand the facility so that we can serve more people. But of course, this goes with funding, so we have to identify more funds to continue to support these patients. We are hoping that in three years, one of our referral hospitals in Kigali will have a facility with two radiotherapy machines.

Most of our patients are poor. They get chemotherapy free of charge, so I want to continue to ensure their access to treatment and work on a plan to bring radiotherapy to the country.

LISTEN: What lessons have you learned in doing this work?

 

Do you have a story about a particular patient you’d like to share?

I have a lot of my patients in my heart, but there’s one patient I will always remember. He’s a 9-year-old boy named Kachonga. He came to see us from the Congo with his mother. For almost three years, the child had been going to different hospitals in the Congo and Burundi. He was treated incorrectly for tuberculosis for almost eight months.

Then Kachonga and his mother heard that there is a cancer center in Rwanda. They came and discovered that he had Hodgkin lymphoma. The child was treated for six months with chemotherapy, and now he’s back to school and doing very well.

When I see Kachonga for follow-ups, and I compare how he is now to when he came to see me, I feel very happy. He’s doing well.

What is it about Kachonga that made an impression on you?

Kachonga was very sick. His mother had almost no hope. But Kachonga himself still had hope that he would be cured. He was standing strong, despite being really sick.

LISTEN: What do you want people to know about cancer—both how it’s treated in Rwanda and on a global level?

 

*Name has been changed

Read Kachonga's story here.

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Thu, 02 Feb 2017 15:21:27 -0500 https://www.pih.org//article/dr.-cyprien-shyirambere-discusses-cancer-care-in-rural-rwanda
Mexican Doctor Studies at PIH University in Rwanda https://www.pih.org//article/studying-abroad Dr. Kurt Figueroa is a student at the University of Global Health Equity, a Partners In Health institution that launched in 2015 and trains health professionals in Rwanda how to manage the challenges of providing health care in poor places. He and his fellow students—who are nurses, clinicians, psychologists, and other health experts—will come away with a two-year Master of Science degree in Global Health Delivery.

Unlike most of his peers, Figueroa is not Rwandan. He moved from working at a small PIH clinic in the Sierra Madre mountains of Chiapas, Mexico—his home country—to a similarly remote hospital that PIH supports in Rwanda. When he’s not in class, he works at Butaro District Hospital as the oncology clinical officer.

Here he shares his experiences as a global health student and as a doctor providing care in the far reaches of Mexico and Rwanda.

What attracted you to the university?

I first heard about the University of Global Health Equity when they were accepting applications for the first group of students in 2015. At the time, student positions were only for people based in Rwanda. So I sent emails asking about the program and they said I needed to wait for one year, when they would probably open it for international students. So I waited and kept working in Mexico. After one year, I applied again, as well as to another program, and I was accepted to both.

What made me choose the University of Global Health Equity was that it was a two-year program, and also that it was another opportunity to work with the organization that helped me take my first steps in global health—PIH.

What skills and experiences are you gaining from the program?

Critical thinking and empathy. I have learned to assess patients’ situations in order to really understand what is going on with them—what are the main problems that they have—so I can give them the best attention.

Another skill that I have been developing in this course is research. I speak with my supervisor about many opportunities to research and improve the quality of care.

What makes the master’s program unique?

Having the opportunity to work with students from different disciplines. Some are pharmacists, nurses, agriculturists, and psychologists. Other colleagues are doctors. Receiving their perspectives about life and about how to deal with people and about leadership gives me a huge opportunity to improve myself.

The other thing is the high-quality faculty. Our professors are very well-known in global health. They have been working in many other universities and many other programs.

What are the classes like?

Classes at the University of Global Health Equity are highly interactive. It’s not only the professor giving the classes and students taking notes—it’s interaction.

Between asking questions and having pre-course tests and a lot of lectures, there is also the opportunity for discussion. We will give our own understanding of the topics, and they will guide us in the right way. We have the opportunity to interact with other professors by watching videos of them teaching classes at Harvard, for example. Or we have visiting professors that come from Tufts University, as well as Yale and Harvard.

The faculty includes directors of PIH country programs. Dr. Alex Coutinho is the executive director of PIH in Rwanda. He gives us lectures about the Rwandan health system, leads case studies, and tells us about his experiences. Also we have Dr. Agnes Binagwaho, the former minister of health, and her years of experience highly enrich the learning experience.

Tell us about your day job at Butaro District Hospital.

I give general consultations to patients in oncology. Patients are referred to us by other hospitals or health centers when they are suspected to have cancer. My job is to address them and do all of the workup to see if they have a real oncology situation. Then I admit them for treatment. I also do rounds in the ward, discussing patients’ statuses, treating them, and following up on their care.

How has your job changed since you started studying at the university?

