Partners In Health Articles New Yorker’s Ariel Levy Reflects on Ophelia Dahl, and Optimism as a “Moral Choice” The New Yorker staff writer Ariel Levy has an intimate understanding of pregnancy and loss. On her second day of a trip to Mongolia in 2013, she went into premature labor in her hotel bathroom and delivered her 5-month-old son, who died within 24 hours.

She wrote about the experience later that year in an article for The New Yorker, “Thanksgiving in Mongolia.” She then expanded the story into her New York Times bestselling memoir, "The Rules Do Not Apply," which published in March 2017.

By that time, Levy had spent nearly four years mulling over the delicate balance of life and death as it relates to pregnancy. Partners In Health has worked for decades to improve that balance and to make childbirth much safer in some of the world's poorest places. When the opportunity arose for Levy to profile Ophelia Dahl, a personal friend and PIH co-founder, she didn’t hesitate.

Last October, Levy traveled with Dahl to Sierra Leone. The country choice was intentional; the West African nation has one of the worst maternal mortality rates in the world, with 1 in 17 women dying in pregnancy or childbirth. Levy wanted to explore PIH’s work, Dahl’s role in shaping it, and the other side of her personal tragedy—what happens when a mother dies in childbirth.

That profile, "Ophelia Dahl's National Health Service," appeared in The New Yorker in December.

Levy recently answered questions from PIH staff about her travels, aspects of her Dahl profile she chose not to include, and her take on the importance of universal health care.

You’ve traveled a lot, including to poor countries. How was Sierra Leone unique? What struck you?

I had never been to a country before in which almost half the hospitals operate—insofar as they can—without the benefit of electricity or running water. I mean, that still blows my mind. If you're having an emergency, you think, "If I can just make it to the hospital, I'll be OK." But in Sierra Leone, because of the condition of the roads and the rarity of a working, gassed-up vehicle, making it to the hospital is no small project. And once you get there, there's a real limit to what can be done without basic functioning utilities. 

You have written about your personal experience in Mongolia and the realities of what care is like in developing countries. How did that shape your reporting in Sierra Leone, which has one of the highest maternal mortality rates in the world?

So that was my initial point of connection with this story: I lost a baby, which seemed to me like a tragedy; it felt to me like a crime against nature at the time. When I heard that 1 in 17 women died in Sierra Leone during pregnancy or birth or its immediate aftermath, I was struck (and that's the right word: I did actually feel struck) by what a radically—horrifically—different reality that is. In America, you get pregnant, and somewhere in your mind you are aware that the worst thing that could happen is that your baby might die. In Sierra Leone, you get pregnant, and you are aware that YOU might die. 

What intrigued you about Ophelia? How did your personal relationship and past experiences with PIH inform your conversation and subsequent writing of the piece?

Well, like every other kid, I loved Roald Dahl's work growing up. The thought that in one story I could consider the way his imagination shaped this person, Ophelia, whose own imagination, in turn, shaped an organization that has saved and improved the lives of millions of people all over the world, I just thought that could be pretty cool. And you put that together with the history of Sierra Leone, and the Ebola crisis, and the life-and-death struggle of mothers and babies...I mean, all I can say is, “Sheesh!"

Were there any moments from the trip that stood out to you, but didn’t make it into the piece?

I met a woman at Koidu Government Hospital (in eastern Sierra Leone) who had just lost a baby because of a placental abruption, which is exactly how I lost a baby. She had to lay there in the recovery area with several other women who had just given birth, who were holding their living infants in their arms. I found that very close to unbearable. She did not seem any less devastated than I was when that happened. But when that happened to me, everybody asked, "Did they figure out what went wrong?" People aren't going to ask her that. She doesn't live in a society where people have the luxury of expecting things will work out the way they want them to. 

PIH takes pride in doing whatever is possible for patients. Yet, there are always people who say what we’re proposing can’t be done. What gives you hope, if anything, that social justice solutions like universal health care are possible?

Ophelia told me that pessimism is the worst possible expression of privilege. Because then you're basically writing off millions of people who simply can't afford to think that way: they can't look at the statistics and conclude, "You know, it doesn't look so good for my family. I think we'll just give up." I try to hang on to that idea when I feel hopeless, that optimism is a moral choice. That the alternative is a failure of not just empathy, but imagination. 

Thu, 07 Jun 2018 22:08:58 -0400
Ophelia Dahl Writes for WBUR on How to Reduce Maternal Mortality Worldwide Partners In Health Co-founder Ophelia Dahl recently wrote for WBUR’s Cognoscenti, the Boston-based public radio station’s opinion page, about the need to reduce maternal mortality in countries like Sierra Leone, where 1 in 17 women die in pregnancy and childbirth. For comparison, the rate is 1 in 3,800 in the United States.

“The reason why some women die in childbirth and others don’t has nothing to do with biology or culture, and everything to do with apathy,” she wrote.

“We have the tools to reduce maternal mortality, to stop what my colleagues would call ‘stupid deaths,’ especially in poor countries like Sierra Leone.”

In her article, Dahl leans on PIH’s example to explore what is needed to reinforce a health care system so that women don’t have to fear pregnancy and childbirth. Those lessons can be applied from the poorest to the richest nations in the world—from Sierra Leone to the United States.

Read Dahl’s entire article here.

Tue, 05 Jun 2018 15:38:44 -0400
Inspiring Interview with Dr. Paul Farmer in The Harvard Gazette To coincide with the class of 2018’s graduation this month, the official news outlet for the university spoke with Professor and Partners in Health Co-founder Dr. Paul Farmer. After a flattering introduction, the interviewer got right to it.

Q: Do you still love what you do?

A: Oh yeah, more than ever. I love the work I get to do and the chance to see patients in radically different settings. Some people would find the travel part of it unsettling. I just came back from Delhi, Mumbai, and West Africa via Texas. It was great to talk to college students in Texas, where I was predictably asked, “How do you avoid burnout?”

Q: It’s a good question.

A: The students always ask it. I said, “You know, I compare myself to my classmates from med school, Class of ’88. I’m at less risk than any of them for burning out.”

You’ve got to do what you really like. I’d like to see all of my own students here be happy and productive, and know from teaching here and elsewhere that this requires a great diversity of opportunities and experience.


The rest of Farmer’s humble, candid, and uplifting interview can be read here.

Wed, 23 May 2018 14:21:07 -0400
Global Views, Local Ideas: Lab Leaders Collaborate at Annual Workshop Laboratory Director Roger Calderon needed more space to support tuberculosis work in Lima, Peru, so he led design and construction of a new lab made from a shipping container. Four people can work in the 400-square-foot facility, which has centrifuges, freezers and a customized ventilation system that recirculates the air 27 times an hour.

Lab Manager Mokenyakenya Matoko needed a better way to manage information at Botšabelo Hospital in Maseru, Lesotho, so last November he implemented a system that tracks samples, ensures patient data is backed up and enables staff to process stocks electronically, rather than on paper.

Fabienne Anglade, a pathologist and interim lab director in University Hospital in Mirebalais, Haiti, needed a faster way to get analytic results for samples and specimens. So she streamlined the analysis process, reducing the turnaround time by 10 days in just six months and enabling express results for emergency cases.

The three innovators recently shared those experiences, and many others, with nine of their fellow laboratory leaders from Partners In Health sites, at the second annual PIH Lab Workshop and Training. The weeklong event was held in Boston in March.

Goals of the event included sharing expertise, standardizing lab practices, building a cross-site support network, implementing new policies and lab tools, and more. Daniel Orozco, director of laboratory services for PIH, said the workshop also was a time to step away from the microscope, and look at the bigger picture.

Test Results
(Left to right) PIH lab leaders Damson Kasawa from Malawi, Francis Kioko Mutisya from Liberia, Gaspard Muvugabigwi from Rwanda, Rupal Ramesh Shah from Haiti, Musa Bangura from Sierra Leone, and Florance Joseph from Haiti read results from sample-testing equipment during a weeklong lab workshop and training in Boston.
Daniel Orozco, Directory of Laboratory Services, speaks with Valeria Macias, Secondary and Tertiary Care Director in Mexico.
Daniel Orozco, PIH director of laboratory services, speaks with Valeria Macias, director of secondary and tertiary care for Compañeros en Salud, as PIH is known in Mexico.

“It’s a very technical job, and it’s very easy to get immersed in lab work,” Orozco said. “Sometimes, we don’t stop to think about why diagnostics matter.”

PIH supports more than 20 laboratories across eight sites. Some are home to more basic diagnostic capacity; others are designed to focus on a single disease, such as tuberculosis. While some sites, like Sierra Leone, have had lab facilities for only a few years, others, like Haiti, have had such capabilities for decades. Laboratory expertise and technology also vary across sites, depending on whether staff are catering to a small clinic or a large referral hospital.

Challenges like machine failure can vary, as well—and sometimes occur even at newer facilities like University Hospital, despite specialized technologies. Orozco said new, highly specialized equipment needs to be incorporated into lab environments with appropriate levels of planning, training and support.

Those necessities are not always there.  

“Our lab staff work under very difficult circumstances,” Orozco said. “Sometimes there is no electricity. Sometimes there is no water.”

And amid all of that, he added, lab work generally gets much less attention in medical circles than highly touted vaccines or drugs. But even the best medicines are worthless without accurate diagnoses and research, which can involve not only short-term symptoms but also long-term analysis, as lab technicians follow the course of a disease over months or years.

“Without diagnostics, medicine is blind,” Orozco said, quoting Alain Merieux, president of the Merieux Foundation, which supports laboratory networks and the fight against infectious disease in developing countries.

PIH held its inaugural lab workshop a year ago in Toulouse, France. This year’s Boston location meant a first trip to the U.S. for Zhanel Zhantuarova, a lab quality officer in Kazakhstan.

Taking a break from a training on a blood sample machine at Harvard Medical School, Zhantuarova said “interesting” didn’t even begin to describe her week.

“The only problem is that it goes too fast,” she said. “They need to slow down the time.”

Zhantuarova said being in Boston enabled her to work in person with other Kazakhstan team members; meet PIH Co-founder and Chief Strategist Dr. Paul Farmer for the first time; and even take in a screening of “Bending the Arc,” the 2017 documentary that tells the story of PIH’s evolution from a small village in Haiti three decades ago, to an organization working in some of the poorest settings around the world.

Musa Bangura, Laboratory Manager in Sierra Leone, presents before PIH co-founder Dr. Paul Farmer participates in a roundtable discussion with PIH lab staff visiting Boston from nine different  countries.
Musa Bangura, laboratory manager for PIH in Sierra Leone, presents recent work by his team to PIH Co-founder and Chief Strategist Dr. Paul Farmer, shortly before Farmer participated in a roundtable discussion with PIH lab staff visiting Boston from nine countries.

“I was so moved,” she said of the film.

Zhantuarova also said she had talked at length about clinical trials and other topics with Calderon, who has more than 20 years of experience with Socios En Salud, as PIH is known in Peru. The interaction was invaluable.

“He gave me his card and told me to contact him whenever I have questions,” she said.

PIH CEO Dr. Gary Gottlieb said PIH’s lab teams exemplify, “the very best of accompaniment and direct work on the ground,” with results that are vital to PIH’s success.

“A broad array of trustworthy lab data is critical to diagnostic precision," he said. "Excellent labs allow our clinicians to treat all of our patients more rapidly and more effectively, with the right medicines and treatments.”

“This team is as critical as any component in the delivery of care that we have."

Thu, 17 May 2018 16:17:02 -0400
‘Mountain Kingdom’ of Lesotho Making Huge Strides with Health Reform Every three months or so, Atlehang Seisa saddles up.

The lead nurse at Mapheleng Health Center in a bucolic corner of Lesotho, Seisa joins a small team of doctors on quarterly trips by horseback, to villages over the hills. The team stays at the remote villages for a week at a time, providing health services ranging from HIV testing to outpatient care. Some of the staff come from Mapheleng, which is supported by Partners In Health (PIH), and others come from Maluti Adventist, the only hospital in the region. They provide all the care they can over each weeklong stay, because they won’t be able to come back for months.  

Mapheleng, itself, is not easy to reach. From the nearest paved road, the health center lies at the bottom of a long, rutted dirt road that winds down steep, green hillsides and is crossed by several creeks. The views of broad valleys sweeping toward mountains on the horizon are jaw-dropping. Traversing those mountains on horseback seems incredible.

But on a February day at Mapheleng, during late summer in Lesotho and across southern Africa, the arduous rides are the last thing Seisa mentions. He has other concerns. The health center serves about 6,200 people across 28 villages, including those reached by horse. Difficulties are many. Sometimes, for example, Mapheleng has power shortages when its solar panels lose their charge after a couple of cloudy days.

“We don’t have a way to store power,” Seisa said. “It can be quite a challenge in the winter.”

 Atlehang Seisa
 Atlehang Seisa is lead nurse at Mapheleng Health Center, which serves about 6,200 people across 28 villages in a beautiful, remote region of Berea District. Some of the communities are so isolated that Seisa joins a team of doctors to reach them by horseback, on weeklong trips about four times a year. 

But on this particular day, the sun is shining, the lights are on and the chatter is loud. Several families wait for outpatient services in a central reception room. Just outside the front entrance, expectant mothers talk with village health workers (VHWs), who live in surrounding communities and help their neighbors access health services and maintain treatment.

It’s a scene replicated at 72 health centers in Lesotho, where a sweeping health reform has brought about transformative change in just four years. The reform is combating some of the world’s highest rates of HIV and TB, vastly improving maternal and child health, and reshaping how care is delivered, from mountain villages to urban centers.

And it’s finding resourceful ways to meet challenges, such as supplying delivery packs to health centers so inconsistent supplies of electricitysuch as Mapheleng’sdon’t prevent pregnant mothers from having sterile, safe environments for childbirth.

Partners In Health (PIH), known locally as Bo-mphato Litsebeletsong Tsa Bophelo, is supporting the reform as the primary technical advisor to Lesotho’s Ministry of Health.

The goal is to scale the reform nationally, from four pilot districts to all 10 districts across the country, blazing a trail toward universal health coverage in the vibrant, largely agricultural, and stunningly beautiful land known as the Mountain Kingdom.


Over two weeks in February, a whirlwind tour of PIH’s work in Lesotho included visits to patients’ homes and rural health centers like Mapheleng; conversations with HIV patients, VHWs and new mothers who were able to deliver their babies safely; and even a meeting in the highest halls of government, with Lesotho’s prime minister.

The firsthand look at the reformconducted by PIH staff, for this reportrevealed remarkable innovation, dedication and achievements, along with daunting challenges brought by rapid growth in patient demand and limited resources.

But above all, one thing was clear: Lesotho is building a health system that could become a model for impoverished countries around the world.  

“We hope this reform will encapsulate PIH’s global approach for actualizing universal health coverage,” said Dr. Abera Leta, executive director of PIH in Lesotho. “But we are far away from reaching the universal health coverage target, and that is where we need to fill the gap. We still have to go a long way to really reach many segments of the population.”


Ebb and flow

The 72 health centers involved in the reform and their surrounding “catchment areas”—meaning, the populations they serve—reach about 40 percent of Lesotho’s 2.1 million people, the Basotho.

Their home is a high-altitude country that’s about one-fourth the size of the American state of Pennsylvania and entirely surrounded by South Africa. All 10 of Lesotho’s districts touch some part of the border.  

Many Basotho cross that border frequently. Unemployment is high in Lesotho, and better luck for mining, trucking, construction and manufacturing jobs can be found in South Africa. As a result, many adults, particularly men, stay in South Africa and work for weeks or months at a time, returning only sporadically to their families and homes in Lesotho.

Mpho Phoofolo, for example, said her husband works in construction in South Africa, and sometimes returns only twice a year to their one-room home in the Berea District village of Ha Matoeba.

Mpho Phoofolo
Mpho Phoofolo, 27, receives free postnatal care for her newborn daughter, Itumeleng, and her 5-year-old son Katleho (not shown) at nearby Mapheleng Health Center. The center is about a 10-minute walk from Phoofolo's home, where she sat with Itumeleng on a sunny day in February. 

Phoofolo, 27, held her newborn daughter, Itumeleng, as she talked about her family. Phoofolo is HIV-positive and has been on antiretroviral therapy, or ART, for five years. She gets treatment, as well as services for Itumeleng and her 5-year-old son, Katleho, at Mapheleng. The health center is about a 10-minute walk from Phoofolo’s home, meaning Seisa can get there with no need of a saddle.    

A green bag containing Phoofolo’s medicines sat atop a pile of clothing beside her bed as she held Itumeleng. Outside, Phoofolo’s mother, Mamoletsane Phoofolo, stirred a soft porridge called “lesheleshele” in a covered pot over a bed of smoldering ashes. She lives nearby, and Phoofolo said neighbors often help out, too, by fetching water for her family. She didn’t know when her husband would return home.

Border crossings dot the region and usually are busiest in the capital, Maseru, which lies in a west-central part of the country known as the lowlands.

Traveling north from the capital, a two-lane highway passes through three reform districts in a row: Berea, then Leribe, and then Butha-Buthe, moving progressively northeast and gaining altitude, from the lowlands into the highlands.

To the south of all those regions lies Mohale’s Hoek, the fourth pilot district for the reform. The district’s mountainous topography and large population of transitory miners contribute to high rates of HIV and TB. Weakened immune systems and airborne diseases like TB can thrive in crowded, poorly ventilated conditions such as mines. Workers who contract HIV or TB in mines, or infidelity while away from home, are prone to bringing the diseases back to their families and communities.

Dr. Mahlape Tiiti, district health manager for Mohale’s Hoek, said about 29 percent of the district’s 170,000 people have HIV, the worst rate in Lesotho.

Nationwide, about 25 percent of Lesotho’s adult population has HIV. That percentage is the second-highest in the world, behind only the nearby Kingdom of eSwatini, which was called Swaziland before a name change in April.

Tiiti said people who live two hours or more from health services—common in Mohale’s Hoek, and many parts of Lesotho—are less likely to be tested for HIV, or to consistently access treatment.

The Ministry of Health and PIH are working to change that from the ground up, by building a strong primary health care platform, decentralizing care and improving district management, staffing, systems and supplies.

Dr. Afom Andom, PIH’s lead technical advisor for the reform, said PIH’s role also includes funding a primary health care coordinator in each of the four districts, along with one pharmacist and one data clerk per district, to improve communication channels, medicine distribution and medical record-keeping.

Village health worker coordinator Daniel Masupha carries records through Mapheleng Health Centre in Berea District, Lesotho.
Daniel Masupha, village health worker coordinator at Mapheleng Health Center in Berea District, keeps meticulous records of the center's tuberculosis patients, recording their screenings, symptoms, treatment and results. Here, he holds some of the red, well-worn notebooks he's filled with his documentation. 

Tiiti said the increased structure and communication is paying off.

“I think one thing that the reform has done is establishing district health management teams, which oversee all the health issues in the districts,” she said. “Initially, there was separation of services. The hospital was on its own, the district management team was on its own…there was really no connection. Each entity had its own separate management.

“But the reform has combined them together, and I think that has benefited us a lot,” Tiiti continued. “Because now, communication and working relations are much better. Because each department is represented on the management team, the job is much easier.”

The work is yielding clear results.

The number of people receiving HIV testing in the reform’s four pilot districts, for example, has more than quintupled, rising from 61,560 people tested in 2013 to 327,617 four years later.

Correspondingly, more testing has meant more treatment: The number of HIV patients enrolled on ART has more than doubled, from 7,364 in 2013 to 15,324 in 2017.

 Dr. Patrick Mkondanyirazo examines Mokone Tukiso, who started ART in December 2016. He was admitted to Botsabelo MDR-TB hospital the week before.
Dr. Patrick Mkondanyirazo examines multidrug-resistant tuberculosis (MDR-TB) patient Mokone Tukiso, who also has taken antiretroviral therapy for HIV since December 2016. He was admitted to Botsabelo Hospital in Maseru, for MDR-TB treatment, a week before this photo in February.

And, crucially, more than 90 percent of all people diagnosed with HIV now are receiving sustained treatment.

Dr. Nyane Letsie, director-general for the Ministry of Health, said those impacts show why Lesotho’s health reform must continue moving forward.

“We don’t have any option except to roll out the reform—and this will save many, many, many more lives,” Letsie said in February, at a meeting with ministry leaders and PIH staff in Maseru. “Our dream is to make sure the approach now is standard, and all the districts are able to maintain a high quality of care.”


Safe deliveries

The reform has made maintaining a high quality of care an emerging challenge for facilities such as St. Peter’s Health Center, where demand for services is rising.

Situated on the side of a mountain in the rural, highland district of Butha-Buthe, near Lesotho’s northern edge, the small St. Peter’s campus is overflowing. The health center serves more than 8,200 people, from 43 villages across the region. Many of those people travel for hours to reach St. Peter’s, crossing rivers and climbing mountains, most often on foot. Staff treat patients for HIV, tuberculosis, diabetes and more, while providing services ranging from child immunizations to prenatal and postnatal care, deliveries and general checkups.

They do all of that with limited resources, and very limited space.  

Masefako Ntjabane Liotlo, manager and lead nurse at St. Peter’s, said the health center’s on-site staffing includes two nurse assistants, four midwives and five counselors.     

Masefako Ntjabane Liotlo (standing, right), manager and lead nurse at St. Peter’s Health Center in Butha-Buthe District, talks with patients outside of the facility, which serves more than 8,200 people from 43 villages across the rugged, mountainous region. 
Masefako Ntjabane Liotlo, manager and lead nurse at St. Peterís Health Center in Butha-Buthe, Lesotho, examines 28-year-old Maletuka Motobe
Masefako Ntjabane Liotlo examines 28-year-old Maletuka Motobe. A mother of three, Motobe came to St. Peter's because of stomach problems.

Their facilities include a main building surrounded by several smaller, one- or two-room buildings, on a sloped site with little room for expansion.

Mpai Rutsoa, the primary health care coordinator for Butha-Buthe District and a professional nurse, said the tight conditions at St. Peter’s likely are a result of the center’s initial design, which predates the reform. St. Peter’s was built to provide one or two services, she said, rather than the many services now offered there.

“It’s kind of a supermarket approach,” Rutsoa said. “So, they have to be creative, to manage their space.”  

The cramped quarters can lead to difficult choices. Liotlo said the health center offers services for children younger than 5 only on Thursdays, while cervical cancer screenings are offered on Mondays, Wednesdays and Fridays.  

Blood draws for HIV patients also occur only on Thursdays, in a room otherwise designated for postnatal care. That means trays of samples sometimes sit on beds where, at other times, women rest after giving birth.

Liotlo, a short-haired, bespectacled woman who exudes steadiness and experience, would prefer that all those services were provided daily, and that she had a large space dedicated solely to maternal and child care.

Offering services for young children just once a week, she said, “means that some of them, we miss them.”

On a sunny Thursday morning in February, several women sat outside the front entrance and talked while their children played nearby. Litsoanelo Rosalia Lerapa said she had been at St. Peter’s since 8 a.m., after walking an hour while carrying her 2-year-old son, Mokhomotsi. As midday neared, she still was waiting for his checkup. 

But Lerapa, 22, said the free services she and her son receive at St. Peter’s are invaluable. She stayed in the health center’s maternal waiting home for about a month before giving birth to Mokhomotsi, because nurses said he might come early and she needed to be near the St. Peter’s delivery room when labor began.

Litsoanelo Rosalia Lerapa, 22, stayed for about a month in the maternal waiting home at St. Peter's before giving birth to her son Mokhomotsi, a healthy and active 2-year-old. Lerapa said she walked for about an hour to reach St. Peter's on this February day, so Mokhomotsi could get a checkup. He is her first child. 

Mokhomotsi, about 2 years and 7 months old that February day, was healthy and active, and ran around the health center in Superman sandals.   

There are just two beds, and one small bathroom, in the maternal waiting home where Lerapa stayed. A mattress often is placed on the floor between the beds, for a third mother. Demand has risen so much that when the waiting home is full, some expectant mothers sleep in other buildings at St. Peter’s.

Liotlo said the number of deliveries at the health center has risen dramatically since the reform began, from 12 in 2014 to 82 in 2015, 97 in 2016, and 89 last year.

A key aspect of Lesotho’s national health reform is encouraging and enabling expectant mothers to deliver their babies in a health facility. Facility-based deliveries are much safer than delivering at home, where—should complications arise—there is no access to medication, a blood bank, or trained professionals to perform emergency cesarean sections.  

As the reform enters its fifth year, the number of facility-based deliveries across four pilot districts has doubled, from 6,012 in 2013 to 12,109 in 2017.

That increase has a clear driver: Before the reform, just 2 percent of the 72 health centers in those districts were providing facility-based deliveries.

That number now has reached 95 percent, and every one of those health centers now has a maternal waiting home. If complications arise, PIH funds transportation to the nearest hospital.


Home by home

St. Peter’s reach extends far beyond its busy campus.

Based at the health center are 68 village health workers, or VHWs, who go door to door, and family to family, to ensure every need is met in the area. VHWs across Lesotho’s reform districts monitor patients’ treatment, help them keep up with medicines and refer them to health facilities when needed, often providing free transportation.

“We are nothing without VHWs,” said Jeannett Letsoso, lead nurse at Pontmain Health Center in Leribe District, just south of Butha-Buthe. “Without them, we are doomed.”

As part of its role in the reform, PIH has installed a VHW coordinator at each of the 72 health centers across the four pilot districts, to improve management and structure of the VHW system. VHW supervisors are just below the coordinator level, adding another layer of local oversight.

Mathato olele, 38, is a VHW supervisor at Pontmain. The health center sits atop a large hill in a big-sky part of Leribe with wide open spaces and vast tracts of farmland, where cornfields often stretch to the horizon and villages can span huge areas. Pontmain serves about 8,200 people across 52 villages, a catchment area very similar to St. Peter’s further north, and has 116 VHWs. 

