Partners In Health Articleshttps://www.pih.org On Universal Health Coverage Day, 'We the Peoples' Are Still Determined https://www.pih.org//article/universal-health-coverage-day-we-peoples-are-still-determined Dr. Joia Mukherjee, chief medical officer for Partners In Health, leads a rally outside the United Nations General Assembly in New York City in September, calling for universal health coverage that truly reflects health as a human right for all. Video by Nina Peskanov/PIH

Following rigorous debates at September's United Nations General Assembly in New York City, and marking Universal Health Coverage Day on Dec. 12, Dr. Joia Mukherjee, PIH's chief medical officer, and Hani Termanini, PIH partnership strategy officer, describe the critical question facing all of us amid the ongoing fight for true universal health care.

Seventy-four years ago, at the end of World War II, the United Nations was born to foster international collaboration and prevent the recurrence of fascism epitomized by the Nazi government. The Peoples of the United Nations, represented by their leaders, drafted a document that sought a collective fight against the destructive forces of extreme nationalism, and warned against a “separate peace”—meaning, a nationalist mentality of every country fending only for itself. The charter of the United Nations encouraged mutual interdependence and embodied an unwavering determination “to reaffirm faith in fundamental human rights, in the dignity and worth of the human person, in the equal rights of men and women and of nations large and small.”

At the end of September, the member states of the United Nations met at the UN General Assembly. Members held a summit on climate change and a high-level meeting on universal health coverage, addressing two of the most pressing issues of our time. These issues are fundamentally interrelated: Caring for our planet and for each other must be the task of our globalized world, the UN meetings suggested, particularly as we all work to ensure a better future for the next generation.

Yet, the 74th session of the UN General Assembly was divided by two fairly dichotomous views, of both climate action and health care. One view promoted profit over regulation; nationalism over global collaboration; and a lack of recognition of basic human rights, including women’s sexual and reproductive rights, over the broad inclusion of all in the fruits of science. It is alarming in the 21st century to hear world leaders—such as the presidents of the United States and Brazil—promote, from the platform of the UN, the very policies and ideas the UN was created to combat. 

But this debate is not new.

At the 1978 Alma Ata conference, the international community pledged health for all by the year 2000.  Yet, these pledges were not backed up by political will or financing mechanisms. The promise of achieving universal health coverage was hamstrung by nihilism—and the result has been selective primary health care, with poor countries administering just small packages of what’s considered feasible. 

To fulfill the promise of health for all, international solidarity is an imperative."

We now are hearing this mindset again: Rather than fighting for universal health coverage that embodies the progressive realization of the right to health, world leaders are talking about “sets” of “essential” health interventions that impoverished countries can afford with their domestic resources. 

Accepting the narrow scope of health that is possible with domestic resources of impoverished countries obscures the cause of massive global inequality. That inequality is the result of historical and contemporary forces, from colonialism to neoliberal capitalism. The political rhetoric of U.S. President Donald Trump, Brazil President Jair Bolsonaro, and others, is only a visible fraction of a much deeper and more pernicious system. Nationalism—backed up by racism, xenophobia, and militarism, and the neoliberal capitalism that it champions—ensures that impoverished people and impoverished countries will remain poor and sick and that our earth’s ecosystem will continue to hurtle toward catastrophe.

Belief in such a system is openly expressed not only by right wing leaders but also by some academics, such as those who advocate for the teaching of medicine as an exclusively technical discipline, one devoid of understanding of social context or social justice as determinants of well-being. These nihilistic views serve a political ideology rooted in the defense of the unjust status quo, and are in direct conflict with those calling for a just and equitable society. A fight in which health professionals, closer than anyone to suffering, can turn the tide.

At Partners In Health, informed by decades of working hand-in-hand with communities and governments in some of the world’s most impoverished places to ensure that everyone has the right to quality health care, we have learned several critical lessons.

Care for people means care for Earth."

First, every person is a person—or “tout moun se moun”, as the saying goes in Haitian Kreyol. Health is a human right, and in today’s globalized world we all need to organize and engage in direct actions to denounce the forces of ill health and pronounce a stronger sense of global responsibility for respecting, protecting, and fulfilling the right to health.

Second, to fulfill the promise of health for all, international solidarity is an imperative. The limited health budgets of impoverished countries have external causes—from un-taxed resource extraction to neoliberal constraints on lending. We need to remind ourselves that today, and for centuries, Western countries have enriched themselves by extracting human and material resources from the very countries some now claim are “aid dependent.” Development aid given by rich countries to impoverished ones pales in comparison to the large and often illicit outflows of cash out of the global South.

Third, care for people means care for Earth. Walking in solidarity with people and governments on their journey toward health and well-being is intimately linked to achieving environmental justice. Rationalizing public spending, to invest in peace rather than war and to restore the dignity of our planet and its inhabitants, will reap dividends that could be channeled toward further investments in the economic and social advancement of all peoples.

The 74th UNGA meeting in September posed a historical question that requires a loud and clear answer: Do we want an interdependent, caring world, or one based on nationalism, extreme shortsightedness, and greed? We, the Peoples, have a choice to make and a decision to act upon.

 

Joia MukherjeeDr. Joia Mukherjee, MD, MPH: Chief Medical Officer at Partners In Health and Associate Professor in the Department of Global Health and Social Medicine at Harvard Medical School

 

 

Hani Termanini

Hani Termanini, MBA, MPA: Partnership Strategy Officer at Partners In Health

 

 

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Wed, 11 Dec 2019 13:20:42 -0500 https://www.pih.org//article/universal-health-coverage-day-we-peoples-are-still-determined
Need to Know: How Kangaroo Mother Care is Keeping Babies Healthy in Liberia https://www.pih.org//article/need-know-how-kangaroo-mother-care-keeping-babies-healthy-liberia Spend a day at the Partners In Health-supported J.J. Dossen Hospital in Harper, Liberia—or in the homes and communities the hospital serves—and you’ll find mothers and babies enrolled in a vital program called kangaroo mother care (KMC).

Mothers like 22-year-old Cecile Johnson, and babies like her 10-week-old daughter, Sheba Nyemade. Sheba is Cecile’s fourth child. Her first three were born full-term, and now are 2, 3, and 5 years old. But with Sheba, Cecile needed an emergency cesarean section when she was just 28 weeks pregnant. She received the lifesaving care she needed, and baby Sheba was born Aug. 4 at J.J. Dossen, weighing 1.4 kg (2.2 pounds).

PIH’s care for the family has continued in the months since.

While kangaroo mother care has a light-hearted name, it’s a well-known approach that clinicians around the world use to decrease deaths of premature newborns, especially in countries where incubators and reliable electricity are hard to come by. Those conditions apply in Liberia, which has one of the world’s highest infant mortality rates: 26 deaths per 1,000 live births. That’s a stark comparison with rates in wealthier countries, such as the U.S., which sees about 4 newborn deaths per 1,000 live births.

KMC is an intervention following childbirth, in which health workers place a newborn on the mother’s chest for skin-to-skin contact. The direct contact promotes temperature regulation, early breastfeeding and mother-infant bonding. Clinicians recommend constant skin-to-skin contact for all infants born at a low weight. Premature births, like Sheba’s, are the cause of low birth weight about 15 percent of the time. In low-resource countries like Liberia, KMC also is recommended due to the unavailability of medical equipment, inadequate staffing of trained health workers, and unreliable utilities.

PIH Liberia provides KMC at J.J. Dossen Hospital and in the Maryland County communities it serves, with nurses providing care and follow-up directly in new mothers’ homes. Infants at the hospital are eligible for KMC if they have a birth weight of less than 1.8 kilograms (about 4 pounds).

Cecile began doing KMC while still at the hospital, after delivering Sheba. But with three other small children at home, when Sheba was discharged at a healthier weight, it was a better fit for Cecile to transition into PIH’s community KMC program.

She was able to do so with the help of community health worker Evelyn Toee. Evelyn has been with PIH since 2015, and was part of the first class of CHWs who PIH trained in Maryland County. She visits Cecile every Tuesday, to check on her, Sheba, and Cecile’s three other children. During each visit, Evelyn notes Sheba’s weight, makes sure Cecile has enough baby formula, and checks in with Cecile about how Sheba is doing, to see if additional support is needed. The results are evident: Sheba has been gaining weight and is continuing to receive care, such as immunizations, at J.J. Dossen.

Community health worker Evelyn Toe

Community health worker Evelyn Toe
Community health worker Evelyn Toee records information (top) about newborn Sheba Nyemade at the home of Sheba's mother, Cecile Johnson. Evelyn has been with PIH-Liberia since 2015 and visits Cecile every Tuesday (bottom), crossing small bridges to reach her home and check up on Sheba, who was born prematurely and at a low weight, but now is gaining weight and has improving health through a practice known as kangaroo mother care.

PIH health workers began providing community-based KMC in August 2018 and have enrolled 56 babies since, all born with low weights. While four of those newborns failed to recover and two were lost to follow-up—meaning, clinicians lost contact with the family—42 of the newborns enrolled in KMC from the surrounding community graduated. Graduation from KMC means babies reached at least 3.5 kilograms (almost 8 pounds) in weight and received vaccinations at 10 weeks old. For a recent graduation, many families involved in community care gathered at the hospital to celebrate.

Here, learn more about KMC at J.J. Dossen Hospital and beyond, with responses compiled by PIH experts including Viola Karanja, deputy executive director for PIH in Liberia.

Why is kangaroo mother care (KMC) important?

Kangaroo care is a proven, important strategy to promote optimum growth and development for premature infants. The direct contact prompts the infant’s body to release hormones, specifically oxytocin, that relieve stress and stabilize body temperature, breathing rate, and heart rate. Providing kangaroo care in communities and homes also can shorten hospital stays for new mothers and babies.

How do you practice kangaroo care?

Nurses encourage mothers to start KMC very soon after birth, when a newborn meets the low-weight criteria. The infant is placed between the mother’s breasts, wearing only diapers, socks and a head cap. The baby’s head is turned to one side and slightly elevated, hips flexed and abducted—meaning, with legs spread—and arms well flexed. The baby lies stomach-down, its abdomen resting just above the mother’s stomach.

The baby is then wrapped in a warm, locally made KMC binder or blanket, around the mother. The mother then covers the baby with an extra blanket, and is able to move around or sleep as she chooses. The mother should carry her baby for as long as the baby can tolerate, removing the baby preferably only during diaper changes. The minimum duration is 60 minutes per session, during the first 12 weeks of life.

Estimating child mortality levels and trends is difficult. When do you know that kangaroo care is effective?

We know KMC is effective by setting criteria and monitoring outcomes.

As an example, we’ve enrolled 56 babies from J.J. Dossen, with low birth weights, into community-based KMC. The smallest baby in the program was enrolled at the hospital at 890 grams (less than 2 pounds), and discharged into community KMC at 1.2 kilograms (about 2.6 pounds). After four months in the community program, the baby graduated at 3.5 kilograms (almost 8 pounds).

A dedicated team of community health workers, nurses and a pediatrician monitored all 56 families, mostly through home visits. The team visited most families once a week after they left the hospital, weighing the baby each time and checking for warning signs of jaundice, poor feeding, cord infections, or sepsis. The team also provided ongoing mentorship in KMC and breastfeeding, along with social support such as new bed nets, mattresses, and blankets.

Cecile Johnson and her daughter Sheba
Cecile Johnson's daughter, Sheba, is continuing to receive checkups at J.J. Dossen Hospital, where the close attention of nurses and community health workers helped Cecile deliver Sheba safely at just 28 weeks. In the weeks since, kangaroo mother care has helped regulate Sheba's body temperature, promoted weight gain and decrease her risk of infections. 

What happens as a result of effective kangaroo care?

Effective KMC strengthens bonds between the mother and her baby, improves the baby’s regulation of body temperature, and promotes weight gain. The baby’s risk of infection also decreases, and the baby becomes healthy, strong, and ready to be discharged home.

What is PIH doing to encourage KMC? How else does PIH support these families?

PIH Liberia has provided thorough, ongoing training for 10 nursing aides in the pediatric and obstetric wards at J.J. Dossen. The aides are the hospital’s KMC champions, and able to describe and explain KMC, help mothers begin KMC with their new babies, educate and counsel new mothers of preterm or low-weight babies, enroll newborns into KMC, mentor mothers on how to perform KMC independently, and teach mothers about healthy breastfeeding.

PIH Liberia also provides social support to mothers and families, including baby formula for mothers with low milk supplies, or for caregivers of premature babies whose mothers died in childbirth. Staff members also ensure that mothers are educated on family planning options, and able to make the best choices for themselves. PIH Liberia also encourages and supports teenage mothers who are interested in going back to school.

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Mon, 09 Dec 2019 12:10:09 -0500 https://www.pih.org//article/need-know-how-kangaroo-mother-care-keeping-babies-healthy-liberia
PIH Staff Picks: Essential Reading, Watching, and Listening for Social Justice Warriors https://www.pih.org//article/pih-staff-picks-essential-reading-watching-and-listening-social-justice-warriors For Partners In Health staff, commitment to social justice isn’t just a job—it’s a passion. Ask any PIHer what they’re reading, listening to, or watching in their free time, and chances are they’ll make at least one recommendation related to the fight for basic human rights for all.

Below are some of these recommendations—the books, podcasts, and films that staff around the world say motivate and enlighten them most. Heading into the season of giving, and of holiday travel, we hope this list provides you company, insight, and inspiration.

The Divide: A Brief Guide to Global Inequality and its Solutions

The Divide book cover

Written by Jason Hickel

Jason Hickel’s The Divide: A Brief Guide to Global Inequality and its Solutions is the most readable, and indeed, eloquent analysis of the rise of global inequality, a damning critique of ill-thought foreign aid, and a stirring call to action. Every PIHer would be well advised to read it, and more than once.

- Dr. Paul Farmer, co-founder and chief strategist

 

And the Band Played On: Politics, People, and the AIDS Epidemic

And The Band Played On book cover

Written by Randy Shilts

San Francisco journalist Randy Shilts wrote And the Band Played On in 1987 in the middle of the HIV epidemic in the United States. It outlines the political landscape at the time and provides historical insight into a very complex time in the U.S.  I lived through this time as a new HIV nurse and read this book right after it came out. Shilts gave me insight into what was happening behind the scenes and validated so much of what I was feeling. I recently re-read it, and it brought me back to that tumultuous time.

- Dr. Sheila Davis, chief executive officer

 

La Casa de los Espiritus (The House of the Spirits)

The House of the Spirits book cover

Written by Isabel Allende

I love reading novels, especially when they are historical. Isabel Allende, one of my favorite authors, always manages to make me binge read. Her first novel narrates the postcolonial story of Chile, with a mix of brave women, love, revolution, social class, and politics.

- Dr. Valeria Macias, executive director of Compañeros en Salud (PIH in Mexico)

 

For Sama film poster"For Sama"

Directed by Waad al-Kateab and Edward Watts

"Injustice anywhere is a threat to justice everywhere." - Martin Luther King, Jr.

In "For Sama," al-Kateab records her life in Aleppo, Syria, documenting some of her major life milestones while her home city crumbles. The film is put together as a love letter from al-Kateab to her daughter, Sama.

"For Sama" is a re-humanizing love story that calls out on us to move away from our comfortable sidelines, join the struggle, and fight. Truly fight.

Whether in Aleppo, Syria or in El Paso, Texas, injustice has the same bitter taste. And whether it is for Sama al-Kateab, now 4, or for Jakelin Caal Maquin, always 7, it's about time for each of us and all of us in what King calls the "inescapable network of mutuality" to work alone and work together to make sure that justice is served.

- Hani Termanini, associate partnership strategy officer

 

Custer Died for Your Sins: An Indian Manifesto

Custer Died for Your Sins book cover

Written by Vine Deloria, Jr.

The late Vine Deloria was able to walk in both worlds successfully, using his humor throughout his advocacy for American Indian rights and social justice. He was eloquently able to inform readers about still pertinent indigenous issues through his writing. While this book was published back in 1969, it is a must read or re-read for those wanting to understand indigenous issues and viewpoints.

- Nitumigaabow Champagne, executive director of COPE (PIH on Navajo Nation)
 

Democracy Now!

Democracy Now logo

Hosted and produced by Amy Goodman

I listen to the Democracy Now! podcast every day. Amy Goodman is a fantastic reporter, with a great team providing the most progressive voice on Haiti, climate change, and global affairs.

- Dr. Joia Mukherjee, chief medical officer

 

American Street

American Street book cover

Written by Ibi Zaboi

American Street is a beautiful novel by emerging Haitian-American author Ibi Zaboi, written from the perspective of a young Haitian girl, Fabiola Toussaint. Toussaint ends up immigrating by herself to live with her aunt and cousins in Detroit after her mother is detained at customs in New Jersey. It’s an intense plot with stark prose and some magical realism sprinkled in, and tackles some tough topics – culture shock, racism, substance abuse, gang violence, class oppression, and police brutality.

Fabiola’s voice never wavers in its truth, clarity, bravery, and humor. She and the book definitely inspired me to continue to seek out authors with backgrounds unlike my own, or who represent communities that don’t often have the chance to be heard.

- Maia Olsen, NCD Synergies program manager

 

We Should All Be Feminists

We Should All Be Feminists book cover

Written by Chimamanda Ngozi Adichie

My recommended reading is We Should All Be Feminists. The title says it all!

- Vicky Reed, director of nursing for PIH in Sierra Leone

 

 

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Tue, 03 Dec 2019 16:37:03 -0500 https://www.pih.org//article/pih-staff-picks-essential-reading-watching-and-listening-social-justice-warriors
On the Frontlines of Malawi’s Food Crisis https://www.pih.org//article/frontlines-malawis-food-crisis Silvester Dambe said that when he first began visiting Keredonia Wilfred, she was so weak that she declined medicine for her HIV, thinking her recent diagnosis meant she had no chance of living.