When I was in Mexico, I was a general physician with PIH, and at that time I was seeing cases ranging from hypertension and diabetes to infectious diseases and trauma. And it was in a small rural clinic. I was the only doctor. Now that I am working in Butaro District Hospital, I have a whole team. It’s not my team; we work together. And as we work together we are developing a lot more specialized care.

What are you going to do when you graduate after two years?

Global health for me is not a career; it’s a lifestyle. So I see myself working in global health settings. If I have the opportunity to stay here in Rwanda, I believe that I will do it. Maybe I’ll go back to my country because my people need me there. And it’s not only Chiapas and Rwanda—there are a lot of neglected poor communities all over the world. I see myself doing this anywhere.

The interview was edited and condensed for clarity.

Applications for the Master of Science in Global Health Delivery open February 8, 2017.  For more information or to apply to the program, visit www.ughe.org.

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Tue, 31 Jan 2017 10:46:05 -0500 https://www.pih.org//article/studying-abroad
PIH: Executive Order Should Be Reversed https://www.pih.org//article/pih-reverse-executive-order Partners In Health is unequivocally committed to supporting our staff around the world who may be affected by the Executive Order banning immigration to the United States from seven predominantly Muslim countries.

PIH is an international organization with a multinational staff of diverse talents that provides care for some of the world’s most vulnerable people. Our staff is deeply committed to making connections across countries, faiths, and cultures to work toward the common good of humanity. 

We firmly believe this Executive Order should be immediately reversed, and we will support efforts to accomplish that goal.

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Sun, 29 Jan 2017 15:06:42 -0500 https://www.pih.org//article/pih-reverse-executive-order
All Heart: Two Sisters' Miraculous Surgeries in Mexico https://www.pih.org//article/all-heart-two-sisters-miraculous-surgeries-in-mexico For days, Dr. Rodrigo Bazúa had been tending to a steady stream of healthy teenagers at the public clinic in Plan de la Libertad, Chiapas. It was late summer 2015 and the teens, all 15 and older, were Seventh Day Adventists eager to attend a religious camp in a neighboring community. Organizers required that each one get a medical certification to prove they were healthy, so Bazúa was doing a ton of paperwork.

Rebeca Velasco was among them. The soft-spoken 20-year-old with shiny black hair had no history of illness. She was active and didn’t complain of any aches or pains. By most measures, she seemed healthy. A less attentive doctor might have happily signed her papers and sent her away.

But Bazúa, only one year out of medical school, was thorough. He looked in her eyes, ears, and mouth. He listened to her lungs. All normal. Then he listened to her heart. Here, he lingered for a beat or two longer than he had with other teens.

Bazúa heard a murmur. He placed his hand on the upper left side of Rebeca’s chest and felt a throbbing pulse. That was definitely not normal. In good conscience, he couldn’t sign her papers. He also knew she had to see a cardiologist to determine whether what he heard was innocent, or life-threatening. Within months, they would all discover Rebeca needed open-heart surgery, or she would die.

The news seemed especially cruel to the Velasco family. Exactly one year before Rebeca’s exam, another doctor had informed them that their youngest daughter, 12-year-old Leydi, needed immediate medical attention for a congenital heart defect. Now their oldest, Rebeca, was heading in the same direction. None of it made sense to their parents, Antonio Velasco and Florinda Hortencia Trujillo, who looked to their remaining three children—Carlitos, Elionay, and Daisy—and wondered, “Who’s next?”

The common factor linking the sisters’ cases was that both were detected by doctors working with Compaňeros En Salud, as Partners In Health is known in Mexico. In 2012, Plan de la Libertad was among eight communities where PIH, in partnership with Mexico’s Ministry of Health, began mentoring first-year doctors. PIH has since expanded the arrangement to 10 communities throughout Chiapas, where rural residents can now receive essential primary care and—when necessary—referrals to specialists in larger urban hospitals.

Strange symptoms

Leydi was among the first patients to benefit from the Right to Health Care program, what PIH calls its referral system. Velasco said they’d known their youngest daughter had a heart defect since birth, yet doctors at the time thought the hole in her heart would heal by itself. For most of her life, everything seemed normal.

But after she turned 10, Leydi began experiencing strange symptoms: fainting spells, shortness of breath, and pain in her left arm and lung. In July 2014, the family took her to the local clinic up the hill from their tidy, cement block home. They found the facility clean, stocked with medicine, and—surprisingly—staffed. Before PIH began working in the community, no doctor had kept a reliable schedule in this remote, mountainside community.

Dr. Eduardo Peters greeted them. The first-year doctor from Mexico City was fast-talking, friendly, and eager to help. He took down Leydi’s medical history and gave her an exam. He believed Leydi’s symptoms signaled serious heart problems and recommended she immediately see a cardiologist.

It’s a miracle that you’re alive.