Umbrellas and hats provide shade on a bright day at Pontmain Health Center in Leribe District, where hills and cornfields abound. 

olele oversees 11 of those VHWs. They serve 670 households across five villages, including her own village of Lumela.

“Lumela” also is the customary greeting in Lesotho’s language of Sesotho. The first “l” in the greeting is pronounced as a “d” sound, as in, “doo-meh-lah.”     

Additionally, “Sotho,” in all its uses, is pronounced “sue-too,” as in “Luh-sue-too,” for the name of the country. 

olele said she has been a VHW since the reform began, in 2014. Pontmain administrators notified the chief in her area that a VHW was needed, so the chief held a public gathering, where olele’s neighbors elected her to serve them. That elective practice is common with VHWs across the reform districts.

olele, wearing a white-and-blue Pontmain Health Center hat and matching Converse sneakers, spoke in Sesotho as public health nurse Keneyoe Kali translated to English.

One of her most memorable patients, she said, is a 62-year-old woman who had a relapse of TB and needed daily injections in her posterior. The patient, olele said with a rueful smile, was not very happy about treatment.

The woman lived in Lumela village, but far enough away to make it a substantial daily trip for olele. She complained every time she saw olele approach, grumpily resisting the injections.

But olele persisted, visiting her patient for 56 straight days. The woman recovered, and became free of TB after a lengthy battle with the disease.

Now the two chat happily whenever they see each other, olele said, and have become lasting friends.

olele’s dedication is one example of why treatment for TB, the world’s deadliest infectious disease, is seeing broad success from the reform.

Mathato Tšolele, 38, is a village health worker supervisor at Pontmain Health Center in Leribe District. She supervises 11 VHWs, who collectively serve 670 households across five villages, including Tšolele's own village, Lumela. Her neighbors and fellow residents elected her in 2014 to serve them as a village health worker.

While 108 people in the four pilot districts were cured of the airborne disease in 2013, 833 were cured in 2017.

That’s a sea change in Lesotho, which had the world’s highest TB incidence rate as recently as 2014. Data from the World Health Organization (WHO) showed that in that year, when the reform began, Lesotho had a TB rate of 852 people per 100,000.

The latest WHO data, from 2016, shows that Lesotho’s TB incidence rate has fallen to 724 people per 100,000. That rate is the world’s second-highest, behind South Africa.

The same outreach that is improving TB care is having similar effects on maternal health in the area around Pontmain. Letsoso, the health center’s lead nurse, said Pontmain now is conducting about 20 deliveries a month, compared to none before the reform. Staff also are seeing more pregnant women in their first trimester, leading to greater successes with prenatal care.

“Since the reform, we’ve had much fewer maternal deaths,” Monica Mpala, primary health care coordinator for Leribe District, said while holding the grab handle above the passenger seat of a truck bouncing along the road to Pontmain. “The reform is like a wake-up call for everyone.”


‘Success challenges’

Dr. Abera Leta, PIH’s executive director in Lesotho, said that while the national reform is facing challenges, they primarily are “success challenges” from the rapid growth in services.

“When people start to access care, you have to provide a lot of supply,” Leta said. “When you compare where we were to where we are, it is quite a change.”

PIH is doing everything it can to meet that demand.

Gottlieb visit
PIH CEO Dr. Gary Gottlieb, left, visits with MDR-TB patients at the Malaeneng temporary home in Maseru. He is accompanied by RN Tseko Motsela, PIH Lesotho Executive Director Dr. Abera Leta, and Director of Community Health Likhapha Ntlamelle. 

“Every day, we receive a lot of calls, emails and visitors,” he said. “We deal with all of them, to make sure the caller gets what we can offer, and what the system can offer. Whatever is happening, we want to help them. We want to deliver on our promise.”

PIH CEO Dr. Gary Gottlieb was on hand for the staff meeting, and applauded the achievements of all those assembled.

“You all have been extraordinarily flexible and innovative,” Gottlieb told the room. “You are truly a blessing, to this country and to PIH. Lesotho is becoming a world-class story in transformation.”

That transformation goes far beyond the data and numbers. The impacts are societal.

Dr. Letsie, the Ministry of Health director-general who has been a leader in the ministry’s collaboration with PIH, said at Motebang Hospital, in Leribe District, that the reform was stabilizing health services across the entire region.

She told Ministry of Health, PIH and district health leaders that patients who previously had flooded Motebang from outlying areas and neighboring districts were now, instead, accessing services at health centers near their homes. She said that change was easing the burden on the hospital and its staff, and spreading care to communities that, before the reform, had none.

The trend also was changing health data across several districts, Letsie said, in ways that couldn’t yet be analyzed in isolation, and would only truly unfold in months and years ahead.

Additionally, Letsie said, the reform’s increased support and structures were proving that local health centers can retain local doctors, which is empowering them and reinforcing community support for health care.

As more and more people saw their family members, friends and neighbors receiving high-quality care, overall trust in local health systemsand thereby, use of those systemswas increasing.

“What the reform has brought is that we have changed our district and local structures,” she said. “This is bringing big changes to communities, and to people’s lives.”

Village health worker Mamakalo Mohatle leaves Lesotho's Mapheleng Health Centre with three new mothers.
Village health worker Mamakalo Mohatle, in striped shirt at right, leaves Mapheleng Health Center with three new mothers.


‘Don’t give up’

The reform’s impacts are recognized at the highest levels of Lesotho’s government.

During a visit to Lesotho in early February, Dr. Gottlieb heard strong praise from several Ministry of Health officials such as Letsie, and also was invited to speak about the reform in person with Lesotho Prime Minister Thomas Motsoahae Thabane.

The two met for a conversation of about 15 minutes on Feb. 6, in a formal seating room on the top floor of a Maseru government building used by Lesotho’s Ministry of Foreign Affairs and International Relations. The beginnings of an evening thunderstorm rumbled outside the large windows as the sky darkened, but the mood of the conversation was bright.

“I must say that over these past few years, there has been remarkable progress,” Gottlieb said to Thabane. “The reform districts have awakened.”

Gottlieb then spoke about Khabo Health Center in Leribe District, where, as at so many other health centers under the reform, maternal deaths are falling and facility-based deliveries are rising. Mother-to-child transmission of HIV also is falling, he added, helping Lesotho move toward the goal of “ridding the country of HIV.”

The ministry and PIH have placed HIV testing, counseling and ART as key priorities for the reform. The efforts are working: More than 90 percent of all people diagnosed with HIV in the four pilot districts now are receiving sustained ART.

Thabane was reflective in his remarks. The 78-year-old statesman has been through decades of political battles, of wins and losses. His career began in the mid-1980s, when he served as principal secretary for health under Lesotho’s second prime minister, Leabua Jonathan. Thabane became prime minister himself in 2012 but left power three years later, when his All Basotho Convention party lost parliamentary elections.

He returned to power, and to Lesotho, in June 2017. He had been living in South Africa in the interim.   

“We are now in a period where we should really be doing the right things,” he said to Gottlieb. “We have always had this bad name, of being ‘the dark continent,’ but it’s not dark now.”

The prime minister then added a joke.

“It’s going to be dark in an hour or two from now, but we’ll switch on the lights,” he said, gesturing at the sky outside. “But Africa as the dark continentwe don’t want it, and we don’t deserve it. 

“But the good thing is that in that process, and in the efforts that we make, there is so much goodwill and friendship internationally,” Thabane continued. “And all we have to do really is…embrace it. Embrace it for the benefit of those who are really suffering. And not because they are careless, not because they have done anything wrong, but simply because the environment around them, that they were born into, was not favorable.”

The two leaders spoke more, about political conditions, health care and, on a personal side, their shared experiences with aging. Thabane, whose head is shaven, jokingly said that he cuts his gray hair so people think he is youngerand then advised Gottlieb to do the same, spurring laughter in the room.  

Gottlieb then said that PIH is, “excited to tell the world about the progress that we’ve made here in Lesotho. To tell the people of Lesotho in any way that you think is right. To tell the world so that we can get more support and more funding to be able to move this forward, so that we can move from four districts to 10 districts, so that this platform becomes the platform for this country for a long, long time into the future.”

“Fantastic,” Thabane replied.

The prime minister then urged Gottlieb and PIH to continue with reform efforts.  

“My dear friend, don’t give up,” Thabane said. “Don’t give up. You have friends in many, many places. And you have a friend in us.”


Tue, 15 May 2018 13:45:57 -0400
A Mother, Her Twins, and an 8-Hour Ambulance Ride in Mexico Alejandra Catalina Ramirez was starting to feel big—a completely normal sentiment for a petite woman in her sixth month. This being her third pregnancy, the 29-year-old had naturally begun showing much earlier than she had with each of her two sons. But at the rate she was growing, who knew how large this baby would be after three more months?

She arrived at the clinic in Soledad, Chiapas, for her prenatal appointment in March 2017 and was greeted by three doctors working with Compañeros En Salud, as Partners In Health is known in Mexico. Dr. Ariwame Jiménez had two visitors that day from the main office in Jaltenango—Dr. Martha Arrieta, her new supervisor, and Dr. Mariana Montaño, the maternal health program coordinator.

“Looks like you’ve got two in there!” said Arrieta, who noted Ramirez’s size as she welcomed her to the clinic.

Ramirez lay down on the examining table and lifted her blouse. Arrieta methodically moved the wand of an ultrasound machine over the mother’s rounded abdomen. All at once, the room filled with the steady wub, wub, wub of a mighty little heart. The doctor swished her wand into a different position. Another wub, wub, wub echoed through the exam room.

What had started as a joke suddenly became reality: Ramirez was pregnant with twins and, she would discover in a later ultrasound, they were boys. The mother beamed and didn’t seem surprised—twins ran in her family. She couldn’t wait to return home to share the news with her 28-year-old husband, Norberto Hernandez, and their sons, 7-year-old Alexis and 4-year-old Yoiner.

For good measure, the doctors recommended that Ramirez travel to a more specialized hospital in Huixtla, where technicians could perform a more detailed ultrasound. Thankfully, she did; what she discovered helped save her and her sons’ lives.

Breaking barriers

One-third of women living in Chiapas still give birth at home, usually with the assistance of a traditional midwife, according to Mexico’s National Institute of Statistics and Geography. That number nearly doubles to 60 percent, Montaño said, in the 10 rural communities PIH supports.

Most local health centers are not equipped for deliveries, and the closest public hospital for many Chiapanecans is in Jaltenango, a good three-hour drive down rutted dirt roads cut through the Sierra Madre mountains.

These and other barriers help explain why maternal mortality in the state of Chiapas is among the highest in Mexico, with 81 deaths for every 100,000 deliveries compared to 36 in 100,000 nationwide as of 2015, the year of the most recent government data.

In an effort to save more women’s lives, PIH has been partnering with Mexico’s Ministry of Health to educate expectant mothers on the importance of delivering in a hospital, while also providing technical and culturally appropriate training to local health care professionals. Together they began operating Casa Materna, a maternal home next to the Jaltenango hospital. There, expectant mothers receive pre- and postnatal care at the hands of obstetric nurses and first-year doctors, all supported and supervised by PIH clinicians. At least 21 women have given birth at the home, and clinicians have provided 970 consultations since its doors opened in May 2017.

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

Women who live far from the hospital are encouraged to stay on hospital grounds, for free, as they approach their due date. When labor begins, they walk from the hostel to the hospital for immediate access to doctors and nursing staff. A pair of ambulances stand nearby to transport mothers to a specialized hospital one and a half hours away in Villaflores, should they need an emergency cesarean section.

Together, these measures meet the needs of most laboring mothers. But there still are rare cases, such as Ramirez’s, that test the system.

An epic voyage

Several weeks after her first visit to Soledad, Arrieta returned to supervise Jiménez. Ramirez, now about seven months along, was among the patients the two doctors saw that day. She arrived with her new ultrasound images, which the doctors pored over with growing concern. Ramirez was carrying an excessive amount of amniotic fluid—a risk factor for premature labor. They recommended she undergo a procedure that would remove some of the extra fluid.

The procedure involves a measure of risk—it sometimes causes internal bleeding that can endanger the pregnancy. But for Ramirez, there was equal risk in doing nothing. The doctors informed her that she would likely go into labor within two weeks if she and her husband decided against removing the extra fluid. In that case, they advised, she should head to Jaltenango sooner rather than later to be near the hospital.

Hernandez wasn’t thrilled with either option. He had already missed too much work while traveling with his wife for doctors’ appointments outside the community, and was thinking about their other sons back home. In the end, the couple decided to remain in Soledad and try their luck.

An early morning view of the Sierra Madre mountains in Soledad. (Photo by Cecille Joan Avila / Partners In Health)
A quiet side street near PIH's main office in Jaltenango. (Photo by Cecille Joan Avila / Partners In Health)

That luck turned sour within days of Ramirez’s last appointment. Her water broke when she was 33 weeks along, roughly two months early. Panicked, they left their sons in the care of Hernandez’s mother and hailed a taxi to Jaltenango.

Meanwhile, Montaño and a social worker based at the hospital worked their contacts to find a facility that could perform an emergency c-section and provide intensive care for premature infants, both of whom—the clinicians assumed—would require incubators. San Cristóbal was full. Comitán said no. Finally, Montaño got a green light from a hospital in Tapachula, but officials there requested that a doctor and nurse accompany the couple in the ambulance.

Arrieta, who was supervising another PIH doctor in a neighboring community, fielded the call from Montaño: Would she be able to go along for the ride? “!” came the response.

Within hours, Arrieta arrived in Jaltenango and, along with a nurse from the hospital, jumped into the back of the awaiting ambulance. Hernandez was already in the passenger seat. Ramirez lay on a gurney, losing amniotic fluid and enduring waves of early labor pains.

The anxious crew took off for the eight-hour ride south. None of them had ever traveled to the Tapachula hospital, but that didn’t matter at the moment. They would get there. They had to.

The boxy vehicle swayed back and forth over the mostly paved roads. A mountain range rose between them and their destination. Up they went, then down, navigating switchbacks along narrow two-lane highways. Arrieta stood the entire way, her legs straddled behind Ramirez’s gurney to keep it in place. She could hear Hernandez vomiting out the passenger window the entire drive.  

On the morning of April 29, the group arrived at the Tapachula hospital and wheeled the laboring mother into the emergency room. Nurses assured Arrieta that the family was in good hands. The journey had been a harrowing adrenaline rush. Now, with her task complete, Arrieta felt drained—and reluctant to let go and return home.

Ten hours later, though, Arrieta arrived back in Jaltenango, filled with a sense of despair. What if they hadn’t succeeded? What if, despite all their best efforts, the worst had happened?

But Arrieta didn’t need to worry. Montaño was there at the office, waiting with good news. Ramirez was recovering after her c-section, and both boys were alive and hooked to oxygen and feeding tubes. Gabriel had come first, weighing in at 3 lbs. 5 ozs., and Emanuel had come second, at just over 3 pounds. They wouldn’t be able to return home until they could breathe on their own and had gained a significant amount of weight.

Ramirez was discharged within days, but she and her husband had nowhere to stay. They knew no one in Tapachula, couldn’t afford housing, and needed to be near their sons for regular feedings.

So, like many families of the hospital’s in-patients, the couple slept outside. They accepted food and café con leche from a local order of nuns who visited daily. They called home regularly to check on their older sons. And they tried their best to remain patient as days spun into weeks, and their small sons grew stronger.

Ramirez knew exactly how long they had followed this routine: “One month and 10 days.” Finally, on June 4, doctors examined the twins and declared them well enough to return to Soledad. With help from PIH, the family paid for public transportation for the long ride back home.

Yoiner Hernandez, 4, slips around the corner of the family's wood-slat kitchen. (Photo by Cecille Joan Avila / Partners In Health)

Together, in Soledad

The sun dipped slowly behind the lush, coffee-growing mountains ringing Soledad, where children in school uniforms and heavily laden donkeys trudged past Ramirez’s red mud-brick home. The heat of the day was finally relenting on a late afternoon in November.

Ramirez sat on her cement stoop, her long black hair wet and tied back into a ponytail. She balanced one 5-month-old son on each knee. Gabriel and Emanuel wore caps and footie pajamas, both so plump they looked like small Stay Puft Marshmallow Men. Alexis and Yoiner were in constant orbit around their mother, who seemed completely unfazed by their questions and commotion.

One of the twins began to fuss as feeding time drew near. They both slept well, Ramirez said, but Emanuel was “more difficult” than his older brother. Months had passed since those frantic days in April, when she and her husband feared they would lose their twins.

“It was such a dangerous time,” Ramirez said. She thanked PIH for supporting her family through it all. “I don’t know what would have happened.”

The rest of her sentiment—if PIH doctors hadn’t been there—was understood.

One (mostly) happy family, from left: Alexis Hernandez, 7; Ramirez; Gabriel; Nicol Ramirez, an 8-year-old cousin; and Emanuel. (Photo by Cecille Joan Avila / Partners In Health)


Fri, 11 May 2018 12:42:56 -0400
The Ups and Downs of an Oncology Nurse in Haiti Magda Louis Juste is a woman on a mission. She may not be big in stature, and her voice might carry more squeak than roar, but there is no doubt that she commands attention when she enters a room.  

Louis Juste is among a tight-knit, highly competent group of oncology nurses at University Hospital in Mirebalais, Haiti. She has been a nurse for eight years, more than half of which have been with Zanmi Lasante, as Partners In Health is known in Haiti. 

An extrovert by nature, Louis Juste says she loves her job providing care for the dozens of cancer patients who circulate through the ward every week. But that’s just one outlet for her energy. She is currently studying to become a lawyer, advocates for prisoners’ rights in the capital of Port-au-Prince, and volunteers with a nonprofit called PUSH, which helps young Haitians hone their professional skills and improve their employability. 

In honor of International Nurses Day, Louis Juste reflected on her role in Haiti, the importance of advocating for patients, and what the next generation of nurses needs to know.

What do you like most about your job?*

People usually think nurses only give to patients; they don’t realize how much patients give to nurses. When you work with patients, especially those with cancer, they are struggling. They have socioeconomic problems that impact their lives and family, but they’re still strong and happy. That makes you strong. The patients are super heroes to me. They give me strength.

What is the relationship like between doctors and nurses?

A doctor doesn’t collaborate with nurses. They give orders, and you have to execute them.

Usually the doctor writes in a chart and says what they want you to do for each patient. Sometimes they write, ‘Give nursing care.’ I used to say to them that they should not write, ‘Give nursing care.’ I know what I have to do. That’s my job. You can write, ‘Give 20 mg Benadryl for a day.’ But tell me that I should give nursing care? It’s not acceptable. They treat nurses like maids.

But the problem is not just the doctor; it’s the system. In Haiti, there are a lot of nursing schools. A lot of them are not certified. So doctors have seen a lot of nurses who don’t really know what they are doing, and that’s why they think that nurses only give pills or injections. 

In what ways do you advocate for your patients?

When a patient comes to the hospital, and the patient is sad, you should notice that as a nurse. You’re not a psychologist, but you should have some notion of psychology to understand patients, talk to them, and refer them to a psychologist. If they are having economic or family problems, you can refer them to a social worker. 

Patients sometimes come from very far, and if they are palliative patients who have to come every week, it’s very difficult because they don’t have money for transportation. So they don’t come. Nurses then call to ask why, and patients say they don’t have money. That’s when, as a nurse, you can talk to the doctor, tell them that a particular patient lives far away, and ask them to maybe consider giving chemo to the patient every three weeks. You advocate for the patient, and the patient knows that. 

Sometimes doctors give patients medications, and the patients don’t understand what they are supposed to do. They don’t want to talk to the doctors, because they see they are in a hurry. But they know you’re more patient, you have more time for them, and they ask you to help. 

I understand nurses sometimes have too many patients. Sometimes the nurse can’t really remember a patient’s name. I think it’s very important to remember. When you do, patients feel safe and that someone cares for them. You have to call patients by their name, not Bed 1.

What advice would you give students interested in nursing in Haiti?

If they want to become a nurse, they have to work hard at school. Sometimes students think that if they’re going to nursing school, they don’t need to know anything about math, that they just need to know biology or chemistry. It’s not true. You have to learn everything. Whatever they offer at school, you take it. 

When you are searching for a nursing school, check to see that it’s certified.  Then when you are at school, you have to learn to become a very competent nurse. If you’re competent and do your job, people will respect you. 

I want nurses to be aware of their position, of their worth. They shouldn’t just give pills or execute orders. We need to have more professional development opportunities for nurses in Haiti so that they can take advantage of the broad scope of specialization within the field. We need to start to change the image of nursing here. If you are a nurse, you are competent, and you should have autonomy to do your job. 

*This interview has been edited and condensed.

Fri, 11 May 2018 10:56:15 -0400
One Mother's Fear in Lesotho: Will My Newborn Also Live With HIV? Thabo Lerata* was born at 1 p.m. on Jan. 1, 2018, the first baby of the New Year to be delivered at Holy Cross Health Center in the highland district of Mohale’s Hoek, Lesotho.

His 36-year-old mother, Mathabo Lerata,* made quite a trip to bring him into the world.  

Lerata left their home around 9 a.m. that day—while in the early stages of labor—to begin walking to Holy Cross. The trip would require crossing a broad field atop a plateau, then descending a switchbacking dirt road to the closest paved road, at the bottom of a steep slope. She carried a few belongings as the hot day began.  

January is the heart of summer in the Southern Hemisphere, and the sun can beat down heavily on the high-altitude ridges of Mohale’s Hoek, in Lesotho’s southwest. South Africa entirely surrounds Lesotho, a small, agricultural nation that proudly calls itself the Mountain Kingdom.

Partners In Health (PIH), known in Lesotho as Bo-mphato Litsebeletsong Tsa Bophelo, has worked in the country for more than 12 years. That work significantly expanded in 2014, when PIH began supporting Lesotho’s national health reform, as the primary technical advisor to the Ministry of Health. The reform’s goals include reducing child mortality and mother-to-child transmission of HIV, improving maternal health, and combating HIV and TB, of which Lesotho has some of the world’s highest prevalence rates. PIH and the ministry are piloting the reform in four districts, including Mohale’s Hoek, but the goal is to expand nationwide and ensure that all of Lesotho’s 2.2 million people have access to health care, in the most remote locations.  

On the way back to the main road from Ha Mohlekana.
The view outside the Lerata family's home, near the village of Ha Mohlekana. The Leratas walk across the field in the foreground, left to right, before turning toward the camera to reach the village, and a dirt road leading downhill to the nearest paved road.

The Leratas’ one-story home fits that description.

It would take Lerata more than an hour to reach the PIH-supported Holy Cross on New Year’s Day. Stepping out her front door, she had views all around of rugged mountains that sometimes resembled the American Southwest. She first crossed the top of the plateau—a wide field strewn with large rocks, patches of dirt, and thin, faded tracks. Lerata later said it can get very windy up there, and very cold in the winter. On clear days, she can see across the nearby border into South Africa. On the other side of the plateau is the village of Ha Mohlekana, a small cluster of homes and buildings near the dirt road that leads down the slope.

Lerata makes the walk all the time, as do her 15-year-old daughter and 7-year-old son, and said the trip from her door to pavement takes about 30 minutes. That seems optimistic at first glance, but she’s lived there for more than 13 years and says it confidently—30 minutes.

From the paved road, it’s usually 30 more minutes by foot to Holy Cross.

Unless, of course, you’re pregnant. Or in labor.

Lerata said her contractions with Thabo started Dec. 31, but she initially didn’t realize they were contractions, because they felt different than they had with her first two children.

Her first two children were born at the district hospital in Mohale’s Hoek, farther away from the family’s home than Holy Cross.

The proximity of the health center—relative proximity, at least—was a blessing with her third child.

Lerata's village health worker, Malerato Tsoelesa, had visited her at least twice a week since before her pregnancy with Thabo. Tsoelesa regularly checked on the entire family, to accompany Lerata and her children to the PIH-supported Holy Cross for free doctor visits, and then to guide Lerata's prenatal care. In all, Tsoelesa works with seven families around the village. All of them have children.

Malerato Tsoelesa at Matsebo's home.
Village Health Worker Malerato Tsoelesa at the home of the Lerata family. Tsoelesa visits the family twice a week, to support their health care. She guided mother Mathabo Lerata through her pregnancy with her youngest child, Thabo, who was born Jan. 1. 

But Tsoelesa wasn’t able to be at Lerata’s home that morning, because things happened so quickly. Lerata’s husband was away in South Africa, working in mines.  

The resulting situation was vastly different from labor and childbirth in the U.S.—and most other countries around the world, for that matter. Walking such a distance and in such rugged conditions while in labor, or even late in pregnancy, would be unthinkable.

But not in Mohale’s Hoek.

Lerata told the story offhandedly six weeks later, sitting in her living room and holding Thabo on her lap. She didn’t say whether she had been alone on the morning he was born, or whether she had taken a taxi from the paved road or just continued walking to the health center.  

Those details didn’t seem to matter all that much.

Lerata acknowledged that people often exclaim when she tells the story of that day, but said she shrugs it off, herself, saying the walk wasn’t too bad because her labor started gradually. 

Besides, as she told the story on the morning of Feb. 13, she had something else on her mind. Thabo was due for his six-week checkup at Holy Cross, which would include a PCR test (the acronym stands for polymerase chain reaction). The test would be held the next day, and Lerata would be able to see the results within about an hour, during the same visit.

The test would be the first indicator of whether Thabo had HIV, like both of his parents.

Lerata said her husband learned he was HIV-positive in 2008, and has been on antiretroviral therapy (ART) since about that time. She was diagnosed a year later, and also started ART promptly.

Both of their older children are HIV-negative. Those results and both parents’ commitment to ART meant Thabo’s odds were good, too. But there was still a risk.