The senior community health worker gradually convinced her to stay on antiretroviral therapy, though, telling her that it was not the end of her life, and that he would keep visiting her to provide access to medicine and care through his role with Partners In Health in southern Malawi. Dambe reassured Wilfred that if she kept up with treatment, she would have an excellent chance of staying healthy, for a long time to come.

That was 12 years ago.

He’s still visiting Wilfred today, at her family’s home high in the mountains surrounding Dambe Health Center in Malawi’s Neno District. During his visits, he now gets to watch Wilfred, 55, play with her three grandchildren. She has maintained her antiretroviral therapy and managed her HIV, which is no longer the specter it once was for her.

Keredonia Wilfred and her grandson, Samuel Peter Gerald
Keredonia Wilfred, 55, holds her grandson, Samuel Peter Gerald, at their family's home in Ndoma Village, Malawi, near Dambe Health Center. Twelve years ago, Wilfred thought an HIV diagnosis meant the end of her life. Community health worker Silvester Dambe convinced her otherwise—and is now helping her access health resources for Samuel Peter. 
Health worker Silvester Dambe walks to Keredonia Wilfred's home
Senior community health worker Silvester Dambe, 56, has lived in the Dambe area all his life, and has been visiting Keredonia Wilfred and her family for 12 years, to provide access to health services, checkups, and support, in Ndoma Village, Malawi. (Photos by Mike Lawrence / PIH)

Lately, as Dambe strides up the steep hills in Ndoma Village toward Wilfred’s home, his focus has been helping the family through a different health concern. Malnutrition is a serious threat now and in coming months for the 140,000 people whom PIH serves across Neno, where a food crisis looms as many continue to suffer from harvests lost during Cyclone Idai last March.

The cyclone pummeled southeastern Africa, killing an estimated 1,000 people across Mozambique, Zimbabwe, and Malawi; affecting 1 million; and destroying vital crops at the end of the rainy season, leaving farmers no opportunity to replant. In Malawi alone, the flooding killed 60 people and displaced nearly 90,000 across 15 of the country’s southern districts, including Neno.  

The Malawi government recently estimated that 1.1 million people would not be able to meet their food requirements through March 2020, when new harvests finally should ease the burden.  

Dambe is one of 96 community health workers (CHWs) on the front lines of the fight against malnutrition in the most mountainous, isolated part of Neno, with which he shares a name.

The 56-year-old has lived in the Dambe area all his life. He’s been a CHW since 2007, when PIH, known locally as Abwenzi Pa Za Umoyo, began partnering with the Malawi government and working in Neno.  

In addition to supervisory roles as a senior CHW, Dambe regularly visits 15 homes, including Wilfred’s. As he arrived at her home for a scheduled visit one afternoon in October, she was seated outside with her daughters, 19-year-old Sofia Gerald and 20-year-old Lusca Gerald. In Sofia's lap was her 2-year-old son, Samuel Peter Gerald.

Senior community health worker Silvester Dambe
Senior community health worker Silvester Dambe, 56, regularly visits 15 homes in the region, providing health screenings, checkups and access to resources, in addition to supervising other community health workers for PIH. (Mike Lawrence / PIH)

Dambe keeps a close eye on Samuel Peter during his visits, making sure the toddler is staying healthy in the critical early years of childhood development. After chatting with the family and going through basic health checkups, Dambe uses an adjustable armband to measure Samuel Peter’s mid-upper-arm circumference, or MUAC, a standard gauge for malnutrition. Anything less than 12.5 centimeters (about 5 inches) appears in a red zone on the armband, signaling high risk.

Samuel Peter’s upper arm measures 15 centimeters (about 6 inches) on this day, though, appearing in the green zone on the armband and indicating adequate health. It’s positive news for the family, which has faced challenges growing food since Wilfred’s husband passed away about three years ago.

But if problems arise, additional health services are not far away. Their home is atop a ridge, and Dambe Health Center is visible atop another ridge, across a valley. It’s about a 40-minute walk or a 10-minute drive away. The health center serves more than 11,400 people across 18 villages in the region, and offers malnutrition clinics every Thursday.

James Lipenga, CHW site supervisor for the Dambe region, said only eight children younger than 5 were enrolled in the malnutrition clinic as of early October—a significant drop from previous years, and a testament to the dedicated work of CHWs like Silvester Dambe.

PIH in Malawi has adopted a household model for CHWs, meaning every household has a CHW assigned to it, who visits regularly and provides access to care. Lipenga said that in the Dambe region, malnutrition care includes screenings and checkups, such as the MUAC measurement. CHWs' work is designed around early detection, referral, and treatment, to prevent severe malnutrition and provide families with access to services such as clinical needs and social support programs.

The road between Dambe and Nsambe health centers in Neno District, Malawi, along the border with Mozambique
The road between Dambe and Nsambe health centers in Neno District, Malawi, along the border with Mozambique. (Photo by Zack DeClerck / PIH)

When malnutrition cases arise, CHWs help families and young children access the clinic and other services at the health center. For severe cases, PIH staff at the health center refer and transport families to the PIH-supported Neno District Hospital, about a two-hour drive down steep, rugged dirt roads to central Neno.

Across Neno District, PIH's malnutrition program provides monitoring and lifesaving treatment for more than 2,400 children under 5 per year, as of 2017 data. 

It’s a ground-up, home-by-home system built on the foundation of CHWs, who provide vital, lifesaving care for their neighbors, in the communities where they live.

For Silvester Dambe, that used to mean a lot of walking. Before Dambe Health Center was built in 2016 and more CHWs joined the ranks, he served families in the large catchment area for Nsambe Health Center, as well as Dambe, requiring three-to-four-hour walks each way to reach homes. He covered that territory for nine years, including frequent visits to Wilfred, to enable her to maintain her HIV treatment and raise a family that continues to be healthy.

“That was how we developed a good relationship,” Dambe said, recalling long conversations about health, resources, and positivity.

The conversation on this particular day was warm, with the familiarity born of long friendships. As Dambe prepared to leave, with other visits on his schedule, their goodbyes were brief—he and Wilfred both knew Dambe would see her and her family again soon.

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Mon, 25 Nov 2019 15:15:25 -0500 https://www.pih.org//article/frontlines-malawis-food-crisis
Rice Farming Program Combating Malnutrition in Rwanda https://www.pih.org//article/rice-farming-program-combating-malnutrition-rwanda The hardest part about growing rice in a lush river valley in southeastern Rwanda, a dedicated group of farmers says, is “keeping the beds”—in other words, frequently yelling and waving to scare away flocks of hungry birds that descend on the paddies.

Farmers’ piercing calls create a steady background noise along this rural stretch of the Kadiridimba River, where rice paddies form a checkerboard across the flooded lowlands and—scavenging birds or not—an innovative agriculture program is changing the lives of 18 families with children affected by malnutrition.

The Kadiridimba is a major source of water for Kayonza District, and a major thoroughfare for agriculture in Rwinkwavu, a region in Kayonza where Partners In Health supports Rwinkwavu Hospital, strengthens the health system and provides health services in numerous communities. Last year, staff with PIH’s livelihood program successfully worked with the local government to dedicate one hectare of river-fed land—about 2 ½ acres—for a rice farming program. Parents of malnourished or diabetic children now work the one-hectare paddy and use the harvests for food, income and, potentially, growth of a small business.

Parents of children with malnutrition use their harvests for food and income
Parents in PIH's rice-farming program work in their rice paddy from 7 to 11 a.m. every weekday, often walking on elevated muddy banks in between soaked beds. 
Rice beds need to be moved as they grow, creating different size beds across a paddy
Rice beds need to be moved as they grow, creating different size beds across a paddy over a growing cycle of about three months. Rice ready for harvest can be taller than waist-high, and straw covers empty beds that farmers recently harvested.

Partners In Health has worked in Rwanda since 2005, and is known locally as Inshuti Mu Buzima. Kayonza is one of three districts in which PIH works, and across all of them, livelihood programs—formally called the Program on Social and Economic Rights, or POSER—are a key part of caring for people’s entire health needs, beyond clinical care.

Malnutrition care

Christian Mazimpaka, PIH’s clinical director for Kayonza District, said many people who receive health care and screenings from PIH are then connected with POSER programs because of malnutrition.

“At the hospital they get food, but when they go home, it is a problem,” he said. “These programs are to make sure after they are discharged, they can get food, and they are not coming back to the hospital.”

Clement Cyiza, a POSER program assistant, said PIH supports 800 households in Rwinkwavu with programs including agriculture training, direct food assistance, livestock, and more. Cyiza said those 800 households include more than 50 local community groups, in which neighboring families take on collaborative projects.   

Such as growing rice to produce additional food for their children.

Clementine Nyirashyirambere was one of five parents who sat on a thick bed of straw in their shared paddy on a sunny afternoon earlier this year, and talked about the program. She is a mother of six children, including two enrolled in PIH’s malnutrition program. She said PIH has provided health checkups and care for her family, direct food support along with the rice farming effort, additional training on how to grow better vegetables at home, and transportation for her children to visit Rwinkwavu Hospital.

And with harvests under their belts, she and her co-workers already were talking about expanding their sales. 

Florenti Rukiriza helps parents with rice farming to supplement their food and income
PIH agriculture facilitator Florenti Rukiriza (left) has been farming rice for decades. He said the program in Rwinkwavu began with a community survey and now has reaped four harvests, with a fifth expected in late November. 

Food security

The parents’ success has come with a lot of dedication. They work in the rice paddy from 7 to 11 a.m. every weekday, learning daily lessons in the labor-intensive process. Beds of rice have to be moved as they grow, transplanted from one soggy patch to another over about three months, until they mature. Beds of rice that are ready for harvest are taller than waist-high. Empty beds that recently have been harvested are covered by thick layers of straw, heavy enough to sit on and walk across, until the next planting.

Florenti Rukiriza, a PIH agriculture facilitator and a father of four himself, has been guiding the new farmers along the way.

Rukiriza, 52, said he’s been farming rice “since before the genocide.” That’s a common marker of time in Rwanda, where the 1994 genocide against the Tutsis led to the deaths of 1 million people—nearly 20 percent of the country’s population at the time—and displaced millions more. 

Community empowerment and building health from the ground up, through programs such as communal rice farming, are a crucial part of Rwanda’s national revival in the 25 years since.

Rukiriza said before the program began, they surveyed community members to assess needs for seeds, land, and supplies—such as an irrigation pump for the Kadiridimba, which is heavily farmed and flows sluggishly through the valley.

After the first planting in August 2018, the group now is about to reap its fifth harvest, in late November. Members collected more than 2,100 kilograms of rice across four harvests. Each harvest bore about five sacks, each weighing 100 kilograms. Cyiza said each sack sold for about 30,000 Rwandan francs, or more than $32.

Altogether, that amounts to about 630,000 Rwandan francs, or $675. Divided among the 18 families in the program, that means each family gained 35,000 francs, about $38, over the year. In rural areas such as Rwinkwavu, that's more than enough to feed a family of five for a month.

Mazimpaka, the clinical director for Kayonza District, said those gains are translating directly to greater food security for people in PIH’s malnutrition programs across Rwanda. The rice farming program is part of a larger effort called All Mothers and Children Count, which includes a variety of maternal and child health initiatives, POSER programs, and more.

Sabrine Mutesi said her son, Ibrahim Arnold, 3, is much healthier and more energetic since the family joined PIH's malnutrition program.
Sabrine Mutesi and her family are involved in PIH's malnutrition program in southeastern Rwanda. She said her son, Ibrahim Arnold, 3, is much healthier and more energetic since the family joined the local rice-farming collaborative. Seated behind her are PIH program assistant Clement Cyiza, left, and Mutesi's mother, Franana Gakasi, holding Mutesi's 6-month-old son, Ramadhan.

Child health

“When we started this project, we did a survey,” said Mazimpaka, who also is project manager for All Mothers and Children Count. “All the beneficiaries reported they only had food security for five months out of the year.”

That 2016 survey spanned 2,400 households, across the three districts—Kayonza and Kirehe in the southeast, Burera in the north—in which PIH works in Rwanda.

Since that time, Mazimpaka said, average food security for families surveyed has grown to eight months out of the year, rather than five.

That’s only a start, of course. But for parents including Cristine Mukabarisa, who has children in the Rwinkwavu malnutrition program and has been growing rice alongside Nyirashyirambere and others, the impacts have been very real.

She gave a simple description of how her children have been doing since the group began harvesting.

Abana baraho,” she said in Kinyarwanda, as Cyiza translated. “(My) children are so good.”

Wading across a heavily farmed stretch of the Kadiridimba River
Clementine Nyirashyirambere, Jerardine Mukamdayisabye, and Veronica Mukamgiruwomsanga, left to right, wade across a low stretch of the Kadiridimba River on their way home from their communal rice paddy in Rwinkwavu, Rwanda.  

 

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Wed, 20 Nov 2019 11:18:17 -0500 https://www.pih.org//article/rice-farming-program-combating-malnutrition-rwanda
Watch: Dr. Christophe Millien Discusses Urgent Needs in Haiti https://www.pih.org//article/watch-dr-christophe-millien-discusses-urgent-needs-haiti In part as a response to this growing pressure on our systems and staff, PIH is crowdfunding the cost of six major equipment replacements or upgrades at PIH’s University Hospital in Mirebalais, Haiti (HUM). Dr. Christophe Millien, chair of the Obstetrics and Gynecology department at HUM sat down to explain the urgent need for equipment in his department.

While Dr. Millien focuses on the lifesaving power of ultrasound machines, PIH is crowdfunding the cost of six other major purchases, including: an electrosurgical machine, another anesthesia machine, patient monitors, replacement probes for the ultrasounds, and patient-return electrodes for electrosurgical machines.

Donate

Watch Dr. Millien below as he walks us through the situation at hand:

 

Contribute to the crowdfund for this new ultrasound machine, as well as five other vital equipment purchases. Take me to the crowdfund ]]>
Mon, 18 Nov 2019 11:01:22 -0500 https://www.pih.org//article/watch-dr-christophe-millien-discusses-urgent-needs-haiti
Patients, Clinicians in Liberia See Success in Diabetes Control https://www.pih.org//article/patients-clinicians-liberia-see-success-diabetes-control Most mornings on his way to work in Harper, Liberia, Dr. Jacquelin Pierre says he is met with a beautiful sight. As he climbs the hill above the ocean, sunlight glinting off the waves, a group of runners wearing brightly colored workout gear greets him. 

“Hey Doc,” they yell out, smiling and catching their breath. “We’re doing physical exercise,” they say. Sometimes they call out numbers. “95!” they call out. Or, “100!,” high fiving him as they run on.

Pierre is PIH’s noncommunicable diseases (NCD) program lead in Liberia, and among the runners are some of his diabetic patients. The numbers they yell out are their latest blood sugar readings, and they bring him joy. 

When Pierre arrived in Liberia’s Maryland County 15 months ago, many of the patients he saw at J.J. Dossen Hospital and Pleebo Health Center presented with both hypertension and sky-high blood sugar. Most didn't know what was wrong. Some even had blood sugar readings of more than 500—a life-threatening level that is considered a medical emergency. 

Complications from uncontrolled diabetes can quickly lead to heart disease, nerve damage, skin conditions, and damage to sight and hearing, particularly in Liberia, where awareness of diabetes is limited. “Sometimes you cannot imagine how a patient can live with such high blood sugar for a long time,” said Pierre.

Breaking down barriers to access

Liberia still lacks exact data on the prevalence of diabetes, but the rate has more than doubled across sub-Saharan Africa since 1980, triggered by sedentary lifestyle changes like greater access to cars and fast food. And diabetes care across the continent can be expensive. In parts of West Africa without access to free health care; the bill for glucose strips, a month’s supply of insulin, and a blood sugar monitor can easily total $300—a significant barrier to access for the vast majority of Liberians, 84 percent of whom lives below the poverty line of $1.25 per day. 

PIH has been partnering with Liberia’s Ministry of Health since 2014 to overhaul access to diabetes care and improve patient outcomes. The PIH approach hinges on a combination of building capacity at health facilities in conjunction with health education, access to medication, lifestyle changes, and support groups. Diagnosis and treatment is free of charge at Ministry of Health sites supported by PIH, such as at J.J. Dossen Hospital and Pleebo Health Center in Harper, where Pierre sees patients. As of late September, he said, there were already 1,166 patients enrolled in the NCD program.

“We all know that if we want to do something sustainable, the first thing to do is build capacity. We’re training young doctors and nurses in NCDs,” said Pierre, who previously rolled out PIH’s NCD program in Haiti in partnership with the ministry of health that saw an overall drop in mortality from complications from 27 percent to 6 percent. “That’s the same thing that my team and I at PIH, together with the ministry of health, are doing in Liberia.”

Diabetes patient in Liberia undergoes a blood sugar check
Theophilus Allison (left), a Ministry of Health NCD nurse aide, tests the blood sugar level of Alexander Quaye (right) during a community outreach event at Tubman University near Harper, Liberia. Photo by Laura Romcevich / Partners In Health

A patient leader for diabetes

The PIH team includes not only clinicians but patient leaders. Among them is Alexander Quaye, an associate professor of economics at Harper’s Tubman University, who was diagnosed with type 2 diabetes a year ago. Through a combination of diet, exercise, and medication, Quaye has seen his blood sugar level drop fivefold, from 541 to 111.

His story began in November 2018, when he was escorting another sick colleague to the hospital. But when he arrived, Dr. George Methodius, Maryland’s chief medical officer, took one look at Quaye and insisted he have his blood sugar level tested. He hadn’t been experiencing any symptoms, although with hindsight he remembers feeling tired.

“The nurse who did my sugar test was afraid. It was 541. The hospital gave me a bed and four IV lines,” said Quaye, who was more shocked than anyone. He had simply been expecting to drop off his colleague and head back to work.