Peters contacted his supervisors, who requested an appointment at the pediatric hospital in Tuxtla Gutiérrez, the capital of Chiapas. Over the course of six months, PIH staff escorted Leydi and her family to and from Tuxtla for a series of diagnostic tests. They learned she had patent ductus arteriosa, which happens when an opening between two major blood vessels leading from the heart fails to close naturally after birth. If not corrected, a patient’s heart can fail.

The good news is that patent ductus arteriosa is a relatively common birth defect. Corrective surgery is straight forward. A catheter is inserted into a vein in the patient’s upper thigh and snaked up to the septum, the thick wall that divides the heart into four chambers. The surgeon then releases from the catheter a tiny, umbrella-like device, which plugs the hole in the septal wall. Tissue grows over the device within six months, and the hole is permanently closed. 

On January 17, 2015, Leydi was admitted to the Tuxtla pediatric hospital and underwent surgery. Velasco remembered feeling completely helpless as the family sat in the waiting room, drying their tears. But the surgery went well. The only indication she’d been through the ordeal was a small incision near her groin. The following day, her father said, she practically walked out of the hospital.

Leydi’s recovery was gradual. She was still experiencing symptoms one month later, but nothing as severe as before the surgery. By her six month appointment, she and her family had noticed a remarkable change. “Thanks be to God, her heart is normal, her color normal, and her lack of air and fainting spells have disappeared,” her father said. “The surgery has been a success.”

A stunning diagnosis

But the family’s celebration was short-lived that August. Relief at Leydi’s recovery morphed into shock at the news that Rebeca might have heart problems as well. Instead of traveling to nearby Villaflores for camp, Rebeca and her father were escorted to a cardiologist’s office in Tapachula, this time with Dr. Azucena Espinosa, PIH’s director of the Right to Health Care program in Mexico. 

“We were thinking it was just a check-up to rule out certain health problems,” her father said. “In our minds, there was the idea that this isn’t serious, that she could continue living a normal life.”

Dr. Margarita Olvera delivered different news. Rebeca, the cardiologist told them, had an ostium secundum atrial septal defect. Most people have four separate chambers in their heart, two atria and two ventricles. Rebeca's heart was structural sound, except for a hole in the wall separating her atria. As a result, the right side of her heart had enlarged significantly over time. If she didn’t have surgery, the doctor explained, Rebeca's life would not be the same.  

I just want my sister to stay, to have our whole family together.

“’It’s a miracle that you’re alive,’” Trujillo remembered Olvera saying. She struggled to understand how her oldest daughter, who used to walk 10 km every day to school, had a life-threatening heart condition. “I didn’t accept it at all.”

Her father felt equally stunned. “From one person who I have seen all my life, 20 years seeing her as a normal girl, and then suddenly they tell me that she has a serious problem,” he said. “It seemed like it was a dream and that, waking up, everything would be different.”

They worried about the economic blow their family would take. Like most of their neighbors in the Sierra Madre, they were coffee farmers and struggled to make ends meet. The past three years had been especially trying, due to a fungus called la roya that had plagued most coffee plantations. Harvests had shrunk by as much as 80 percent. There simply was no money to spare. Would they have to sell their land, their home? Would public health insurance cover the entire procedure?

“The whole family was wondering what was going to happen,” Trujillo said.

What was most troubling, though, was imagining life without Rebeca. “It doesn’t matter if we end up in the street,” Trujillo remembered her 14-year-old daughter, Daisy, saying. “I just want my sister to stay, to have our whole family together.”

 

Coffee beans dry in the midday sun outside the Velasco home in Plan de la Libertad.

 

“Another opportunity to live”

Through it all, the Velasco family leaned heavily on their faith. And on PIH.

Espinosa was there to comfort the family immediately after the diagnosis, and in the weeks and months ahead. She ensured they would receive the organization’s full support—including transportation to and from Tapachula, scheduling appointments with specialists and surgeons, and navigating the labyrinthine public health system. And she collaborated with hospital director José Manuel Pérez Tirado, who guaranteed necessary staff and supplies would be available for the open-heart surgery. 

When the family learned that Rebeca’s procedure would require a stockpile of blood, their community rallied around them. PIH staff drove 20 people—friends, neighbors, and fellow parishioners from the family’s church—to the blood bank in Tuxtla so surgeons would have what they needed.

Six months later, everything was in place for the surgery. Rebeca and her mother were alone in her hospital room early the morning of February 3, 2016. At 8 a.m., hospital staff arrived and told Rebeca she had to bathe before entering the operating room. The young woman calmly did as she was told. Trujillo and the nurses waited outside the bathroom and heard the shower turn on. Then they heard singing. Rebeca had chosen a hymn her parents knew well, one that had given them comfort in the past.  

Afterward, hospital staff wheeled Rebeca down to the operating room. Before passing through the double doors, they paused and Trujillo remembered them saying “’Seňora, say good-bye to your daughter.’” But Trujillo’s own heart had started to race, she felt light-headed, and was only able to say, “Adios!” before Rebecca was pushed out of sight.