Dr. Afom Andom, PIH’s lead technical advisor for Lesotho’s national health reform, said that without ART, the risk of pregnant women with HIV passing the virus to their children can reach 40 percent. Transmission can occur in utero, during childbirth and while breastfeeding. 

Lesotho's Ministry of Health and PIH are taking significant steps to reduce that rate. Andom said a scaled-up HIV program, begun in 2016, has made Lesotho the first country in sub-Saharan Africa to implement widespread screening practices known as “test and treat.” The increased screening and a corresponding emphasis on long-term, sustained ART have combined to reduce mother-to-child transmission to less than 6 percent, across 72 health centers in the reform’s four pilot districts. The goal is to ultimately achieve a rate of less than 2 percent.

Lerata consistently uses Holy Cross for her ART and services for her children—all three of them have received immunizations, checkups and more at the health center.

On the morning of Thabo’s six-week checkup and PCR test, Lerata brought him to Holy Cross in a taxi. She said the trip cost 6 South African rand (US$0.50). The rand is commonly used in Lesotho, along with the national currency, the loti.

The mood inside Holy Cross that morning was festive. It was Valentine’s Day and several of the nurses were wearing red, some because of the holiday and others just because. 

Rain began falling against a window as Lerata fed Thabo in a clinic room around 10 a.m. He was fussy and hungry, which his mother described as common. He had been crying, eating and moving around more than his two older siblings had when they were infants.

As registered nurse midwife Mamakama Mofolo began the checkup, Thabo soon began crying again.

His check-up was conducted by Mamakama Mofolo, registered nurse midwife.
Registered nurse midwife Mamakama Mofolo gives a postnatal checkup to Thabo Lerata, who was 6 weeks old on this February day at Holy Cross Health Center in Mohale's Hoek, Lesotho. 

Phephi, phephi (Sorry, sorry),” Mofolo said softly, as she checked Thabo’s head circumference, bone development, body length and more, moving from head to toe and repeating the Sesotho apology, pronounced like “peppy.”

As Thabo fussed, another baby could be heard crying in the hallway. Holy Cross serves more than 11,550 people, from villages throughout the region, and was busy that Wednesday morning.

After the checkup, Lerata fed Thabo again, quickly calming him down. Then it was time for his PCR test.

Four counselors were waiting in a small room across the hall. Marelebohile Motlomelo, Makanelolo Mahlatsi, Nthabeleng Ichasake and Matseko Mokhamo gave Lerata pre-test counseling, advising her on the procedure and what the results would mean.

Motlomelo then leaned forward and made small pricks in one of Thabo’s big toes, drawing a few drops of blood. She used a container that resembled a floppy disk to absorb the sample, then placed the container in the health center’s PCR machine.

It’s rare for health centers in Lesotho to have such a machine—most often, samples are sent to district or national labs for analysis. The machine at Holy Cross is supported by multiple aid partners, in response to the high number of infants exposed to HIV in Mohale’s Hoek.

Processing Thabo’s results would take about an hour.

Marelebohile Motlomelo, lay counselor, draws blood for the PCR test.
Marelebohile Motlomelo, lay counselor at Holy Cross Health Center, draws blood for Thabo's 6-week PCR test, which would give the first indicator of his HIV status. 
Waiting for results.
The morning of Feb. 14 was nerve-wracking for Mathabo Lerata and very busy for her infant son, Thabo, who had a postnatal checkup, immunizations - including uncomfortable shots - and then another blood sample, to test his HIV status. Both of Lerata's older children are HIV-negative, and she and her husband have been dedicated to ART for years, but risks for Thabo remained. 

In the meantime, Lerata brought her son into a larger room at the health center, for immunizations. Several other mothers held infants in the room, sitting in rows of chairs while waiting for shots.

When it was Thabo’s turn, Nurse Assistant Mookho Matekane kneeled by their chair and gave him vaccines against polio and pneumococcal conjugate, along with a pentavalent, which combines five vaccines into one shot.

Thabo didn’t like the shots, understandably, and began to cry again. It was about 10:50 a.m., less than an hour after he and his mother had arrived at Holy Cross. The healthy, active 6-week-old had had a tough morning.

And it undoubtedly was just as hard for Lerata, as she waited at the health center for PCR results. Infants at risk for HIV also are tested at 14 weeks and at nine months, and then given a definitive test at 18 months, so Thabo’s results that day would be preliminary. But Dr. Andom said the six-week results are a strong early indicator of an infant's status. Changes of that status in later tests are rare. 

Soon enough, Thabo’s results were ready.

Lerata returned to the counseling room, and sat in a chair next to a desk. Motlomelo read the results out loud.

HIV-negative, just like his brother and sister.

Lerata’s eyes watered, and a smile broke across her face. She laughed and took a deep breath, as the results were written in a register and in Thabo’s bukana, a small book kept by the family that contains a child’s birth information, medicines and health history.

Mathabo Lerata's eyes watered and a relieved smile broke across her face as a counselor read these test results, which showed Lerata's infant son, Thabo, was HIV-negative at 6 weeks old. 
After her infant son received a postnatal checkup, immunizations and a successful PCR test, Mathabo Lerata then got care for herself at Holy Cross Health Center, with resupplies of her antiretroviral therapy and consultations with staff. 

All of the counselors smiled as everyone leaned back in their chairs, a morning’s worth of tension palpably erased.

Kea leboha (Thank you),” Lerata said in Sesotho. “Kea leboha.”

The rest of their visit passed quickly. Lerata walked outside to the adjacent, one-room HIV facility, where she received a refill of her ART. A large filing cabinet had drawers labeled for active ART patients, pre-ART, and more.

Next door, pharmacist Malefetsane Letsosa filled the prescription.

Outside, Mary Lesesa, the primary health care coordinator for Mohale’s Hoek, translated more of what Lerata had said in Sesotho after the PCR results were read.

“She was a bit frightened,” Lesesa said. “But when the results came out, she was very happy."

That emotion was evident as Lerata prepared to leave the health center. She swept Thabo onto her back, snuggled into a baby carrier, and wrapped him securely there with a large, brown-and-peach blanket.

Then Lerata, her 7-year-old son—who had come along that morning—another mother, and Tsoelesa, Lerata’s village health worker, left Holy Cross and proceeded up the road, talking and laughing as they began another long walk home.

* Names have been changed.

Matsebo (left) leaves the health center with her village health worker Malerato Tsoelesa (center), and her other son.
Mathabo Lerata (center) leaves Holy Cross Health Center with her healthy baby, Thabo, swaddled and carried on her back. Lerata is joined by her village health worker, Malerato Tsoelesa (right), and another mother. 
Tue, 08 May 2018 15:03:43 -0400
New Maternal Waiting Home in Haiti Offers "Priceless" Care This pregnancy was different.

Natacha Jean Paul had already given birth to three girls, so she thought she knew what to expect while expecting. But the 39-year-old mother began feeling unbearable pain while seven months along. No matter how she shifted her body, her baby lay in an awkward position.

She visited a hospital near her home in Port-de-Paix, a coastal community along Haiti’s northern shore. Doctors there recommended she travel to the capital of Port-au-Prince for specialized care. But that was half a country away and the price of public transportation would cost her dearly. Her sister, who is a trained nurse, recommended she travel to the closer University Hospital in Mirebalais, Partners In Health’s 300-bed teaching facility in the Central Plateau that offers free care.

Paul arrived at University Hospital on Sept. 18, 2017, and was seen by an OB-GYN, who confirmed that her baby boy was breech, or not head down. She also learned he was hydrocephalic, meaning his head was abnormally large from a buildup of fluid on the brain. The doctor recommended she stay nearby so that staff could monitor her risky pregnancy.

Normally, staying nearby would have been impossible for Paul. She had no family in MIrebalais, and she definitely couldn’t afford two months of lodging as she waited for her Nov. 23 due date.

Luckily, Zanmi Lasante, as PIH is known in Haiti, had a new maternal waiting home to accommodate women in situations like Paul’s by providing free lodging at the University Hospital campus. Paul was admitted that same day, given a welcome kit including basic toiletries, and settled into a room she shared with two other expectant mothers.

Since opening in February 2017, Kay Manmito—“mothers’ house” in Haitian Creole—has welcomed 420 women with complicated pregnancies, along with mothers whose newborns were in the hospital’s neonatal intensive care unit (NICU). They come from all over Haiti, traveling from Cap-Haitien in the north to Léogâne and Les Cayes in the south. The facility will eventually host 44 women at a time—12 expectant mothers, 18 NICU mothers, and 14 mothers participating in kangaroo care.

Once key infrastructure is in place, kangaroo care will begin May 2018 and will allow mothers of premature infants to stay in the same room as their babies so they can maintain constant skin-to-skin contact, which helps underweight newborns regulate body temperature and feed more frequently.

A nurse auxiliary is always on hand at Kay Manmito to answer women’s questions, take vital signs, and help determine when labor has advanced enough to go to the delivery ward. Other PIH staff visit daily to offer educational sessions on topics such as breastfeeding, nutrition, breast exams, and more. Thursday afternoons have featured prenatal yoga, taught by Amos Sampeur, a program assistant. Staff also have taken the women to a nearby hotel pool to cool down on particularly hot days, and organized plays to recognize special occasions, such as Mother’s Day or Christmas.

Residents get three meals a day, eaten in a communal dining room. Before a recent lunch, the women broke out into song—as they do before every meal—to bless the food and each other. Staff said most women share their stories and possessions with each other, creating a home away from home.

“The mothers are really proud about Kay Manmito and the way we treat them,” said Sophonie Joseph Sylvestre, the maternal home’s director. “They feel like they’re part of a family.”

Kay Manmito is an anomaly in Haiti. Roughly 40 percent of women still give birth at home, often without electricity, running water, or a sterile birth kit. There is no doctor, surgeon, or anesthetist on hand, either, in case an emergency cesarean section is required, for example.

But many health centers are not properly equipped or staffed for deliveries either, a fact that doesn’t encourage women to give birth there.  

All of these factors translate into dangerous situations for Haitian women, who have a 1 in 90 chance of dying during or after childbirth. In the United States, that risk is 1 in 3,800.

The million-dollar-question is: What must happen to prevent maternal death in Haiti?

As every woman who has given birth knows, babies don’t arrive on anyone’s schedule but their own. False alarms and premature labor are common everywhere. Expectant mothers in the U.S., for example, often make several trips to the hospital before “real” labor begins.

Most Haitian women don’t have that luxury. They can’t afford multiple trips to their local health facility whenever they suspect labor has begun. Instead, they pack a small bag and trek to the closest clinic or hospital as their due date approaches and wait—sometimes sleeping outside for days in anticipation.

When University Hospital opened in 2013, staff frequently saw full-term pregnant women camped overnight on the cement sidewalks and courtyards. Mothers of NICU babies slept outside the ward so they could be available for regular care and feedings. There had to be a better solution—for mothers, babies, and the hospital.

The front entrance at University Hospital in Mirebalais. (Photo by Cecille Joan Avila / Partners In Health)
Women staying at Kay Manmito share meals three times a day, only after singing a prayer of blessing. (Photo by Cecille Joan Avila / Partners In Health)

Kay Manmito was born out of that need, and inspired by the success of similar facilities in other countries where PIH works. Having maternal waiting homes near health facilities in Lesotho, for example, has increased the likelihood that expectant mothers will give birth at those facilities rather than at home, dramatically improving their chances of a safe delivery.

In the PIH-supported districts where Lesotho’s national health reform is taking place, the rate of facility-based deliveries has doubled in just four years, from 25 percent in 2013 to nearly 50 percent in 2017. Each clinic and hospital is home to a maternal waiting home where expectant mothers stay until labor begins, just like Kay Manmito.

Sylvestre said many women who have stayed at Kay Manmito found it clean and comfortable, and the staff welcoming and friendly. They enjoy the food and camaraderie and participate in the educational activities. One mother, she remembered with a smile, was disappointed that her c-section got scheduled earlier than anticipated. She was so comfortable that she wanted to stay longer.

After delivering in the hospital, most mothers swing by Kay Manmito to show off their newborns before returning home. Those are joyous occasions—new mothers beam, and pregnant residents realize that, someday soon, they too will cradle newborn daughters or sons. But there also are tragic moments, when mothers who have lost their babies return to the waiting home, pack up their things, and leave feeling hollow. Not every story has a happy ending.

For her part, Paul had faith that everything would turn out alright. She was five days away from her due date and feeling heavy, but hopeful. She had enjoyed her stay and marveled at how much it would’ve cost if she had had to pay for the free, comprehensive care she’d received so far.

“The care found here,” she said, “is priceless.”


Fri, 04 May 2018 07:51:36 -0400
PIH Featured as The Economist Calls for Universal Care "As this week’s special report shows, the goal of universal basic health care is sensible, affordable and practical, even in poor countries. Without it, the potential of modern medicine will be squandered.”

So argues the cover story of the latest issue of The Economist magazine, a seven-part examination of how best to provide care for all.

PIH features prominently.

The section “An affordable necessity” begins with PIH Strategic Advisor Dr. Bailor Barrie recalling the state of Sierra Leone in 2014. In “First things first,” he reflects on PIH’s progress in improving primary health care, and in “A crazy system” he notes the shortcomings of mental health care virtually everywhere.

PIH Founders Dr. Paul Farmer and Dr. Jim Kim also appear, pushing for better, more widespread access to surgery in “Kindest cut." Not surprisingly, Rwanda’s great strides—made largely during the tenure of former Minister of Health Dr. Agnes Binagwhaho, now the Vice Chancellor of PIH’s University of Global Health Equity—are called out again and again.

It's flattering stuff, to be sure. But also, and far more importantly, inspiring. The premier English-language news magazine dug deeply into the topic of universal health care and concluded, as PIH has always believed, that a world full of hope and good health is not only the right world, but a world “within reach." We just need to keep fighting for it.

The full series can be read here.

An introductory overview can be read here

Mon, 30 Apr 2018 16:54:01 -0400
MSF's Dr. Liu and PIH's Dr. Farmer Raise the Alarm Usually poor. Generally living in the slums or countryside. Busy just trying to stay alive. People who suffer tuberculosis struggle to be seen, let alone treated.

On behalf of them, today Dr. Paul Farmer, a founder of Partners In Health, and Dr. Joanne Liu, the international president of Médecins Sans Frontières, published a jointly written op-ed in Project Syndicate, a Czech-based organization that offers free news commentary to some 500 media outlets around the world. 

Farmer and Liu call on the world to imagine TB not as some Victorian disease, one of sanatoriums and "consumption," but as what it currently is, the world's most deadly infectious disease, responsible for the death of roughly two million people annually. They urge drug companies to develop more and better treatments. They implore "a broad coalition" to "rush to the aid of these patients." And they lament the global indifference that has made them leaders in the fight.

"It is a sorry situation when nongovernmental organizations, rather than governments, academic institutions, and drug companies, must push for the use of available new drugs," they write.

Read the full piece here:…

Mon, 26 Mar 2018 16:06:51 -0400
TB Patient Advances Care in Liberia Partners In Health community health worker Patricia Mankuah often uses a motorcycle taxi to reach her patients in Harper, a town in remote southern Liberia, and last summer, she frequently hired Paul*, a friendly, trusted 30-something with a reliable motorcycle.

In mid-August, she noticed that he had a persistent cough. Knowledgeable about tuberculosis, she screened him for the airborne infectious disease and accompanied him to PIH-supported Pleebo Health Center, for a free checkup. As it turned out, Paul didn’t just have standard TB. He had multidrug-resistant TB, or MDR-TB, an especially deadly and hard-to-treat version.

Two days later, Mankuah and a specialist visited Paul at his house, to help prepare him for admission to the TB Annex in the capital of Monrovia, the only facility in the country that treated MDR-TB. But Paul lived with, and financially supported, 14 family members in his two-room home, including his pregnant wife. As the family breadwinner he wasn’t about to abandon them for an eight-month, hospital-based, inpatient treatment, and especially not one a day-and-a-half’s drive away.

The decision proved consequential. By sticking with his family even at the risk of infecting them and dramatically shortening his own life, Paul set off a chain of events that would become a landmark in PIH's work with MDR-TB patients.

PIH had set its sights on MDR-TB in the nation of 4.7 million three years earlier. After helping the country beat Ebola, PIH medical staff realized that MDR-TB had become a huge threat. Many patients who had been on treatment earlier had no way to continue during the epidemic, when fears of Ebola caused hospitals to close and drugs to stock out. Many more had simply never had access to the thousands of dollars of pills and injections needed to treat MDR-TB, thanks in part to a national health care budget that can afford to spend just $50 per person, per year. All in all, just 20 of the country’s estimated 430 MDR-TB sufferers were receiving treatment in 2015.

With the encouragement of the National Leprosy and Tuberculosis Program, PIH TB Program Director Dr. Maxo Luma kicked off an MDR-TB program. He, two other PIHers, and a Ministry of Health physician assistant drove through downtown Monrovia looking for patients who were either lost to follow up or otherwise no longer being treated.

Luma and a government counterpart initiated a comprehensive care approach, beginning with transformation of the TB Annex to ensure a dignified space for care. Through intensive case finding and improved linkages to care, bolstered by robust social support programming, the number of patients identified and enrolled on treatment increased, to 120 currently.

The TB Annex in Monrovia in 2016, before it was refurbished. (Photo by Rebecca E. Rollins / Partners In Health)
Luma at the TB Annex in 2016. (Photo by Rebecca E. Rollins / Partners In Health)

Simultaneously, PIH recognized that one treatment facility was not enough. In 2017, in an effort to help decentralize TB care, construction began on a TB ward in PIH-supported J.J. Dossen Hospital, near Harper.

When Mankuah helped discover Paul’s condition, the facility was months away from opening. And of course Paul didn’t want to leave home anyway.

Luma turned to Ernest Cholopray, the deputy program manager of the national TB program. Cholopray advised PIH to go one step further. Treat Paul in his home, he urged.

So they did. On August 28, Luma and a clinician from the National TB Center travelled from Monrovia to Harper. There, staff members from J.J. Dossen—including Mankuah, a social worker, and another clinician—joined them. Together they visited Paul.

After exchanging greetings and pleasantries, they assessed the home’s ventilation and risk of disease transmission, and provided family members and neighbors education and counseling on TB infection control. To maximize the treatment’s odds of success, they also made sure Paul and his family had enough to eat.

Then the team discussed with Paul the treatment plan, including the local clinician who would provide the daily injections and how potential side effects would be managed. Family members showed great support for Paul.

Today, in late March, Paul is just two months shy of completing the first phase of his treatment, well on the way to being the first MDR-TB patient in Liberia ever treated and cured outside of the capital.

The story of Paul, his family, and MDR-TB treatment in Liberia is an inspiration. But future stories like his could be at risk. The United States president’s proposed budget would cut funding for not just MDR-TB treatment in Liberia, but all TB treatment in Liberia, by 75 percent.


*Name has been changed for privacy.

Fri, 23 Mar 2018 13:44:01 -0400
Melquiades Huauya Ore: From MDR-TB Patient, to Survivor, to Movie Star and Advocate It took four strong, kind-hearted volunteers nearly two hours to carry Melquiades Huauya Ore, lying waiflike in a bedsheet, from his home in El Agustino neighborhood in the hills of Lima, Peru, down a series of steep stairs to the closest health center. They did this every day, for several weeks, so that the then 20-year-old could take his medication against multidrug-resistant tuberculosis, one of the deadliest forms of the disease. After Huauya painfully swallowed a handful of pills, his generous volunteers would lay him gently back in the makeshift stretcher and hike back up the stairs to home.

For Huauya, the daily journey was exhausting. All he wanted was to stay at home, curled into a ball in his bed, resting. Yet, if he was to beat the disease and not infect his family, he had to make the pilgrimage.

Then, one day, something truly unexpected happened. Huauya was told there was a foreigner who wanted to see him. A lung expert from the United States. The young patient felt honored to receive the special attention, and descended once again, this time to Sergio E. Bernales Hospital in Lima.

Dr. Jim Yong Kim, a co-founder of Partners In Health (PIH) and Harvard-trained epidemiologist, sat in the exam room and greeted Huauya in Spanish. While the frail young man slumped in a chair, his posture the picture of dejection, Kim began his exam. He spoke in a soothing tone and lifted his patient’s shirt to better listen to his heart and lungs. The image was shocking: Huauya was nothing but skin and bones.

The interaction between Kim and Huauya would become one of the most moving story lines in Bending the Arc, a 2017 documentary that tracks the 30-year evolution of PIH. But on that day, movie scenes were the furthest things from the minds of doctor, patient, and everyone in the exam room.

Under the watchful eyes of Kim and his community health worker, Huauya placed pills in his mouth, tilted up his head, and forced his Adam’s apple to bob up and down. Finally, the medication had passed, and his observers whispered words of encouragement.

The day remains emblazoned in Huauya’s mind. He was impressed by how Kim, a relative stranger who would go on to become president of the World Bank Group, had treated him with such compassion and kindness. He remembers the doctor pleading gently with him to stay the course: “’Please, don’t give up. Please, continue with your treatment.’”

An MDR-TB hotspot

Patients like Melquiades shouldn’t have existed in Peru. Up until the late 1990s, the country was considered a shining example of how to administer TB protocol outlined by the World Health Organization. The Ministry of Health ensured that patients were tested and treated for drug-sensitive TB, which can be cured with antibiotics such as Isoniazid and Rifampicin. The prevailing idea was that multidrug-resistant tuberculosis, or MDR-TB, simply didn’t have a chance to mutate within the population, because its easier-to-cure cousin got stamped out immediately. So when Kim and fellow PIH Co-founder Dr. Paul Farmer began visiting the country, they had no plans to tackle TB.

All that changed, however, when a Boston priest affectionately known as Father Jack died of MDR-TB in 1995. The priest was a good friend of Kim and Farmer’s, and it was at his request that they began working in Carabayllo, a slum north of Lima. The doctors discovered their friend had MDR-TB after he fell extremely ill and traveled back to Boston for care. A battery of tests revealed the truth.

Father Jack’s diagnosis came too late for a cure. But it sparked a renewed effort by Kim, Farmer, and staff at Socios En Salud (SES)—as PIH is known in Peru—to discover how entrenched MDR-TB was in Carabayllo, where most of their patients lived.

As it turned out, MDR-TB was everywhere. Carabayllo families live in close, cramped quarters in poorly ventilated homes, a dangerous breeding ground for an airborne disease. People are extremely poor and make difficult choices with scarce funds: Should they pay for medication with a day’s wages, or buy food for their children? And when it comes to transportation, most residents get around the city in public buses, where germs easily pass among passengers. All these factors, and more, combined to make the slum a hotspot for the disease.  

A scene from Carabayllo, a hillside slum north of Lima, Peru, around 2001. Partners In Health began working here in the late 1990s, eventually focusing on the treatment of MDR-TB. (Photo courtesy of Partners In Health)

A painful journey

Huauya can’t be sure how he caught MDR-TB, but he suspects it happened while riding public buses to and from work throughout the congested capital city. He remembers suffering from a persistent cough that didn’t go away after a couple of weeks of his mother’s homemade remedies. At a nearby health center in January 2002, a doctor took a chest x-ray and asked Huauya to provide a sputum sample to test for TB. The scan revealed a small manchita, or spot, on his lungs, and his test came back positive.

The 17-year-old was immediately placed on first-line antibiotics, which normally cure a regular case of TB in six months. But three months in, Huauya wasn’t feeling better. Further tests revealed he had MDR-TB, which required a different, more toxic line of drugs. The daily injections and handfuls of pills made him nauseous, gave him headaches, and spurred a bout of depression. For 10 months straight, he was hospitalized while doctors tried to get his condition under control.

“In the hospital, I got to the point of coughing up blood,” Huauya said. “Doctors said my lung looked like a colander. That’s how bad the situation was.”

Huauya’s hospitalization was hard on his two younger siblings, especially his 13-year-old youngest brother, Alex. Minors weren’t allowed into the TB wing. Yet Alex insisted on a surprise visit one day with their mother, Edifenia Oré Meza.

When Huauya heard Alex had come, he told his mother to bring his brother into the hallway and place him in a specific spot. He knew that if he peered through the moon-shaped window in the TB ward door, he’d be able to see Alex. His mother complied. Alex appeared in the appointed spot. And the two brothers enthusiastically greeted each other through the glass pane.

“That was one of the most beautiful moments for me,” Huauya said.

Eventually, Huauya was stable enough to return home and continue his treatment at a local health center. He was still incredibly weak, and relied on his family to help him get out of bed and do such simple tasks as go to the bathroom—and much harder ones, such as traveling down hillside stairs to the health center.

It was around that time Huauya met Kim and SES, whom he credits for connecting him with a community health worker. Twice a day for about one year, a middle-aged woman with a slight limp arrived at his family home to bring his medication. She stayed long enough to assure he’d swallowed his pills, then took off to the next patient’s home. There were many patients like him, Huauya learned.

“We really felt such great relief to avoid all of that” back and forth to the health center, Huauya said. He could finally rest and recuperate properly at home, and it was all to the credit of his community health worker, whose name—sadly—he couldn’t remember due to the tremendous strain of his illness and the powerful medication he took daily.

“I used to say to myself, ‘What a super human!’ She treated me as if I, too, were her son.”

Over the course of months, Huauya could tell the drugs were working. He started walking unsupported, his appetite returned and he regained weight, and his cough disappeared. Every two months, he sent sputum samples to the health center to be tested.

Several long years after he began MDR-TB treatment, Huauya—then 22 years old—was pronounced cured in July 2006. While a major milestone, it wasn’t the end of his journey. His battle with MDR-TB had taken its toll. The disease had eaten a section of his left lung, which had to be removed in 2007. Afterward, he spent one week at the health center and then returned home to recuperate.