At the NCD clinic the next morning, Pierre and the clinical team met with Quaye to discuss some ways he could adapt his diet to improve his health, integrating more fruits and vegetables into his daily meals. It seemed like Pierre was suggesting the impossible. Southeastern Liberia may be home to fertile land watered by the long rainy season, but few fruits or vegetables are farmed or readily available there.

“But doctor,” said Quaye, “how can I do that? Here in Harper we have nothing. It’s only rice every day. It seems like for me, diabetes is a very difficult disease to deal with, and I’m going to die.”

Together they came up with a plan to improve his diet. “It’s possible for you to get better, and we’ll take care of your disease together—not only us as health care providers, but with you,” Pierre assured him.

First up was breakfast. They replaced visits to cookshops—the popular roadside coffee shops that serve fried eggs and hot sugary donuts—with oatmeal and fresh milk. They added avocados, known in Liberia as butter pears, along with other fresh fruits and vegetables, such as seasonal mangos and juicy oranges. They adapted recipes to include less sugar, salt, and palm oil, and they replaced rice with the Ghanaian staple kenkey, which is pounded from maize and is widely available in the southeast. 

Patient who has successfully controlled his diabetes in Liberia
Quaye, an associate professor of economics at Harper’s Tubman University, has successfully controlled his diabetes and serves as a model for other patients in Liberia. Photo by Kyle Daniels / Partners In Health

Now, Quaye hasn’t eaten rice for a year—an astonishing feat in a region where most people rely on rice and sauce several times a day. He regularly goes for long walks in the mornings, even in the rainy season, and encourages others in his community to get their blood sugar level tested, including his mother, who was also subsequently diagnosed with diabetes and learned to adapt the meals she cooks at home. He takes Metformin, a common medication for type 2 diabetes, twice daily, and he watches his blood sugar level like a hawk. 

“It is incredible how he has made himself healthy with what is available to eat in Harper,” said Pierre, who also oversees regular cooking workshops and patient support groups for patients diagnosed with diabetes in Harper. There, patients can also trade tips with others suffering from the same condition. 

“We’re doing integrative social medicine based on patient education,” Pierre said. “We do home visits to get an idea about patients’ economic status, how they live, and we take the time to educate them about how to use the minimum they have to adjust their diet to the disease they suffer from. That’s what we did for Alexander, it’s what we’re doing for all NCD patients, and it works.”

taking a blood sugar test for a patient in rural Liberia
A patient has a blood sugar level test taken at the NCD clinic at J.J. Dossen Hospital. Photo by Stephanie Chang / Partners In Health

Opening health workers' eyes

The approach is impacting not only patients but also health workers, many of whom had had little access to information about diabetes until recently. 

Cyrus Randolph, a physician’s assistant, has been working with PIH and the ministry of health on the NCD program for the past two years. After overseeing the training of nurses and physician’s assistants at Pleebo Health Center, also in Maryland, he has seen a drop in the number of patients suffering from complications. 

Recently, he was thanked by the parents of one young patient who had no idea their daughter was sick. They didn’t realize that the reason she wasn’t doing well at school wasn’t an academic one. As it turned out, she had been going into diabetic ketoacidosis—a serious condition that requires immediate supportive care, including fluids and insulin. 

Since she was diagnosed with type 1 diabetes, she is suddenly excelling at school. “Her blood sugar is well controlled and she’s passing her exams,” Randolph said. “It’s wonderful to be able to help more patients like her.”

“Until recently, some health workers in Liberia had no idea about diabetes,” he said. “Now we have established protocols and are building a system for providing them support and hope.”

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Thu, 14 Nov 2019 15:42:20 -0500 https://www.pih.org//article/patients-clinicians-liberia-see-success-diabetes-control
After Long Uncertainty, Teen With Diabetes Finds Care at Malawi Clinic https://www.pih.org//article/after-long-uncertainty-teen-diabetes-finds-care-malawi-clinic Sofiya Simoni said it took a lot of legwork to figure out why her son Kerefasi was suffering from fevers, stomachaches, and vomiting.  

Now 14 and in sixth grade, Kerefasi Wiliyamu began feeling those symptoms several years ago. He and his mother live in Masinde Village in southern Malawi, near the commercial city of Blantyre. The closest health center to their home is a facility named Mdeka, but when Simoni took Kerefasi there for tests, clinicians found no disease. Neither did staff at a private clinic they tried next.  

But when they visited Partners In Health-supported Zalewa Health Center—where tests again showed no malaria, no HIV—they were referred to Lisungwi Community Hospital, also PIH-supported. Simoni and her son had finally found a place that could answer their questions: PIH’s Advanced NCD Clinic.

The clinic is held weekly at the hospital and provides specialized, personal care for children and adults with advanced cases of non-communicable diseases, or NCDs, ranging from type 1 diabetes, sickle cell, heart problems and kidney failure to severe asthma, epilepsy, and more.  

PIH's Benson Phiri welcomes families to an Advanced NCD Clinic in Neno, Malawi
Benson Phiri, community health worker program officer for PIH in Neno District, Malawi, welcomes families to PIH's Advanced NCD Clinic at Lisungwi Community Hospital. Kerefasi Wiliyamu is at center, in black pants, and to his right is his mother, Sofiya Simoni, in the striped skirt.

For Kerefasi, the condition that had been keeping him out of school and significantly affecting his health was one that, in countries like the United States, would be much easier to diagnose: type 1 diabetes. But in Malawi’s rural, remote Neno District, accessing proper treatment and medicine for an NCD like type 1 diabetes can be challenging—which makes the specialized care that Kerefasi is now receiving all the more remarkable.  

Kerefasi Wiliyamu, 14, talks with clinical officers at the Advanced NCD Clinic

Clinical officer Kenwood Kumwenda gives a checkup to Kerefasi Wiliyamu
More than 100 patients are enrolled at PIH's Advanced NCD Clinic at Lisungwi Community Hospital, but many visit just monthly, meaning clinical officers are able to provide specialized, personal care that can be harder to find in crowded outpatient wards or health centers. Here, Kenwood Kumwenda chats with Kerefasi and checks his vitals, while clinical officer Medson Boti talks with Kerefasi's mother, Sofiya Simoni.

PIH, known in Malawi as Abwenzi Pa Za Umoyo, started the Advanced NCD Clinic at Lisungwi in November 2018. PIH also offers the clinic weekly at Neno District Hospital and monthly at Matope Health Center, to reach as many as possible of the 140,000 people PIH serves across Neno’s rugged mountains and lowlands.  

Clinical officer Kenwood Kumwenda said more than 100 families are now enrolled at Lisungwi’s Advanced NCD Clinic, which sees about 20 families per week.  

“It was established because, initially, we only had IC3, which is Integrated Chronic Care Clinic, where we see NCD plus HIV (clients) together,” Kumwenda said. “But it was noted that there are some clients who are very sick, and they need advanced care. Because in IC3, for example, we can't do ultrasounds or other advanced things like electrocardiograms,” or closely monitor and adjust insulin for children with type 1 diabetes.   

Kerefasi Wiliyamu receives monthly insulin to manage his Type 1 diabetes
After visiting several doctors at different health facilities, Kerefasi Wiliyamu, 14, at last received a diagnosis for his type 1 diabetes at PIH's Advanced NCD Clinic in Neno District, Malawi, where he receives regular insulin packages and specialized care.

On a hot, dry Thursday in October, Kerefasi and his mother made their third visit to the Advanced NCD Clinic. They first received a general checkup and consultation, as Kumwenda and clinical officer Medson Boti checked his vital signs and chatted with Kerefasi about how he had been feeling lately.  

Kerefasi and his mother said he was feeling good, much better than he’d been for some time, but a problem remained. Despite the insulin he’d been receiving at the clinic, his blood sugar levels weren’t dropping.  

Kumwenda later said that was because Kerefasi wasn’t getting as many meals as he needed, and skipping his insulin because of weakness he would feel after taking the medicine on an empty stomach.  

Food insecurity is all too common in Neno District, and the community around Lisungwi.  

“This is a rural community, and most of the people, they are poor, and they cannot afford the diabetic diet we advise, meaning three regular meals a day," Kumwenda said. “Most of them, they maybe afford one, and eat one meal per day, or two. So with diabetes, on insulin, that's a very big challenge. So they may end up opting not to give the insulin. Instead, they say, ‘I will give it when I have food.’” 

NCD nurse Victor Kaphaso advises Kerefasi about his insulin
NCD nurse Victor Kaphaso advises Kerefasi about his insulin, in the pharmacy room at PIH's Advanced NCD Clinic. 

Taking insulin without eating can lead to dangerously low drops in blood sugar for people with diabetes. That compounds existing problems of malnutrition that, for many people in Malawi, will be especially dire in the months ahead.   

Last March, Cyclone Idai struck southeastern Africa and massively exacerbated an already heavy rainy season. The cyclone killed an estimated 1,000 people across Mozambique, Zimbabwe, and Malawi; affected 1 million; and forced hundreds of thousands from their homes. In Malawi alone, the flooding killed 60 people and displaced nearly 90,000 others across 15 of the country’s southern districts, including Neno.  

Relief efforts have been ongoing, but the needs remain great. The Malawi government’s annual food security report, released in September, estimated that 1.1 million people across the country will not be able to meet their food requirements from October through March 2020, when new harvests finally will ease the burdens.  

Kumwenda said Kerefasi and his family could be a candidate for additional food support from PIH, through its Program on Social and Economic Rights, or POSER. The Advanced NCD Clinic provides POSER support to many of its patients, usually through cash for transportation costs, furthering PIH’s belief that social assistance is a critical part of medical care.    

“In this area, people have difficulties in accessing the health center, in terms of transport,” Kumwenda said. “Because they have to travel on foot. There's no—most of them, they don't have a means of transport. They don't have bikes or they don't have anything. So, they have to travel by foot.”  

Kumwenda said some patients travel more than 60 miles, each way, to reach the clinic.  

Roads in Neno District
Many clients travel to PIH's Advanced NCD Clinic on foot, leaving early in the morning to avoid the hottest hours of dry, arid October days, when temperatures can climb above 100 degrees Fahrenheit.

Simoni said she and Kerefasi had left their home at 6 a.m. that day, to reach the clinic by about 8 a.m. They took a bus part of the way, she said, and happened to catch a passing hospital vehicle that gave them a lift. Had they not caught that vehicle, they would have continued on the transportation regularly paid for by PIH.  

The ride was welcome on a hot day. October heat can be brutal in Neno, particularly in the lowland Lisungwi community, which doesn’t have the cooler mountain air found in the district’s higher elevations. On this Thursday, temperatures at Lisungwi topped 38 degrees Celsius, or about 100 degrees Fahrenheit.  

Despite all of those challenges—heat, distance, food insecurity, and failed diagnoses at several facilities—Kerefasi, finally, is feeling better. He said his favorite subject in school is English, and he likes to read, especially poetry. Simoni said they’d return to the clinic the following week, to keep more frequent checkups to monitor Kerefasi’s blood sugar.  

Kumwenda said that kind of improvement is his favorite thing about the Advanced NCD Clinic.  

“You know, in Malawi, when you talk of type 1 diabetes, everyone will say: ‘Who is going to manage this?’” Kumwenda said. “Even heart failures. Even chronic kidney disease—they are difficult to manage here.”  

Kumwenda said those difficulties gave him doubts, when he joined the clinic in September 2018, about whether they would be able to find success. He took the position not knowing whether they would actually be able to help the advanced NCD patients they were hoping to treat.  

Kumwenda, Boti, and all of PIH’s team in Malawi are steadily putting those doubts to rest.  

“What I most like most (is that) most of the patients, now, since we started, we are helping them,” Kumwenda said. “They are stable. They are going home, they are happy. They come here (and say), ‘I am fine now, I am able to walk.’ So I think this is very interesting to me.” 

Kerefasi Wiliyamu and his mother, Sofiya Simoni, leave the Advanced NCD Clinic
Kerefasi Wiliyamu and his mother, Sofiya Simoni, leave the Advanced NCD Clinic at PIH-supported Lisungwi Community Hospital. They've been visiting the clinic for three months to manage Kerefasi's type 1 diabetes, and will return in a week, to maintain regular checkups while Kerefasi's blood sugar levels remain high.  

 

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Thu, 14 Nov 2019 09:02:37 -0500 https://www.pih.org//article/after-long-uncertainty-teen-diabetes-finds-care-malawi-clinic
Stopping Severe Malnutrition in Sierra Leone https://www.pih.org//article/stopping-severe-malnutrition-sierra-leone In Sierra Leone, where extreme poverty means nearly half of families don’t have enough food on a daily basis, children are particularly vulnerable to malnutrition. The consequences of this lack of nutrition are staggering, and long-term. Nearly 40 percent of kids in Sierra Leone have suffered stunting, or impaired growth that can permanently damage cognition and overall health, limiting their potential and that of the country.

Partners In Health has been combating this injustice since 2014, when our partnership with the Sierra Leonean government began. In Kono District, clinicians at PIH-supported Wellbody Clinic have been treating young children for severe acute malnutrition (SAM) and have established a social support program that provides food assistance to families.

But this work to prevent the lifelong harms of malnutrition wasn’t reaching everyone truly in need. Some children were not fairing as badly, but still fell under the category of moderate acute malnutrition (MAM). They did not qualify for the SAM program, nor did clinicians want to see their conditions worsen.

In response to this critical gap, PIH established the MAM program this year. By providing treatment and nutrition support to more malnourished children and their families, clinicians are stopping this life-altering, potentially deadly condition in its tracks earlier, and saving and improving more lives throughout Kono.

Take a look at this photo essay to see how the new program works:

Women prepare food at Wellbody Clinic

Each month at Wellbody Clinic, around 50 mothers and caregivers gather to prepare and share large quantities of highly nutritious food for their children diagnosed with moderate acute malnutrition. The clinic’s nutritionist guides the group, and all of the ingredients and tools are supplied by PIH.

A woman measures out rice.

The women work together to debone dried fish and measure out rice, which they will then cook over a fire.

Women combine ingredients

They combine the fish and rice with Bennimix, a locally available food supplement. The three ingredients are ground together to create a large quantity of highly nutritious food. Each family takes home a share.

Children play together

While the women cook, their children play together in the shade.

A woman and her baby

Families walk away from each cooking session with not only a month’s worth of therapeutic food for their infants, but also a greater sense of community.

A bucket scale used to weigh babies at Wellbody Cinic

In between the monthly cooking sessions, children receive regular checkups at the clinic, during which they are weighed in a bucket scale and measured to ensure that their healthy growth is on track.

John Suluku

They also receive regular home visits from PIH’s community health staff, such as John Suluku, an acute needs program officer and leader of the MAM program.

Lansana and Fatmata

Lansana Sidibay, 18 months, steadily gained weight and grew after his mother, Fatmata Mansaray, enrolled him in the MAM program at Wellbody Clinic. Fatmata still makes Bennimix for Lansana, who is now a healthy and spunky toddler, and has taught family and neighborhood friends how to make the nutritional supplement for their children.

Loko Kallon

Loko Kallon, 13 months, also graduated from the program. After Loko lost her appetite and was running a fever, her mother, Finda Kallon (above right), took her to Wellbody and discovered she was suffering from malnutrition. Meals fortified with Bennimix, provided through PIH, allowed Loko to get to a healthy weight and regain her energy.

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Wed, 13 Nov 2019 14:34:17 -0500 https://www.pih.org//article/stopping-severe-malnutrition-sierra-leone
Innovative Solution to Food Deserts on Navajo Nation https://www.pih.org//article/innovative-solution-food-deserts-navajo-nation On Navajo Nation, grocery stores are few and far between. Most people shop at gas stations and trading posts, where healthy foods are scarce. To widen access to fruits and vegetables—and improve overall health—Partners In Health (PIH) and its sister organization on Navajo Nation, Community Outreach and Patient Empowerment, launched an initiative to encourage shops to stock and sell produce and traditional Diné foods.

Through the Healthy Navajo Stores Initiative, PIH is supporting shop owners with the technical assistance they need to source and stock healthy foods, plus supplying them with tools, from refrigerators to marketing materials, to promote their new inventory. As of this year, PIH has partnered with 31 convenience stores and trading posts to help them provide healthier options, as well as cooking demos to build community and customer engagement.

The initiative goes hand-in-hand with the Fruits and Vegetables Prescription program, through which more than half of health facilities serving Navajo Nation have provided families vouchers to buy produce and healthy Diné items. Together, the programs are helping both small businesses and families, and closing the loop on PIH's work to revitalize the food system on Navajo Nation.

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Fri, 08 Nov 2019 11:39:57 -0500 https://www.pih.org//article/innovative-solution-food-deserts-navajo-nation
Need to Know: MUAC and Malnutrition https://www.pih.org//article/need-to-know-muac-and-malnutrition Spend a day at any Partners In Health site and there’s a good chance you’ll hear a phrase you’re unfamiliar with. Perhaps it’s a clunky acronym or polysyllabic drug name. But don’t worry: Keeping up with the ever-evolving world of global health is hard, even for insiders. In Need to Know, we cut through the complexity and deliver the most pertinent and interesting information on a single subject. Today, we fill you in on mid-upper arm circumference.

What is it?

Mid-upper arm circumference, often shortened to MUAC, is a measurement that allows health workers to quickly determine if a patient is acutely malnourished. PIH, as well as many other organizations, measures the circumference of a patient’s arm at the midpoint between his or her shoulder and elbow.

Why is it important?

The burden of malnutrition is staggering. According to a series of articles in The Lancet, more than 3 million child deaths every year are associated with malnutrition. Put another way, nearly half of all children who die each year do so because they don’t have access to enough of the right food. Our health workers in Haiti, Malawi, Lesotho, and Rwanda, among other locations, encounter malnourished patients every day. MUAC provides a fast and effective screening method.

How do you make the measurement?