Velasco found his wife in the waiting room shortly afterward. He had been up for hours and looked tense. Trujillo sensed her husband’s unease. “’Don’t worry,’” Velasco remembered her saying. “’I was with her. She was well.’” Then she shared the story of Rebeca breaking into song in the shower, and they both settled in for an unbearable wait.

Doctors had said they could expect news by noon, but noon came and went without word. Another hour passed. Then another. Just when Velasco and Trujillo were beginning to feel desperate, the surgeon arrived to say all had gone well. Rebeca was still under anesthesia, so her mother stayed at the hospital waiting for her to awake.

The rest of the family stayed the night with relatives and returned by 10 a.m. to see Rebeca resting in bed, half-conscious but happy. Trujillo fed her apple juice, maneuvering around the multiple machines hooked up to her oldest daughter. She would later tell them she remembered opening her eyes after the surgery to see her doctors’ faces.

“I understood that I had survived everything, that everything was over,” Rebeca said. “I felt like crying from happiness because I had another opportunity to live.”

The family was prepared to stay up to three months in Tapachula as Rebeca recovered. But a mere eight days after her surgery, she was discharged. After a quick check-up on February 19, she and her family returned to Plan. 

A family reunited

 

(From left) Antonio Velasco and Florinda Hortencia Trujillo are happy to have their daughters, Leydi and Rebeca, home and recovering well.

Within weeks of her surgery, Rebeca sat rosy-cheeked and relaxed in her family’s living room, where the walls were covered with pictures of the five Velasco children and certificates from their many accomplishments. A rooster crowed outside, and the zinc roof crinkled with the passage of the midday sun. Freshly harvested coffee beans dried on the cement patio abutting their home.

Beyond a minor infection along her incision, Rebeca had no complications. Even when her heart was in bad shape, she said she never felt a thing. “Now I feel the same, as if nothing happened.” She hopes to return to university soon to study psychology. Meanwhile, Leydi looks forward to finishing high school and the day she can run, carefree, after her schoolmates.

Their parents were simply relieved this nightmare was over and thanked PIH staff for their support.

“Alone, we wouldn’t have been able to do it,” Velasco said. “Really, for us, it was a blessing.”
 

 

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Wed, 18 Jan 2017 13:15:54 -0500 https://www.pih.org//article/all-heart-two-sisters-miraculous-surgeries-in-mexico
Blindness https://www.pih.org//article/blindness-uveitis-partners-in-health-sierra-leone-eye-care When the number of new Ebola cases finally began to level off in Sierra Leone in early 2015, nurse John Welch, a Partners In Health clinical director in the northern Port Loko District, went to investigate some of the health complaints he was hearing from Ebola survivors. Many of the farmers and street vendors and others that PIH had discharged from its Ebola treatment unit were sounding less than cured. Welch had sent them back into the world after a final chlorine spray dubbed the “happy shower,” but now they were describing everything from joint pain to depression.

Uveitis raised particular alarms. Pronounced “yew-vee-eye-tis,” it is an inflammation of the eye caused by infection, injury, or autoimmune response. As the eye swells, it can bleed or change color, and vision deteriorates. One patient described “looking through brambles.” Untreated, the retina and optic nerve wind up permanently damaged, and, within a year, a person can go blind.

To Welch’s good fortune, one of Sierra Leone’s four ophthalmologists, Dr. John Mattia, happened to work just down the road from PIH’s Ebola treatment unit. But he painted a grim picture of the situation.

Systemic diseases such as Ebola rarely if ever produce uveitis in more than 3 percent of patients, but around the country, eye care specialists were seeing it much more often. And they had few to none of the steroid eye drops and tablets known to treat the disease. “I thought of uveitis as a death sentence for the eye,” Mattia recalls.

So in the cities of Kenema and Freetown, Bo and Makeni, Ebola survivors with uveitis were doing for themselves as best they could, buying saline eye drops or rubbing hand sanitizer in their eyes. 

Their understandings of the cause of their failing eye sight was equally crude but logical. Many thought the bizarre eye problems were the result of whatever Westerners had fed them while they had been incapacitated in Ebola treatment units, or maybe all that stinging chlorine was to blame.

After talking with Mattia, Welch and colleagues became convinced they had to do something. They could hardly imagine the challenges to come—the donors who would show them empty pockets, the nongovernmental organizations that would shrug off requests for help, the international newspapers that would downplay the prevalence of uveitis. Nor did they fully appreciate the struggles that Mattia and his colleagues had already faced.

All they really knew was that they couldn’t stand idly by. “If our patients survive Ebola and end up debilitated from uveitis, then it’s pointless to say ‘We’ve won,’” Welch thought.