“That’s Melquiades?”

Huauya had been sick for so long, good health felt like a luxury. “The only thing I thought about was making up all the time I’d lost with my family.” He worked on weekdays in a tienda, or store, to help meet the family’s expenses. On weekends, he took classes in computer informatics. For a year and a half, he even worked for PIH as part of the logistics team.

PIH staff remember Huauya as a shy, diligent type who kept to himself. Dalia Guerra, a nurse who has worked with PIH in Peru since 1997, met him when he was still undergoing treatment. She said he was always a polite, compliant patient who never asked for additional help, as other patients had.

Life returned more or less to normal. Normal, that is, for a young man who had narrowly escaped death. Then one day, Cori Shepherd Stern, producer of Bending the Arc, reached out to Huauya through SES after seeing old footage of him with Kim. They wanted to follow up on his story and see if he was open to an interview. The former patient agreed, honored to be part of the project.

Many months later, Huauya traveled to the United States, his first time in the country, to watch Bending the Arc’s premiere at the Sundance Film Festival in 2017. He felt nervous sitting among PIH co-founders and Hollywood movie stars, and at the same time incredibly excited as the lights turned down and the documentary began.

There’s a poignant moment in the film, during an interview with Kim, when the filmmakers show him a clip of Huauya. The young man, then 31 years old, has healthy bronze skin. His face is filled out, and his broad shoulders tell how far he’d come since those long ago days at Sergio E. Bernales Hospital. Huauya smiled as he retold his story. At times, he seemed just as amazed as Kim that he had risen, like Lazarus, from his death-bed.

Kim was shocked at the sight of his former patient.

“That’s Melquiades?” he asked in disbelief. Tears welled in his eyes. “To think, we almost let him die?”

But, of course, they hadn’t. Huauya was there watching the film in the same room, a stone’s throw away from his former doctor.

“I really loved feeling the lived emotions of Dr. Jim Kim,” he said in a later interview. “To see that kind of reaction from him after seeing me—that was really beautiful.”

Huauya spent several days traveling in the United States before returning to his neighborhood in the hills of El Agustino, where he lives with his parents, beloved maternal grandmother (who still chides him to eat), and his younger sister and nephew. The Strongheart Group, a nonprofit advocacy organization that is working with the subjects of the film Bending the Arc to impact real change in the world, is training him to become an advocate for TB patients. Naturally shy when he was younger, he has found strength in sharing his story and has become an impassioned advocate for global health equity.  

Looking back on his three years of treatment, Huauya remembers having—and then losing—faith that he would be cured. What pulled him out of the abyss, time and again, were the constant support and presence of his family, his community health worker, and PIH staff.

“There are many people who now are carrying the weight of TB treatment completely by themselves, without family or support. No one should be alone in this fight,” he said. “Everyone has the right to health. Everyone deserves equal access to health and the opportunity to reach their goals and fulfill their dreams.”


Fri, 23 Mar 2018 12:29:08 -0400
Dauntless Lesotho man defeats MDR-TB, defies family history A severe form of tuberculosis killed Moeketsi Ts'osane’s mother in 2008, and one of his brothers in 2010. Health workers suspect the disease may also have contributed to the 2005 death of Ts'osane’s father, who had worked as a miner in South Africa.

So when Ts'osane was diagnosed with MDR-TB himself, in 2015, his family and friends had grim hopes for his future.

“The people around me, because of what had happened…to them, it was the end of me,” the 29-year-old Ts'osane said in February, sitting at work in Maseru, the capital of Lesotho. 

The only person who didn’t give up hope was Ts'osane. 

“I knew I would get through from the start,” he said. “I had to condition my mind and myself, but I knew I would get through.

“I had to make it,” added Ts'osane, who is married with a young daughter. “I had to.”

That kind of positivity exudes from Ts'osane, a slim, engaging accountant for the Oblates of Mary Immaculate, a Christian missionary organization. He said he’s an avid reader, frequently listens to motivational speakers and tries to interact with positive-minded people—foremost among them is his wife, Ts'epang Faats'e Ts'osane.

So, when Moeketsi Ts'osane tells you he firmly believes that, “the positivity I put in made a lot of difference” in battling MDR-TB, you listen. Because this is someone who had to overturn recent history, change the perceptions of friends and loved ones, and save himself from a deadly disease that had taken two members of his immediate family, if not three. 

The risk for his father would have been significant. South Africa has the world’s highest rate of TB, at 781 people infected per 100,000, according to 2016 data from the World Health Organization. That could be largely due to the mining industry, which is large in South Africa and an ideal incubator for TB, which spreads through the air and can be rampant in crowded, poorly ventilated spaces such as mines.

The country’s incidence rate is followed by that of Lesotho, a mountainous, largely rural kingdom that’s entirely surrounded by South Africa. Lesotho’s rate for TB, the world’s deadliest infectious disease since 2015, is 724 people per 100,000.

Nowhere else on the planet is close. In the U.S., for comparison, about three people per 100,000 had TB incidences in 2016. 

When it comes to multidrug-resistant tuberculosis (MDR-TB), the devastating strain that killed Ts'osane’s mother and brother, Lesotho again is at the top, sharing the highest incidence rate in the world, of 49 people per 100,000, with nearby Swaziland.   

That means that of Lesotho’s total population of about 2 million, nearly 1,000 people are battling MDR-TB. The good news is that their chances of survival now are much better, and getting increasingly better, than they were just a decade ago.

Ts'osane is an example of why. 

Likhapha Ntlamelle, community health director for Partners In Health (PIH) in Lesotho, said Ts'osane’s mother was one of the first MDR-TB patients treated at Botšabelo Hospital. The Maseru hospital is the headquarters of Lesotho’s first National MDR-TB Program, which PIH operates in its role supporting the Ministry of Health.  

PIH is known in Lesotho as Bo-mphato Litšebeletsong Tsa Bophelo. Ntlamelle has worked for PIH since 2007, when the National MDR-TB Program began. In addition to her work at Botšabelo, she and her team of community nurses conduct educational outreach about MDR-TB across the country. She knows Ts'osane and his family well, and said that when his mother came to Botšabelo a decade ago, her MDR-TB was so far along they were unable to save her life. 

His brother also had one of the worst forms of MDR-TB, a kind that affected his brain, Ntlamelle said. 

Ts'osane has two other siblings, a brother and sister who live in Maseru with their grandmother. Among all of his family members, Ts'osane said, his grandmother felt the greatest impact from what MDR-TB had done to them, and from what it could do, after Ts'osane’s own diagnosis. 

“It was very emotional for her,” he said. 

Ts'osane had visited his mother and his brother at Botšabelo when they were patients there. Given his family’s health history, and the mental and emotional trauma it had brought, health staff expected challenges when Ts'osane began the grueling MDR-TB treatment himself in 2015.

“We thought we would experience more problems with him,” said Tseko Motsela, a community nurse at Botšabelo. 

Instead, the opposite occurred. Buoyed by dauntless positivity and the timely advent of new TB medicines, Ts'osane persevered. Ntlamelle said he was one of the first patients at Botšabelo to be treated with bedaquiline and delamanid, the first new TB drugs developed in about 50 years.

Moeketsi home visit 2016
PIH community nurse and treatment supporter Tseko Motšela (foreground) visits the home of Moeketsi Ts'osane in March 2016, in Maseru, Lesotho. Ts'osane was about a year into the arduous treatment for MDR-TB. (Photo by Rebecca E. Rollins / Partners In Health)

He took pills daily, went for monthly checkups at Botšabelo for hearing, vision, and ECG tests to monitor his heart rate, and suffered side effects including rashes and nausea. Otherwise, Ts'osane told PIH staff in 2016, “it’s just normal.”

Two years later, in a seating room of the church office where he works, Ts'osane said lingering effects have been minimal. 

“My legs are still a bit sore,” he said. Despite some aches, he plays in a recreational soccer league for fun.

Seated nearby, Ntlamelle smiled. 

“It really makes me very, very happy to see him,” Ntlamelle said. “People tend to think everybody who has MDR-TB will pass away. (Now), when we say MDR-TB can be cured, they know it’s true.”

Ts'osane said he especially wants his nearly 3-year-old daughter, Bohlokoa, to know that’s true. He plans to talk with her about MDR-TB when she gets older.  

“She has to be aware,” he said. “Definitely, I am going to talk to her. She has to know that if she gets sick, she is going to be OK.”

Bohlokoa already has proven that she can fight through diseases, too. Ts'osane said his daughter was diagnosed with TB, a non-MDR strain, when she was 9 months old. She successfully completed treatment six months later.  

"I think she is tougher than me," Ts'osane said.

Motsela said PIH’s MDR-TB team in Lesotho is trying to share Ts'osane’s story widely.

“I think his story could impact others who are demoralized,” he said. 

So could his energy and outlook. 

As Motsela, Ntlamelle and others pulled away from Ts'osane’s workplace that day in February, two days after he turned 29, Ts'osane ran up to the van’s window, waving. He was holding a green facemask, the kind that MDR-TB doctors and nurses wear when around patients indoors, or in close quarters. 

Motsela had left his mask inside, after wearing it with other patients earlier in the day. Ts'osane wanted to return it—after all, it was not something he had much use for lately. 

Tue, 20 Mar 2018 10:14:31 -0400
'The Core of Our Program:' Likhapha Ntlamelle Leading MDR-TB Outreach in Lesotho Slowing the spread of multidrug-resistant tuberculosis (MDR-TB) in Lesotho means going to many more places than hospitals and clinics.

It means going to taxi associations. Mining companies. High schools. Primary schools. Prisons and police facilities.

Likhapha Ntlamelle, director of community health for Partners In Health (PIH) in Lesotho, has visited them all. Any place with poor ventilation and people in close quarters—whether a crowded prison cell, mine shaft, classroom, or 15-passenger taxi in winter with the windows closed—can increase risks for the airborne spread of TB, which became the world’s deadliest infectious disease in 2015. TB is prevalent in much of Lesotho, a mountainous, largely rural country where many people have to travel for hours, often on foot, to reach the nearest health facility.

Additionally, 2016 data from the World Health Organization shows that Lesotho and nearby Swaziland share the world's highest incidence rate for MDR-TB, a severe, deadly and hard-to-treat form of TB. 

That’s why the even-keeled Ntlamelle works tirelessly with her team of six community nurses to conduct regular educational outreach sessions across the country’s 10 districts. They discuss how MDR-TB spreads, its symptoms, and treatment, which can require months of daily injections and thousands of pills over the span of two years. Whether meeting with private businesses, public groups, or individuals, Ntlamelle and her team have a simple message: If you have a significant cough that has lasted for two weeks and suffer from night sweats, fever, and weight loss, it’s time to go to a health facility and get checked for TB. 

“This is what we tell everybody in the country,” said Ntlamelle, 57.

Ntlamelle has worked for PIH in Lesotho, known locally as Bo-mphato Litsebeletsong Tsa Bophelo, since 2007, when PIH and the Ministry of Health launched the country’s first MDR-TB program. She usually travels for outreach about two days a week. Ntlamelle spends the rest of her time in the capital, Maseru, at sites including PIH’s main office; the PIH-supported, 24-bed Botsabelo Hospital, which is the country’s only facility for treating drug-resistant TB; and the nearby Malaeneng temporary housing facility for MDR-TB patients. 

The fluid, travel-heavy nature of Ntlamelle’s job is very familiar to her. Her mother was a nurse, so they moved frequently and lived in four different districts during Ntlamelle’s youth. Her mother eventually settled in Mohale’s Hoek, and Ntlamelle was married in the northern, highland district of Butha-Buthe. 
She’s the mother of two boys, now 26 and 32, and lives in Maseru.  

Ntlamelle is a vital leader in Lesotho’s fight against MDR-TB. Her value was evident on a February morning at Botsabelo, when gregarious hospital administrator Mabatloung Mofolo stood outside the community health office. Mofolo often jokes with co-workers and is always ready to laugh, but when she spoke about Ntlamelle’s impact on the hospital, she gave a simple, serious remark.   

“The core of our program,” Mofolo said.

That program has seen significant growth over its first decade. 

Botsabelo staff enrolled 42 MDR-TB patients in 2007, the program’s first year. Enrollment quickly rose, and averaged about 150 patients a year from 2008-14. Numbers jumped to 215 patients in 2015 and 250 patients in 2016, before falling back to 158 in 2017. 

In all, more than 1,600 patients have been enrolled at Botsabelo over the years. The hospital had about 300 active patients as of February. PIH is the only non-governmental organization providing MDR-TB treatment in Lesotho.

“Initially we had very few patients, but now we are seeing more and more patients with MDR being diagnosed,” Ntlamelle said. “That means more and more people are being put on treatment, so that’s cutting the transmission of TB.”

At any given time, about 75 percent of MDR-TB patients at Botsabelo are co-infected with HIV. Co-infection is common among the two diseases, as being stricken with either one weakens the immune system and increases risks of contracting the other.

seko Motšela (left) and Nurse Likhapha Ntlamelle scan a patient’s medication log, which records the daily doses of drugs needed to treat MDR-TB, in Maseru, Lesotho, in March 2016.
Community Nurse Tseko Motšela (left) and Community Health Director Likhapha Ntlamelle review a patient’s medication log, which records the daily doses of drugs needed to treat MDR-TB, in Maseru, Lesotho, in March 2016. (Photo by Rebecca E. Rollins / Partners In Health)

A marked decline in death rates could be the best reflection of Botsabelo’s progress. While about 90 percent of MDR-TB patients at the hospital died in 2007 and 2008, 31 percent died in 2016—the year when the hospital saw 250 patients—and 18 percent died in 2017.

“With TB you can see people’s lives changing, because they come in sick and they go out cured,” she said. “You go to families and you want to cut the transmission, and you want to see the success rate in the country going up, and reduce the defaulters (people who leave treatment).”

Ntlamelle and her department work closely with Ministry of Health officials and nurses, and with the Ministry of Social Development. They do much of their outreach at the grassroots level.

Ntlamelle and community nurses visit schools to refer children with TB symptoms to health facilities, where they can give sputum samples. They also collect samples door-to-door in the districts of Maseru and Mohale’s Hoek, which have the country’s highest numbers of mine workers and families. Many adult men in Lesotho go to South Africa—which entirely surrounds Lesotho— to work in mines, then contract MDR-TB on the job and potentially spread the disease when they return home. 

Ntlamelle said her team also screens workers directly at mines and small quarries in Lesotho, a task that is getting easier as more people learn about MDR-TB, and learn that it can be cured. 

“Previously, people would not allow you to (screen them), so society is changing,” Ntlamelle said. 

Many MDR-TB survivors in Lesotho have no other choice, though, but to return to the same job where they contracted the disease. Unemployment is between 24 and 28 percent nationwide and “coupled with high inequality and poverty,” according to The World Bank.  

She added that when they enroll taxi drivers as patients at Botsabelo Hospital, for example, they inform the driver’s taxi association not only about the driver’s condition, but also when the driver is healthy and able to work again. 

Despite the challenges, Ntlamelle is optimistic about what lies ahead for MDR-TB treatment in Lesotho. Botsabelo’s use of bedaquiline and delamanid—the first new TB drugs developed in about 50 years—is showing strong results. The pills soon could eliminate the need for injections as a standard part of treatment.

“The new developments make it exciting and give you hope for the future,” she said. 

Ntlamelle sees reasons to be hopeful all the time at Botsabelo. 

“You see young children taking treatment, and you see them grow—they are cured, they have families, and their families are TB free,” she said. “It’s exciting to see that.”

Thu, 15 Mar 2018 11:55:58 -0400
Parents Managing HIV, Four Healthy Kids in Lesotho On a sunny morning in February, near the end of a hot, dry summer in the southern Africa nation of Lesotho, Mafelleng September held her month-old infant on her lap while two young children played on the floor in front of her.

A fourth child—the oldest, at 9 years—was away at school. Her husband, Hlalele, also wasn’t home that morning, as he was out looking for labor work around their rural community of Motse Mocha. That meant September had her hands full as she nursed their infant, Katleho, kept an eye on 3-year-old Felleng and watched 5-year-old Teboho busily sort a deck of cards into piles. Soft music played over a radio, and a breeze wafted in through a window.

September is 35 years old and HIV-positive. She’s been on antiretroviral therapy (ART) since 2012. Her husband began ART last year. All four children, however, are HIV-negative. While Katleho has more tests ahead, to check his status through infancy, the results are incredibly heartening for a family in a remote corner of one of the most HIV-prone regions in the world.

They’ve had a lot of help. Village Health Worker (VHW) Makatieho Mpeli has been looking after the family since at least three years ago, when she accompanied September to the regional Holy Cross Health Centre for the delivery of Felleng. September again gave birth safely and successfully at Holy Cross in January, when Katleho was born.

Mpeli lives near Motse Mocha, which is in the mountainous district of Mohale’s Hoek. She works with 12 families in the area, accompanying them to health facilities, helping them access medicines, providing education and checking up on treatment and conditions. She said she visits about four families a day, but one of those families always is the Septembers. Mpeli visits their two-room home daily, to help with cooking, cleanup and care for the four active children.

The main aspects of the Septembers’ care—maternal and child health, and HIV treatment—are priorities for Lesotho’s national health reform, which began in 2014. Partners In Health (PIH), known locally as Bo-mphato Litsebeletsong Tsa Bophelo, is supporting the reform as the primary technical advisor to Lesotho’s Ministry of Health. 

VHWs like Mpeli are on the front lines for the reform’s goals of reducing child mortality, improving maternal health, combating HIV and TB, and ultimately, achieving universal health coverage. As part of its role in the reform, PIH has installed VHW coordinators at 72 health centers across four of Lesotho’s 10 districts, to improve management, oversight and structure of the VHW system.

Those districts include Mohale’s Hoek, where hard-to-reach homes are a fact of life.

Motse Mocha lies in a valley dotted by small farms and homesteads, and surrounded by high ridges that can offer views into South Africa. Reaching the Septembers’ home requires bouncing along a rough dirt road and then clambering down a steep, rocky path, where a wrong turn can lead to ducking under the barbed-wire fencing of neighboring homesteads or stepping across boulders on the edge of small cliffs.

Public health nurse Moleboheng Adam (left) and village health worker coordinator Bonang Motlomelo (right) walk to the home of the September family, at far left. (Photo by Cecille Joan Avila / Partners In Health)

Dr. Mahlape Tiiti, the district’s health manager, said nearly 80 percent of Mohale’s Hoek’s 170,000 people live in rural areas—and most of those people, she added, live in “very remote places” without easy access to health services.

Tiiti said the lack of access to health services and health education, rooted in Mohale’s Hoek’s rugged topography, contributes heavily to the district’s HIV prevalence rate of 29 percent across all ages. That’s the highest such rate in Lesotho. Tiiti said people who live two hours or more from health services—common in Mohale’s Hoek—are less likely to be tested for HIV, or to consistently access treatment.

Those challenges are familiar across Lesotho, where the nationwide HIV prevalence rate of 25 percent among adults is the second-highest in the world, behind only nearby Swaziland.

More than halfway into Lesotho’s health reform, VHWs like Mpeli are helping turn that tide. 

Mpeli visited the Septembers that February morning along with her VHW coordinator, Bonang Motlomelo, and district health staff. Mpeli and Motlomelo sat on a mattress on the floor next to Mafelleng September, while the children played. Talk soon moved to breastfeeding, immunizations and the process for Katleho’s upcoming six-week checkup at Holy Cross.  

While the two younger children were born at the health center, the two older boys were born at Mohale’s Hoek District Hospital, before the reform began.

September said delivering little Katleho and Felleng, now 3, at the closer Holy Cross was much better than delivering at the hospital, where September had to pay for services and care felt less personal. Holy Cross provided baby clothes and a bukana—a small book in which a child’s immunizations, doctor visits and health data is recorded—along with basic care supplies, food, and more, all for free.

PIH’s role in the reform also has included funding cooks, food and materials such as bed linens in maternal waiting homes—where expecting mothers can stay for days or weeks before giving birth safely—in all 72 health centers across the reform’s four districts.

The free services can be invaluable. September said that five years ago at the hospital, when she delivered Teboho, the delivery cost 75 South African rand (about US$6) and a bukana cost 15 rand, among other fees. Hlalele provides for the family by working whatever maintenance and labor jobs he can find in the area, sporadically bringing home about 200 rand.  

That income is stretched thin. Teboho and Felleng would be in preschool if the family could afford to send them, Mpeli said. Instead, Teboho will start primary school next year, when he’s 6.

Mafelleng September held Katleho close that morning, as she talked with health staff. The conversation eventually moved to general chitchat and laughter. Soon, it was time to go.

After many good-byes, the district health staff walked up the steep path and departed by truck, on their way to other homes and then back to Holy Cross. Mpeli also was off to other homes, except by foot, walking as she does every day. She waved as she steadily made her way down the dirt road, wearing a round-brimmed hat and carrying a long umbrella in case the sun became too hot, off to the next home, and the next family.    

Fri, 09 Mar 2018 10:21:34 -0500
#ThanksToHer: Kazakhstan TB Doctor Has Changed Thousands of Lives When asked how many tuberculosis (TB) patients she’s treated over the past 20 years in Kazakhstan, Dr. Zhenisgul Daugarina smiled before giving numbers for just the past three.

"Over the past three years, 268 patients have been discharged from (our) MDR/XDR-TB treatment department, and another 568 have been transferred to other units to continue treatment," she said.

Daugarina was referring to patients with multi-drug-resistant or extreme-drug-resistant TB at the primary TB hospital in Astana, Kazakhstan’s capital.

Extrapolating those numbers over nearly two decades—the length of Daugarina’s career so far—reflects a love for medicine that spans a lifetime.

She was born on May 8, 1974, in the Kazakhstan village of Karasu. Daugarina’s given name translates in Kazakh as "flower of victory," a description that matches her power, unconquerable character and determination.

Her dreams of becoming a doctor began in childhood.  After graduating from secondary school in 1991, in the town of Arkalyk, Daugarina entered the State Medical Institute of the city of Tselinograd, which now is Astana.

Daugarina took the next step in her education in 1997, when she began clinical residency in the institute’s Department of Phthisiology, which oversees treatment of TB of the lung. She began working as a TB doctor in the pulmonary-therapeutic department at the same time.

Daugarina got firsthand experience of one of TB’s deadliest incubators from 1999 to 2002, when she worked as a TB doctor in a Kazakhstan prison. Many inmates in Central Asia and Eastern Europe at that time—and in some cases, still today—faced extremely crowded conditions that were highly conducive to TB transmission, and inmates who developed active TB while incarcerated could spread the disease at home after their release. 

During her time as a prison doctor, Daugarina became particularly interested in how inmates responded to the grueling TB treatment regimen. That study would become a career—in February 2002, Daugarina became head of the MDR/XDR-TB treatment department in the TB Dispensary of Astana. She still holds that position today. 

"Patients are all different,” she said. "Sometimes they are very sick, and some of them die after they are admitted to the hospital. You always try to think that it could be your family member in place of this person. Anyone can get sick.”

Daugarina’s personal attention to care is easy to see in the Astana hospital, where patients often call her, “Mom.” At first, the parental interaction can sound unusual, or like a joke. But it soon becomes obvious that Daugarina really is like a mother to her patients, who sometimes feel lost after being diagnosed with severe strains of TB. Daugarina saves their lives, fates, marriages and more, and asks nothing in return.

The experienced doctor acknowledged the risks and challenging circumstances of her job, but said she couldn’t imagine doing anything else.

"My job is my lifestyle,” she said. “I love my patients…and I would not change my profession."

Yekaterina Sakhabutdinova, PIH endTB Observational Study Manager in Kazakhstan

Mon, 05 Mar 2018 14:16:18 -0500
A Haitian Mother's Lifelong Battle with Leukemia Martha Cassemond curled her petite shoulders forward and shrank into her chair. The 25-year-old patient was shy and reserved. Her hands fidgeted whenever she spoke. Clearly, she was nervous, a normal reaction for someone not used to talking about her battle with cancer.

A visitor wanted to know what Cassemond did each day. She looked down, her hands formed small fists, and she ground them into her eyes. Anyen, or "nothing," she said in Creole, fighting back tears.

Oldine Deshommes knew it wasn’t true. The social worker with Zanmi Lasante, as Partners In Health is called in Haiti, has known the patient for years. She translated the question a second time.

Again, Cassemond said she did nothing. This time, she couldn’t stop tears from sliding down her cheeks and falling on her zebra-print summer dress. That was the problem, she said. She cooked, cleaned, and stayed at home most days with her 2-year-old son, Jamesly Louis-Saint. She just wanted a job to help support her family, and felt ashamed that she hadn't yet succeeded.

Like many cancer survivors, Cassemond has been through a long and painful journey. She was sick for many months, got access to free cancer care through PIH, and gradually felt better. She had been focused on her illness for so long that it was hard to envision a healthy life. It’s a common tale among patients in Haiti, where quality health care is rare, and a cancer diagnosis is typically a death sentence.

PIH has been striving to change that perception since 2010, when Dr. Ruth Damuse, an internal medicine specialist, started providing oncology care at the hospital in Cange. Three years later, she and her team transferred oncology services to the newly finished University Hospital in Mirebalais, where patients arrive from across Haiti with a variety of diseases—from breast and cervical cancer to leukemia and lymphoma. Many patients come in late stages of the disease, but others arrive in early enough stages to hope for a cure.

Dr Ruth
Dr. Ruth Damuse (from left), director of the oncology program at University Hospital, and Ms. Magda Louis-Juste, an oncology nurse, consult on a patient's case. (Photo by Cecille Joan Avila / Partners In Health)

Damuse and two other internists, Dr. Danjoue Satyre and Dr. Joarly Lormil, see new patients four days a week, while three nurses and two auxiliary nurses administer curative or palliative chemotherapy to more than a dozen patients each day in the tidy, but packed, oncology ward. Cushioned recliners and beds are always full, and patients often spill over to a back wooden bench where they sit for hours attached to IVs.