There are specific paper MUAC bands that are color-coded. If the girth of the patient's arm falls within the green part of the band, it indicates that the patient is not malnourished. A measurement that falls within the yellow part of the band indicates that the patient may be at risk of malnutrition. Lastly, the red portion of the band indicates that the patient is severely malnourished and at risk of death. Some bands include a fourth color, orange, which indicates the patient is moderately malnourished.

What happens after the measurement is taken?

Well, that depends on the measurement. Generally, if a child is malnourished, we provide treatment with ready-to-use therapeutic food, commonly known as RUTF. These foods are high in fat and protein and fortified with the vitamins and minerals necessary to treat severe acute malnutrition. A few weeks of treatment with RUTF can bring about significant improvements. PIH will often take steps to improve the long-term food security of patients’ families. This might include enrolling people in job training, delivering food assistance, or providing materials for farming.

Malnutrition is a complex problem. Is a paper arm band all you’re using in the fight against it?

Absolutely not. MUAC is an immensely helpful tool but it’s not foolproof. For instance, a simple arm measurement doesn’t tell us whether a patient has kwashiorkor, or protein malnutrition. Furthermore, the accuracy of MUAC diminishes as the child ages. That’s why we’re constantly devising and implementing new ways to alleviate the root causes of malnutrition and catch malnourished children earlier.

In Malawi, for instance, we conduct regular community malnutrition screenings to identify young patients who haven't been able to travel to clinics, which are sometimes hours away by foot from their family home. Meanwhile, in Haiti, we opened a facility in 2013 that has dramatically scaled up the production of Nourimanba, a ready-to-use therapeutic food made from locally grown peanuts. PIH produced 165,000 pounds of the nutritional supplement last year alone. MUAC is merely one part of a comprehensive strategy that helps us make proper diagnoses and act accordingly.

a nurse in Haiti feeds a child enrolled in the malnutrition program
Nurse Esther Mahotiere, nutrition program coordinator, feeds Nourimanba to 8-month-old Wisline Sauvene, who was enrolled in the malnutrition program in Boucan Carre, Haiti. Photo by Cecille Joan Avila / Partners In Health

 

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Thu, 07 Nov 2019 11:29:46 -0500 https://www.pih.org//article/need-to-know-muac-and-malnutrition
Research: A Model for Improving Community Health on Navajo Nation https://www.pih.org//article/research-model-improving-community-health-navajo-nation For more than 50 years, Community Health Representatives (CHRs) have formed the backbone of the Navajo Nation’s health system. 

Trained as nursing assistants, the corps of roughly 80 CHRs consult patients in their homes throughout the vast, largely rural Navajo Nation – some 27,000 square miles spanning portions of New Mexico, Utah, and Arizona. CHRs conduct health screenings and home safety assessments, help people access medical resources, conduct well baby checks with Public Health Nurses (PHNs), and work directly with patients to manage chronic conditions. 

In addition to the often long distances between patients and clinicians, CHRs are able to bridge linguistic and cultural divides—between the English and Diné (Navajo) languages, between science and spiritual beliefs, and between western and traditional medicine. 

In 2009, the Navajo Nation invited individuals affiliated with Brigham & Women’s Hospital and Partners In Health (PIH) to help better integrate CHRs into the health system through the Community Outreach and Patient Empowerment program, or COPE. Incorporating as a Native non-profit organization in 2014, COPE has worked with CHRs and the clinical facilities serving the Nation to better coordinate care, conduct training sessions, and develop a standardized suite of health promotion materials for use by CHRs during home visits with high-risk individuals. 

In 2014 and 2015, COPE staff surveyed CHRs about their perceptions of and experience with the intervention, and their findings, published in the journal BMC Public Health, point to a positive impact on clinic-community linkages. 

“We knew that CHRs themselves are in the best position to guide the program,” says Hannah Sehn, who has worked with CHRs as part of the COPE work over the past nine years and a co-author on the paper. “So rather than say, here are all the things that are wrong, we listened to them—we tried to see things from their perspective. And it’s really by implementing the suggestions they gave us that we’ve been able to strengthen their role.”

Community health representative records patient data on Navajo Nation
Jonathan Abeita, who has been a community health representative for 16 years on the Navajo Nation, records information about his elderly patients during a home visit near Crownpoint, New Mexico.

Information as power

One suggestion was to improve communication between CHRs and clinic staff, including by expanding access to patient data. Before COPE began working with the CHR program, CHRs weren’t able to access a patient’s electronic health record (EHR), which had limited their ability to document patient encounters. After COPE facilitated access to EHRs for several groups of CHRs, those groups reported better communication with clinicians and felt recognized by clinicians as part of their patients’ care team. 

COPE also sought to strengthen CHR-clinician relationships by organizing monthly training sessions led by clinicians. “For example, if the training was foot care, we’d have the podiatrist from the health facility lead the training,” says Olivia Muskett, a co-author on the paper who was a CHR before joining COPE staff as the Training & Outreach Specialist. “The CHRs can learn from the podiatrist’s expertise, while the podiatrist gets a better idea of the challenges in the community, the things CHRs are seeing day-to-day.”

Other efforts to strengthen community-clinic linkages include establishing consistent referral processes, enabling clinicians to refer patients to CHRs, and the coordination of case management meetings, where CHRs and other members of the care team, such as PHNs, come together to discuss mutual patients. COPE also supports joint home visits, giving CHRs an opportunity to build collaboration with clinicians, something they say enhanced their ability to address key health challenges, including type 2 diabetes.   

Community health representative checks on an elderly patient on Navajo Nation
Community Health Representative Martha Williams visits with Julia, an elderly patient who has diabetes and multiple health issues, at her family's home near Crownpoint, New Mexico.

Rising concern about diabetes

Over the past several decades, diabetes has significantly increased among American Indians, and its rising prevalence owes in large part to low consumption of fresh fruits and vegetables and increased consumption of highly processed foods. It’s estimated that 1 in 3 individuals on Navajo Nation are now diabetic or pre-diabetic, and with more and more cases in their communities, CHRs have made the management of diabetes a focus of their work.    

Prior to partnering with COPE, CHRs say, they made their own training materials. But given their limited contact with clinicians, they couldn’t be sure that the messages they were sharing in their communities were consistent with the guidance patients were getting in health facilities.  

“CHRs told us they wanted health promotion materials that were Navajo specific,” adds Muskett, “particularly for individuals with uncontrolled diabetes.”

With that feedback, she says, COPE developed a flexible curriculum of modules for addressing diabetes that can be provided to CHRs in either printed format as flipcharts or on pre-configured tablets. Each module used a “motivational interviewing” approach, encouraging CHRs to explore how a patient feels about a given topic rather than offering unsolicited advice. 

As one CHR told a focus group, the motivational interviewing “taught us how to communicate with our patients, how to talk to them, to not just give [them] yes and no questions.” That led, in turn, to increased trust between patients and CHRs, some of whom reported spending home visits “just listening to patients express their emotions.” 

And that’s characteristic of the approach COPE takes to strengthening the role of CHRs, says Sehn. “We see that the answers lie within the community itself,” she says. “From its inception, this has been a community-driven process, and I think that’s why it worked so well.” 

“We are the ones who have to believe change is possible and work with patients to make healthy change a reality,” wrote members of the Gallup and Shiprock Navajo Nation CHR program in a 2011 article for the Journal of Ambulatory Care Management. With the new tools provided by the COPE program “and our many years of experience guiding us,” they added, “we know if we are persistent and believe it, we make a difference.”

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Thu, 07 Nov 2019 10:32:01 -0500 https://www.pih.org//article/research-model-improving-community-health-navajo-nation
Top 7 PIH Innovations During Ebola Outbreak in West Africa https://www.pih.org//article/top-7-pih-innovations-during-ebola-outbreak-west-africa Five years ago this fall, the governments of Liberia and Sierra Leone invited Partners In Health to help respond to the world’s worst Ebola epidemic. Although the organization had never responded to this type of public health emergency, PIH leaders knew they would join the fight and not only deal with the outbreak, but also stay for the long term to help rebuild the nations’ weak health systems. The goal was to better guarantee West Africans’ right to health, both immediately and into the future.

The primary reason Ebola ravaged West Africa and not Spain or the United States—where cases were found, but did not spread—is that Liberia and Sierra Leone lacked strong health systems. In Sierra Leone, for example, 7 million people are served by only 150 doctors. Compare this to the 7 million people in Massachusetts, who are served by more than 20,000 doctors. It then becomes easier to understand—but much harder to accept—why Ebola sickened 28,600 people and killed more than 11,000 people across West Africa.

When PIH arrived in Liberia and Sierra Leone in October 2014, clinicians and staff rapidly cared for the sick, accompanied survivors, and helped transform the health system so that—should Ebola return—the deadly virus would never again take such a heavy human toll. And while not perfect, PIH’s response was guided by the firm belief that everyone deserves the best care possible. 

Here are some of the ways in which PIH and local partners innovated to provide care in the midst of the epidemic:

patients arrive at night to an Ebola treatment unit in Sierra Leone
Clinicians attend to patients who arrived at night to the Maforki Ebola Treatment Unit in Port Loko, Sierra Leone.
  1. First, care not containment

The Problem: Sierra Leone and Liberia did not have readily available infrastructure to house and care for a vast number of patients sick with Ebola, especially in remote, rural areas. Patients were often quarantined in locations where little to no care was provided. Meanwhile, other NGOs’ first order of operation was to build Ebola treatment units, while patients and the community effectively went without care.

The Solution: PIH collaborated with the Sierra Leonean government to work out of the Maforki Ebola Treatment Unit in the northern Port Loko District. The facility, which was originally built as a technical school for former child soldiers following the civil war, was always packed with patients and served as the only treatment unit in the district. The team worked to improve safety standards, operations, infrastructure, and WiFi access, all while clinicians cared for patients. 

And in Liberia, PIH helped the national government design and run Ebola treatment units to the south of the capital, in Grand Gedeh and Maryland counties, and helped respond to a cluster of Ebola cases in River Cess County. Smaller Ebola community care centers were established in Grand Gedeh, Maryland, and Grand Kru Counties to isolate and begin treating patients suspected of Ebola while they awaited lab results.

  1. Rapid-response Ebola treatment

The Problem: Before PIH’s arrival in Sierra Leone, patients suspected of contracting Ebola were only admitted to treatment units during daylight hours. They also did not receive care until a lab test confirmed they were positive for Ebola, which often took multiple days—if such testing was available at all.

The Solution: The Maforki Ebola Treatment Unit was the first in the country to remain open 24/7 to receive new patients. There, PIH quickly adopted aggressive treatment protocols for patients suspected of contracting Ebola, including IV fluid resuscitation, antibiotics, anti-malarial medication, and more. 

IV liquids used to rehydrate Ebola patients in Sierra Leone
PIH clinicians began providing Ebola patients with IV fluid resuscitation soon after they were admitted to treatment units.
  1. Installing lab and ultrasound equipment

The Problem: Testing outside of the capital of Freetown was extremely rare during the epidemic. Clinicians often relied on physical symptoms to arrive at a diagnosis, yet nausea, vomiting, and fever are common manifestations for multiple diseases, not just Ebola.

The Solution: PIH installed lab testing and ultrasound equipment at the Maforki Ebola Treatment Unit and at Princess Christian Maternity Hospital in Freetown within months of arriving in Sierra Leone. This allowed clinicians to properly diagnose Ebola and rapidly treat patients, or triage them out of the Ebola ward.

  1. Separate Ebola screening for pregnant patients

The Problem: At Princess Christian Maternity Hospital, all patients used to be screened in the same location. Because women in labor often display the same symptoms as patients sick with Ebola, they were mistakenly assumed positive and isolated together. This made it easier for the deadly infectious disease to spread. Meanwhile, clinicians hesitated to provide care to women in labor, as contact with body fluids increased their chances of contracting Ebola.

The Solution: PIH opened the first Ebola screening unit at the hospital to safely isolate women suspected of Ebola. If patients tested positive, clinicians treated them separately and provided them with the maternal care they also needed, including helping with obstructed labor, managing eclampsia, and treating infections—all common causes of maternal death. 

  1. Continuous care at district hospitals and clinics

The Problem: During the time of Ebola, local clinicians were overwhelmed responding to the outbreak and were not available to help people who needed more routine health care. 

The Solution: While PIH clinicians cared for Ebola patients in Sierra Leone, other team members worked at Koidu Government Hospital and Wellbody Clinic in the east and Port Loko Government Hospital in the north to provide routine care to patients, including pregnant women, children with malaria, adults with TB or HIV, patients dealing with complications from high blood pressure and diabetes, and more. 

In Liberia, PIH kept hospitals and health centers open and running, including Martha Tubman Memorial Hospital in Grand Gedeh County and J.J. Dossen Hospital and Pleebo Health Center in Maryland County. Meanwhile, community health workers in both counties worked to identify patients with a variety of diseases, such as tuberculosis, leprosy, and HIV, and connect them with care. 

A clinician prepares before entering an Ebola treatment unit in Liberia
A clinician puts on protective equipment before entering an Ebola treatment unit in Bong, Liberia.
  1. Employment of Ebola survivors

The Problem: Stigma toward Ebola survivors was high. Many returned home to discover that their family members had died, all their possessions had been destroyed, and they no longer had jobs. 

The Solution: In Port Loko, PIH employed more than 700 survivors to educate community members about Ebola and help screen for new cases. Others chose to be care providers in the Maforki Ebola Treatment Unit, ensuring patients had food, water, and other basic needs. PIH also helped create the Sierra Leone Association for Ebola Survivors, which continues to provide a supportive community and services, such as literacy classes, to survivors. Other organizations are now replicating these practices in the Democratic Republic of Congo, where the most recent Ebola outbreak is more than one year old.

  1. “The 5 S’s”

The Problem: Responding to Ebola as a medical emergency was first and foremost in people’s minds throughout the West Africa outbreak. However, once survivors emerged from treatment units, they were stigmatized and suffering from the personal loss of loved ones, all their possessions, and any means of employment. National health systems also were left weaker, as many local clinicians had contracted Ebola and died responding to the emergency.

The Solution: PIH approached the situation holistically, as in every country where it works. Clinicians provided quality care to Ebola patients, but also advocated for survivors so that they could access lodging, food, clothing, and gainful employment. They also provided survivors follow-up care when Ebola-related symptoms, such as vision problems from uveitis, emerged in the weeks following their cure. 

Meanwhile, PIH leaders partnered with the national government to ensure the right staff, stuff, space, systems, and social support—the 5 S’s—were in place to help rebuild the health systems in each country.

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Tue, 05 Nov 2019 09:45:10 -0500 https://www.pih.org//article/top-7-pih-innovations-during-ebola-outbreak-west-africa
Quadruplets Born at University Hospital Amidst Haiti Unrest https://www.pih.org//article/quadruplets-born-university-hospital-amidst-haiti-unrest Madeleine* and her husband, Stevenson, knew their family life was about to drastically change. They had seven children at home in Port-au-Prince, Haiti, and found out through an ultrasound that they were expecting triplets. 

Like any woman in late pregnancy, Madeleine was feeling off balance, as her abdomen swelled and her center of balance shifted. On a Saturday in late September, the 33-year-old mother fell to the floor while trying to get into bed. Soon she began feeling pains and noticed fluid discharge, interpreting them as the signs of early labor. With growing concern, she called her physician, who informed her that no one was at the clinic to help. Demonstrations and barricades had blocked all traffic.

Madeleine was one among thousands of Haitians across the country caught in life-threatening situations, as Haiti continues to be mired in more than one month of protests that have resulted in some 200 people injured and 20 killed. Roadblocks and demonstrations have cut off transportation in and around the capital, as well as across the country, as inflation spikes and Haitians struggle to access gas, food, and clean water. Banks, schools, businesses, and many health care facilities have been closed for weeks.

They are doing whatever it takes to take care of patients."

Yet Zanmi Lasante, as Partners In Health is known locally, has kept open all its clinics and hospitals at 12 sites across the lower Artibonite and Central Plateau, including University Hospital in Mirebalais. Staff are working long hours, and scrambling to secure fuel for generators. Some have traveled hours by foot and motorcycle, dodging stones and tear gas, as they pass barricades to arrive for shifts. They are doing whatever it takes to take care of patients.

Fear gives way to relief

So when Madeleine and Stevenson, a 48 year-old shoe shiner, knew they needed to get to a hospital—and fast—a family member began asking around to see if University Hospital was still open. It was. The three hired a taxi the following day and sped toward Mirebalais, typically a 45-minute drive north of Port-au-Prince. 

Not long into the trip, they hit their first roadblock. Their driver, a consummate negotiator, explained the couple’s situation to the demonstrators. A moment of fear gave way to relief. Not only did the demonstrators let them pass, they helped the car clear roadblocks and showed them the fastest back roads to the hospital. Two hours after leaving home, but much faster than they’d expected, they arrived at University Hospital.

Nursing staff swung into action. Madeleine was suffering from pre-eclampsia, they realized, and needed immediate attention. While they worked to get her blood pressure under control, they prepared her for labor so that, late Sunday evening, she safely delivered two babies before midnight. Two more babies followed in the wee hours of Monday morning.

And that’s when Madeline and Stevenson discovered they had quadruplets, not triplets. 

one of quadruplets born at University Hospital in Haiti
One of the quadruplets born in late September, who continues in care at the NICU at University Hospital in Mirebalais. Photo courtesy of Zanmi Lasante staff.

Two girls arrived at 2.5 and 3.4 pounds, and two boys at 3.6 and 4 pounds. Because the newborns were underweight and had arrived more than two months early, they were placed in incubators to maintain their body temperature and receive constant monitoring in the NICU. While waiting to be transferred, Stevenson provided one of the babies kangaroo care, which allows infants skin-to-skin contact with their caregivers to help maintain body heat and stimulate feeding.