 

Ebola survivor and PIH employee Unisa A. Bangura (left) helped Kadiatu Bangura (right, no relation) treat her eye problems. Photo by Rebecca E. Rollins / Partners In Health

Sierra Leone is a poor country roughly the size and population of South Carolina. Even in the relatively good years before Ebola struck, the government could afford to spend just $86 on health care per person per year. This led to dismal results. Surgery outcomes in the top Sierra Leonean hospitals, for example, were on par with hospitals in America in the 1860s.

Eye care was a notable standout. Starting in 2011, Dr. Matthew Jusu Vandy, the senior eye specialist with the country’s Ministry of Health and Sanitation, had managed to grow his small program. Cutting a dignified figure in muted button-downs, the graduate of the London School of Hygiene and Tropical Medicine deftly expanded his budget, funded one third by the government and two thirds by nongovernmental organizations. He increased the number of ophthalmologists from one, himself, to four. (Mattia was his first hire.) And he added roughly a dozen cataract surgeons and nurses. By 2014, at least some eye care existed in each of Sierra Leone’s 14 districts.

Then the largest Ebola epidemic in history hit. Beginning in the summer of 2014, Sierra Leoneans saw their neighbors die in hospitals and avoided the places at all costs. Doctors and nurses died from infection or, fearing for their lives, stopped showing up to work. Pharmacies stocked out of the few medications they once had.

“There was nothing,” recalls Vandy.

After ignoring the virus’s spread through Guinea, Liberia, and Sierra Leone, the rest of the world took note in the fall, when the number of people infected with the hemorrhagic fever began to rise exponentially. “CDC: Ebola Could Infect 1.4 Million in Liberia and Sierra Leone by End of January,” warned a U.S. newspaper headline in September. 

Rich countries finally shifted into gear. One and a half billion dollars in aid headed toward Ebola treatment units.

 

The clinic in Port Loko District, Sierra Leone, where Dr. John Mattia treated many Ebola survivors and led a groundbreaking study of the secondary diseases spurred by Ebola. Photo by Rebecca E. Rollins / Partners In Health

And that’s when uveitis began to present—in the earliest wave of fathers and daughters and aunts and others to survive.

Vandy’s cataract surgeon in the eastern district of Kenema, Ernest Challey, seems to have been the first to diagnose Ebola-associated uveitis in West Africa, in October of 2014, and he reported it to Vandy.

Vandy didn’t know exactly why or how Ebola had spurred the condition, but he definitely knew what they were facing.

“Uveitis is not a new disease,” he says.

Patients with moderate symptoms normally get strong eye drops. Those with severe symptoms also take oral steroids, such as prednisone. Beginning with roughly 12 tablets daily, they must gradually reduce the dose over weeks. Abandoning treatment leaves the body with a severe hormonal imbalance that can be fatal. Even administered correctly, the medication can cause flare-ups of diseases such as tuberculosis. And uveitis can recur.

Of course those concerns were a long way off in the fall. Vandy and his colleagues didn't even have enough medication.

“This was a most challenging time for me,” he says.

After watching powerlessly as uveitis blinded two 5-year-olds, Vandy went on a mission. He traveled the country for weeks talking to anyone who would listen, from heads of international NGOs to government officials, asking for staff and supplies.

His pleas fell on deaf ears. In the fall of 2014, the UN was airlifting ambulances and mortuary trucks into Sierra Leone. Experts from around the world were helping dig mass graves and trying to cure Ebola patients. Whether or not those patients ended up blind was largely beside the point. International aid, late to arrive, was focused on slowing the spread of the epidemic.

 

A tool to examine patients' eyes. Photo by Rebecca E. Rollins / Partners In Health

Thousands of people continued to be infected with Ebola each month until the new year, when the treatment units and infection control efforts finally began to slow the epidemic.

In February 2015, Welch went to investigate the “clinical sequelae” in Port Loko and vowed to help.

PIH was uniquely positioned to respond. They knew and worked alongside many Ebola survivors, having discharged roughly one out of every twenty in the country. And they were friendly with the two other international NGOs in the district, which wasn’t guaranteed, as NGOs were beginning to stake out new turf in the space left by the receding epidemic.

In short order, International Medical Corps, a U.S.-based NGO focused on emergency medical care; GOAL, an Ireland-based NGO focused on extreme poverty; and PIH joined forces.

“At a time when higher levels of management were vying for money and influence, at the field level we came together, all three of us, and provided different parts of the necessary resources,” says Welch.

Within a month, Vandy, Mattia, and The Big 3, as the NGOs jokingly called themselves, cobbled together the Port Loko Ebola Virus Disease Survivor Care Clinic.

Ebola survivors spread the word throughout the district and helped people overcome fears of chlorine and Westerners, and in just April and the first week of May, the Clinic screened 277 survivors. It had to refer some patients, such as those suffering from extrapulmonary tuberculosis, but Mattia, clocking long hours, personally treated any who had eye problems, including 50 with uveitis.