Although Cassemond doesn’t come to University Hospital for chemotherapy, she will depend on its pharmacy for the rest of her life. She visits every three months to pick up her supply of Imatinib, a drug that combats her specific form of cancer—chronic myelogenous leukemia, or CML.



Cassemond was just 12 years old when she got sick. It started with pain in her belly, then her abdomen grew bloated and swollen. A cousin had heard of the PIH-supported hospital in Cange and recommended Cassemond’s family take her there. It was a several-hour car ride from their home in Cornillon, near the border with the Dominican Republic, but she and her father made the journey hoping to find answers.

Dr. Romain Jean Louis, who now directs PIH’s pediatric department at University Hospital, examined Cassemond, took a biopsy, and sent the tissue to Boston for analysis, as there were no reliable pathology services in Haiti at the time. While they awaited results, the preteen remained hospitalized in Cange, and nurses gave her Ibuprofen to manage her pain.

Tests revealed that Cassemond had CML, a rare form of blood cancer for which treatment was not available in Haiti. The drug was relatively new, only a couple years old, and sold for more than $100 per pill in the United States—a hefty price for anyone to pay without the aid of health insurance. The majority of Haitians make less than $2 per day, including Cassemond’s family. There was absolutely no way they could afford the drug.

PIH advocated on Cassemond’s behalf and finally, after 12 months, negotiated a regular supplier of the drug and sent the first shipment to Cange. She was among the first of a growing number of PIH patients who benefited from the medication, which by all accounts was miraculous. Cassemond said her pain disappeared over time, and her belly returned to its normal size. Her energy returned, and she could finally concentrate on something other than survival.

PIH staff found a home for Cassemond near the hospital grounds and helped pay for her schooling. They wanted to keep her close to continue monitoring her condition. Her family visited when they could, and she made the trek back to Cornillon on school breaks.

Cassemond has now been on her medication for 13 years, her only break the nine months she was pregnant with Jamesly to ensure his safe development. She hasn’t noted any side effects. As long as she takes her daily pill on a full stomach, she feels fine. There is no doubt in her mind that the medication keeps her alive.

Cassemond takes a daily dose of Imatinib, shown here. (Photo by Cecille Joan Avila / Partners In Health)
Cassemond stands in her outdoor kitchen, fashioned from poles and canvas. (Photo by Cecille Joan Avila / Partners In Health)

After sharing her story, Cassemond took visitors to her modest, two-room home a stone’s throw from University Hospital. She stepped around discarded plastic bags and tin cans as she wound through her neighborhood, each home in need of paint, a new zinc roof, or other repair.

A group of pint-sized boys ran past, one in nothing but his birthday suit and sucking a green lollypop. Cassemond grabbed the hand of one of the toddlers, whose hair was plaited into spiky braids. She looked back at visitors, as if to say, “This one is mine.” Jamesly clasped his mother’s hand the rest of the way home.

The two rooms were sparsely furnished—a bed and plastic lawn chair in the front, another bed and plastic buckets of clothes in the back. A blue curtain swayed gently at the front door. Cassemond and her partner, Johnson Louis-Saint, couldn’t yet afford a door. Instead, they were making one from a discarded wood sign resting against their front porch.

Cassemond held her son close as he eyed the visitors. He was mischievous, she said, not always this quiet and shy. She smiled as her son stubbornly refused to speak. At home once more, she seemed to soften and relax. She was a mother proud of a wily little son, whom she bathed, clothed, fed, and put to bed every night.

That, many parents would agree, is never nothing.

Thu, 15 Feb 2018 12:49:48 -0500
Marana Toussaint: Mother, Survivor, Advocate in Haiti It all started with a pain in her left breast. She thought the tenderness was just another annoyance of that time of the month, a passing thing really. But then it didn’t go away. And if the discomfort were a symptom of her period, wouldn’t it have been in both breasts?

These thoughts lingered with Marana Toussaint, a sturdy 33-year-old mother of four with an optimist’s outlook on life, as she went about cooking, cleaning, and considering what to do. She spoke with her mother, who recommended she visit University Hospital, Partners In Health’s tertiary facility in their hometown of Mirebalais, Haiti.

On a Monday in January 2014, Toussaint arrived at the hospital for her first appointment with Dr. Ruth Damuse, the director of the oncology program. The composed, gentle-mannered doctor gave Toussaint a thorough exam and detected a small lump in her left breast. She recommended a biopsy, which a surgeon performed the following day, and sent the tissue sample to Boston for testing. Then came the hard part for Toussaint—waiting.

Six weeks later, Damuse received the results and had to break painful news to the young mother: Toussaint had breast cancer. The good news, at least in Damuse’s opinion, was that it was Stage 1 or 2. The doctor most often cared for patients who arrived with advanced cancer. Because Toussaint had detected the lump early, she had a solid chance at a cure.

Zanmi Lasante, as PIH is known locally, began providing cancer care under Damuse’s guidance in 2010 out of Hôpital Bon Sauveur in Cange. In 2013, Damuse and her staff transferred their services to University Hospital, where they have tended to new patients and treated a variety of cancers—from breast cancer and leukemia, to colon cancer and lymphoma.

Breast and cervical cancer diagnoses far outpace any others. More than 50 percent of cancer patients Damuse and her staff care for have been diagnosed with breast cancer.

Toussaint had heard of cancer before, but had never known anyone with it. In her mind, it was a death sentence. And for most people in Haiti, it is. University Hospital is the sole public facility that provides free, comprehensive cancer care. Two other hospitals in the capital of Port-au-Prince—one public, one private—offer oncology services, but cost and access to care remain out of reach for the vast majority of Haitians, who make less than $2 per day.

Damuse recommended that Toussaint undergo a mastectomy to remove the tumor and prevent the cancer’s spread, then take chemotherapy to kill any remaining cancer cells.

It was sobering news. Toussaint had breastfed each of her four children. The surgery would permanently alter her appearance. And she wondered if there was any truth to the Creole phrase, “Venn tete se venn kè.” Roughly translated, it means that veins in the breast directly connect to those in the heart, so a mastectomy would be a sure route to death.

Toussaint returned to her three-room home to consider her options and break the bad news to her husband. What she needed was comfort and support; what she got was rejection. He disapproved of the surgery and eventually left her and their four children. Not long afterwards, he’d moved in with another woman.

Suddenly a single mother with no income, Toussaint turned to her mother and sister for help. She decided to go ahead with the mastectomy and chemotherapy, and she and her children moved temporarily into her family home while she underwent surgery and treatment.

Every two weeks for eight months, Toussaint visited University Hospital and sat for hours in the oncology department, where Damuse and her attentive nursing staff hooked her up to a series of IVs. The chemotherapy left Toussaint wracked by nausea. She vomited and lost her appetite and all her hair—right down to her eyelashes and eyebrows. Many mornings, she suffered from debilitating cramps in her feet that would only release once she began gingerly walking around the house.

Toussaint’s cancer journey affected her children differently, but had the most impact on her oldest daughter, Thamar. Always a solid student, the 15-year-old started to do poorly in school. She hated seeing her mother’s scar, and Toussaint began to shield her chest around her children. The younger ones didn’t completely understand what was going on. Naively, they asked if the breast would grow back. She didn’t want to lie, so she told them that, no, it was not going to grow back.

In January 2015, Toussaint finished her last chemotherapy treatment and was placed on Tamoxifen, a drug that helps prevent the recurrence of her form of breast cancer. It was a major milestone that, unfortunately, she couldn’t celebrate for long.

For three months after finishing chemo, Toussaint didn’t get her period. She knew she wasn’t pregnant, and doubted she was already going through menopause. Again, she turned to Damuse for advice, who referred her to University Hospital’s OB/GYN department for a pelvic exam. The physician found pre-cancerous lesions on her cervix and informed Damuse.

By December, Toussaint was back in surgery to have a total hysterectomy—both her uterus and ovaries removed.

This January, Toussaint marked her third year as breast cancer free. She remains on Tamoxifen, which she picks up at a pharmacy in University Hospital. She will remain on hormone therapy for up to another three years. Whenever she does come, she tries to swing by the oncology ward. On a recent morning, she arrived with her jet-black hair in a neat bob. Her skin shone, her shoulders were set square and strong. She also wore a smile, because, as she said, she didn’t want her face to look blasé.

There is no doubt Toussaint is a survivor. Two cancer diagnoses in as many years and a partner’s betrayal would be earthshattering for many people. She weathered it all, she said, by searching for what made her happy—friendships among fellow cancer patients, reading, and watching television.

She also derived strength from her faith. Toussaint attends a Baptist church in Mirebalais, where she sings in the choir and has often talked to other parishioners about her cancer journey. Not long ago, a fellow choir member spoke to her about a lump she had found in her breast. At Toussaint’s advice, the woman visited University Hospital and learned she had breast cancer.

Toussaint watched as the woman followed a path similar to the one she had recently traveled. Surgery, chemotherapy, hair and weight loss. And then, thankfully, recovery. She shared this story as if it were a minor detail about her day—nothing special.

When told that she saved a life, Toussaint looked surprised, as if the thought had never occurred to her. She didn’t say a word, and just kept smiling.

Thu, 08 Feb 2018 11:01:35 -0500
New Distribution Center, Software Vastly Modernizes Medical Storage in Haiti Around noon one day last November, an industrious group of workers opened boxes within the cavernous, climate-controlled distribution center at Partners In Health’s headquarters in Port-au-Prince, Haiti. A forklift operator hauled in a pallet of supplies to be inventoried and placed on floor-to-ceiling shelves. One story above, more employees plugged away on laptops in a refreshingly air-conditioned space, while colleagues ate leftovers in an adjoining lunchroom.

Nothing about this scene seems extraordinary. That is, unless you consider the immense obstacles formerly faced by employees at Zanmi Lasante, as PIH is known in Haiti.

A temporary plywood warehouse used to be PIH’s central storage facility. Temperatures often exceeded 100 degrees Fahrenheit. There was never enough space, so boxes of new supplies got stacked wherever there was room. Drugs that required temperature control had to be stored in two off-site locations so they wouldn’t spoil. Unloading freight or loading trucks bound for PIH clinics and hospitals took days instead of hours, because there was no shelving or way to track the materials’ location within the warehouse—beyond workers’ collective memory, at least.

All that changed with the new distribution center’s opening last May.

“Day to night—nothing comparable,” Villarson Avignon, supply chain director for PIH in Haiti, said about the difference the building has made for his team.

The new distribution center is a 17,000 square-foot, state-of-the-art facility that has dramatically increased central storage capacity and helped modernize how inventory is maintained. A 14,000 square-foot storage room occupies most of the space, a third of which is climate-controlled for temperature-sensitive medication. Another 2,900 square feet is mezzanine office space. And a covered loading dock that blocks the sun and torrential rains—depending on the season—has enough space to park three shipping containers and three trucks.

While the distribution center was a major milestone, Avignon acknowledged it only stored 60 percent of the total volume of supplies and medicine that PIH facilities required. He and his team still rely on the dilapidated plywood warehouse, built as a temporary solution in 2012, for storage of less fragile stock. He could really use another 17,000 square feet of fortified storage space, and dreamed of the day PIH might reach that goal.

PIH broke ground on the new distribution center in June 2016, and employees watched the two-story structure fill out over the following year. In April 2017, Avignon and his team began moving materials into the nearly finished space and updated the inventory in OpenBoxes, an open source software system that PIH developed and uses in several countries to track the movement and storage of supplies. The Port-au-Prince facility and University Hospital in Mirebalais were the first to use the software, which was updated so that employees could record shelf location. Now, everything—from sterile gloves and lab tests to vitamins and surgical supplies—has an easily trackable location within the distribution center.

Loading Dock
(Photo by Andrew Jones / Build Health International)
(Photo by Andrew Jones / Build Health International)

“Today we know exactly where we put our inventory,” Avignon said. “We can receive two containers and prepare three trucks to make deliveries to sites at the same time.”

Previously, it would take his team two days to unload just one container. Packing trucks for sites also now takes less time, which means necessary supplies get to where they are most needed right away.

“The difference is huge,” Avignon said.

Jesse Greenspan, a senior supply chain manager for PIH in Boston, said PIH imports much of what it needs for health facilities in Haiti. All materials and medications travel, through a hub-and-spoke model, from Port-au-Prince out to PIH’s 12 sites across the Central Plateau and lower Artibonite. More than 400 deliveries arrived at the Port-au-Prince facility in 2017 alone, including 80 40-foot shipping containers each weighing up to 67,200 pounds.

Boston and Haiti staff next want to improve storage and inventory practices at outlying clinics and hospitals. Many of those facilities have depots that need shelving and air conditioning to protect temperature-sensitive stock. And many staff still use paper and Excel spreadsheets for record-keeping. A PIH software engineer is tweaking OpenBoxes to make it more user-friendly and improve the efficiency of data collection.

Once in place, these adjustments will lead to a more efficient distribution system from Port-au-Prince out to PIH-supported facilities. Clinics and hospitals will have the essential medications and supplies on hand. And staff will have the tools they need to place more accurate orders based on reliable data.

These small changes are significant, as was the investment in a state-of-the-art distribution center. Ultimately, they all translate into better and more consistent care for patients.

Thu, 18 Jan 2018 12:39:34 -0500
Ophelia Dahl Tells WBUR We Must Fight "for the Humanity of All People" In an opinion piece for Boston-based NPR station WBUR, Partners In Health Co-founder Ophelia Dahl spoke about her experience working alongside Haitian colleagues in the aftermath of the January 2010 earthquake, and of the remarkable resiliency of Haitians who daily confront disasters—both manmade and natural.

“The perseverance and dignity of Haiti’s people, in the face of unceasing racism, injustice and violence, has strengthened many leaders in the U.S.’s own battles for justice and equity,” Dahl wrote.

Dahl’s comments aired just days after the nation celebrated Dr. Martin Luther King Jr. Day, and last Friday’s eight-year anniversary of Haiti’s devastating earthquake. They also were a response to disparaging comments U.S. President Donald Trump reportedly made a week ago, regarding Haiti and African nations.

The Trump administration announced in November that it was cancelling the Temporary Protected Status designation for Haitians, effectively informing 59,000 immigrants from the Caribbean nation that they must return to their country or face deportation.

The U.S. Citizenship and Immigration Services is expected to announce today how Haitian TPS holders, including those with work permits set to expire within days, can apply to renew that special status through July 22, 2019, the termination date set by the agency.

Thu, 18 Jan 2018 10:41:51 -0500
PIH Making Strides Against TB, Stigma in Kazakhstan Partners In Health and collaborators are taking big steps forward in the fight against tuberculosis in Kazakhstan, where increasing use of the first new TB drugs in decades, an innovative clinical trial, and digital technologies that better connect patients to caregivers all are raising hopes for more successful treatments.

Strong initial results—meaning, more patients getting better—represent a turning point in the former Soviet republic. Kazakhstan lies in the heart of a Central Asian region where severe, multidrug-resistant (MDR) TB is rampant. MDR-TB is a particularly cruel and hard-to-treat version of TB, which became the world’s deadliest infectious disease in 2015. 

Askar Yedilbayev, PIH program director for Kazakhstan and Russia, said more than 6,000 people in Kazakhstan are diagnosed with MDR-TB every year. 

All of them face significant societal hurdles when confronting the disease.

Shynar Maretbayeva, PIH medical coordinator and drug procurement specialist in Kazakhstan, said MDR-TB has been so deadly there, for so long, that many people believe it’s impossible to cure—fueling a sense of hopelessness for those who contract it. Stigma about the disease is so deep-rooted in the country that a diagnosis can leave people socially and professionally ostracized, PIH staff said.

That means successful changes to treatment can have magnified, far-reaching impacts in the vast country of more than 18 million people, bordered by Russia to the north and China to the east. 

Yedilbayev said he sees huge potential in incorporating bedaquiline and delamanid—the first new TB drugs developed in about 50 years—into MDR-TB treatment regimens in Kazakhstan. 

“This is revolutionary, to bring these new drugs to the most desperate patients with drug-resistant TB, and then see their response to therapy,” he said.

PIH’s small Kazakhstan team includes about 20 people, primarily based in Almaty, the country’s largest city. The team is working with Kazakhstan’s government and international aid groups to bolster TB services on multiple fronts, in nine regions across the country. PIH’s work there is supported through two main channels: the Unitaid-funded, multi-country endTB partnership, and USAID’s TB Care II program. 

Significant impacts locally could, ultimately, change how the disease is treated globally. 

“It’s pretty exciting. We’re really going to change the world with a completely novel MDR-TB treatment,” said Dr. Michael Rich, PIH project co-leader and clinical investigator for endTB.

Local action

PIH is working closely with the Kazakhstan Ministry of Health in its fight against MDR-TB. PIH provides technical assistance and management, clinical accompaniment of Ministry of Health care providers, and more—everything except actual treatment, which in Kazakhstan can be given only by nationally certified doctors. 

Expand New Drugs for TB, known as endTB, began in 2015 to foster innovation in places where MDR-TB is deadliest. The $60.4-million project is a partnership between PIH; Médecins sans Frontières; Interactive Research & Development, a global health delivery group; and financial partner Unitaid, a World Health Organization (WHO) partnership that invests in the international fight against TB, HIV, and malaria. 

The project aims to enroll at least 2,600 patients in 17 countries on new TB drugs, while meticulously documenting the drugs’ effectiveness and safety, by 2019. Yedilbayev said the partnership had enrolled nearly 1,400 patients across 15 countries as of September, including 320 patients in Kazakhstan. 

“Basically, these were all patients that were just incurable,” said Dr. K.J. Seung, co-leader of the endTB partnership.

Those outcomes are changing. 

“Many patients who were previously considered untreatable are showing culture negativity, which means they are responding to therapy,” Yedilbayev said.

patient care
Nurse Vera Rastrygina draws a blood sample from MDR-TB patient Nikolai M. at the regional TB clinic for the region of Akmolinsk, Kazakhstan, in September 2016.   (Photo by Askar Yedilbayev / Partners In Health)

‘Prepared to die’

One such patient is a 29-year-old Kazakhstan man, given the pseudonym Dmitry Makarov. 

PIH data manager and drug safety specialist Yekaterina Sakhabutdinova said Makarov was diagnosed with TB in 2013, after likely contracting the disease at home, from his stepfather. Initial treatments failed because of Makarov’s resistance to first-line antibiotics, and doctors soon gave him a diagnosis of MDR-TB. 

Makarov was unemployed, lived with his mother, and had behavioral and psychological disorders along with substance addiction, Sakhabutdinova said. The patient argued with health care workers and resisted the painful, lengthy treatment, which he could not complete before he was discharged from hospitalization. 

His condition worsened and his MDR-TB developed into extensively drug-resistant TB, or XDR-TB, an even more severe strain of the disease. By March 2016, the only care Makarov was getting was palliative. 

“He was prepared to die,” Sakhabutdinova said.

Regional crisis

Makarov’s case reflects a regional MDR-TB crisis that Seung said goes back decades, and extends far beyond Kazakhstan’s borders. 

The fall of the Soviet Union in the early ‘90s undermined state-funded health care systems across the region, drained stocks of medicines, and left countless patients without care, creating conditions that exacerbated a devastating scourge of MDR-TB. 

Carole Mitnick, PIH’s director of research for endTB, added that the regional epidemic also “is fueled by the revolving door of the prisons.” Most inmates face extremely crowded conditions that are highly conducive to TB transmission. Inmates who develop active TB upon returning home can then spread the disease there, she said.

Seung said that while, “every part of the world has different sorts of drivers of the epidemic,” prison conditions and recent history in Russia, Central Asia, and Eastern Europe have raised particular concerns in the global health community about MDR-TB in the region. 

In its Global Tuberculosis Report for 2016, the World Health Organization (WHO) said about 25 percent of new TB patients in Kazakhstan were diagnosed with MDR-TB, and more than 40 percent of patients who initially were diagnosed with TB then progressed to MDR-TB. 

The WHO listed those figures for 30 countries with high burdens of MDR-TB. Among those countries, Kazakhstan’s 25-percent figure was third-highest, tied with Ukraine. The 40-percent figure was the ninth-highest on the WHO list, below neighboring or nearby countries including Uzbekistan, Tajikistan and Kyrgyzstan. 

The only country that had a similarly high rate of TB patients who progressed to MDR-TB, but was not in Central Asia or Eastern Europe, was Somalia, at 47 percent.

patient care
PIH Kazakhstan data manager pharmacovigilance specialist Yekaterina Shahabutdiniova uses an i-STAT blood analyzer procured through the endTB project, while working in the regional TB clinic for Akmolinsk, Kazakhstan, in September 2016.     (Photo by Askar Yedilbayev / Partners In Health)

‘Truly miracles’

To combat the crisis, PIH and collaborators are studying novel treatment methods in Kazakhstan.

Mitnick, also an associate professor of global health and social medicine at Harvard Medical School, said the endTB partnership is tracking a group of Kazakhstan patients, for example, who are taking one of the new drugs as part of the standard MDR-TB regimen. 

Mitnick said Kazakhstan also is at the forefront of studying the use of both new drugs— bedaquiline and delamanid— together. She said 80 percent of 15 patients given both drugs tested culture-negative for TB after six months, indicating a strong response to treatment, and did not see worse side effects than what’s common from traditional regimens.

“We didn’t see any increase in toxicity in new patients who got both new drugs, compared to people who only got one of the new drugs,” Mitnick said. “These are really, really sick people, who get both drugs together.”

Seung said doctors treating people for TB usually can see indicators of success, or failure, after six months. 

“It’s still a little early, because treatment is long,” Seung said. “But we’re getting some really good results on the first six months. Really, that first wave (of data) is just starting to come out.” 

Rich said conversion rates often hovered around 23 percent for patients with XDR-TB, before the new drugs were introduced. He described the new drugs as “truly miracles” for patients who had not responded to treatment with second-line drugs in the past. 

Standard treatment can include daily injections for several months and about 14,600 pills over two years, often with grueling side effects. 

The endTB project includes a trial of new, shortened regimens that contain one or both new drugs and require no injections. About 750 patients across six countries will participate in the trial. 

Mitnick and Yedilbayev said three patients have been enrolled in Kazakhstan since August, on nine-month regimens. 

“It’s the first trial that PIH has ever conducted that really holds the potential to revolutionize treatment for MDR-TB,” Mitnick said.

Rich noted that while about 600,000 people around the world contract MDR-TB every year, and while MDR-TB likely kills about 200,000 people every year, “there’s never been a trial to see which (treatment) regimen works better than another regimen.”

There’s an app for that

Kazakhstan’s 320 endTB patients, overall, represent the largest cohort of the 17 countries in the endTB partnership. But that number is still insufficient in Yedilbayev’s view. 

"It's not enough—there is a need to scale up,” Yedilbayev said, adding that PIH has a goal of about 600 patients in the country. “The Ministry of Health has agreed to expand access to new regions,” in western, northern, and southern Kazakhstan, he added.

That expansion will have PIH fighting TB in about 65 percent of the country, or across nine of Kazakhstan’s 14 oblasts, which are administrative regions similar to U.S. states. 

Reaching patients in all of those areas will be a herculean task. The high numbers of pills and check-ins that MDR-TB treatment requires can create big hurdles for patients, who often can’t travel to see nurses every day and sometimes stop participating in treatment because of frustration, fatigue from side effects, or insurmountable logistics. 

Project Coordinator Nataliya Morozova (left) and Aigerim Yekeubayeva discuss Yekeubayeva's long history with tuberculosis and how she was responding to a new drug regimen that included bedaquiline, during a June 2016 checkup in Almaty, Kazakhstan. (Photo by Askar Yedilbayev / Partners In Health)  

Genevieve Roge, cross-site project manager for PIH STRONG—or, Shorter Tuberculosis Regimen and Operationalization of New Guidelines—is supporting the Kazakhstan STRONG team, which is dedicated to addressing that challenge via a common technology: mobile applications. 

She said the STRONG project is testing digital technologies in Almaty, including an app that will give patients instant connections to caregivers. The app will enable patients to check in about medicines and treatment without traveling, and get reminders about upcoming appointments. 

“I think the most exciting thing for PIH STRONG-Kazakhstan is that we have enrolled 15 patients in this pilot,” Roge said. “It’s very patient-centered, and very user-friendly.”

Roge said the app is intended to make the grueling, nine- to 24-month slog of MDR-TB treatment more bearable. 

It also represents a new component of PIH’s longstanding patient-accompaniment ethic, which has defined PIH’s work for years, at sites around the world and in collaboration with national governments. Accompaniment brings health workers to patients’ homes to provide support and monitor progress outside of hospital settings.

Yedilbayev said MDR-TB teams in Kazakhstan, for example, also use customized accompaniment methods such as video-observed therapy—through Skype, Viber, and WhatsApp—according to what works best for different patients. 

Personal outreach has been potentially lifesaving for patients including Dmitry Makarov, the 29-year-old man who was prepared to die of his disease.

Sakhabutdinova said the daily personal contact helped Makarov adhere to therapy. He showed significant improvement within three months and is on the way to recovery, she said. 

His story is just one example of endTB’s impacts, and of its potential as studies develop in coming years. 

Rich cautioned that the first full set of solid data from the new TB drugs likely won’t be ready until 2022. In the meantime, conversations about work in Kazakhstan already are making waves. 

“We’re getting so much knowledge from using the new drugs, under World Health Organization guidance,” Rich said, adding that endTB could begin influencing global guidelines as early as this year. “And a lot of that is due to the work coming out of Kazakhstan.”