Meanwhile, Madeleine was in critical condition herself. She had lost a good amount of blood and required a transfusion. Hearing that the unrest had calmed, hospital leadership sent an ambulance to the Red Cross in Port-au-Prince that Tuesday to gather lifesaving units of O+ blood. The driver arrived back, safe and sound, and staff immediately provided the new mom with a transfusion.

The family remains in good hands at University Hospital, where they are cared for by a rotating crew of Haitian clinicians who arrive for shifts after overcoming their own obstacles each day. PIH staff form the backbone of a hospital that is trusted and always open, with lights on to receive more patients, like Madeleine and her family, every day.

*Names have been changed for privacy.

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Mon, 21 Oct 2019 12:17:24 -0400 https://www.pih.org//article/quadruplets-born-university-hospital-amidst-haiti-unrest
PIH a "Safety Net" in Haiti During Weeks of Unrest https://www.pih.org//article/pih-safety-net-haiti-during-weeks-unrest PIH CEO Dr. Sheila Davis spoke recently with leaders at Zanmi Lasante, as PIH is known in Haiti, and provides the latest information about the past six weeks of unrest across the country.

I’m reaching out to share with you an update on the ongoing crisis in Haiti, and what PIH is doing to make sure health care continues to reach every patient in need.

The protest movement that began last summer has escalated to massive demonstrations over the last six weeks. Throughout the country, hundreds of thousands have taken to the streets to protest the devaluation of local currency, high inflation (20 percent), and the alleged misuse of billions of dollars meant for social programs and infrastructure investments.

Protesters are demanding that President Jovenel Moïse step down and for a transitional government to assume power until new elections are held. President Moïse has so far refused to do so, further inflaming the protest.

Unofficial estimates say over 200 people have been injured and 20+ killed. It is impossible to predict when demonstrations will end, but movement leaders are vowing to maintain an “unlimited mobilization.”

Zanmi Lasante has kept the doors open and the lights on in every single facility."

The team at Zanmi Lasante is displaying extraordinary courage and shown incredible dedication amidst the strife, even over concerns for their personal safety. With gas stations running dry, grocery shelves emptied, banks closed, and health facilities shuttered throughout the country, Zanmi Lasante has kept the doors open and the lights on in every single facility.

As other hospitals shut down, more people are traveling to our facilities to seek urgent care. The hospital we support in St. Marc delivered 720 babies last month -- a 144 percent increase over the same period last year. While we’re proud to stand as a safety net for the entire Haitian health system, we know that many more mothers are unable to find a safe place to give birth as this crisis escalates.

Staff are scrambling to secure fuel for generators, dodging stones and tear gas—all to care for each other and our patients, many of whom struggle to meet their most basic needs on a good day. If PIH was founded on the idea of providing care that prioritizes the needs of the poor, then our colleagues are exemplifying the best of PIH. But they are in urgent need of fuel, food for patients and themselves, and basic supplies.

I will share updates as the situation progresses. Meanwhile, please keep Haiti and Zanmi Lasante in your thoughts and, if you can, consider making a donation to help us stay open.

Donate

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Fri, 18 Oct 2019 09:52:48 -0400 https://www.pih.org//article/pih-safety-net-haiti-during-weeks-unrest
CEO Dr. Sheila Davis Reflects on 5-Year Anniversary of the Ebola Outbreak in West Africa https://www.pih.org//article/ceo-dr-sheila-davis-reflects-5-year-anniversary-ebola-outbreak-west-africa It has been five years since I went to Liberia and Sierra Leone to launch Partners In Health’s Ebola response. The memories from that first trip are very vivid. I remember sitting on empty planes arriving to airports, where most people were trying to leave the countries. I remember repeated temperature screenings in and out of every place we went, including along the roadways when we would need to get out of our car and line up to get our temperature checked before piling back in. I still have a pair of pants from those days with bleach stains up and down the legs, as we had to step in pans of bleach every time we went in buildings. And then there was the endless handwashing.   

It was a challenging time organizationally, as this was the first time we were entering two new countries to respond to a disaster of epic proportions. PIH responds to crises—acute and chronic—in every place we work: the tragic Haiti earthquake almost 10 years ago, hurricanes, floods, fires, cholera outbreaks, and the omnipresent crisis of devastating poverty. The decision to respond to Ebola was not a moral dilemma; we knew we could provide help and ease suffering. But the logistical challenges of setting up operations in two new countries simultaneously was another story. 

The decision to respond to Ebola was not a moral dilemma; we knew we could provide help and ease suffering."

I remember every PIH country site offering to send staff and provide operational support, although all sites run with not enough of their own staff on a daily basis. It was never a question that we should go and that everyone would pick up the slack, as many staff were needed immediately to provide logistics, operational, and on-the-ground support. The sense of solidarity that staff throughout all PIH sites showed to people they have never met, in places they have never been—that’s what was and remains the most compelling part of the PIH community. 

In Liberia, we were asked by the Ministry of Health to work in four of the southernmost counties, where there was limited access to any care, and the distances between sites on very difficult roads proved nearly impossible. We set up Ebola screening units and began working immediately to strengthen and rebuild the shattered health system. We remain in Maryland County today, home to J.J. Dossen Hospital and Pleebo Health Center. These facilities have transformed from empty, broken buildings with few—if any—staff, to bustling places full of clinicians, staff, and patients. They are also home to lifesaving surgeries and innovative community programs addressing mental illness and maternal and child health. Together with the government, we revitalized the entire country’s multidrug-resistant tuberculosis program, and patients now have access to care in a safe, dignified facility with expert clinicians. 

In Sierra Leone, we had planned to work in Kono District, where our sister organization Wellbody Alliance had been for a number of years. Instead, we were asked to go to Port Loko, the hotspot of the epidemic. True to our mission of partnering with the public sector, we joined the Ministry of Health in providing care at the Maforki Ebola Treatment Unit. We saved thousands of lives through the care delivered by PIH in partnership with the government in very difficult circumstances in the ETU, in community care clinics, and at Princess Christian Maternity Hospital—the high-risk hospital in Freetown, where women were dying in the parking lot. During our efforts, we hired more than 900 Ebola survivors to become part of our staff as community health and outreach workers and in all other aspects of our work. 

new mother of twin girls receives care in Sierra Leone
Kumba Komba is cared for at the Koidu Government Hospital postpartum area in Sierra Leone. She safely gave birth to twin girls via C-section at the facility. Photo by Jon Lascher / Partners In Health

We have remained in Sierra Leone, and now the once empty Koidu General Hospital is thriving and serving more than 500,000 people in Kono District. We are focusing on reducing maternal mortality by building a comprehensive maternal center of excellence, and have transformed the mental health hospital in Freetown. Just as in Liberia, we’ve brought our expertise from other PIH sites to tackle MDR-TB and provided the first comprehensive care for patients ever available in Sierra Leone. 

When I visit West Africa now in my current position as CEO, I will see the amazing influences of Haiti, Rwanda, Malawi, and all PIH sites. If Ebola were to strike again in the places we work, I know that the outcome would be very different because of our past five years of experience in Liberia and Sierra Leone. We responded to a disaster, and we stayed. Our mission of responding to human suffering and providing quality health care for all is what connects us throughout the world, and what will sustain us moving forward.

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Wed, 16 Oct 2019 13:00:56 -0400 https://www.pih.org//article/ceo-dr-sheila-davis-reflects-5-year-anniversary-ebola-outbreak-west-africa
How Three Girls Defied the Odds to Join First Medical Class https://www.pih.org//article/how-three-girls-defied-odds-join-first-medical-class All over the world, millions of girls are denied basic human rights, such as access to health care and education. Since 2012, October 11 has marked the annual International Day of the Girl, a celebration that advocates for girls’ empowerment and human rights.

This year, at Partners In Health, we are celebrating girls who have broken down barriers, defied stereotypes, and beaten the odds to work toward their dreams.

Promoting gender equity is a central mission at the University of Global Health Equity, a PIH initiative in the rural, northern Rwanda community of Butaro. When admitting its first class of medical students, the university prioritized the education of young women, who have been historically underrepresented in higher education and medicine in Rwanda.

The inaugural class includes 30 students, two-thirds of them women. Every one of them has a strong belief in health equity and providing for the poor. Today, we share the stories of three of these young women, each of whom had experiences as young girls that have inspired them to pursue careers in global health. 

For this International Day of the Girl, we celebrate their achievements, and their journeys toward becoming the next generation of women leaders in global health.

female medical student in Rwanda
Alima Uwimana

‘We are still so grateful’

Alima Uwimana, 20, could hardly believe where she was when she stepped foot on campus in Butaro, alongside 29 strangers who would be her classmates and community for the next six and a half years. For her entire life, until that moment, her new reality had never seemed like a possibility.

Uwimana grew up in a rural village in western Rwanda, near borders with the Democratic Republic of Congo and Burundi. Her family often struggled with money, and never thought they’d be able to send her to university. 

But Uwimana, the youngest of 10 children, now could be the first to graduate from college. Of her six sisters, she is the only one to make it to high school, where she excelled in the sciences and worked hard to maintain good marks.

She now is attending UGHE on a full scholarship, thanks to the generosity of UGHE donors and a partnership with Rwanda’s Ministry of Health.

“We were all laughing and smiling so much,” Uwimana said, recalling the moment she and her family learned she would join UGHE’s inaugural medical class. “We were so thankful. My family had no idea it was possible for me to get a full scholarship. We are still so grateful.” 

Uwimana is an aunt, with 28 nieces and nephews, and she wants to help each of them believe in themselves and pursue their passions, as she did.

“I want to show them that even though they may not have a lot of money, if they have commitment and patience and if they study hard, they can achieve their dreams,” she said.

Uwimana knew her dream at a young age. She remembers watching television as a girl and listening to Rwanda’s newest minister of health at the time, Dr. Agnes Binagwaho—now UGHE’s vice chancellor—outline her vision for the country’s health system. Binagwaho called for quality health care for all and an agenda that focused on the poor and vulnerable. 

I feel that I will achieve my dream of being a medical doctor who will be serving the vulnerable and the poor who are in need.”

Uwimana thought about her own family, who had faced so many challenges with the health system due to financial difficulties, and how Binagwaho’s vision could affect them. 

One of Uwimana’s brothers lost his abilities to speak and hear, due to ailments that could have been cured had their family had the money for the specialist he needed. Her nieces and nephews, the very ones she hopes to inspire with her career, have often suffered from malnutrition, and her siblings have gone into debt to get them treatment. 

Listening to Binagwaho, Uwimana began to understand not only her feelings while watching her family’s struggles, but also how she could help. She could become a doctor who cared for those in need, regardless of their economic status. She thought that maybe she could even be Rwanda’s minister of health and, like Binagwaho, change the system so families like hers could get the health services they needed. 

“I was inspired by the way she put the health of the citizens first, and she is the one who first saw that everyone deserves health regardless of financial capacity,” Uwimana said. “I was inspired by her and thought, one day, maybe I could be like her.” 

Now, as a first-year medical student at the university led by Binagwaho, Uwimana can’t help but smile when asked how she feels about studying under the woman who inspired her, years ago, to pursue this path. 

“I’m so happy and excited. I feel blessed being here,” she said, glancing toward the entrance to Binagwaho’s office. “I feel that I will achieve my dream of being a medical doctor who will be serving the vulnerable and the poor who are in need.”

female medical student in Rwanda
Marie Immaculee Dusingize

‘A smile is enough’

Marie Immaculee Dusingize, a 19-year-old from Rwanda’s Southern Province, knows the inside of a hospital far too well for someone her age. 

When she was 10, she started complaining of debilitating stomachaches. She couldn’t keep food down and had to resort to an extremely strict diet to minimize her pain. Dusingize spent many days and nights in different hospitals and health centers seeking treatment, but to no avail. To this day, she still experiences aches and pains and maintains the same rigid diet.

Her time in the hospital, while challenging, opened Dusingize’s eyes to the problems people face seeking health treatment. Her experiences left her dissatisfied with the quality of available health care, but it was the inequities she saw in the experiences of other patients that truly had an impact on her.

“I remember someone rich came in with just the flu and got treated right away, while someone with a serious kidney condition had no money for the exam and was turned away,” she said . “How can poor people die in front of the door of the hospital just because they don’t have money to pay?”

When I become a doctor, it will be my chance to give out what I have never been given or what I have seen others deprived of."

Dusingize has always looked out for others in need. Early in high school, she noticed how many graduating students would throw away most of their things at the end of the year. She thought about her neighbors—who couldn’t afford basic needs like shoes, clothing, and school supplies—and realized she could do something. So she stood next to the trash can, and when students came to throw their things away, she would ask them to give them to her instead.

“My friend saw me by the trash can and asked what I was doing, and when I explained it to her, she helped me announce it to the school. We decided to make it permanent,” she said. And that was the origin of her nonprofit, Charity Foundation. “Every time we throw away things we no longer need, those things may be useful to those who can’t afford them.” 

Dusingize attributes this selflessness to her mother, who showed her the power of a helping hand. Her mother has been by her side throughout her years of illness. While her mother has no formal medical training, Dusingize says she has been a healer in her own way. 

“What I learned from her is that we should give what we have. It’s not necessary that we say that, because I am not a medical doctor, I can’t help,” Dusingize said. “A smile is enough. She could always smile at me and say words that would make me forget that I was even sick, so I really regard her as a medical doctor.” 

The values that Dusingize draws from her mother have guided her to where she is today. 

“When I become a doctor, it will be my chance to give out what I have never been given or what I have seen others deprived of,” she said. “I feel like the world will be mine to change.”

female medical student in Rwanda
Eden Gatesi

‘We share the same vision’

Eden Gatesi didn’t get to spend much time with her mother when she was growing up. Her mother was a nurse, and would leave early in the morning to take care of patients, then return home late at night. The precious time they spent together, however, had a big impact on Gatesi.

“What impressed me most was even the little time she could spend at home, we would get visitors coming over to thank her for saving the lives of their beloved ones,” Gatesi recalled. ”That showed me that dedicating my life to being a health professional would help me to have an impact on my community and save their lives as my mom does.”

Although Gatesi knew she wanted to follow her mother’s footsteps, she felt pressured by societal and cultural norms. Many people in her life didn’t understand how she could spend so many years at school, and felt she should instead focus on raising a family. She didn’t know a single female cardiologist, the profession she knew she wanted to pursue. Gatesi, herself, began to experience doubts about whether she should follow her dreams.  

All that changed in 2016, when Gatesi was invited to attend a prestigious camp called Women in Science, organized by the UN-backed nonprofit GirlUp. The camp was an opportunity for girls from across the globe interested in science and technology to come together for two weeks of leadership development training. 

“It was a great honor for me,” Gatesi said. “It was my first time ever leaving the country, because the camp took place in Malawi, but it was a very good experience for me to meet girls from all over the world. We don’t share the same culture, but we share the same vision and same ambition.”

Being around these like-minded girls, who all had dreams of having an impact on the world through science, removed any doubt from Gatesi’s mind about becoming a cardiologist.

..the future of Rwanda’s health sector is really bright because it has us—girls and boys who are passionate about becoming doctors and are not hindered by people’s mindset and view of gender.”

Gatesi returned home with a renewed belief in herself. But she knew there were many other girls who hadn’t had an opportunity like hers, and might still be experiencing the same doubts that she had. She joined a group called Dear Doctor, which brings together students who have an interest in careers in medicine, as a way to give back to girls like herself. 

“I came back to school wishing to help other girls who think that they can’t (be a doctor),” she said. “Joining the Dear Doctor club helped me to show them that they really can.”

As part of the club, Gatesi helped organize events where girls discussed challenges females face in the medical field, and invited doctors to speak about their careers. She also facilitated visits to nearby hospitals to meet with patients, and coordinated student internships with local health centers. 

Now, as a member of UGHE’s majority-female, inaugural medical class, Gatesi brings the lessons she learned growing up to a university that prides itself on its commitment to equity. Here, she has found another community of people who share her vision, and said she feels optimistic about this new generation of leaders.  

“Starting my journey at UGHE, where we are 20 girls and 10 boys, it has shown me that the future of Rwanda’s health sector is really bright because it has us—girls and boys who are passionate about becoming doctors and are not hindered by people’s mindset and view of gender.”

 

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Thu, 10 Oct 2019 22:08:53 -0400 https://www.pih.org//article/how-three-girls-defied-odds-join-first-medical-class
"The Right Medicine": Young Woman Triumphs Over MDR-TB https://www.pih.org//article/right-medicine-young-woman-triumphs-over-mdr-tb Cylian B. Kargbo is planning for her future. “My birthday is coming up!” the 12-going-on-13-year-old from Calaba Town, Sierra Leone, proudly announced, looking ahead a few weeks when she would celebrate with, first and foremost, “pizza!” Further down the line, Cylian has even bigger dreams: “I want to be a lawyer—study abroad, then come back to Sierra Leone to help the people in my country.”

Warm, thoughtful, and fiercely intelligent, Cylian has a bright future ahead, from her next month to her next 10 years. But it wasn’t always guaranteed. Plans for law school or even a birthday party began slipping away when, last July, she experienced her first symptom of multidrug-resistant tuberculosis (MDR-TB).

“Side pain,” Cylian remembered simply, citing the reason her family first took her to Ola During Children’s Hospital the capital city of Freetown. There, she was diagnosed with and treated for malaria, but her pain persisted. By October, said her father, Manso Kargbo, it got so severe that Cylian was unable to sleep.

Cylian's father, Manso Kargbo
Cylian's father, Manso Kargbo, ensured  his daughter got the care she needed. 

Another trip to the hospital resulted in a diagnosis of tuberculosis (TB). But even TB drugs did nothing to improve Cylian’s health, which was deteriorating faster and faster. By the third week spent in her local emergency room, Cylian was in and out of consciousness, on oxygen, and unable to digest food. The Kargbo family’s friends and neighbors suspected witchcraft, and suggested that Cylian be seen by a traditional healer.