“I didn’t want to let my people down,” he says.

Crucially, the Clinic also tracked patient demographics and diagnosis. Over the coming months, that information would become the first-ever study of Ebola survivors published in a leading medical journal, “Early clinical sequelae of Ebola virus disease in Sierra Leone: a cross-sectional study.”

But even in May, the conclusions were clear. Not 3 percent, but fully 18 percent of Ebola survivors had uveitis.

 

Alpha Jalloh (center and below) tested Ebola survivors' vision in Port Loko District, Sierra Leone. Photo by Rebecca E. Rollins / Partners In Health

Eye problems appeared in vastly more Ebola survivors than previously imagined. Photo by Rebecca E. Rollins / Partners In Health

Back of the napkin estimates suggested the disease was poised to blind 1,000 people in Sierra Leone. The team felt passionately that the eye care program needed to expand to help all Ebola survivors in the country, and, not unlike Vandy earlier, they set out to find allies and money to do so.

It didn’t go well. Even with the Ebola epidemic shrinking and proof that uveitis was widespread and a pop-up clinic could treat it, PIH nurse Joyce Chang, who took over from Welch, struggled. 

“The feedback we got was this is not an Ebola response,” says Chang.

Governments and foundations understood that uveitis was the result of Ebola. But their strict funding rules, established long ago and far away, tended to define activities outside of a treatment unit’s plastic fence as “rebuilding” or “recovering,” which came with a smaller, harder-to-access pot of money.

NGOs balked as well. It wasn’t part of their plan, or they were packing up, moving on to other crises. Others simply weren’t eager to collaborate. There was the “sad but real feeling,” says Piero Pertile, a PIH project manager, that some NGOs didn’t want to prevent blindness if they would have to share credit for the work.

The media didn’t exactly swing the needle, either. The New York Times, for example, published a riveting story about uveitis on the front page, above the fold, in early May. A spooky pair of eyes—one blue, the other green and dilated—stared out at readers. But the piece focused on the frightening medical mysteries of uveitis in a single American and only nodded at “anecdotal and unconfirmed” accounts of West Africans going blind.

When PIH Chief Medical Officer Dr. Joia Mukherjee visited Sierra Leone in late April 2015, the project was in danger. Meager funding, conflicting agendas, shrugging disregard—all threatened to undo months of progress toward a national eye care program. A stall-out would hardly be unprecedented. Time and again, valiant global health efforts have amounted to half-measures. Water wells have been drilled without any way to maintain them. Free immunizations have been offered at health centers too remote for people to reach. HIV treatment programs have ignored infected children.

Mukherjee would have none of it. Someone needed to short-circuit the system, to fully bridge the gap between the powerless and the powerful, so that treatment for uveitis could be given to everyone who was sick.

“I went rather ballistic,” she says.

At 8 p.m. on April 30, she sat down at her computer and launched a fusillade. She emailed everyone from PIH CEO Dr. Gary Gottlieb to the Chief of Ophthalmology at Massachusetts General Hospital, in Boston.

At 9:13 p.m., she shut her laptop and declared a national eye care program under way.

 

Yealie Mansaray (right) examined dozens of Ebola survivors in Port Loko District, Sierra Leone. Photo by Rebecca E. Rollins / Partners In Health

On May 22, the team ordered $292,000 worth of supplies, and in late June, DHL, the only shipper delivering to West Africa during the Ebola epidemic, delivered 500 pounds of steroid tablets, eye droplets, and ophthalmic instruments to the PIH office in Freetown.

With medication and supplies to hand out, Chang, Pertile, and Vandy now had little trouble attracting partners. The first of some 14 to sign on was Medecins Sans Frontiers-Holland, the Dutch arm of the international medical humanitarian NGO, followed by a similar organization from Argentina, Medicos del Mundo. The American ophthalmologist featured in The Times, Dr. Steven Yeh, helped Vandy and Mattia create clinical protocols.

Beginning in June 2015, a small group of PIHers traversed the country coordinating the screenings and treatments, largely like they had in Port Loko. Again, Ebola survivors themselves proved invaluable. “The Ebola survivors were key to the success of the program,” says Mattia. “They were the ones who brought their neighbors and checked on them.”

There were challenges. The rainy season slowed progress until September, when mud bogs dried into roads. Some complained that survivors were getting unfairly good health care. And some survivors were reached too late, after uveitis had destroyed their eyes. “There was no way to help them,” says Mattia.

But there was also luck. Initially, clinicians had worried that everything was happening too slowly, but that largely wasn’t the case. Even many Ebola survivors in the east, who were screened a year after being discharged, recovered.

By March 31, 2016, the program had screened 3,058 survivors and treated 379 for uveitis.