Wed, 17 Jan 2018 14:11:44 -0500
PIH Stands with Haiti on Earthquake Anniversary Eight years after nearly 300,000 people lost their lives and hundreds of thousands more were injured when a catastrophic earthquake struck Haiti, Partners In Health stands with the country in solidarity, support, and remembrance.     

The magnitude-7.0 earthquake struck Haiti on Jan. 12, 2010, with an epicenter about 15 miles west of the capital, Port-au-Prince.

Zanmi Lasante, as PIH is known in Haiti, has been providing health care in Haiti’s Central Plateau and the lower Artibonite for 33 years. PIH leadership and staff provided emergency care in the earthquake’s aftermath, attended to the mental health needs of the traumatized, and helped families get back on their feet. Staff also were there when cholera infected thousands of Haitians just 10 months after the quake, and they continue to battle the ongoing epidemic, which has killed more than 9,700 people and sickened 815,000.

Meanwhile, immigration debates continue to place the lives of tens of thousands of Haitians in turmoil. 

In the wake of the 2010 disaster, then-President Barack Obama’s administration granted protection from deportation to 59,000 Haitian nationals in the U.S. who fell under a classification called Temporary Protected Status, or TPS. The federal government regularly renewed their status in following years.

That practice changed on Nov. 20, 2017, when President Donald Trump announced that his administration would not renew the TPS designation for Haitians, claiming that the “stability and quality of life” in Haiti had improved enough for them to return. The administration gave affected Haitians 18 months to leave the country, or be deported. The news sent ripples of fear through Haitian communities in the United States, and reverberated back home.

As Haiti continues to build its health system, a longstanding PIH leader there said the country is not prepared to welcome back the tens of thousands who sought shelter in the U.S. after the disaster.

“The country is not ready to receive 60,000 people and won’t be ready within the next year,” says Dr. Fernet Leandre, co-executive director of PIH in Haiti.

Leandre says health care is one example of how Haiti is not yet ready to support the return of post-earthquake migrants.

Haiti devotes less than 5 percent of its national budget to the health sector, leaving it grossly underfunded. PIH facilities and staff levels are designed to serve the 1.2 million people neighboring its 12 clinics and hospitals, but staff actually care for a much larger number of patients, many of whom travel from all over the country to receive services.

Haiti’s public hospitals and clinics “are not ready to provide basic health care to more people,” Leandre says. Publicly available specialized care—such as pediatrics, cardiology, or oncology—does not even exist in other parts of the country beyond the capital. “This is why people keep coming to our facilities.”

The 2010 earthquake wasn’t the only natural disaster to hit Haiti in recent years. Hurricane Matthew swept across the country’s southern claw in October 2016, completely wiping away homes, livestock, and crops in a span of several hours.

The devastation left lasting scars. The south provides a third of Haiti’s agricultural produce, Leandre says. Hundred-year-old fruit trees cannot be replaced in a day, and fishermen who lost boats to the storm can’t afford to replace them.

“It will take a decade to see the level of the production from the south getting back” up to normal, Leandre says.

That means there will be less food to go around in a country that already struggles to feed its people. PIH enrolled more than 9,000 new cases of starving children in its malnutrition program in 2016 alone.

Meanwhile, cholera remains an ongoing battle. Since the outbreak in October 2010, PIH has treated more than 180,000 people. That number continues to grow daily.

PIH and Haiti’s Ministry of Health have also partnered on multiple occasions to vaccinate the population against cholera: 50,000 people north of St. Marc in 2012, 800,000 people in the south in 2016, and 90,000 in Mirebalais at the end of last year.

“With the rainy season, we always have a spike” in the number of patients arriving for care, Leandre says.

That spike occurs even though many Haitians have been exposed to the disease for nearly eight years. Imagine what might happen, he says, if 60,000 Haitians—who have never built immunity to the bacteria—arrive in the country next year.

“Those people are not protected or immunized,” he says. “It will be a big risk until we can eradicate cholera.”

Tell President Trump to support Temporary Protected Status for Haitians ▸

Thu, 11 Jan 2018 09:06:57 -0500
Malawi Program Making GAINs in Maternal Health Clinicians at Partners In Health-supported facilities around the world provided more than 30,000 safe, facility-based childbirths in 2017, according to year-end estimates—and thanks to a growing collaboration, more and more of those safe childbirths are happening in a rural district in Malawi. 

Nurse midwife Maria Openshaw said Global Action to Improve Nurse Midwifery & Care, or GAIN, is a mentoring program designed to improve maternal and child health care in vulnerable populations, by training and empowering nurses and midwives.

The GAIN work that Openshaw is helping lead in Neno District, Malawi, is PIH’s first program in the country focused on building clinical capacity for nurses and midwives, who provide the majority of care for women in labor. The program is a partnership between the Center for Global Health at the University of California-San Francisco’s School of Nursing; Abwenzi Pa Za Umoyo, as PIH is known in Malawi; and Malawi’s Ministry of Health. 

“We’re really excited about this effort,” PIH Director of Nursing Cory McMahon said. “We’re integrating leadership, management and quality improvement with pediatric and maternity skills, for a more comprehensive approach to improving clinical practices and systems.”

The need is dire. Malawi had 634 maternal deaths per 100,000 live births in 2015, according to the World Health Organization, which ranked Malawi’s rate as the 13th-worst in the world. The WHO ranked the U.S. as the 138th-deadliest country to have a baby that year, for comparison, with 14 deaths per 100,000 live births. 

Chifunga Health Center nurse midwife Chipo Kamoto (left) and Luwani Health Center nurse midwife Luka Malla (right) participate in a training activity at Neno District Hospital in Malawi in September. (Photo by Sharon Rose / UCSF SON)

Openshaw said maternal deaths account for 16 percent of all deaths of women in Malawi, and infant mortality stands at 42 deaths per 1,000 live births.

On the brighter side, Openshaw said 91 percent of pregnant women in Malawi are now delivering their babies in a health facility—much safer than delivering at home—and 95 percent of new mothers are getting prenatal care. 

PIH supports two hospitals in Neno District, along with 12 district health centers. Openshaw said midwives attend the majority of deliveries at all those facilities. 

“Midwives are kind of the drivers of the maternity system in Malawi,” Openshaw said. 

But understaffing is a constant concern, she added. Midwives in Malawi have numerous additional responsibilities—everything from stocking medicines to cleaning delivery wards—that wouldn’t be part of their jobs if they were in the U.S. 

“It’s a very broad job description,” Openshaw said. 

McMahon said the GAIN program focuses not only on training, but also on applying lessons in real patient settings—meaning, at bedsides—and addressing systemic gaps that affect clinical care. PIH and the University of California-San Francisco developed the program through extensive focus groups and local assessments, engaging clinical leaders and nurses with PIH and the Ministry of Health to specifically fit the context of health care in Malawi. 

Fifteen nurse midwives are in the first GAIN cohort in Neno District. Another cohort will start the program in March. 

Openshaw said she and Esnath Kapito, a Malawian nurse who also teaches at a nursing school, do side-by-side clinical mentoring with the 15 midwives, along with clinical case reviews, birth monitoring, and more. 

The program’s impacts are extending well beyond Malawi. 

Viola Karanja, director of nursing for PIH in Liberia, traveled to Malawi in September to join a training on maternity care, for example. McMahon said Karanja already is implementing key concepts from the training in maternal health initiatives she’s leading in Liberia.

One of those concepts is Kangaroo Mother Care, which involves immediate skin-to-skin contact between mothers and newborns. Kangaroo care helps regulate newborns’ temperature and vital signs, and supports breast-feeding. The practice is widely used in Malawi for preterm babies. Full-term babies, however, are routinely separated from their mothers and swaddled immediately after birth, which can lead to cold stress and even hypothermia. 

 Nurse Gladys Ntonya helps Chikondi care for her newborn baby Chifundo, while mother and child were staying in the Kangaroo Mother Care room at Neno District Hospital in southern Malawi.     (Photo by Lila Kerr / Partners In Health)

In the September training, GAIN mentors discussed the benefits of kangaroo care for all newborns, not just those born early. Openshaw said she soon saw results. 

“When I came to the Neno District Hospital Labor Ward in the weeks after the training, I saw our midwife trainees already starting to use skin-to-skin for prevention and treatment of hypothermia in term babies,” Openshaw said. “In turn, Kangaroo Mother Care is not routinely used in Liberia, so Viola Karanja was able to learn the technique from our Malawian colleagues, and now has plans to institute Kangaroo Mother Care in Liberia.”

Dr. Emily Wroe, PIH’s chief medical officer in Malawi, said GAIN is having broad impacts on how nurses are trained in Neno District. Training models across the country traditionally have focused on classroom time, she said, with little follow-up in clinical care. She said the GAIN program’s hands-on support and mentorship is creating a “special and unique” program. 

“We accompany patients,” Wroe said, citing a fundamental PIH ethic. “This is like accompanying staff.”




Mon, 08 Jan 2018 10:35:31 -0500
A Mission to Stop Cholera in Haiti A soft rain fell outside University Hospital in Mirebalais, Haiti, as the courtyard filled with people on a Wednesday morning. Inside, the day’s first patients sat beneath ceiling fans that pushed thick air around a dim waiting room in the 300-bed teaching hospital built by Partners In Health. They watched as dozens of doctors, nurses, and community health workers, wearing bright red baseball caps and pastel-colored T-shirts, buzzed in and out of a nearby storage room and up and down the hall.

It was November 15, a highly anticipated day for Haiti’s Ministry of Health and Zanmi Lasante, as PIH is known locally. In collaboration with Massachusetts General Hospital's Center for Global Health, they were launching an ambitious cholera vaccination campaign that aimed to cover the entire commune of Mirebalais, or roughly 100,000 people. Each resident was to receive two doses of the vaccine over the course of a month, along with interventions to help treat drinking water at home, and educational messages about good hygiene and sanitation.

Just before 8 a.m., most teams had gathered what they needed: gray coolers filled with vaccine vials, registers to record names, and thick stacks of green vaccination cards they would fill out and hand to patients as a personal record—and reminder—of their two doses.

A supervisor called roll in Creole, then sent teams on their way.

Moun ki genyen bagay yo, ale!” Or, “Go, if you have everything!”

The vaccinators streamed out of the waiting room to set off on foot, climb into heavy-duty pickups, or hop on motorbikes—three to a seat—for the long days ahead.

 Jean Roland Doux (seated), a vaccinator in one PIH-supported team, fills out a patient's vaccination form at the Church of the Nazareen in Penier Siwal . (Photo by Cecille Joan Avila / Partners In Health)

A plague descends

The Aba Kolera, or Stop Cholera, project has the lofty ambition of eliminating the transmission of cholera in central Haiti through hygiene promotion, vaccination, and access to clean water. It’s an innovative approach to address the immediate burden of cholera. Building and maintaining a nationwide water and sanitation system is an important goal that PIH supports, but one that remains some time off.

The 66 vaccination teams were to visit 84 schools, 59 churches, and five health centers in a week’s span, then methodically move door-to-door throughout the entire commune of Mirebalais to ensure complete coverage. The task was ambitious. But so was the team.

“We are trying to change the status quo on cholera in Haiti, and globally,” says Dr. Louise Ivers, PIH’s special advisor, executive director of the Center for Global Health at Massachusetts General Hospital, and the Aba Kolera project’s program director.

Haitians never knew cholera before 2010. Shortly after the devastating earthquake in January that year, the United Nations brought in a group of peacekeepers from Nepal—where the capital, Kathmandu, had recently suffered an outbreak of the disease—and set them up in a camp near Mirebalais with poor plumbing. Contaminated sewage leaked into a tributary of the longest river in Haiti, the 200-mile Artibonite, which is a water source for countless Haitians.

Dr. Myrtha Thermidor, MOH's deputy director of the general vaccination program, pours a vial of cholera vaccine into a patient's mouth at the public school in Fond Michel. (Photo by Cecille Joan Avila / Partners In Health)

The result was a cholera epidemic of historic proportions. Since October 2010, more than 9,700 people have died and at least another 815,000 were sickened from the disease. Cholera causes such severe vomiting and diarrhea that—if left untreated—a patient can die from dehydration within 24 hours. Haiti’s epidemic has been devastating, and is second only in size and severity to the one currently ravaging isolated, war-torn Yemen.

Battling a new disease

PIH was among the outbreak’s first responders in Haiti. Within several months, staff set up 11 cholera treatment facilities throughout the Central Plateau and immediately began treating the sick. More than 3,300 community health workers were trained to identify symptoms and triage neighbors to nearby health centers. Since those early days, PIH has treated more than 180,000 people. And while the number of sick now pales in comparison to 2010, staff still treat patients for cholera today.

Doctors, nurses, and community health workers also work to prevent cholera infections by teaching about proper water and sanitation practices and vaccinating as many patients as possible, which boosts immunity for up to five years. In 2012, PIH vaccinated 50,000 people in communities north of St. Marc. And following Hurricane Matthew in 2016, leaders traveled to the south to help the government vaccinate 800,000 residents.

When PIH proposed the most recent campaign, Haiti’s political climate was hardly ideal. Former President Michel Martelly left office in February 2016, with no clear successor following a contested election. A series of interim governments passed through Port-au-Prince until President Jovenel Moïse was elected in November 2016, and took office in February.

Crier resting
 Joel Israel (center) uses a bullhorn to call residents to a church next to the St. André School in Trianon, where one PIH-supported team is providing cholera vaccinations. (Photo by Cecille Joan Avila / Partners In Health)

Dr. Ralph Ternier, director of community care and support in Haiti, and his team had been waiting to start the Mirebalais vaccination campaign since the beginning of 2017, following national committee approval that the city was a cholera hot spot. The delays were stressful. They made connections with each administration and pushed the urgency of the situation. After all, this was part of the national plan to vaccinate the Central Plateau and lower Artibonite. Plus, the nearly 270,000 doses of Shanchol and Euvichol issued from the global stockpile had an expiration date. If they were going to launch this operation, they had to act fast.

Their pleas finally gained ground and, the last week of October, Ternier got a green light from the government. He and his team swung into action—calling on dozens of PIH and government staff, gathering supplies, printing banners, and pushing out radio ads to publicize the campaign. They knew they faced obstacles, such as rough terrain in the middle of rainy season and a mostly rural population. Yet they also knew the cost of not trying—what PIHers call “stupid deaths” from diarrheal disease.

“I strongly believe we are doing the right thing for the people, so we cannot fail,” Ternier said on the eve of the most recent campaign’s launch. “We cannot fail. We cannot.”

Launch day

After sending off the last vaccination teams from University Hospital, Dr. Maurice Junior Chery, assistant coordinator of the cholera program, tapped his smartphone en route to his first stop. As one of 10 supervisors, his job was to check stock and supplies, ensure vaccinators followed protocol, and investigate any reports of patient side effects.

The PIH pickup zipped by cement-block houses with zinc roofs, roadside lottery stands, and makeshift barbershops and slowed at the sight of a campaign banner draped above the road beside the clinic in Sarazin. A couple dozen men and women sat patiently on benches under an awning to escape the gentle rain. The group needed registers, pens, and pencils, and so hadn’t been able to start work. Chery took note and passed word along to the rest of the supervisors. Someone, he assured the group, would arrive soon with supplies.

Heading back toward the city, Chery and his team pulled over at a roadside store, where vaccinators had set up shop under an awning. At least 20 people crammed into the tight space, most of them schoolchildren in tan-and-white-checkered shirts.

Blondine Tirogène pried the aluminum foil from a vial and poured the milky substance into a woman’s mouth. Her colleagues took down patient names, handed each person a green vaccination card, and told them to keep it safe. They would be back in two weeks to administer the second, and final, dose.

 Dr. Maurice Junior Chery, assistant coordinator of PIH's cholera program, copies patient information from a vaccination card to an official register at the public school in Fond Michel. (Photo by Cecille Joan Avila / Partners In Health)

Everything running smoothly, Chery and his team hopped back in their pickup and headed to the other side of Mirebalais. They veered off the main road to pass sugar cane fields and banana trees, rumbled through a small stream, and climbed up a chalk-white hill to the public school in Crete Boule.

But no one was there, except for the team’s leader, Jomert Lapointe. School was closed due to the rain, so his team was searching for an alternative vaccination spot. (Such closings are common in the wet season, as officials don’t want schoolchildren fording rain-gorged streams.) Chery’s team unloaded supplies into the storage room and headed back to town.

That night after dinner, Ternier sat with Chery and other supervisors, including Dr. Kenia Vissieres, director of the cholera program, Dr. Myrtha Thermidor, the Ministry of Health's deputy director of the general vaccination program, and Miss Esther Mahotiere, the nutrition program coordinator. They rehashed the first day, discussing minor hiccups and sharing early victories.

Some vaccinators had trouble opening vials. Others had used pencils instead of pens to fill out vaccination cards—a problem, because the information could rub off more easily. Despite these small challenges, they had already reached thousands of people.

Pa pike bebe

The next day dawned cloudy, yet dry—a good sign for turnout. The first stop for Chery and his team was the public school in Fond Michel, where they moved tables under the awning of a dilapidated building. Children dressed in checkered white-and-navy shirts and navy slacks or skirts gathered in pockets around the schoolyard and stared at the visitors. They laughed and spoke loudly, interrupting the one teacher attempting to give a lesson inside.

Rose Marie Renati, a PIH health agent, lined up the children. The first ones put on brave faces, despite worry lines creasing their brows. They each gave their name, age, and address, then tilted their head back to receive the salty tasting vaccine.

Kids in line
 Thermidor carefully pries the seal from a vial of cholera vaccine as children wait their turn at an orphanage in Fond Michel. (Photo by Cecille Joan Avila / Partners In Health)

Gade sa,” said Thermidor, handing one boy his vaccination card and telling him to put it in his backpack.

Having seen everyone, Miss Ketty Tout-Puissant, PIH’s nurse coordinator for community activities in Lascahobas, gathered the children into a classroom to teach a catchy anti-cholera tune. Some children continued singing the chorus even after the vaccinators had packed up.

The team’s next stop was a nearby orphanage. Two caretakers and 30 children emerged from ramshackle buildings, some in worse shape than others, to greet the visitors. As the nurses and doctors set up their supplies, Driver Holiere Robuste organized the children into a line and coaxed the youngest ones to join.

Pa pike bebe, pa pike,” said Robuste. Or, “It’s not a shot, baby. It’s not a shot.”

After the last child was vaccinated, and a few neighbors as well, Renati placed the children in a circle around a five-gallon bucket of water and a bar of soap. She picked a young girl from the crowd and both methodically washed their hands, while Renati preached the benefits of good hygiene. Each child then took turns sudsing up. They giggled as bubbles slipped off their slick hands.

The rest of the afternoon flew by. The team stopped by a church in Fond Cheval, where Tout-Puissant advised vaccinators to write only in pen, not pencil. Then it was off to a church neighboring the St. André School in Trianon, where schoolchildren received their vaccinations alongside a stone altar, under garlands of fake flowers. At Dramane, young and old formed a line that curled around a mud-and-stone house abutting the dirt road.

Past sugar cane fields and rolling hills, a crowd filled the Church of the Nazarene in Penier Siwal to wait for a vial from their neighbor, Jean Roland Doux—an elderly man who embraced his job with efficiency and panache. Loudly, he called out patients’ names and emptied vaccine into their mouths with a flourish.

At each rally point, residents arrived en masse and waited patiently for their turn. They knew the importance of the cholera vaccine; surely, many of them had lost friends and family to the horrible, and completely preventable, disease.

By the campaign’s last day, the team had reached more than 88,000 people. It was a major milestone, but no one could celebrate quite yet. They had another round to go.

On December 10, the same crew of vaccinators grabbed supplies, coolers, pens and pencils and repeated their first performance for another seven days. When all tallies had been counted, the team had twice vaccinated at least 80,000 people—or nearly the entire commune of Mirebalais.

Ternier and his crew had done the right thing. They had persisted, despite the obstacles. They did not fail their mission. They did not.

Rose Marie Renati, a PIH health agent, teaches children at an orphanage in Fond Michel how and why they should thoroughly wash their hands with soap and water. (Photo by Cecille Joan Avila / Partners In Health)


Thu, 21 Dec 2017 15:46:14 -0500
2017: The Year in Quotes Inspiration in a sentence—that’s what we were looking for as we sifted through our stories about Partners In Health in 2017. Like any round-up, this collection of quotes falls short of conveying the breadth and depth of all that was accomplished this year. PIH staff saw 1.5 million patients in clinics and hospitals, never mind the hundreds of thousands consulted in their homes. But hopefully these few quotes, chosen for their pithiness, hint at one important aspect of the work: our deep gratitude for the chance to serve such amazing people.


"Human beings to me are not more or less human depending on the nation state in which they were born. I want everyone to have access to health care."

Dr. Joia Mukherjee, PIH’s chief medical officer, on the thinking behind her recently published undergraduate textbook, An Introduction to Global Health Delivery 


"Let us encourage the women in our lives to come stay at the birth waiting home to have a safe birth!"

—PIH staff in Sierra Leone announcing on local radio that pregnant women nearing their due date can stay in free housing near the local clinic


"While these emergencies serve as sharp reminders of the fragility of human life and that of marginalized communities, I could not emphasize enough how the impoverished people of this world live in a constant state of catastrophe. More than the occasional natural disaster, these communities are faced with adversity every day as they struggle to find the means to survive."

Dr. Hugo Flores, executive director of PIH in Mexico, following the earthquake that struck the country in September


"At night, the river makes noises and they both cry and pray for Maria’s pains to go away."

Carmen Contreras, director of intervention projects for PIH in Peru, on a couple who lost their home in floods last March and whom PIH helped get access to health care


"When they act rascally, it’s a good sign."

Esther Mahotiere, nutrition program coordinator for PIH in Haiti, on seeing a formerly malnourished boy playing near his home


"We have motivated, well-trained, and decently supplied staff who reach from the Dominican border to the coast of St. Marc, and that just wasn’t here 30 years ago."

Dr. Paul Farmer, a PIH co-founder and chief strategist, on the organization’s progress in Haiti


"You hear sirens from ambulances passing much more frequently than normal, and you know those ambulances are unlikely to be carrying the sick."

Jon Lascher, executive director of PIH in Sierra Leone, on the floods and landslides that hit the country in August


"The more our students are spread across the world to serve vulnerable populations, the more we will be able to change the world."

Dr. Agnes Binagwaho, vice chancellor of PIH’s University of Global Health Equity in Rwanda, on her hope for graduates


"One of my biggest dreams is to open a prosthetic clinic for amputees in Rwanda, and it would be nice to do that with PIH."

—Recent college graduate, former MIT intern, and prosthetic designer Claudine Humure, whom PIH helped survive bone cancer as a teen in Rwanda


"No matter what comes my way, no matter how I cry, one thing I know that is definitely in my heart, my tomorrow must be greater than today."

—a gospel choir singing at the graduation of 15 nurses who completed an advanced training program in Liberia, with PIH’s assistance


"There’s nothing better than patients telling you they’re happy."

Matumisang Khasipe, a nurse midwife for PIH in Lesotho, on why she loves her job

Mon, 18 Dec 2017 10:50:31 -0500
New Year, New Maternity Ward in Liberia Every month, at least one or two pregnant women travel great distances—often spending hours bouncing down dirt roads on the backs of motorcycles—to arrive at the gate of Pleebo Health Center in southeast Liberia. The Partners In Health-supported center is in Maryland County, one of the poorest places in the world, with 84 percent of people unable to adequately feed, clothe, and shelter themselves. “They come because they hear the care in Pleebo is good,” says Viola Karanja, director of nursing for PIH in Liberia.

That care soon will be even better. In order to accommodate growing demand, the team is poised to build an addition to the nine-bed facility. “If we expand, the numbers of deliveries will definitely double. Well, maybe not double, but definitely increase,” Karanja predicts. “‘It’s clean, no one is sharing a bed, it’s well run’—one mother will tell another, will tell another.”

Pleebo Health Center was one of PIH’s first infrastructure projects after the government of Liberia invited the nonprofit organization to work in the country’s remote southeast. PIH shuttered the old health center in town in 2015 and flung open the doors to the new one later that year. In just the first month, clinicians saw 2,019 people. 

Successive renovations and improvements have followed. Staff have been trained. HIV and tuberculosis programs have dramatically expanded, and PIH’s Liberia team has incorporated new programs, such as mental health care. All the while, the number of expectant mothers coming  to deliver has increased, from 512 in 2015 to 938 in 2017. 

A mother hasn’t died in childbirth at Pleebo for a year and a half—85 percent more successful than the national

average—but crowding has become an issue. Demand now is so high that, after childbirths, mothers and their newborns sometimes end up on mattresses on the floor. There simply aren’t enough beds in the post-partum ward. A new, roughly 3,000-square-foot maternal child health center will be able to comfortably accommodate roughly twice as many women and newborns.

“Everybody is important,” says Karanja, but I prioritize mothers who are pregnant.

Mon, 18 Dec 2017 10:39:31 -0500
"New Yorker" Celebrates PIH Co-Founder Ophelia Dahl as World Changer Partners In Health is proud to announce that Ophelia Dahl, a co-founder and current board chair, made The New Yorker's end-of-year World Changers list for her decades-long work building health care systems in some of the poorest places around the world.

The New Yorker's Ariel Levy profiles Dahl in the magazine's December 18 & 25 issue. The annual list celebrates people and entities who are making their mark on the world in an array of areas, from music, technology and television to climate change and democracy—and, in Dahl's case, global health. 

Levy carefully weaves the personal story of Dahl, the second-youngest child of author Roald Dahl and actress Patricia Neal, with the evolution of PIH. Dahl co-founded PIH 33 years ago with Dr. Paul Farmer, Dr. Jim Yong Kim, Todd McCormack, and Tom White.