Doctors and nurses had another theory: MDR-TB, the drug-resistant strain of the world’s leading infectious disease killer.

An Escalating Illness, and a Lifesaving Partnership

Though TB was eradicated long ago in most wealthy parts of the world, poverty and a lack of strong health systems have allowed it to plague Sierra Leone, where, according to the World Health Organization, roughly 300 cases of TB are found per 100,000 people. For comparison, high-income countries find less than 10 new cases of TB per 100,000 people—around the rate at which MDR-TB cases present in Sierra Leone. The specialized drug regimens and care required to cure patients with MDR-TB were never available in the country, leaving countless people to die and the deadly airborne disease to proliferate.

This unjust reality faced a turning point in April 2017, when Sierra Leone’s National Leprosy and Tuberculosis Program, led by Dr. Lynda Foray, and Partners In Health (PIH) jointly established the country’s first and only MDR-TB treatment program, located at Lakka Hospital in Freetown. The National Tuberculosis Program brought in the critical equipment to diagnose MDR-TB, the lifesaving drugs to treat it, and the hundreds of team members to deliver the care. Despite this commitment, a gap remained—which PIH swiftly filled.

Lakka Hospital in Freetown, Sierra Leone
Lakka Hospital, located on the outskirts of Freetown, Sierra Leone, is the country's only facility offering MDR-TB care. 

PIH infused Lakka with the other resources necessary to cure MDR-TB: a robust supply chain to ensure the availability of critical equipment and drugs for managing TB complications; the addition of clinical mentors with expertise in the disease; and continual building renovations to make receiving and delivering care more comfortable and dignified.

Together, Sierra Leone’s Ministry of Health and Sanitation (MOHS) and PIH also ensure 24-hour electricity and running water at the facility, in addition to providing support packages to outpatients who couldn’t otherwise afford food or transportation to the hospital for check-ups.

Lakka Hospital's pharmacy, stocked with help from PIH
The pharmacy at Lakka Hospital, jointly stocked by PIH and Sierra Leone's National TB Program.  

So far, clinicians at Lakka have treated more than 322 MDR-TB patients, and have seen a cure rate of 74 percent—among the best success rates globally, even with only a handful of doctors working specifically on TB within the country.

Saving Cylian, Through Food, Medicine, and Care

Support from the government and PIH arrived at Lakka not a moment too soon, and neither did Cylian. “When they referred me to Lakka, I was unable to walk, I was unable to eat for myself,” she said. Nor was she able to stand or sit on her own. “Her condition was so critical,” Kargbo said. “There was no flesh; only bones. You could count her ribs.”

Dr. Rashidatu Fouad Kamara, MOHS lead clinician at Lakka; Dr. Mariama Mahmoud, the facility’s now medical superintendent; and TB doctor Dr. Michael Mazzi reassured Kargbo that his daughter would get better, and immediately began her on treatment. This consisted not only of medication, but also food, which her body desperately needed to tolerate harsh MDR-TB drugs and grow stronger. PIH and the National TB Program began a special meal program, with foods rich in protein and fat, and asked Cylian what she liked to eat. Fried rice, her favorite, became a regular menu item, and was arguably as essential as drugs.

“With that special food, it was like magic,” Kargbo said. “Cylian’s health was changed within two months. She started to walk. Dr. Kamara and Dr. Mazzi exercised with her every day.” This success inspired hospital staff to introduce enriched meals to other TB patients in similar situations; today, they equally benefit from an enhanced diet.

A meal provided at Lakka Hospital
Meals provided at Lakka are an essential part of treatment for MDR-TB, and help patients heal. 

Kargbo stayed with his daughter for more than one month as she recovered, then sent one of Cylian’s cousins to stay and keep her company. But even in the family’s absence, he knew Cylian was in good hands. “I’m so grateful,” he said. “It was not only the nutrition and feeding they provided to Cylian, but they also provided psychosocial counselling. I think of that—to have people get close to Cylian, to embrace her.”

With this comprehensive health care, Cylian’s health only continued to improve. After five months at Lakka, she was healthy enough to be discharged and continue treatment at home. And soon later, she was declared free of MDR-TB.

“Imagine—when Cylian was first taken to the hospital, she cannot walk, she cannot breathe properly without oxygen. Now, she can breathe for herself. She can walk. She can eat. She’s gained weight,” Kargbo said. “With timely intervention, Cylian recovered within a short time. I can embrace my child in her healthy condition.”

A TB Advocate is Born

Cylian isn’t the only one looking forward to the days ahead; her father is, too. “I hope for Cylian to achieve all her dreams,” he said. “Whatever she wants to be, that will be determined by Cylian. And I will give her the support to reach those heights. If you have a dream, you must have somebody to help you reach it.”

Last March, hinting at what type of attorney she might someday become, Cylian urged her government and PIH to continue fighting to eradicate TB and MDR-TB in Sierra Leone and around the world. Paying a visit on World TB Day to the facility that helped save her life, she shared her story in front of patients, staff, and Dr. Alpha Wurie, Sierra Leone’s Honourable Minister of Health and Sanitation. Her speech ended in an appeal for more support for Lakka, and for others to seek treatment there.

“We beg other patients who have TB, do not sit in your house,” she said. “Let them come and see the doctor and they will give them the right medicine.”

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Thu, 10 Oct 2019 15:12:19 -0400 https://www.pih.org//article/right-medicine-young-woman-triumphs-over-mdr-tb
Battling Mental Illness, One Home Visit at a Time https://www.pih.org//article/battling-mental-illness-one-home-visit-time Community health workers are the bridge connecting their neighbors, friends, and family to local clinics across the 10 communities in which Partners In Health works in rural Chiapas, Mexico.

In July, Compañeros En Salud—as PIH is known in Mexico—launched a new initiative that trained five workers in the provision of mental health care, with the hopes of soon growing their number to 10.

This innovative program directly addresses a mental health care gap in Mexico. There are an estimated 210 psychologists and four psychiatrists in the entire state of Chiapas, home to 5 million people. Broken down by population, that means there are roughly four psychologists for every 100,000 people, compared to 12 psychologists for every 100,000 people in the rest of Mexico. About 1.4 million people in Chiapas suffer from depression and other mental illnesses.

There are simply not enough properly trained clinicians available to address the burden of mental illness in Chiapas.

That’s why PIH’s community mental health workers in Monterrey, Honduras, Laguna del Cofre, Salvador Urbina, and Capitán are key to reaching the most vulnerable patients battling depression and anxiety. After patients have been diagnosed by a PIH-supported clinician in these rural communities, they are connected with a community mental health worker, who visits their home regularly to provide counseling and support.

In honor of World Mental Health Day, each community mental health worker below shares why she is committed to providing care to her neighbors, friends, and family.

Zoemia Salas Morales

Zoemia Salas Morales, Community Mental Health Worker

“My work consists of making home visits to patients who have been diagnosed with depression and anxiety, giving them short therapy sessions so they can understand their feelings better and get tools to overcome these conditions.

Sometimes it’s hard to be a community mental health worker. After doing my work, I have to get back home, cook for my family, take care of my husband and children, do the laundry, and clean the house. Even then, some people in the community judge me because they think I should be staying at home, that I’m not doing enough for my family. But they don’t understand I’m doing this because I want to help people, even if it means walking long distances to get to my patient’s houses.

There are some patients who refuse to get treatment because they’re ashamed of themselves. They fear people around them will find out they’re suffering from a mental illness, but that’s just a stigma we’re trying to overcome. I like to keep learning about mental health, because it’s so much different from physical pain. Sometimes people don’t realize that what’s being hurt is their feelings, and how important it is. I’m here to help them have a safe space to talk about it.”

Roselia Díaz

Roselia Diaz, Community Mental Health Worker

“I want to help people suffering from mental illnesses, because in the past I’ve suffered from them too. I can understand how my patients are feeling, and I want them to know that if I’ve been able to overcome these problems, anyone can.

It has been hard for me because I’m a very shy and anxious person. But while I help others, I know I’m helping myself too, conquering my own fears, and turning them into self-confidence.”


Juana Roblero

Juana Roblero, Community Mental Health Worker

“The community mental health workers’ program immediately called my attention, because I knew my mom had suffered from depression and I didn’t know how to help her. I thought that if I became one of them, not only would I be able to help out my mom, but the rest of the people in the community, too.

Sometimes we don’t have any idea of what others are going through. And sometimes even these people can’t exactly explain how they’re feeling. That’s when I come in, helping them out with these problems, giving them hope.”

Carolina Guzmán

Carolina Guzman, Community Mental Health Worker

“As a community mental health worker, I feel like there are a lot of things depending on me and my perseverance. It is important not to give up on others. Because after all, I’m doing this to help them, and helping is never a burden. When it comes straight from your heart, it will never feel like it’s hard, or impossible.

I know I still have a lot to learn, but I’m positive that every single day I’m becoming a better person.”


Nelcy Roblero

Nelcy Roblero, Community Mental Health Worker

“People know me because I’m a hard-working woman, and my passion is to help other women, men, and children. I’m very happy to be a community mental health worker, because now people don’t have to travel long distances to the closest towns in order to get this kind of attention.

I like it when patients come to me and tell me how much I’ve helped them. I enjoy watching them flourish, because more than a worker, I would like for them to see me as a trusted friend, lending a hand to them, showing them that they’re not alone. Beyond the poverty and marginalization, there are so many capable, strong, and loving people around here.”

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Wed, 09 Oct 2019 14:49:14 -0400 https://www.pih.org//article/battling-mental-illness-one-home-visit-time
Dr. Kilongo Papy Mulailwa Thanks PIHers for Supporting New Surgical Theater https://www.pih.org//article/dr-kilongo-papy-mulailwa-thanks-pihers-supporting-new-surgical-theater Thanks to this support, we exceeded our funding goal for this project and work can begin on a new surgical theater to help Dr. Papy, the heroic general surgeon serving the 500,000 people in Kono District, keep his patients safe from infection.

Dr. Papy sent along this video with his personal thanks.

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Wed, 09 Oct 2019 13:58:44 -0400 https://www.pih.org//article/dr-kilongo-papy-mulailwa-thanks-pihers-supporting-new-surgical-theater
Mental Health Care for Homeless Begins with Clean T-Shirt, Warm Meal, and a Bath https://www.pih.org//article/mental-health-care-homeless-begins-clean-t-shirt-warm-meal-and-bath Three years ago, Winston Appleton had all but given up on life. He slept rough in the shadow of decaying mansions in Harper, Liberia. He lived on a diet of mud and “Italian white”—the Liberian term for low-grade heroin. He talked to himself, using discarded plastic straws to inhale the smoke, vapor drifting up towards the crumbling eaves. Unaware of his surroundings, he sometimes fell asleep in the middle of the road.

When Partners In Health’s mental health team first spotted Appleton in the rainy season of 2016, he was hallucinating and walking around unclothed. They tried to invite him to a nearby clinic for access to care, but when they greeted him he shied away. They knew they needed to patiently earn his trust. 

The process started with a clean t-shirt. The PIH-ers left it out for him along with new pants and shorts. Then they offered him warm bowls of rice and sauce and cold sachets of drinking water. Next they gave him a toothbrush and toothpaste, and gently offered him the chance to bathe in the local river, a common spot for Harper residents, many of whom lack running water. After a few weeks, Winston agreed. Finally, wearing clean clothes and feeling good about himself for the first time in decades, Winston went with the team to the clinic, where they were able to diagnose him with schizophrenia and prescribe him an antipsychotic. 

Such is the transformative work of PIH’s homeless outreach program in Liberia. Since it began in 2016, Program Manager Bethuel Nyachienga and his 12- person mental health team have helped 149 homeless people in Maryland county, home to the district of Harper, access not only medication but toothpaste, soap, and clean clothes. The results speak for themselves: since being diagnosed and entering into care, more than 50 percent of patients have moved back in with their families. 

Homeless Outreach in Liberia

Mental health services are extremely limited in southeastern Liberia, where traditional medicine and beliefs of witchcraft carry great weight. There, homelessness is often preceded by mental illness; many people are ostracized from their families and communities once symptoms show. 

But collaborating with traditional and faith healers and community leaders, PIH is working to change that dynamic. Since 2016, the team has treated more than 1,500 people for mental health conditions at three clinics in Harper and Pleebo districts and J.J. Dossen Hospital. They include the 149 people who benefited from the homeless outreach program.  

It’s not in any book. We started it to create dignity. … And then we see that they start to be accepted in society.”

Supervised by psychiatric nurses, community health workers in Harper and Pleebo districts approach homeless patients and gain their trust through daily visits, which often involve bringing them food and clean water to drink. Over time, patients accept clean clothes, assistance with finding privacy to bathe, and the chance to visit a clinic for a mental health assessment. If they are placed on medication, community health workers monitor their side effects daily, while also encouraging them to reunite with their families and attend their regular clinic appointments.

The idea came from Nyachienga, whose work in Liberia builds on his background treating patients in Dadaab refugee camp in Kenya. “It’s not in any book,” he said. “We started it to create dignity. They have no place to sleep, nowhere to eat, and no one to talk to. We give them clean clothes. We give them food. We give them medication. And then we see that they start to be accepted in society.”

Garmai Cyrus, PIH’s mental health coordinator in Liberia, said that something as simple as hygiene makes a significant difference in patients’ lives.  “Bad hygiene separates people,” she said. “Wearing dirty clothes, not bathing, not brushing your teeth changes a whole lot. As we started offering hygiene care to these patients, we saw that something else was happening; they were becoming more acceptable in the community.”

The outreach program is now a cornerstone of PIH’s mental health care approach in Maryland county.

The first person whose life the program transformed was Sophie Prowd, a woman in her early 30s who had lived half her life on the streets of Harper. Her trouble started when she showed symptoms of psychosis and her husband took her to a traditional healer, who said Prowd was a witch. Prowd was sent to live with her father in Harper, but he wanted nothing to do with her, maintaining strong convictions that she was cursed.

Noticing Prowd’s matted hair and dirty clothes, Nyachienga offered her the towel from his own house. A haircut soon followed, and after a few days, she agreed to medication for her diagnosis of schizophrenia. As the treatment began kicking in, a local business owner, Linda Howard, offered to cook for Prowd and ensure she took her medication. The two subsequently struck up a friendship, and one rainy night, Prowd knocked on Howard’s door and said, “Auntie, it’s too cold in the street.” Delighted that her new friend had become confident enough to speak up and advocate for herself, Howard invited her in to stay with her and her family.

mental health patient who now works at friend's restaurant
Sophie Prowd, who was diagnosed with schizophrenia and used to live on the street, is now connected with care, doing well, and working at her friend's restaurant in Harper, Liberia. Photo by Stephanie Chang / Partners In Health

Three years later, Prowd is still living with Howard’s family, and now manages and sells drinks at the family restaurant, which is the biggest in Harper. When Howard was away recently in neighboring Cote d’Ivoire, Prowd took care of the business in her absence. “Every time I buy a soft drink from Sophie, I take great pride in knowing how far she has come,” said Nyachienga.

Step by step and toothbrush by toothbrush, the program is bringing relief from the crushing weight of mental illness stigma. Every day it is turning patients’ lives around and reducing stigma in the community. “We meet them where they are,” said Cyrus. “We respect them for that. Sometimes they don’t feel like getting in the car to go and bathe. We will simply say, ‘Are you ready today?’”

Partnering with Traditional Healers

Nyachienga likes to tell people in southeastern Liberia that mental illness can be healed—and he has dozens of patient stories to prove it. The team has also taken the rare step of engaging traditional and faith healers—the local communities’ trusted, respected gatekeepers—to join together and help them provide access to treatment. 

Many local healers have gone from voicing skepticism about mental illness to accompanying patients through care by checking for side effects to medication and ensuring they attend clinic appointments. Doing so, they retain their position as trusted figures and serving as a vital link in the chain of access to mental health care. 

“People believe in them, they trust them, they look up to them for everything,” said Cyrus, adding that some patients prefer to be accompanied by traditional healers when they go to the hospital. “So we started talking to them about what mental illness is, showing them how their work recognizing the signs and symptoms of mental illness is important.” 

People believe in them, they trust them, they look up to them for everything."

In a part of the country where witchcraft is used to explain atypical behavior, particularly that without a visible cause, how did they explain mental illness?  “We used the brain to explain it to them,” said Cyrus. “A lot of people went through the war in Liberia, so we explained that if your brain has had trouble seeing bad things, it’s the interpretation of the brain that we can treat.” 

The traditional healers have so far been able to help reach around 500 people in Harper and Pleebo communities and enroll 65 people into mental health care. As a result, many of them will never have to experience the indignity of sleeping in the street, or lacking access to food, water, and soap. 

The Future of Mental Health Care 

The homeless outreach program is part of a treatment plan that shows that good mental health really is a spectrum—from clean clothes to medication and restoring confidence and self-respect. The team hopes to further expand its work, running more income-generating programs and perhaps even opening a halfway home for patients who can’t return to their families. 

woman selling rice in market in Liberia
Jewel, who was diagnosed with bipolar disorder and is receiving mental health care, started a rice selling stand in her local market with a $100 grant from PIH.

The Liberia team also realizes that the vital need to provide mental health care to homeless populations isn’t confined to Maryland County, which is why they traveled to neighboring Sierra Leone to train their colleagues on how to deliver care to homeless patients in Kono District. Their mentorship helped Sierra Leone’s mental health team initiate their own homelessness outreach program this year, which so far has provided ongoing care and support to 13 of the most vulnerable people in Kono.

As for Appleton back in Harper, he’s among those who haven’t yet been able to go home. His schizophrenia began during the war, and his family is no longer interested in reconnecting with him. But as Nyachienga said, Appleton is now a part of the extended PIH family and is often found sitting outside the gate to the office, chatting with the team, visiting the pharmacy for medication refills, and—most importantly of all—smiling.