Some, like John Kaifinch, relapsed. The 30-year-old Ebola survivor from East Freetown was diagnosed with uveitis, got the right medication, and stuck to the regimen. After his eyesight returned to normal, he was hired by PIH to help find other survivors in need of screening. But two months later, he began coughing blood and was diagnosed with tuberculosis. Then, a month after undergoing TB treatment, his uveitis recurred. “It’s a stubborn disease,” he says. And indeed, follow-up has proven key.

But lasting successes are also clear.

“What PIH and the Ministry of Health contributed to survivor care has transformed how we’re going to deal with outbreaks in the future,” says Dr. Sharmistha Mishra, a clinical consultant with the World Health Organization.

The WHO’s 31-page “Interim Guidance: Clinical care for survivors of Ebola virus disease,” published in April, leans heavily on what was learned in PIH’s uveitis treatment campaigns. Hopefully it will make the disease easier to fund and treat in the future.

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Mon, 09 Jan 2017 16:46:48 -0500 https://www.pih.org//article/blindness-uveitis-partners-in-health-sierra-leone-eye-care
The Best Books, Podcasts, and Websites for Community Organizing https://www.pih.org//article/community-organizers-recommend-the-best-books-podcasts-and-websites-for-cha How do we ensure that every human has the right to health? PIH staff have learned, and employed, many strategies over the decades. Below, three community organizers share some of their favorite resources, from a children's book to a proudly wonky website.

 

Ortal Ullman’s picks

Rules for Radicals: A Practical Primer for Realistic Radicals, by Saul Alinsky

This classic, first published in 1971, is for anyone looking to really dive into the thinking of an organizer. Alinsky was a powerhouse, maybe best known for fighting to improve housing in poor parts of Chicago, and is often credited as the "father of modern community organizing," having inspired young Barack Obama, Hillary Clinton, and many others. Rules for Radicals is your handbook to his basic beliefs and strategies.

Beautifultrouble.org

Ever heard of an artistic vigil? Want to plan a flash mob? Beautiful Trouble has got you covered. The two-year-old site—a collaboration between the YesMen, Ruckus Society, and many more activists—is chock full of powerful, artistic ways to organize and take action on any number of issues. Sure, writing a letter to your congressperson is always a good use of time, but Beautiful Trouble can help you imagine more creative strategies to show your constituent power.

The Good Fight with Ben Wikler

Wikler says his podcast aims to tell David versus Goliath stories “from the behind-the-slingshot point of view." With topics like "The 347 Climate Wins You've Never Heard Of," each episode is a dose of sunshine. Wikler put the show on hold one year ago. His day job as the Washington director of MoveOn.org simply got too busy. But there are still 44 episodes, with each reminding us that, while the fight for social justice is long, the underdogs have plenty to celebrate.

A is for Activist, by Innosanto Nagara

For the tiny change-makers in your life, there's nothing like a progressive grassroots alphabet book. “F” is for "Fair pay." “P” is for "Power to the People." Nagara's words and illustrations offer activists of any age a reminder of the great (and many) tools in our belt.

 

Justin Mendoza’s picks

Washingtonpost.com/news/wonk, thelancet.com, and thehill.com

When you're trying to advocate, it's really important to keep an eye on relevant political happenings. For me, that usually means checking the Wonk blog, which offers expert opinions from a ton of different folks. The Hill is also important, especially for insights on seemingly mundane things, such as congressional floor votes, that can shape the timing of advocacy campaigns. The Lancet, a weekly medical journal, is one of my favorite places for global health policy. Their opinion pieces are written by leaders in the field and address the issues that matter most.

Nudge: Improving Decisions about Health, Wealth, and Happiness, by Richard Thaler and Cass Sunstein

This book is an awesome introduction to behavioral economics, the way we make decisions about our lives and what's important to us. Written for a general audience by a pair of distinguished professors, it makes me think carefully about how to present choices, opportunities, and messaging to the people I organize. Think of it as Freakonomics with a policy agenda.

 

Adarsh Shah’s picks

Organizing For Social Change, by Kimberley Bobo and Steve Max

The 4th edition of this hefty tome is the most comprehensive grassroots advocacy resource I have come across. Essentially a textbook, it walks any aspiring organizer through crucial theory and skills, from power mapping to building coalitions, generating community power to pressuring officials. If you are looking for a place to start a deep and intellectually informed engagement with community organizing, this is the place to start.

Results.org/skills_center/resources

RESULTS, an advocacy organization focused on poverty reduction, has created lots of really excellent material. And unlike other toolkits and trainings, RESULTS’ “Meeting Face-to-Face with Members of Congress” or “Advocacy at Town Halls and Public Events” are action-focused and based on many years of experience in both domestic and international issues. Whatever you are passionate about, these resources can get you started on the road to, well, results.