"Dahl took over as executive director of P.I.H. in 2001, working out of a room at Harvard Medical School with eight employees and an annual budget of twelve million dollars," Levy writes. "During the fifteen years that Dahl was executive director, P.I.H.’s revenue increased tenfold."

Levy's profile details how Dahl's dedication to helping others began early in her life.  

Dahl visited Haiti for the first time as a teenage volunteer and discovered a world completely unlike the one in which she was raised, in the English countryside of Buckinghamshire. In her article, Levy writes that "most people encounter poverty and then relegate the knowledge of others’ misery to the periphery of their mind. Dahl had a different experience."

Dahl told Levy: "To have seen this and to not do anything, I knew wasn’t an option. I would never sleep well again."

Since those early days, Dahl has helped mold PIH's unique model of health care delivery, focused on providing a "preferential option for the poor."

As Levy writes: "Emergency intervention is distinctly not P.I.H.’s project; in contrast with organizations like Médecins Sans Frontières, which specialize in addressing intense crises, P.I.H. works to remake entire health-care systems, by collaborating with local governments. Its commitments are long-term and large in scale...P.I.H. has been in Rwanda for twelve years, and in Haiti for more than thirty."

PIH now operates in 11 countries around the world, providing maternal and child health services, treating patients with deadly infectious diseases such as HIV and multidrug-resistant tuberculosis, and tending to patients with chronic illnesses, such as diabetes, hypertension, and depression.

In the article, Dahl says she is "unfailingly optimistic" about PIH's future.

"I think to not be optimistic is just about the most privileged thing you can be. If you can be pessimistic, you are basically deciding that there’s no hope for a whole group of people who can’t afford to think that way,” Dahl says. 

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Mon, 11 Dec 2017 10:30:11 -0500
A Global Health Primer with Dr. Joia Mukherjee Dr. Joia Mukherjee doesn’t have much free time on her hands. In her words, she has “a day job, a night job, and a weekend job.” So when a representative from Oxford University Press asked if she would write an undergraduate textbook on global health, she inwardly scoffed, then politely declined.

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

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

Photo by Zack DeClerck / Partners In Health

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

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

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

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

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

What is the difference between public health and global health?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Fri, 08 Dec 2017 15:27:20 -0500
Sierra Leone’s Newest Fight It was a landmark, a triumph, a watershed moment—without fanfare. On Oct. 6, two doctors stood under the awning of a yellow hospital on the western edge of Freetown, the capital of Sierra Leone, and gave instructions to the first patients to be discharged from the first tuberculosis treatment program of its kind in the country.

“If you have a problem, if you have a question, call us,” one doctor said. “You have my number.”

“What can we eat?” asked one of the patients.

“Everything,” the doctor said.

“Should I wait to go back to work?” asked another patient.

“You can continue to work as long as you have energy,” the doctor said.

Quiet settled over the group as the five men proved too chaste to ask another logical question.

“You can live your normal life,” a second doctor volunteered. “You can be with your wives.”

Multidrug-resistant tuberculosis—an advanced, cruel, and hard-to-treat version of standard TB, known as MDR-TB—has been spreading inside the West African country for years. The World Health Organization estimates that 700 people in Sierra Leone suffer from the disease, but admits that far higher numbers are “a frightening possibility for the nation.” A year ago, none of those people had received meaningful medical care. A handful of the lucky ones had been isolated in hospitals, so they could waste away without their bacteria-laden coughs infecting others.

But that's now no longer the case thanks to the passionate work of Program Manager Dr. Linda Foray, of Sierra Leone’s National Leprosy and Tuberculosis Control Programme, and the steadfast support of Partners In Health, with funds from USAID's TB CARE II. In April, they launched the nation's first MDR-TB treatment program, at Lakka Hospital. It currently treats 84 MDR-TB patients and counting. And at 2 p.m. on that Friday in October, the first people in Sierra Leone to survive the disease waved goodbye to staff and fellow patients and walked out the gravel drive.

The subdued mood felt oddly appropriate.

© Partners In Health
Nurse Esther Vamboi prepares to discharge Mansaray.

No one should have to fight MDR-TB; its existence is a testament to our decades of collective indifference. A cure for TB was invented in the '40s. Rich countries quickly all-but eliminated the disease. Poor countries, however, lacked the money and health care systems to tackle TB.

So TB continued to spread, through mining camps, farms, homes, cities, and more, everywhere from Latin America to Asia. In the '90s, the rise of HIV, which weakens immune systems, caused TB infection rates to skyrocket. (From 1995 to 2005, the prevalence of TB increased by factors of five in many poor countries.) Simultaneously, poverty, wars, and preventable epidemics, including Ebola, caused TB programs in poor countries to fall apart.

TB patients who had managed to get medication found themselves having to stop midway through treatment. And the TB mycobacterium, wounded but not killed, grew resistant to the most affordable and effective drugs. It became MDR-TB.

It’s hard to assess exactly how much Sierra Leone is paying for our decades of disregard. The country holds the sad distinction of having one of the highest TB rates, which suggests that MDR-TB rates also should be exceedingly high. But the MDR-TB data is spotty.

“In the scientific world, some say, ‘Oh, the prevalence of MDR-TB in Sierra Leone is very low,’” says Dr. Marta Lado, PIH chief medical officer in Sierra Leone. “But if you didn’t have any way of detecting it, reporting it, or treating it, of course your ‘data’ about the prevalence is going to be low.”

And “low” is of course its own form of condescension. In the United States, which has roughly one-tenth as many MDR-TB sufferers as Sierra Leone, a single new case causes alarm.

Sierra Leone clearly needed an MDR-TB program. Two years ago, PIH leaders started pushing for one, and in August 2016, they began advising and supporting Foray. Leaning heavily on experience with MDR-TB in Peru, Haiti, Lesotho, and elsewhere, PIH leadership helped lay out how and where to treat people.

© Partners In Health
A hospital-issued discharge card that allows patients to return to their normal lives.

Most notably, the team traded crude chest X-rays and colored dyes for new GeneXperts, toaster-sized devices that quickly and simply analyze a person’s sputum for telltale DNA.

The GeneXperts added a sense of urgency. While training with them in March, a PIH lab technician diagnosed a patient with MDR-TB but the program, still evolving, didn’t have the medication to treat her within the country. PIH leadership pushed everyone to step up efforts immediately—not just out of solidarity, but also as a matter of doctrine.

“PIH has one main idea: We need to support the improvement of the health care system in this country,” says Lado. “If people go to the hospital and get charged a lot of money, or don’t get high-quality health care, or don’t get an accurate prescription, or there´s a problem of power and water supply, or the admission process is inefficient, or there’s no waste management and everything’s dirty, then people aren’t going to come to the hospital. We said, ‘We can put all the GeneXpert machines that we want in the country, but if we don’t have the medication to treat patients, we’re not going to help people get better, and they’re not going to come to the hospital.’”

Staff found the right drugs and enrolled the patient in treatment, and the program officially began in April. They predicted 50 patients in the first year. Just eight months along, they're already helping 84, in part because of 20 new GeneXpert machines in the country.

“They’re seeing one new patient every day,” says PIH Deputy Policy and Partnership Director Dr. Bailor Barrie.

At 4:30 p.m. on that historic Friday in October, MDR-TB survivor Joseph Alan Mansaray reached his aunt’s home in Freetown. The 47-year-old father, husband, and plumber had left a year and a half earlier when he, like others, had voluntarily isolated himself in Lakka Hospital. His aunt, waiting at the side of the road, greeted him and the PIH staff member who had accompanied him. She had not expected to ever again see Mansaray outside the hospital.

“Thank you,” she said.

Mansaray agreed that the discharge ceremony wasn’t exactly festive, but for him, the reason was clear.

“So many friends died while we waited for treatment,” he said.



* The program described in the report above has been funded through the TB CARE II project and is made possible by the generous support of the American people through the United States Agency for International Development. *


Fri, 01 Dec 2017 12:34:14 -0500
NYT Columnist Kristof Promotes PIH's 'Superb Work' Fighting Cervical Cancer in Haiti Partners In Health received a heartwarming show of support Saturday from The New York Times columnist Nicholas Kristof, who promoted PIH's reproductive health and cervical cancer efforts in his annual holiday giving guide

The guide lists charities and nonprofit organizations that Kristof endorses for donations, as alternatives to traditional holiday gifts. Kristof cited the national political climate when praising PIH's work in Haiti and elsewhere. 

"President Trump is cutting off funds for some reproductive health organizations, like the U.N. Population Fund, so aid groups in this sphere could use a boost," Kristof wrote, in his column published online Saturday. "Partners In Health, a leading health aid organization, also does superb work fighting cervical cancer and other diseases in Haiti."

Honor someone with a gift to PIH →


Zanmi Lasante, as PIH is known in Haiti, launched a two-year program in November 2015 to dramatically increase HPV vaccinations and cervical cancer screenings for young girls and women in several parts of the country. HPV, or human papillomavirus, can cause an infection that has been linked to more than 90 percent of cervical cancer cases worldwide. PIH's program in Haiti aimed to vaccinate 20,000 girls in St. Marc, Mirebalais, and Belladère against HPV, and to screen 20,000 more women for cervical cancer in St. Marc and the surrounding area.

PIH is a champion for maternal and reproductive health across all of its sites, in 11 countries around the world. 

Kristof's mention is a strong, timely endorsement at the start of the holiday season. Kristof long has been familiar with PIH, its work, and co-founder Dr. Paul Farmer. Kristof published a column by Farmer, “Humans Aren’t Winning the War on TB,” on his blog in March, for example. Kristof also cited PIH in a 2012 column about reductions of HIV deaths in Lesotho, and sat next to PIH CEO Gary Gottlieb at a Vatican event earlier this year.

Fri, 01 Dec 2017 11:30:17 -0500
World AIDS Day: Dr. Joia S. Mukherjee Calls for Renewed Activism, Says End to Pandemic is Possible In commemoration of World AIDS Day, Dr. Joia S. Mukherjee describes why this is no time for complacency in the long, global battle against the deadly disease:

World AIDS Day is always a reminder. A reminder of those we have lost in the almost four-decade struggle against AIDS. A reminder to reflect on the greatest global victory of the 21st century. The collaborative global community response is to provide AIDS treatment to all as a basic human right. In an era where bad news and fragmentation reigns, the global response to the AIDS pandemic represents the most commendable aspects of humanity; a willingness to intercede on behalf of the common good. 

Partners In Health has proudly worked side-by-side with people living with AIDS as part of a global social movement for three decades. The success of the movement for HIV treatment access not only garnered billions of dollars of new money for HIV treatment, but also served to shift the public health paradigm from prevention-only to long-term treatment.

This paradigm shift has ushered in a new era in global health, resulting in stronger, more resilient health systems with the capacity to treat a variety of conditions, from non-communicable diseases, mental illness and cancer to women’s and children’s health needs. Adult, child, and maternal mortality have dropped in many of the world’s poorest countries.

The success of this movement should not be underestimated. In 2000, only 685,000 people with HIV had access to antiretroviral therapy—the life-saving medications that have transformed AIDS from a fatal disease to a manageable and treatable condition. This year, UNAIDS announced that as of June 2017, 21 million people living with HIV worldwide had access to antiretroviral therapy. Yet our work is far from over.

Scientific evidence has shown—and I firmly believe—that it is possible to end the global AIDS pandemic. However, to do so, 90 percent of people with the disease must be on effective treatment so that they do not spread the virus. More money is needed to achieve this goal. Treatment must be provided to the 17 million people living with the disease who are not on antiretroviral therapy.

We also need second- and third-line drugs for those currently on HIV drugs who are living longer and whose disease eventually develops resistance to their drug treatment. It is important that people on antiretroviral therapy get tested regularly to detect the presence of resistant strains. We have the technology to regularly monitor for resistance and without this critical step, people may die of resistant, but treatable, HIV. In addition, failure to implement new diagnostics and drugs could lead to a second wave of death and new infections. Lastly, preventive therapy must be expanded with PrEP, a single drug for those whose sexual partners are HIV positive.

As the U.S. Congress enters a contentious December of budget-wrangling and spending debates, we must voice our support for expanding global health funding. The U.S. must increase its support of the Global Fund, and increase funding of the President’s Emergency Plan For AIDS Relief (PEPFAR). 

Investing in these steps now is critical to end the global pandemic. Increased international funding is needed to combat the major epidemics of our time and to achieve universal health coverage as part of the UN’s Sustainable Development Goals. The gains against HIV and improvements in health will be lost if we lose focus of the fundamental principle that health is a cornerstone for global development.

World AIDS Day is a time to celebrate past successes. Impacts from PEPFAR and the Global Fund have amounted to a sea change for people living with HIV. The World Health Organization reports that new HIV infections fell by nearly 40 percent between 2000 and 2016, and HIV-related deaths fell by a third in that time, saving more than 13 million lives.

But rather than make us complacent, these victories should serve as a reminder that we can do better, and that we can accomplish great things through collaboration and solidarity. Forty years into the war against HIV, on this World AIDS Day, we must commit to end the epidemic and fight for health for all.

Dr. Joia S. Mukherjee is the Chief Medical Officer of Partners In Health, an associate professor in the Division of Global Health Equity at Brigham and Women’s Hospital, and an associate professor in the Department of Global Health and Social Medicine at Harvard Medical School.




Fri, 01 Dec 2017 09:59:03 -0500
Fellowship Providing Vital Support for Nursing Leaders As she spoke to nurse managers from Rwanda, Liberia and Haiti, Dr. Lynda Tyer-Viola—a longtime nurse manager in Texas—cited a daily situation that’s true for medical professionals anywhere. 

“The everyday minutiae sucks all the air out of the room,” she said, referring to the flood of unexpected, urgent tasks that arise in busy hospital environments. Such tasks often detract from larger projects or duties, Tyer-Viola said, and can change whatever plans managers thought they had for their day.

Heads nodded around the table. Multitasking work situations were very familiar to Angeline Charles, operating room nurse manager at the Hôpital Universitaire de Mirebalais (HUM) in Haïti; Emmanuel Dushimimana, director of nursing and midwifery at Butaro District Hospital in Rwanda; and Viola Karanja, director of nursing for Partners In Health (PIH) in Liberia.

Graciela Cadet (Courtesy photo)

Also part of the group, but not present on that November day in Boston, is Graciela Cadet, nurse manager in HUM’s intensive care unit. Together, the four rising stars are PIH’s first Nightingale Fellows. The new, yearlong fellowship program began in May and includes online instruction and webinars, monthly conference calls, mentorship from veteran nursing leaders such as Tyer-Viola, and an individual leadership project that each fellow will complete at their site.

“Nurses often are placed into leadership positions without being given the skills or support that’s needed to be successful,” said Cory McMahon, PIH director of nursing. 

One such skill is how to manage all of those unexpected tasks. 

Tyer-Viola told the small group of fellows that, simply put, they need to delegate. As assistant vice president of nursing for women’s services at Texas Children’s Hospital in Houston, with a nursing doctorate from Boston College, she knows a thing or two about how to avoid getting overwhelmed. 

“As leaders, you have to learn when to push yourself away from that, and step away, with trust that others will handle the minutiae appropriately,” Tyer-Viola said. “Don’t cut your long-term goals short—because that’s actually what you’re measured by, in the long run.” 

Emmanuel Dushimimana (Photo by Zack DeClerck / PIH)

PIH designed its Nightingale Fellowship for nurses in senior or executive leadership positions, to provide support and training, and ultimately improve patient care. The program focuses on critical analysis, health information systems, strengthening health systems, performance monitoring, evaluation and supervision, quality assurance, resources management, and customer relations.

Karanja said sharing common challenges with nursing leaders at other PIH sites has been incredibly beneficial. 

“We’ve learned quite a lot about different experiences through one another,” said Karanja, who has more than 20 years in nursing and worked in South Africa, Kenya and South Sudan before joining PIH in 2015. She’s focusing on improving maternal and child health in Liberia. 

Dushimimana also said the program is fostering new connections among the fellows, who were strangers to each other before meeting last May. 

“Now, we are exchanging ideas everywhere,” he said, listing WhatsApp and email as long-term communication channels.

Dushimimana said his individual project for the fellowship, “will target the education of new pediatric cancer patients, who usually don’t know a lot about cancer or chemotherapy.”

A lack of knowledge about treatment can stop some parents from bringing their children to chemotherapy at Butaro District Hospital in Rwanda, he said, “because they see the child not improving (right away) and they think that means the prognosis is bad.”

Angeline Charles (Photo by Zack DeClerck / PIH)

In her native Haiti, Charles has worked her way into management with Zanmi Lasante, as PIH is known there. She began as an operating room scrub nurse in 2010, and became operating room nurse manager in 2013. She hopes to continue growing as a leader in the medical field, where she already has gained wide recognition. 

“Ms. Charles is truly a surgical nurse expert in all things related to the operating theater, from patient care to surgical practice, scheduling, operating room (OR) management, supplies and essential medicines, and more,” McMahon said. “The OR is a place where there is little room for error, and so maintaining appropriate ‘stuff, staff, space, and systems’— to use a popular PIH description of essential needs—is critical, and Ms. Charles is really the lead in this.” 

McMahon said Charles soon will travel to Liberia to help expand and improve OR operations and surgical care at J.J. Dossen Hospital in Maryland County. The trip arose through Charles’ relationship with Karanja during the fellowship program. 

“I would like to become a strong leader with a large vision and become an agent of change of an organization or a country, able to influence a group and lead them in the right direction,” Charles said. 

Karanja. (Photo by Zack DeClerck / Partners In Health)
Viola Karanja (Photo by Zack DeClerck / PIH)

Her individual project aims to reduce infections after surgeries at HUM. 

Also at HUM, Cadet hopes to use her project to improve doctors’ performance and patients’ outcomes. 

“I really like the fact that I will be able to participate in the decision-making of my institution, to promote best practice in nursing and provide direction,” Cadet said. “My country really needs young dynamic professionals with those advanced skills in order to improve the Haitian health system.”

Developing young professionals is a key goal of the fellowship, and starting in 2018, the program will merge with an institution that’s doing just that: the University of Global Health Equity, a PIH initiative in Rwanda. The university will support the fellowship beginning with next year’s cohort. 

Karanja said she hopes the Nightingale Fellowship will have broad impacts on hospitals and patients for years to come. 

“I think it’s going to empower us to be better leaders,” Karanja said. “It’s a program that we would like to continue—not just for us, but for others.”

Wed, 29 Nov 2017 15:14:49 -0500
PIH Warns Against Withdrawal of TPS for Haitians On Monday, the Trump administration ordered the end of a humanitarian program that granted temporary protected status to 59,000 Haitians living and working in the United States following the devastating 2010 earthquake in Haiti. These Haitians are asked to leave the country by July 2019.

The Department of Homeland Security defended its decision in a statement, claiming that “significant steps have been taken to improve the stability and quality of life for Haitian citizens, and Haiti is able to safely receive traditional levels of returned citizens.”

Partners In Health finds this decision inhumane, short-sighted, and surely disastrous for thousands of Haitian families—not to mention the entire Caribbean nation. Having worked in Haiti for the past three decades, we know that many challenges remain since the 2010 earthquake that killed 300,000 people and left more than a million homeless. These challenges have only magnified in the last year following a series of debilitating hurricanes.

The current health system cannot sufficiently meet the demands of Haiti’s nearly 11 million people. We have partnered with the government and local communities to improve this situation, yet much work remains.

At least 10,000 Haitians died and nearly one million have been sickened from cholera since October 2010. This diarrheal disease, which can kill within 24 hours, still plagues Haiti. This is largely because most people, especially those living in rural areas, lack access to clean drinking water and reliable sanitation systems.

PIH staff continue treating the sick, as well as vaccinating Haitians against cholera and offering options to improve safe water access. Last week, hundreds of staff launched a comprehensive campaign in Mirebalais, aiming to provide 100,000 people with two doses of the oral vaccine.

Meanwhile, basic vaccination rates are low nationwide. Haitians are currently battling an outbreak of diphtheria, a disease almost never seen in the United States because it is part of the vaccination regimen for all children.

Hurricanes Matthew, Irma, and Maria ravaged wide swaths of southern and northern Haiti in just over a year, destroying crops and aggravating regional food insecurity. Many Haitians are subsistence farmers who live on less than $2 a day. With no harvest, they not only lack food, but also any means to earn income. Their poverty intensifies and, quite often, this leads to poor health outcomes for them and their families.

This is “the stability and quality of life” that many Haitians currently endure. Should 59,000 Haitians living in the U.S. be forced to return, the situation will only worsen. The World Bank reports that the entire Haitian diaspora sent $2.36 billion in remittances back to Haiti last year alone. That money, which equaled one-fourth of the national income, supports entire families—and would destabilize the entire nation should it diminish or completely disappear.

We stand in solidarity with the Haitian people in asking the Trump administration to reconsider this order, and thereby continue to stand on the side of justice.

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Wed, 22 Nov 2017 16:08:56 -0500
'Everyone in Freetown Knows Cholera': Door-to-Door With Vaccine Teams in Sierra Leone The teams wound down dirt paths, high-stepped through muddy slums, and climbed stairs cemented into lush hillsides. Never mind the lack of road signs and house numbers—they knew where they were going. They lived nearby.

How di body?” one would ask a neighbor.

Body fine,” the person would reply.

A team member in rubber gloves then would reach into a soft-sided cooler, tear the top off a tiny vial of milky solution, and let the person shoot it like a liqueur. Another would make notes in a log book. The third would hand over a paper record. And the fourth would mark the lintel of the front door: “OCVR217,” meaning Oral Cholera Vaccine Round 2, 2017. The large chalk letters felt portentous. Evil, in the form of cholera, should now pass over this house.

A de go!” or “Bye!” team members would say and walk on to the next home. And the next.

Marked door
A vaccination team member marks a home in Freetown to show that the family completed the first of two doses. (Photo by Jon Lascher / Partners In Health)

Such was the scene in Freetown, Sierra Leone, in early October, when roughly 2,000 teams, 8,000 people total, fanned out to complete the largest cholera vaccination campaign since a vaccine was invented in 1885. Consultants are assembling a final report, but preliminary national data suggest strong results. Thanks in part to Partners In Health’s support, as many as 90 percent of half a million people took both doses, thus protecting themselves against the “kaka vomits,” as cholera is sometimes referred to locally.

“This was a huge success,” says Dr. Dennis Marke, program manager at the Ministry of Health and Sanitation’s Expanded Program for Immunization.

Seen alongside similar campaigns—recently carried out by UNICEF in Bangladesh, and Doctors Without Borders in Zambia—the record-setting goal of distributing 1,036,300 vials of the vaccine in Freetown not only saved thousands from severe, life-threatening diarrhea and dehydration. It also testified to the dramatic strides made by Sierra Leone’s Ministry of Health and PIH in fighting a disease that still threatens some 2 billion people worldwide.

The need for a vaccination campaign in Freetown was clear. Seen from afar, the capital is one of the most beautiful in Africa. Green mountains decline into a colorful downtown, which pushes up against white-sand beaches. But up close, the city, population 1 million, is a mess. A five-story high mountain of trash marks the center of downtown.

Superlatives tend to ring especially hollow in the summer. During August’s heavy rains, landslides broke loose up high and buried houses, primarily in the Regent and Juba neighborhoods. Down low, runoff swept through Congo Cross, Kroo Bay, and other decades-old shantytowns near White Man’s Bay. Health clinics were inundated with water up to the knees. Bridges collapsed. Houses, such as they were, washed away, wooden planks and scraps of metal flushed into the sea.  

“Within an hour, it was a flood,” said Serla Matukomaron, who was asleep on the floor of her shack by the ocean at the time. “Everyone was shouting, everyone was busy.”


Top: A view of the capital from up high. Bottom: A shantytown on the edge of the dump at the center of the city. (Photos by Jon Lascher / Partners In Health)

“A handicapped man couldn’t walk,” recalled her neighbor, “so someone came and carried him.”

Matukomaron, a fisherman’s daughter and mother of two, felt the rising water while she slept on the elevated floor of her shack. She awoke at 3 a.m. and gathered her children.

“The water came higher than their heads,” she said. She got her children to safety by floating them through the slum’s dark, labyrinthine alleyways in a plastic washing tub.

When the rains finally abated in late August, the damage was clearly more than other rainy seasons. Reuters declared the deluge one of the deadliest recent natural disasters on the continent. The landslides and flooding displaced an estimated 6,000, killed 1,141 (including family members of PIH staff), and left the capital—never the most sanitary city—with pools of water contaminated by toppled outhouses, broken pipes, and blankets of trash.  

Marke kept his eyes on the horizon. While the military tried to figure out what to do with bodies after morgues ran out of space, he pulled together a small group of nonprofits and began formulating a plan. PIH-Sierra Leone Executive Director Jon Lascher, who helped pioneer the launching of cholera vaccination campaigns during emergencies, met with Dr. Marke each morning for a week.

PIH Deputy Policy and Partnership Director Dr. Bailor Barrie chose to defer beginning a PhD program in the U.S. to help Dr. Marke, whom he first met as a medical intern in 2003.

“We all agreed that cholera was next,” says Barrie.

Just beginning to formulate a plan was progress. Five years earlier, Marke might have simply thrown up his hands. Few residents of Freetown were likely to buy the vaccine for themselves. The vaccine’s $3 price is a week’s rent for roughly half the population. And his immunization department would have been largely powerless to get its hands on a significant amount. As recently as 2012, the World Health Organization considered a cholera vaccine too expensive to recommend.

But this wasn’t five years ago. Two big steps had been taken since.

A vaccination team member shoulders a cooler of the temperature-sensitive medicine. (Photo by Jon Lascher / Partners In Health)

First, PIH had helped make sure cholera vaccine was available to the world. In Haiti in 2012, PIH and the Haitian Ministry of Health refused to accept that poor people didn’t deserve a $3 vaccine, and had bought and delivered their own cholera vaccines. The program, run by two PIH physicians and Lascher, proved an overwhelming success. Ninety percent of patients received both doses. The World Health Organization promptly changed its position and stockpiled the vaccine.