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Wed, 09 Oct 2019 09:36:12 -0400 https://www.pih.org//article/mental-health-care-homeless-begins-clean-t-shirt-warm-meal-and-bath
The Social Worker Extraordinaire Helping Breast Cancer Patients https://www.pih.org//article/social-worker-extraordinaire-helping-breast-cancer-patients Oldine Deshommes never has an empty office. The social worker is a go-to resource for every cancer patient passing through the double doors of the Roselene Jean Bosquet Center at University Hospital in Mirebalais, Haiti. Her role is to connect them with support and resources, which she always delivers with a broad smile and a warm hug.

Deshommes has worked with Zanmi Lasante, as Partners In Health is known in Haiti, for nearly 10 years, starting shortly after the devastating January 12 earthquake by providing psychosocial support to survivors living in temporary shelters in the capital of Port-au-Prince. She then transitioned to serving cancer patients at the PIH-supported Bon Sauveur Hospital in Cange before moving with the rest of PIH’s oncology team in 2013 to University Hospital in Mirebalais, where there are now three physicians, four nurses, and one psychologist meeting patients’ cancer care needs.

In 2018 alone, clinicians provided care to 569 patients at the oncology clinic at University Hospital in Mirebalais, treating everything from breast and cervical cancers to leukemia and gastrointestinal cancers. Deshommes surely met, and helped, the vast majority of those patients.

In honor of Breast Cancer Awareness Month, Deshommes reflects on her career as a social worker, shares the barriers cancer patients face in Haiti, and addresses what remains to be done to provide patients with the best care possible.

How did you get into social work?

From an early age, I was always available to listen, advise, and help family members and friends manage difficult situations. That's why in the Faculty of Human Sciences at the State University of Haiti, I opted to study social work, a profession essentially of helping others. It's about helping people use their own resources and community resources for their needs. 

What are some barriers women face in accessing cancer care in Haiti?

The challenges within our health system in Haiti, the low economic level, and the low education levels of the majority of people living in Haiti are reasons why women who have breast cancer most often arrive at the hospital at an advanced stage of the disease.

Many stayed longer at home before going to the hospital for lack of money or lack of awareness. Others claim to have spent all their money on medical care before coming to University Hospital in Mirebalais. The care offered here is certainly free, but our patients come from all regions of the country. They therefore need money for transportation, food, and other daily expenses. Some patients miss their appointment at the hospital for lack of financial support. 

breast cancer patient visit in Haiti
Deshommes (right) leaves a home visit with breast cancer survivor, Marana Toussaint (center), who lives near University Hospital in Mirebalais.

A vast majority of the patients you support are battling breast cancer. Tell us what concerns they have, and how you help.

The majority of patients are or have been small traders, who during their illness have spent all their savings and have nothing left to continue the fight against cancer. Some receive financial help from their extended family or friends. But sometimes those people who help do not continue, because they become discouraged or lack money themselves. At University Hospital in Mirebalais, we give financial help to those who are in need. But many patients are in this situation, and we do not have much money to give this type of assistance, so it is not enough to help everyone.

Patients suffer because they can’t afford school fees for their young children. They are worried about their future in a country like Haiti, where there is not really a structure that can take care of these children.

And yet, we cannot stop thanking those who donate to our patients. In our oncology service at University Hospital in Mirebalais, prostheses and special bras are given to patients who have had a mastectomy. We know they are concerned about their physical appearance. We also give wigs and scarves to those who are in chemotherapy. These donations also contribute to the work we do to improve the quality of life of our breast cancer patients.

 You facilitate group sessions for women battling breast cancer. What benefits do you see women gain from these sessions?

Support groups allow patients who are experiencing similar situations to get together for counseling and emotional support. Through these sessions, patients realize they are not the only ones to live this difficult experience. Some patients come out of their social isolation and make friends. The psychosocial team leading these groups sometimes gives information on cancer, treatments, and services offered at University Hospital, as well as general information about resources patients could use. We also hold psychoeducation sessions. These groups allow us to better understand and act on the overall suffering of cancer patients.

It makes me think about what we can always do. Every minute counts." 

What have you learned from breast cancer patients over the years, especially those who are in palliative care?

In palliative care, the person often questions his life—what she had time to do or not. It makes me think about what we can always do. Every minute counts. Over time, patients taught me at least two lessons in life:

1) I understand how important it is to look after our relationships with others, especially those who are dear to us. Social support is very important in the management of palliative care patients.

2) Our love for those who are sick makes it sad to think about their imminent death, but can also give us the courage to plan what we can for their future and also to live serenely the last stage of life. I consider this a victory in the fight against cancer in palliative care.

Is there anything you wish you could do for your patients, but can’t, due to financial constraints?

We know that loved ones have an important place in the care of patients suffering from cancer, so we encourage them to accompany their sick parents to their appointments at the hospital. We try to give them psychosocial support, help them better understand cancer and its treatments, and organize special support groups for them. But it is difficult for us to accompany them as we would like. Because the majority of patients are themselves struggling to find money for transportation, they find it difficult to pay transportation for another two or three people who would accompany them. If we would like caregivers to come to appointments too, we would often need to help with transportation, but we do not have enough money to always do it.

cancer patients and family members await care
Cancer patients and their family members await care as oncology nurse, Ms. Guerdie Duvert, passes with a tray of chemotherapy.

What other resources exist in Haiti to support cancer patients and their families?

 In Haiti, there are not really community-based social support organizations to help cancer patients. The Haitian state does not have a strong policy or health system to care for cancer, a disease that causes a lot of deaths and can also have repercussions on patients’ socioeconomic situation. Patients often cannot work during treatment, which leads to the impoverishment of families, children who are forced to leave school, or children whose mental health is affected by the loss of their parents. Sometimes this leads to juvenile delinquency.

At University Hospital, when a patient's needs cannot be met, we would like to be able to connect her to other social support community organizations. We make referrals to a cancer support group based in Port-au-Prince, but it cannot always meet patients’ needs. We would like to have more resources to help patients and more places to which we can refer them and their loved ones who are suffering from cancer. 

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Tue, 08 Oct 2019 22:28:32 -0400 https://www.pih.org//article/social-worker-extraordinaire-helping-breast-cancer-patients
Heart Patient, Advocate, and Soon-to-be-MD https://www.pih.org//article/heart-patient-advocate-and-soon-be-md As we come together for World Heart Day on September 29, we celebrate Erneste Simpunga and other people living with a range of heart diseases within the communities where we work. 

Simpunga, 29, was diagnosed with rheumatic heart disease at age 16, in his home country of Rwanda. After a lengthy journey to surgery, he had two heart valves replaced in July 2008, at Brigham & Women’s Hospital in Boston. The experience inspired him to become a doctor, and on November 8, 2019, his 30th birthday, he’ll graduate from the University of Rwanda’s School of Medicine and Pharmacy.

While he hopes to conduct his residency and his fellowship in the U.S., Simpunga’s long-term goal is to work in Rwanda, as a cardiologist, cardiac surgeon or professor of clinical anatomy. Rwanda currently has about seven cardiologists for its population of 12 million.

In the years following the surgery that saved his life, Simpunga has been an ardent patient advocate. He’s spoken at events including the 10th anniversary of Partners In Health’s work in Rwanda; the 2016 Team Heart Boston Gala; a global forum on noncommunicable diseases (NCDs) in Sharjah, United Arab Emirates; and at related events in Kigali, Rwanda’s capital.

He is a member of Rwanda’s NCD Alliance, and has served on the first advisory committee for the alliance’s “Our Views, Our Voices” patient advocacy initiative.

Here, he shares some of his incredible life story.

Frightening news to hear

In May 2006, when I was 16 and in secondary school, I got a very somber diagnosis from one of the two cardiologists in my home country of Rwanda.  

He told my father not only that I had rheumatic heart disease (RHD), but also that because of the disease, one of my heart’s four valves needed to be replaced. A second valve needed surgery or even a replacement, as well.  

It was frightening news to hear—but my family and I had known it was coming.

By the time I was able to see that doctor, a cardiologist in the capital city of Kigali, I had been suffering debilitating symptoms of RHD for more than two years.

The summer of 2005 was when I finally determined that something was seriously wrong with my health. I then stayed for some time at the health center closest to the small community where I grew up, in Rwanda’s Eastern Province. Care providers at the health center gave me several inaccurate diagnoses, before, eventually, I was referred to a district hospital, and then finally to the University Teaching Hospital of Kigali.  

There, we learned that there was a long line of patients waiting for treatment ahead of us, and a cardiologist could see us in four months if we used health insurance to pay for the visit.

I was very thin, with a hugely distended abdomen and built-up fluid in my legs. I was short of breath nearly all the time, even when I was at rest. I couldn’t walk briskly uphill for more than 30 seconds—as I had to do on my daily walk to school. Rwanda, itself, is known as the Land of 1,000 Hills. Because I had to move slowly, walks that used to take me just 10 minutes now took more than an hour—and if I tried to walk any faster, I would get heart palpitations and sometimes faint.   

An unbearable cost for care

Knowing all of that, my family decided to see the cardiologist at his private clinic, rather than wait, and to pay 100 percent of the cost.

That cost quickly grew.

The cardiologist said our family would need to find about $15,000US, because the surgery I needed couldn’t be performed in Rwanda, and I would have to go to India.

He added that, in most cases, the outcome was really good, especially for young people like me—even though my condition seemed advanced.

We looked at him for a moment, in silence, as we took in that news. Then, my dad said:

“Doctor, this is my first time to hear of such a disease. We used to think my son might have HIV or tuberculosis, given how thin and tired he is. Are you telling us the truth, that this is a heart disease? Are there any other patients like him?”

The doctor insisted on his diagnosis, and reiterated that a good outcome was likely if proper treatment began as soon as possible. However, we had to tell him that our family could not afford the cost.

The doctor said another option, then, would be to wait for visiting teams of foreign doctors who could perform the surgery I needed, and who would come to Rwanda and treat local patients through future partnerships with the Rwanda Ministry of Health. But that could take a year or two, or more. The doctor’s concern was that the longer we waited, the less potential I had to be a candidate for treatment from those teams, because my condition could worsen.

Rwanda already was working with an Australian cardiac surgery team, by chance, and had been for two years—but that was a pediatric team. At 16, I was too old for pediatric treatment and would have to wait for a cardiac surgery team that was treating adults.

That was just one example of the many hurdles that arose.

So, the doctor and my family made a plan, while we waited.

“I will put him on daily medications and I will need to check on him while we wait, possibly every month,” the doctor said.

The long wait for surgery

 Luckily, I did well on the medications, which included about 180 pills a month and penicillin injections. I later learned that other patients with a similar disease, and similar treatment, were not so lucky—some saw their conditions worsen despite the medications, and needed hospital visits up to twice a month.

I remained on the medications, awaiting surgery, for two years.

Heart patient following cardiac surgery in the United States
Simpunga visits his cardiologist at Boston's Brigham & Women's Hospital in July 2008 following surgery, which was possible with support from PIH and Team Heart. Photo courtesy of Erneste Simpunga

At last, in April 2008, I was presented to Team Heart, a medical nonprofit that’s based in Boston and has worked for more than a decade to build sustainable cardiac care in Rwanda. Team Heart brings volunteer doctors and nurses to Rwanda every year for surgical missions, working with the Rwanda Ministry of Health, collaborators including Partners In Health, and many others.

Their visit in 2008 was Team Heart’s first trip to Rwanda. They planned to see 12 patients. As it turned out, I was the sickest—so sick, in fact, that I wasn’t a candidate for surgery in Rwanda.

However, I was given a second chance. In July of that year, Team Heart and PIH brought me to Boston, where my surgery was performed safely by some of the same doctors who had visited Kigali just months before.

After doctors successfully installed two artificial valves in my heart, I stayed in Boston for three months, living with my lead surgeon and having regular checkups with cardiologists. The extended stay gave me a unique opportunity to attend the 2008 Rwanda Day in Boston, and to meet Rwanda President Paul Kagame and the country’s minister of education at that time. I thanked both of them for supporting the medical partnership that was enabling me to live a healthy life, return to school and so much more.

But challenges still remain.

Replacing two of my heart’s four valves means I have to take three different medicines—totaling about five pills every day—and see a cardiologist at least twice a year, for the rest of my life. One of the medicines is a blood thinner, which requires me to have my blood tested once a month. This is not always easy.

When I returned to Rwanda after my surgery and recovery in 2008, there was only one hospital in the country, in Kigali, that could do the monthly blood test I needed.  Resources have grown since then, with the help of the government, and now blood tests are offered in several districts.

I am grateful that the country has continued to advocate for people with heart conditions. There now are about five visiting teams that offer heart surgeries, and the government is providing scholarships for aspiring cardiologists. I am also happy that the country has affordable health insurance and everyone is enrolled in the system.

From patient, to advocate

The major challenge I see is our very poor patient-doctor ratio, especially in specialized areas like cardiovascular medicine. Enormous demand is created when a country has just seven cardiologists and one cardiothoracic surgeon for 12 million people, and while that number slowly is improving, there is still a long way to go. When I was sick more than a decade ago, there were just two cardiologists in Rwanda, for its more than 9 million people at that time.  

International help is direly needed. For example, top-ranking medical schools could provide more support for young Rwandan doctors specializing in cardiology. More also can be done to ensure postoperative medications are always available for patients, who need to take them every day to continue feeling well. Additionally, health care providers at the community level must be trained on how to diagnose RHD earlier, to potentially prevent more serious complications down the road.

I know the Rwandan government is aware of these issues, and working to address them. But system-wide change takes time, and more partners are needed to accelerate the process.

Overall, my wish for Rwanda is to have a young generation free of rheumatic heart disease. I encourage anyone experiencing symptoms to not ignore them, and seek out care that they might need. For those fighting the disease and those with lifelong care, like me, my wish is that care and resources across Rwanda one day will equal what is available in developed countries.

 

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Sat, 28 Sep 2019 13:28:48 -0400 https://www.pih.org//article/heart-patient-advocate-and-soon-be-md
PIH Leader in Devex: UN Health Declaration Undermines Equity https://www.pih.org//article/pih-leader-devex-un-health-declaration-undermines-equity Truly achieving health care for all will require global solidarity and cannot involve different sets of services for different countries and communities, determined by their wealth and whims of the markets, Dr. Jean Claude Mugunga wrote in an opinion piece published this week in Devex, an online news and information source focusing on global development.

Mugunga is a physician and associate director of monitoring, evaluation, and quality for Partners In Health. His opinion piece follows the United Nations General Assembly’s adoption Monday of a political declaration on Universal Health Coverage (UHC)—a declaration that Mugunga says “definitely doesn’t align” with his beliefs.

Dr. Jean Claude Mugunga
Dr. Jean Claude Mugunga

“A (version of) UHC that means a few select services for everyone while the rest of the services are left to the market does not serve to promote equity,” Mugunga writes. “It also exaggerates the agency of resource-poor countries to ‘determine’ these sets of services. Overall, this serves to undermine the meaning of health as a human right.”

Mugunga says that for himself and his family, the issue is “not just a policy debate.” He was born in rural Rwanda, shortly after world leaders’ 1978 adoption of the Declaration of Alma Ata had raised hopes of sustainable, equitable global systems that would ensure health care for all.

“We had been excluded from the fruits of modern medicine for the entirety of our lives to date. And this had been painful. Like my four older siblings, for example, I was very prone to malaria-induced fever and seizures,” he writes. “But Alma Ata meant that my mother would no longer have to wait or sell valuable livestock or land to secure user fees to take me to the nearest health facility.

“That hope was short-lived.”

Mugunga describes how, in the decades since, commoditization and privatization of health care has veered the UHC discourse away from the ideals of Alma Ata. He then applies his data analysis expertise to the financing gap for achieving UHC in low- and middle-income countries, and makes the case that high-income countries can bridge that gap with a tiny portion—about 0.18 percent—of their gross national income.

“In an era of globalization, there needs to be an increasingly globalized notion…for who bears responsibility for protecting and fulfilling the right to health,” he writes.

Read Mugunga’s full piece here.

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Thu, 26 Sep 2019 15:04:10 -0400 https://www.pih.org//article/pih-leader-devex-un-health-declaration-undermines-equity
Opinion: Universal Health Coverage Must Meet the Needs of the Missing Billion https://www.pih.org//article/opinion-universal-health-coverage-must-meet-needs-missing-billion This opinion piece was written by PIH’s Dr. Dan Palazuelos, director of community health systems, and Dr. Joia Mukherjee, chief medical officer, in anticipation of the United Nations General Assembly High-Level Meeting on Universal Health Coverage in New York City, starting September 17.

We remember when we first met Aminata* from Sierra Leone. She is an adolescent, about 14 years old, with visual impairment. There are no schools that can teach her in her home country. She is an orphan and sometimes helps her aunt prepare fried cakes that she sells in the market. A community health worker from our organization, Partners In Health, identified her as vulnerable and brought her to the clinic. There it was found that she has HIV. She says she hasn’t yet had sex, but she begins to cry when asked. Because her mother died of unknown causes, we don’t know if Aminata was infected at birth, is indeed sexually active by choice or for survival, or is a victim of sexual violence. 

We do know this: Aminata is at risk of premature death, of not fulfilling her potential. As an orphan girl with HIV/AIDS and visual impairment, there will be many challenges for her to stay healthy—the cost of transportation to the clinic and the support of her overstretched aunt to provide her with an education and food insecurity. These and many other social factors will make it difficult for Aminata to adhere to antiretroviral treatment, to protect herself against unwanted or premature pregnancy, and to live a healthy life. Without community-based care and social support to target a vulnerable young woman such as Aminata, we know she will fall sick more often, is more likely to get pregnant against her will, will receive less education, and will have fewer opportunities for employment and income generation.