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Mon, 09 Jan 2017 16:30:10 -0500 https://www.pih.org//article/community-organizers-recommend-the-best-books-podcasts-and-websites-for-cha
Together, We are Partners In Health https://www.pih.org//article/together-we-are-partners-in-health

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Fri, 23 Dec 2016 14:03:35 -0500 https://www.pih.org//article/together-we-are-partners-in-health
Haiti's New Pathology Lab Accelerates Cancer Diagnosis https://www.pih.org//article/haitis-new-pathology-lab-accelerates-cancer-diagnosis Inside a whitewashed room the size of a generous walk-in closet, three Partners In Health laboratory technicians and a pathologist meticulously slice tissue samples and embed them in paraffin. They are the first employees to christen the new pathology section in the Mirebalais Regional Reference Laboratory.

To outside observers, their work may seem tedious. But to cancer patients, it’s lifesaving.

The paraffin cassettes are no larger than a stick of gum and travel easily to Boston, where volunteer pathologists analyze them and send their diagnoses to PIH oncology staff at the University Hospital in Mirebalais, Haiti. Before the pathology section opened in October, patients waited 90 days for a diagnosis. Now, they get one in 20.

“It’s a paradigm shift having pathology services outside of Port-au-Prince and, soon, being able to do all processing of biopsies onsite,” says Daniel Orozco, PIH’s director of laboratory services.

Pathology is the first section to open in the two-story, 15,800-square-foot regional reference laboratory. The facility—built in partnership with Build Health International, a Massachusetts-based construction company, and Haiti’s Ministry of Public Health and Population—will eventually house sections devoted to parasitology, chemistry, immunoserology, hematology, and both medium- and high-level containment labs (BSL-2 and BSL-3) for microbiology and mycobacteriology.

Patients aren’t the only ones benefitting from the new lab; staff with Zanmi Lasante, as PIH is known in Haiti, have gained specialized skills and learned to use state-of-the-art technology.

“I love the new intellectual challenge,” says Myrléne Mompremier, who used to work as a general lab tech in PIH’s clinic in Boucan Carré. Now, she takes pride in her promotion to histopathology technician.

Opening the pathology section first was essential given the number of oncology-related biopsies University Hospital surgeons perform. There were almost 2,000 last year alone, most of them for breast cancer.

Biopsies used to go directly to PIH’s partner institutions, including Brigham & Women’s Hospital, the Dana Farber Cancer Institute, and Newton-Wellesley Hospital. Now, instead of traveling 1,600 miles from Mirebalais to Boston, tissue samples are walked 100 yards across campus from University Hospital to the regional reference laboratory. PIH pathologist Dr. Fabienne Anglade and her three technicians, each of which had several weeks of on-the-job training from visiting Boston pathology technicians, receive the samples in their new workspace.

PIH pathologist Dr. Fabienne Anglade (center-left) trains histopathology technicians Chantalé Bellévue (from left), Myrléne Mompremier, and Lagrénade, who came from different PIH labs to work in the new pathology section. (Photo by Lauren Greenberg / Partners In Health)

Together, they process 100 tissue samples every month from University Hospital’s surgery and oncology departments. Each specimen arrives with a label bearing the patient’s name, age, and file number. The tissue is sliced and separated according to doctor’s orders, then embedded in paraffin within one of three processing machines in an adjoining room.

“Surgery is all about timing,” says Dr. Michelson Padovany, a University Hospital surgeon who specializes in oncology. “With the pathology lab, we can reduce the time to have results and give better care. You can also do more surgeries.” As many as 2,000 more, he estimates.

Chantalé Bellévue, one of the histopathology technicians, is proud to help provide cancer patients with quicker diagnoses.

So is her colleague Prophete Lagrénade. “With this new service, we will contribute to improving the quality of life and economic condition of our patients,” he says. Like Bellévue, he worked in a University Hospital general laboratory before transferring to the new facility.

Next year, Orozco hopes to have an imaging system installed so technicians can email digital snapshots of prepared samples to Boston for diagnosis, cutting wait time even further. It’s no far-fetched dream. PIH is already doing the same in Rwanda.

Meanwhile, other areas of the research lab receive final touches. Down the hall from the pathology section, Orozco prepares for the opening of the high-level containment (BSL-3) laboratory, which will be used to study and diagnose airborne infectious diseases, such as tuberculosis. He points around an empty suite that will soon be filled with ventilation hoods, automated instruments, lab benches, and other accoutrement necessary for the high-tech facility—all donated by the U.S. Centers for Disease Control and Prevention.

Once this section opens in spring 2017, it will be the only BSL-3 lab outside of Port-au-Prince, and one of few in the Caribbean focused on diagnosing tuberculosis and multidrug-resistant TB. 

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Fri, 23 Dec 2016 11:27:51 -0500 https://www.pih.org//article/haitis-new-pathology-lab-accelerates-cancer-diagnosis