Second, Marke now had the infrastructure to deliver the vaccine. With limited resources, he had built a thorough, albeit fragile, web of refrigeration throughout the country over the last few years. At the government’s central warehouse one day in October, a logistician opened the latch on a thick door, pushed aside a clear plastic curtain, and showed off the network’s centerpiece: a cavernous new walk-in refrigerator nicknamed France, for its country of origin. It could keep a full battery of vaccines between 2 and 8 degrees Celsius, whether stored on the bottom shelf near the door or near the cooling fan in the back, and whether the national power grid suffered one of its daily outages or not. From France, virtually any drugs could travel to solar-powered refrigerators, double-insulated coolers, and more throughout Sierra Leone—without spoiling.

Dr. Marke
The Ministry of Health and Sanitation's Dr. Dennis Marke, right, an immunization expert, inspects an early shipment of the vaccine. (Photo by Jon Lascher / Partners In Health)

All of which is to say, when cholera became a clear threat, and Marke asked about ordering the vaccine in late August, representatives in Geneva replied with hearty encouragement.

All they had to do was hand out the vaccines.

Marke, Barrie, Lascher, representatives from the World Health Organization, and other colleagues divided the city into areas, evaluated which were most threatened by cholera, and alerted staff at those 19 local health centers that drugs were on their way. Each health center would use its vehicle to pick up the medicine at the central warehouse. (Marke’s team can afford only one vehicle.) Then health care workers, trained on how best to distribute the vaccine, would walk the drugs to homes and schools. Along with sharing what they knew about delivering temperature-sensitive cholera vaccines to poor people in the tropics, Lascher and Barrie offered to loan out two dozen PIH case managers, one manager to ensure that the drugs were accounted for and in good condition at each facility in the city.

On Sept. 7, the first 518,150 vials of cholera vaccine arrived from Korea. The vials were packed in lipstick-sized boxes that were inside larger, cardboard boxes; surrounded by cold packs; nested inside Styrofoam boxes; and stacked inside bigger boxes.

The central warehouse soon looked like a cardboard explosion. Incinerators and refrigerators were double-checked. The drugs were distributed to the respective health centers, only to be shuffled again later, when population census info proved inaccurate. And a week later, on Sept. 15, 2,000 teams of health care workers fanned out into the city to administer the first dose.

“Seeing Dr. Marke pull all this together in a short time makes me really admire him,” said Barrie. “Even though it was a new vaccine, the acceptance rate was very high.”

Indeed. Three weeks later, a small team approached elderly sisters who did not necessarily look like they wanted to drink a mysterious liquid offered by 20-somethings in matching white vests.


Top: Two vaccination team members take a break after a long morning. Bottom: A team member opens one of the 1,036,300 vials of the medicine that were distributed. (Photos by Jon Lascher / Partners In Health)

The sisters sat on their patio, finishing each other’s thoughts while staring out at the bog water that had overflowed into their neighborhood weeks earlier and, as in other areas of the city, refused to drain away.

“Ten years ago, this place was bushy,” said Princess Hawa Goba, nodding toward a submerged field.

“Now the house is like an island,” said Phebean Brown-Coker.

Others had it worse, they knew. In Lumbley, dogs were rumored to be digging up body parts.

“Some people have nowhere to go,” lamented Hawa Goba.

The team stopped to chat. Had the sisters been offered two doses, they wanted to know?


Had they been warned of the possible side effects, like abdominal discomfort?


Had they chosen to take it?

Brown-Coker and Hawa Goba looked at each other in bafflement, turned their heads toward the pair, and expressed their astonishment in unison.

“Of course,” they said.

Brown-Coker put a finer point on her answer. “It’s a vaccine,” she said.

Some did refuse.

“I vomited after the first dose, I don’t want to take a second,” said a mother, while supervising her teenage son’s bagging of charcoal, which he would sell on the street.

Her doctor had purportedly advised as much, but she couldn’t remember his name. Or when she visited. Or what his rationale was. In any case, she wasn’t going to take it. “I going to sleep,” she said, rising and heading inside.

But like the sisters, the overwhelming majority were more than happy to take it.

“Everyone in Freetown knows cholera,” said Barrie.

Isha Sankoh, a 60-year-old vendor and grandmother, certainly does. After her first husband was killed in Sierra Leone’s civil war and her second husband turned out to be “too mean,” she moved with her five children to low-lying Kroo Bay, in hopes of growing her business selling charcoal, palm oil, and soda pop.

Isha Sankoh
Freetown resident and cholera-survivor Isha Sankoh at home in October. (Photo by Jon Lascher / Partners In Health)

“Every year, I would lose property during the flood, leave and live with neighbors, then go back,” she said.

During the rainy season five years ago, she fell horribly ill and quickly became too weak to walk. Friends carried her to the health center in the slum, and watched over her kids and grandkids while she recuperated.

“I had cholera almost to the death,” she said.

After being discharged, she moved her family to this one-room shack on higher ground. “I plan to change my life,” she said. “I plan to move from here to a better house.”

Had she taken the vaccine?

Of course, she said.

So the team continued on.

Fri, 17 Nov 2017 11:53:32 -0500
Sheila's Story: Reflections for World Diabetes Day Chimwemwe Chipenge easily remembers the date of the diagnosis that saved her daughter’s life: June 31, 2014.

That was the day Chimwemwe told clinicians with Abwenzi Pa Za Umoyo, as Partners In Health (PIH) is known in Malawi, that her young daughter, Sheila, “was getting smaller, losing loads of weight,” and experiencing dizziness, headaches and frequent urination. The clinicians diagnosed Sheila, now 14, with type 1 diabetes.

Sheila had been losing weight and not feeling well for weeks, but she had tested negative for malaria and other routine infections. While diabetes was a shock, and new to the Chipenge family, they were relieved to finally learn what had been causing Sheila’s symptoms. In the months that followed, Chimwemwe and Sheila learned that type 1 diabetes often affects young children, and that Sheila would need insulin twice a day. They also learned that, unlike malaria or other curable infections, type 1 diabetes was an ongoing, incurable condition that would require regular attention.  

In the years since, though, the Chipenge family has discovered that through steady access to care and a supportive community, Sheila is able to thrive.

Her story is an inspiration as the international community recognizes World Diabetes Day—an important moment to advocate and raise awareness for diabetes globally. Staff at PIH organizations around the world, from Malawi to Navajo Nation, are marking the occasion with many diabetes-related events, including patient education sessions in Haiti and a screening campaign in Rwanda.

The care that Sheila receives is part of PIH’s integrated chronic care clinic, a model developed in partnership with Malawi’s Ministry of Health. The model’s goal is to increase access to care for people with non-communicable diseases in rural areas.

PIH’s integrated care model began as an HIV program. Clinicians now are building on that success to offer community-level care and screening for several chronic diseases—such as HIV, type 1 diabetes, rheumatic heart disease, and cervical cancer—under one umbrella. Providing integrated care enables PIH to reach many more patients like Sheila, and to link them to health services and social support. 

That support often starts at home. Over the past three years, Chimwemwe has played a critical role in managing her daughter’s condition. She gives Sheila her insulin injections twice a day, at 6 a.m. and 6 p.m., and cooks healthy, hearty food, such as brown bread and whole-grain porridge, to support the injections.

Chimwemwe also is ready to recognize and respond when Sheila’s blood sugar drops unexpectedly.

When Sheila “gets a fever and sweats a lot, I know that she is dizzy,” Chimwemwe said. “So, I take a little sugar and give it to her.”

Although managing Sheila’s type 1 diabetes is a challenging new reality for her and her family, they continue to receive significant help from the community. Health workers from Neno District Hospital have coached Sheila on how to manage her diabetes at home. PIH helps operate the local hospital in rural southwestern Malawi, where the Chipenge family lives. A community health worker checks in regularly with Sheila and her mother, monitors Sheila’s health, and accompanies Sheila when she needs to visit the clinic.

PIH’s integrated chronic care clinic is a unique program in Malawi and an important model for the region. The clinic shows how complex, non-communicable diseases can be effectively managed in rural settings by investing in strong health systems and providing regular access to screening services, patient education, follow-up care, and life-saving medicines.

Over the next three years and beyond, PIH will continue supporting local communities and patients like Sheila while working with Malawi’s Ministry of Health to strengthen and expand services at district hospitals.  

For her part, Sheila is focused on things close to home—like being a teenager and growing up. She’s now in eighth grade and enjoys spending time with her friends after school.

Sheila said she plans to study hard, so one day she can become a nurse and “save sick people’s lives,” as the PIH team in Malawi helped save hers.

Tue, 14 Nov 2017 12:17:52 -0500
Lovenyou's Transformation in Haiti The Partners In Health truck kicked up gray dust as it rolled to a stop, just down the hill from the two-room shack where 17-month-old Lovenyou Pierre lived with seven of his relatives. Lovenyou’s mother, Jodanie Louis, emerged from the modest home, and he followed close behind.

Lovenyou tightly gripped his 25-year-old mother’s worn jeans and stared at the visitors with bright, liquid brown eyes. His short curls were a light rust color. He wore a blue T-shirt that said “Tough Guy,” and had nothing on his bottom except a fine layer of dust. He had been sick for the past several days with diarrhea—possibly the result of drinking unclean water collected from the nearby river. The closest pump was a “bon ti marche,” or good little walk, of about an hour.

Lovenyou’s tummy troubles weren’t why staff with Zanmi Lasante, as PIH is known in Haiti, were visiting. They had come to follow up on Lovenyou's visit, four months earlier, to the malnutrition clinic in Boucan Carré, where he was diagnosed with severe malnutrition. He was just past his first birthday and weighed 17 pounds—well below the normal growth curve for boys his age, according to the World Health Organization—and measured a below-average 29 ½ inches.

Roughly 1 in 5 children are starving in Haiti, and 1 in 3 are stunted because they don’t have enough to eat. In an average month in 2016, 127 patients received care and nutritional supplements at the malnutrition clinic in Boucan Carré. That’s just a fraction of the total number of starving children PIH helped last year; altogether, staff enrolled 9,000 children as new patients in the 12 clinics and hospitals PIH supports across the country.

Shortly after that first visit to the Boucan Carré clinic, Lovenyou took a turn for the worse. He spiked a fever, had diarrhea, wasn’t eating, and—scariest of all—kept losing consciousness. Panicked, Louis scrounged for the money to pay a driver to take her and Lovenyou to University Hospital in Mirebalais, a 30-minute motorcycle drive from their home.

PIH staff admitted Lovenyou immediately, hooked him up to an IV, and performed a battery of tests to ensure the toddler wasn’t suffering something in addition to starvation. (Some children’s cases become infinitely more complicated when staff discover they also test positive for HIV or tuberculosis.) Tests showed nothing alarming, but did confirm he was dehydrated and in dire need of additional nutrients.

Eight days later, Lovenyou was healthy enough to return home. Louis began taking him regularly to the clinic in Boucan Carré. When she couldn’t afford the motorcycle ride, they walked. By foot, and while carrying a sick child, it took her nearly two hours, one way. Once there, PIH nurses weighed Lovenyou and provided him with a supply of Nourimanba, the nutrient-rich peanut paste PIH produces and distributes to its malnutrition clinics.

Louis religiously fed Nourimanba to Lovenyou three times a day, and his appetite returned. She talked about the experience in a shy, quiet tone, while her son squirmed in her arms. He eventually wiggled free and shimmied to the ground to play with other children.

Lovenyou is Louis’s third child; she has two by another man, who’s no longer in the picture. Lovenyou’s father worked as a mason in the capital of Port-au-Prince and was not home often.

(left) Djenika Decat (Right) Luis
Djenika Decat (left), Lovenyou's older sister. Jodanie Louis (right), Lovenyou's mother. (Photos by Cecille Joan Avila / Partners In Health)

Louis did what she could to make a living. She took out a small loan from Fonkoze, a nonprofit with an office bordering PIH’s clinic in Boucan Carré. With 3,000 gourdes, about U.S. $50, she bought bouillon cubes, candies, cookies, spaghetti, and school supplies to sell on market days in neighboring communities. She repaid the loan, bit by bit, every 15 days. With the profits, she bought food and paid school fees.

Toward the end of the visit, Louis’s older sister, Magdala, appeared from inside their home and welcomed the visitors inside. Sunlight filtered between the wood slats of the walls and under the zinc roofing. Cups, jars, and cooking supplies covered a table across from the doorway. Clothing hung from exposed beams above. Near darkness cloaked the back room, where a single bed filled half the space. An elderly woman lay on a mat on the dirt floor. She was Magdala and Jodanie’s mother, and she clearly was not well.

She had been sick with a fever and headache for five days. Ms. Esther Mahotiere, the nutrition program coordinator, and Ms. Asmine Pierre, lead nurse of the malnutrition clinic in Boucan Carré, knelt down to speak with her. They asked about her symptoms, what medicines she had taken, if any, and encouraged her to go to the clinic.

Back outside, a heavy truck rumbled by on the dirt road below, its bed laden with bananas and hitchhikers. Lovenyou found a stick and chased neighbors through the tall grass bordering their yard. He laughed, deep dimples indenting his cheeks, and ran faster than his little legs could carry him until he wiped out on the ground nearby.

Louis, a slender woman with thick cords of hair, shook her head and smiled. It was the look of a tired mother whose child had been a bit naughty. And it carried a hint of relief.

Lovenyou still had a ways to go to recover, but in the past four months, he had gained 2 ½ pounds and half an inch in height. His condition had improved from severely to moderately malnourished, and he was now visiting the clinic every 15 days, instead of every eight.

Back in the PIH truck headed home, Mahotiere looked relieved.

When they act rascally, she said, it’s a good sign. That means they’re healthy.

(Photo by Cecille Joan Avila / Partners In Health)


Wed, 08 Nov 2017 10:17:05 -0500
Wall Street Journal: Dr. Gary Gottlieb and Money Well-Spent A recent Wall Street Journal interview with Partners In Health CEO Dr. Gary Gottlieb offers a candid perspective on the challenges of implementing and funding global health. Dr. Gottlieb, the former president and CEO of Partners Healthcare and a psychiatrist by training, has led PIH since 2015. Below he speaks to the organization’s “laserlike” focus on investments in maternal mortality, community-based health care delivery, and the use of hard data to drive decision-making up and down the board.

Fri, 03 Nov 2017 14:57:14 -0400
Hospital Attendant Saw Decades of Neno Health History Over seven decades in Malawi’s Neno District, Rosemary Mapemba not only has witnessed transformative changes in health care and quality of life, but also has been a daughter, a mother, a grandmother, a Partners In Health patient, a much-loved PIH hospital attendant, and, now, finally, a retiree.

The last of those things is the only one that makes her sad.

“The government said I’m too old,” the 68-year-old Mapemba said with a rueful smile in October, via Skype, referring to national employment regulations. “I need to work again.”

Mapemba’s desire to continue working is all the more impressive when you consider her commute. She was a hospital attendant at Neno from 2008 through 2016, working for Abwenzi Pa Za Umoyo (APZU), as PIH is known in Malawi. She walked to and from work every day, up and down the mountains between her home—in a village named George 2—and the Neno hospital, about five miles away. The trip took her at least two hours each way. That meant she spent four hours walking every workday, for nine years. Through rugged country. Usually alone.

But it didn’t mean she showed up late.

“She was often the first one at the office, at 7:30 a.m.,” said Stephen Po-Chedley, a volunteer medical informatics advisor at Neno from 2013 to 2014. “We would shuffle around every morning to get out of Rosemary’s way, because she took great pride and was stubbornly persistent in her work, and wanted to make sure everything was cleaned every day.”

Mapemba’s work went well beyond cleaning—she made sure patients had basic needs, kept hospital offices supplied with materials, helped the information technology team handle requests, and more. Her diligence and sunny personality made Mapemba a favorite not only among Neno staff, but also within the larger communities around the hospital and George 2. Mapemba said simply, “I made a lot of friends.” But that doesn’t tell the story of someone whose retirement drew such a broad response—several current and former co-workers were eager to talk about her—and who is a living history of health care in the region.

Mapemba was born on Sept. 28, 1949, in the Nanzanga area of Neno District. She spent much of her childhood in Zambia and suffered full-body burns there, she said, in a fire that killed hundreds and hospitalized her for more than a year. Mapemba returned to Malawi and Neno District in 1964, shortly after the country’s first president, Hastings Kamuzu Banda, had come to power.

Health services for Neno District were based in a police station back then, Mapemba said, before a more formal health center was established in 1978. She recalled how people in the Neno area often would go into forested areas to find plants they used as natural medicines, such as tree roots that functioned “the same as quinine” and were used to treat malaria.

Mapemba said people who were very sick eventually were able to go to Mwanza District Hospital, about 30 miles south, but transportation remained scarce with just one ambulance.

“In those days, health care wasn’t good,” Mapemba said. “Even if you went to the hospital, the providers were not available.”

She said the availability of medicines also was hit or miss—“Sometimes you could find it, and sometimes not”—and did not improve after Malawi’s first multiparty presidential elections in 1994.

Rosemary Mapemba's daily walk to Neno District Hospital
Rosemary Mapemba, 68, walked this rural, mountainous route to and from work at Neno District Hospital for nine years. She said the roughly 5-mile trip took 2 hours each way. 

Mapemba has witnessed generations of change in health care. She gave birth to two of her four children, for example, at hospitals in Blantyre, Malawi’s second-largest city. She delivered her third child at a Red Cross building in Neno District, and her fourth at the regional health center. Two of her 15 grandchildren, though, were born in the new maternity ward at Neno District Hospital.

And earlier this year, one of her grandchildren received malaria treatment known as artemether-lumefantrine, at Neno.

Mapemba said the years have brought broad changes to the community, including a market and more streetlights, along with Neno District Hospital itself. PIH opened the hospital with Malawi’s Ministry of Health in 2007.

“Now, the hospital is good and the doctors treat us well,” she said.

Mapemba experienced that treatment firsthand, after she became so sick in 2006 that nobody would bring her to see doctors.

“They were all waiting for me to die,” she said.

Mapemba’s daughter eventually brought her to PIH’s health facility in Neno, where APZU’s first executive director, Dr. Keith Joseph, and his team diagnosed Mapemba with HIV. They started her on antiretroviral therapy, and suspected she was battling tuberculosis, as well. The timing was fortunate—PIH began working in Neno in 2006, the same year she fell ill.

There were no x-ray facilities in Neno yet, though, so Joseph accompanied Mapemba to Mwanza District Hospital, where she was diagnosed with TB and began treatment for that, too.

Mapemba said she also was struggling with hypertension at that time, but began recovering on all fronts in 2007. About a year later, she started her job as a hospital attendant—helping people at Neno, rather than the other way around.

Po-Chedley said Mapemba didn’t speak much about the hurdles she had faced in her life.

I was aware of some of her health challenges and we discussed them, but she never really framed them as grand challenges. I think she was modest in that sense; you knew she worked hard because you could see it, not because Rosemary told you,” Po-Chedley said. “Rosemary had pride in working with APZU, and I hope she knows how important she was to the incredible work PIH does in Malawi.”

Po-Chedley added that Mapemba, “was a constant, positive, persistent, and hard-working source of inspiration.” She routinely called him “achimwene,” or brother. Mapemba often called long-term expatriates at Neno achimwene or “achimwale,” which means sister. Po-Chedley said that even though she speaks English, Mapemba tried to teach her foreign co-workers a little Chichewa every day.

Beth Dunbar, former director of monitoring and evaluation for APZU, said the same, noting that Mapemba would greet her every morning with, “Mwadzuka bwanji abwenzi?,” which translates to, “How did you wake, friend?”

“I’m sad that she’s retiring; she’s always a happy presence,” Dunbar said in October, sitting next to Mapemba on the Skype call.

Mapemba was reserved and spoke quietly on the Skype, belying the gregarious nature that’s evident in co-workers’ stories, and in photos of her with family and friends. But she smiled widely when Dunbar turned to her and gave a compliment that undoubtedly is felt by many.

“You took good care of us,” Dunbar said.

Fri, 27 Oct 2017 11:04:42 -0400
Refugee Camp Eye-Opening for UGHE Students Orderly lines of homes and shelters stretch far down crowded, uniform roads at Mahama Refugee Camp in southeastern Rwanda, where more than 55,000 people have arrived since 2015 after fleeing political unrest and violence in Burundi.

The turmoil has displaced more than 400,000 Burundians across Rwanda, Tanzania, Uganda, and the Democratic Republic of the Congo, according to the United Nations High Commissioner for Refugees. The U.N. agency oversees Mahama, in conjunction with the government of Rwanda’s Ministry of Disaster Management and Refugee Affairs.

Dr. Agnes Binagwaho and about 20 students from the University of Global Health Equity (UGHE) visited Mahama on a hot day in mid-September. UGHE is a Partners In Health (PIH) initiative, with several sites in Rwanda. Binagwaho is the university’s co-founder and vice chancellor, senior lecturer in global health and social medicine at Harvard Medical School, and former Rwanda Minister of Health.

She said raw emotions from people’s displacement were starkly evident at the camp.

“This is a crisis of recently traumatized people, and it’s still ongoing,” Binagwaho said. “Even if we are happy that they have a house, that they have access to basic sanitation and basic care, it is row upon row of people who are suffering, and you can feel it.”

Dr. Agnes
 Dr. Agnes Binagwaho (center) chats with UNHCR Field Officer Victoria Copa Camara (left) as the University of Global Health Equity MGHD Class of 2019 visits Mahama Refugee Camp. (Photo by Danny Kamanzi / UGHE)

For students in UGHE’s new cohort, the visit to Mahama was a powerful introduction to global health equity, and inequity, during their first week of class. The visit was part of students’ intensive opening to the semester. The week also included a visit to a malnutrition treatment site—and homes of families with children in a malnutrition program—near PIH-supported Rwinkwavu Hospital, a few hours northwest of Mahama.

“The field visits are part of an overall active learning principle, getting students engaged in communities around them,” said Kamille Beye, teaching and learning manager at UGHE. “I think the (Mahama) visit helped expose the students to things that are going on in their own country…I think it opened their minds to a wider view.”

Mahama spans about 120 acres near the Akagera River, which borders Tanzania and is part of the upper headwaters of the Nile. A U.N. guide and camp director met the university group early on the day of the visit and brought them around Mahama 1 and Mahama 2, the camp’s two halves. The group saw sites including a clinical laboratory, a food distribution center, a water filtration area, and an entrepreneurship center for women and girls.

PIH co-founder Ophelia Dahl joined the visit. She praised the forward-looking vision of UGHE and Inshuti Mu Buzima, as PIH is known in Rwanda.

“It was good to meet with colleagues and new master’s students, to meet the people who will implement, on a grand scale, the details of global health equity,” Dahl said.

Mahama is proving to be a potential model for delivering equity in a setting with very limited resources.

All of the children at the camp have access to education, and there are two health centers, which Binagwaho said provide a level of care that’s comparable to what can be found across Rwanda. The Ministry of Health is also training displaced Burundians at Mahama to be community health workers, so displaced people can have links to care through people they know and trust.

“If you want the lives of refugees to be protected… you create social capital, you create trust, and you create safety,” Binagwaho said. “This camp is something new, because community health doesn’t exist (in refugee camps) elsewhere. This is a good practice that should be replicated.”

Class of 2019 student Dr. Charles Nkurunziza, a resident in obstetrics and gynecology at the University of Rwanda’s College of Medicine and Health Sciences, said conditions at Mahama were better than he expected.

“What I saw, it’s not what I thought it would be,” he said. “The health centers are really amazing.”

Andre Ndayambaje expressed a similar view. Ndayambaje, also a new student, lives in Kigali and has a bachelor’s degree in nursing sciences and midwifery, from the University of Rwanda. He’s worked for 11 years at Kigali’s King Faisal Hospital, as a midwifery nurse in the neonatal intensive care unit.

UGHE students continue their full-time jobs while earning graduate degrees in global health delivery. The university opened in 2015—the same year as Mahama, coincidentally—and held its first graduation last May. Seventeen students have received a master’s of science degree so far.

       Students and staff of UGHE listen as camp personnel give an overview of Mahama Refugee Camp. (Photo by Danny Kamanzi / UGHE)     

Ndayambaje has just begun pursuing his MGHD, as the master's in global health delivery is known. He said many of the practices at Mahama help create stable communities—by providing broad access to food, water, shelter, health services and education—and could be implemented outside the camp’s borders.

“They are not solely for refugees,” Ndayambaje said of the camp’s services and infrastructure. “They can be done even for local systems.”

Mahama also faces significant challenges, amid its successes. A September report by the U.N. refugee commission said the Burundian upheaval has created “one of the least-funded refugee crises in the world.” At Mahama, the commission added, space is nearing capacity and expansion efforts are underway, while more displaced people continue to arrive every day.

Beye said UGHE hopes “to build an ongoing relationship with the camp, and possibly other camps, as well,” to help students shape their roles as future global health delivery leaders and have ongoing impacts in the region.

One of UGHE’s first students already is doing just that.

Binagwaho said Dr. Angeline Mumararungu, a health program manager for Gardens for Health International and a member of UGHE’s first cohort, visits Mahama weekly to oversee and support several nutrition-related programs. Mumararungu has helped integrate health, gardening and nutritional education, along with related counseling for more than 400 displaced Burundian families. She trains people at Mahama to provide health and nutrition education, as well.

Binagwaho said Mumararungu’s work reflects UGHE’s vision.

“We want more of our students to go and provide services to the most vulnerable,” Binagwaho said. “The more our students are spread across the world to serve vulnerable populations, the more we will be able to change the world.”

Fri, 20 Oct 2017 11:32:40 -0400