Unfortunately, in many of the 10 countries where PIH works, the vulnerability of people with disabilities, chronic illnesses, and several constrained social situations is woefully common. In any country, the cycle of poverty is worsened significantly when people have disabilities. This is even more catastrophic when the health system itself is debilitated by insufficient staff, supplies, or dignified infrastructure. We at PIH believe that achieving truly universal coverage, and health as a human right, can be achieved through investments in community health workers connected with robust health systems. And we believe the measure of such systems is how well they will reach patients like Aminata.

That is why PIH strongly supports the Missing Billion report on achieving universal health coverage (UHC) with attention to people with disabilities. The report--spearheaded by the London School of Hygiene & Tropical Medicine and the Office of the WHO Ambassador for Global Strategies, but with input from UNICEF, PIH, and others--shines a strong light on a stark reality; people with disabilities are, on average, more vulnerable to poor health, with much lower access to health care services and less health coverage, which results in worse health outcomes.

UHC will be the focus of United Nations High-Level Meetings during the U.N. General Assembly this month. What will it really take to achieve UHC, and to do real justice to the often-used slogans of “reaching the unreached” and “leaving no-one behind”? We believe that the measure of UHC must be how well it reaches the most vulnerable, not the “low hanging fruit” or the 80 to 90 percent coverage commonly accepted as sufficient. Rather, we believe systems to deliver UHC must be guided by a focus on equity, and we must aim to reach that final 10 to 20 percent to be truly equitable.

Worldwide there are approximately 1 billion people with disabilities, and many live in abject poverty. A health system that is designed to reach these populations will be better equipped to serve everyone else. The Missing Billion report makes recommendations to governments, funders, global policy makers, and all other stakeholders.

But as we have seen with so many reports before it that speak truth to power, we know it takes so much more to make these insights a reality. It will take the strengthening of health financing, metrics, data, evidence, legal frameworks, and improved service delivery to address health disparities. We will never reach UHC without reaching the most vulnerable, including people with disabilities and the poor. Aminata’s story, and the Missing Billion report, provide clear guidance. Are we ready to listen?

* Name and clinical details changed to protect anonymity

 

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Mon, 23 Sep 2019 11:07:06 -0400 https://www.pih.org//article/opinion-universal-health-coverage-must-meet-needs-missing-billion
New Emergency Ward a Game Changer in Sierra Leone https://www.pih.org//article/new-emergency-ward-game-changer-sierra-leone There was a gentle hum of conversation as Doris Miatta Komba moved swiftly between the beds in Koidu Government Hospital’s emergency ward. The 32-year-old Ministry of Health nurse is in charge of the new emergency department, a critical area of care that didn’t exist until this May. Her attention was caught by a monitor at the far end of the room. She signaled to a second nurse, who moved to her side and placed two fingers over the wrist of a patient lying attached to the monitor by a clear tube.

The patient—who is male, in his mid-thirties—was admitted to the emergency ward the day before with hypertension, and if it hadn’t been for the timely care he received from these nurses, he would have likely died. He lay in one of six beds in the ward, all of which were occupied by patients with serious and urgent medical conditions, while Komba and her team delivered the specialist care they have been trained to provide.

Koidu Government Hospital, or KGH, is the only hospital in Sierra Leone outside the capital of Freetown to have an emergency ward. It serves a population of more than 500,000 people in and around Kono District. Staff are proud to be pioneering an approach to the care of critically ill patients that could, in the future, be replicated at other hospitals across the country. Since opening in May, more than 430 patients have been admitted and treated at the emergency ward.

Before the hospital’s emergency ward opened, patients admitted with acute, serious medical conditions needed to wait for a bed to become available in one of the main wards before they received the care they desperately needed.

“We can now identify the sickest patients and provide timely care,” said Dr. Chiyembekezo Kachimanga (or Dr. Chembe, as he is known across PIH), clinical educator for PIH in Sierra Leone. “The moment a patient arrives, they are attended by a nurse who is consistently there. Two nurses are on shift at all times. And the emergency medicines are all there too; a pharmacist comes every morning to top them up. Quick access to the right medication and care is a crucial time-saver when treating someone who is critically ill.

 “With this department,” he added, “we hope to reduce mortality at KGH. If we manage symptoms quickly, patients are less likely to die.”

Innovation in emergency care

The emergency ward operates alongside a triage system introduced earlier this year. At triage, a patient’s symptoms are categorized by a clinician into one of four colors: red and orange flag a need for immediate medical attention, and green and yellow signify regular clinical care. Since May, 75 percent of all patients admitted at KGH have required acute medical care, and 11 percent of these patients were flagged as orange or red and so referred straight to the emergency ward.

The patient that Komba has successfully stabilized was marked as red at triage the day before. “Hypertension symptoms usually cause the patient to become unconscious or have severe breathing problems,” she shared. “All of the vital signs are usually off, so they need a lot of support.

“When patients initially come to the emergency ward, they are afraid,” she said. “It is our job not just to assess them, but also to assure them.”

Komba and her staff do this medical and emotional work, all while carrying out an “ABCD” assessment—checking for airway obstructions, breathing issues, circulation irregularities, and disability or dehydration.

After completing the ABCD assessment and successfully stabilizing her patient that day, Komba called the attending doctor to complete a follow-up examination and prescribe the required medication for hypertension.

Working smarter, not harder

The emergency ward has slotted into KGH’s other operations seamlessly. Having a well-equipped, separate space for treating critically ill patients has relieved a huge amount of pressure from hospital staff. Previously, they were required to treat these patients, who were dispersed throughout the hospital’s wards, making it difficult to provide the necessary focused, specialist care.

Clinicians now ensure that all patients are triaged upon arrival at KGH. When patients are discharged from the emergency ward, usually after three to four days, they are able to provide appropriate recovery care in one of the hospital’s regular wards.

Chembe was initially surprised to learn that the most common patient cases admitted to the emergency ward are related to non-communicable diseases, such as hypertension, diabetes, and hepatitis. “When we opened the ward, we didn’t anticipate this would be the case at all,” he shared. “Once patients have been stabilized, we link them directly with the NCD clinic. Our aim is always to make sure that once we discharge patients, they have enough medicine to tide them over to their next NCD appointment.”

 

Emergency department nurses at a hospital in Sierra Leone
Nurse Doris Miatta Komba (sitting) and a colleague complete paperwork for patients at the new emergency ward in Koidu Government Hospital in Kono District, Sierra Leone. Photo by John Ra / Partners In Health

Training for better care 

The emergency ward’s clinical team, made up of Ministry of Health and PIH staff, has received in-depth training on both the new triage process and emergency medicine to ensure that patients receive the best possible treatment. Chembe, Komba, and Moses Bangura, a PIH clinician working at KGH, travelled to Liberia in May to receive a two-week training in advanced emergency clinical care. And in January, 30 PIH and Ministry of Health staff in Freetown and Kono will receive additional training on the management of critically ill patients, especially those suffering from respiratory distress, shock, trauma, and an altered mental status--all common reasons for emergency care in Sierra Leone.

“I am still organizing training topics for emergency care,” Chembe shared. “I want it to become a continuous training schedule. Our clinicians have provided feedback that they want more training—they want to keep refining their skills and to gain a deeper understanding of the science behind why certain procedures need to happen.”

The emergency ward at KGH marks a bold step in strengthening the health care system in Sierra Leone. As word spreads about its quality services, critically ill patients are travelling hours to get treatment, from the capital of Freetown and as far away as neighboring countries, such as Guinea.

“When patients see after three days that they are feeling better, they are so appreciative and happy,” said Komba proudly. After stabilizing her hypertensive patient, and with his medication stored safely in her cabinet, she could rest assured that she had done everything she could to save his life, something that might not have been possible just five months ago. 

 

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Mon, 23 Sep 2019 10:45:31 -0400 https://www.pih.org//article/new-emergency-ward-game-changer-sierra-leone
Research: Health Systems, Like Patients, Can Suffer From Misdiagnosis https://www.pih.org//article/research-health-systems-patients-can-suffer-misdiagnosis As HIV care advanced following the introduction of antiretrovirals, clinicians observed a curious phenomenon: Some patients’ health unexpectedly got worse, rather than better, shortly after they began treatment.

It seemed that HIV treatment awakened patients’ immune systems, allowing them to fight ailments that previously had lain dormant, or unchallenged, because HIV had suppressed their body’s ability to respond. This led some doctors to think patients were getting sicker, when actually, they were starting the arduous process of getting better.   

The phenomenon, of unexpected initial setbacks, became known as immune reconstitution inflammatory syndrome. Failure to recognize it could lead doctors to change treatment plans prematurely or incorrectly, and potentially endanger patients’ lives.  

A newly published study shows that the same phenomenon applies to health systems, and that failure to recognize it can lead to the elimination of new programs or funding streams, before they have a chance to succeed.

“Without substantial or measurable early impact, funders and program implementers may question the utility of their intervention, methods, and goals,” says Dr. Anatole Manzi, director of clinical practice and quality improvement for Partners In Health.

Anatole Manzi
Dr. Anatole Manzi, PIH director of clinical practice and quality improvement (Photo by Zack DeClerck / PIH)

Manzi is lead author of the study, titled: “Health System Reconstitution Syndrome: An Often Misunderstood Phenomenon in Global Health Practice.” Oxford Academic’s Health Policy and Planning journal published the study in August. Several PIH leaders, including CEO Dr. Sheila Davis and Chief Medical Officer Dr. Joia Mukherjee, join Manzi as co-authors. 

The study reveals that programs or interventions put in place to improve health systems often are assessed too early. As a result, funding has been cut from many programs that could have effectively improved health outcomes and saved lives, had they simply been given more time to unfold.

Manzi asserts that when a country or community implements a program to improve a health system, the quality of health care services initially can appear to suffer. There are several reasons why this might occur. Health care workers start finding and reporting more cases, so disease rates rise. And as more people learn to trust what was once a broken health system, demand for services increases—sometimes faster than staffing levels or available resources.

It’s crucial for health system implementers and funders to be aware of this dynamic, the study states, to more accurately assess new programs.

“It’s important for the Global Fund to Fight AIDS, Tuberculosis and Malaria, and other funding institutions, to understand this evolution of health interventions, because they’re affecting our health outcomes,” Manzi says. “Unfortunately, the [current assessment] requirements are setting up countries to fail.”

While the overall effectiveness of programs to strengthen health systems has been assessed in the past, this study is the first to break down the specific evolution of implementation. Manzi and the study’s co-authors use a World Health Organization framework to break down implementation into four phases: quiescent, reactive, restorative, and stability.

The quiescent phase occurs directly after the launch of an intervention, and is when the health system gears up to respond to change.

Delays in effectiveness most frequently happen in the second, or reactive, phase—often marked by baseline data that gets worse, not better. Unfortunately, that often coincides with the time when programs are evaluated for the renewal of a grant or other source of funding.

Manzi suggests that funders continue timely evaluations of projects, but hold off on funding decisions until later reviews. To avoid misinterpreting positive outcomes as negative, he urges program implementers and funders to recognize symptoms of the reactive phase, and avoid prematurely abandoning or changing intervention strategies. Greater consideration of contextual factors for different health systems also can reduce premature decisions to stop funding, and prevent negative implications on implementation, policy, and global health research.

Should programs reach the third, or restorative, phase, practitioners start to see significant improvement in the health system.

Finally, programs reach their desired outcome in the stability phase.

“This is an untold story. Most grants have a renewal timeline of one year or two,” Manzi says. “In many cases, the project is in the reactive phase at the end of the grant. It’s unfortunate for projects that were going to succeed.”

An intervention to eliminate malaria in Rwanda, for example, saw an unexpected increase of cases during the reactive phase, due in part to health workers finding more malaria patients through better data collection, monitoring, and reporting. As the project moved into the restorative and stability phases, though, teams saw remarkable improvements in malaria case-finding and management. Those improvements would not have occurred if funders had pulled the plug after initial results.  

A community health worker visits a family at home in Rwanda
Community health worker Niragire Irene (at rear, blue headscarf) visits a family at their home in eastern Rwanda's Cyarubare District in 2018. Health system improvements that boost screenings and community visits initially can create misleading data, suggesting implementers and funders should take a long view when assessing effectiveness. (Photo by Cecille Joan Avila / PIH)

Another example has occurred in Lesotho, where a slight decline in primary care services followed the launch of a national health reform. Again, the short-term setback primarily was related to a more streamlined system for data collection and reporting.

Stakeholders also must consider the entire scope of impacts and needs that health system interventions can cause.  When only partial impacts are considered, some indicators can begin to improve, while others may significantly worsen if the health system can’t handle the demand.

This often happens with vertical programs, which target one aspect of care rather than health system as a whole. For example, an intervention to increase the number of people who use health facilities can lead to a breakdown in services, if other important elements like medical supplies and human resources are not considered.

That’s why understanding the implications of health system reconstitution syndrome is critical for global health stakeholders, including program implementers, policymakers, researchers, and global health funding institutions.

“Given that typical funding grants for health system strengthening projects range from one to three years in length,” Manzi says, “monitoring and quality improvement early in the intervention becomes critical as a means to shorten the reactive phase and prevent early abandonment of the intervention.”

As global leaders and communities around the world raise their voices to advocate for universal health coverage, and care, it will be crucial to redesign tactics for effective implementation, research, and health financing. Strongly considering these dynamics, and contextual factors for different health systems, will help stakeholders ensure effective implementation of improvement projects, and ultimately, better health outcomes.     

Read the full study here.

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Fri, 20 Sep 2019 15:32:11 -0400 https://www.pih.org//article/research-health-systems-patients-can-suffer-misdiagnosis
UGHE Welcomes Inaugural, Majority-Female Medical Class https://www.pih.org//article/ughe-welcomes-inaugural-majority-female-medical-class Delphine Mizero doesn’t want to become a doctor because of money, she writes in a booklet introducing the University of Global Health Equity’s inaugural medical class. She wants to become a doctor “because of the incredible work” that saved her life, when she had only just arrived in the world.

“I was born with a tumor in my chest that filled with fluid. My mother told me that there was a hot debate about whether to operate on it or to let me, an innocent baby, die because it was too expensive to get treatment,” Mizero writes. “Because we had no insurance then, the operation was very costly, and my mother sold some assets to afford it. My mother told me that she was also extremely afraid of the operation because she had not heard (of) or seen a baby that young having a surgery. It was hard for my mother to decide, but she later accepted the risk and decided on the operation.”

When Mizero grew older and learned the story, it instilled her with a drive to help underserved communities access better medical care. She attended Gashora Girls Academy of Science and Technology in Rwanda’s Eastern Province, where she focused on physics, biology, and chemistry, captained the soccer team, and interned at a local health clinic.

Delphine Mizero
Delphine Mizero said she wants to become a doctor "because of the incredible work" that saved her own life, when she was born with a tumor in her chest that was filled with fluid, and required an operation that was difficult for her family to afford. (Photo by Danny Kamanzi / UGHE)

Then she applied to UGHE, a Partners In Health initiative in the rural, northern Rwanda community of Butaro. Mizero was one of 685 applicants, all vying to be the first students to undertake the groundbreaking university’s six-and-a-half-year medical program. Thirty students made the cut, creating an acceptance rate of just more than 4 percent. That’s on par with 2019 acceptance rates for medical schools at Harvard University (3.4 percent), the University of Chicago (4.8 percent), and Johns Hopkins University (6.1 percent), for example.

UGHE made gender equity a priority in admissions, as part of efforts to increase the number of female doctors in Rwanda and beyond. The Class of 2025 is comprised of 20 women and 10 men, all from Rwanda—and all, like Mizero, with personal experiences of inadequate health services that have inspired them to work toward positive change in their home country. 

Benitha Uwera, for example, said her mother has had long-term lung issues, and her father has battled significant spinal problems.  

Benitha Uwera
Benitha Uwera said her parents' longtime struggles with lung and spine problems motivated her to apply to UGHE, and hopefully reduce unnecessary deaths in rural areas that are far from hospitals. (Photo by Danny Kamanzi / UGHE)

“My parents both went all the way to India to get cured, but nothing has really improved their health condition,” she writes, in the same booklet as Mizero. “I saw my parents in so much agony and pain, and I had a desire since my childhood to grow up and become a useful doctor who will help sick and suffering people. Also, many people are still unnecessarily dying in rural areas, because the hospitals are too far away, and for others, they are economically disadvantaged.”

UGHE’s mission and curricula are designed to train doctors who will help meet that exact need. The private, independent UGHE was launched in 2015, as a Partners In Health initiative with significant investment and collaboration from the government of Rwanda. Construction of the university’s 250-acre campus began a year later. Partners In Health is known locally as Inshuti Mu Buzima, and has worked in Rwanda since 2005. In January, a distinguished crowd of government and global health leaders, including Rwandan President Paul Kagame, formally opened the campus with a celebratory inauguration, and Master’s in Global Health Delivery students moved in.

The newly arrived medical students now have joined them, adding to an increasing bustle around UGHE’s dorms and academic buildings.

“The inaugural cohort of medical students is great,” said Dr. Agnes Binagwaho, UGHE’s vice chancellor and a former Rwanda Minister of Health. “They are motivated, with a clear vision, and are ready to contribute to improving the health status of their country, leaving no one out.”

UGHE’s nationally accredited medical program confers a Bachelor of Medicine, Bachelor of Surgery/Master of Science in Global Health Delivery, combining a bachelor-level medical degree with the university’s existing master-level global health degree.

UGHE's academic facilities include a brand-new science lab
Emmanuel Kamanzi, director of campus development at UGHE, shows a science lab that is part of sparkling academic facilities for university students, including the inaugural medical class that arrived in July. (Photo by Mike Lawrence / Partners In Health)

The curriculum will build upon existing requirements for medical doctors in Rwanda and across East Africa, with academic innovations designed to train a new generation of health professionals who strive to deliver more equitable care.

Studies begin with six months of introductory coursework to establish an academic foundation around themes including patient care, health sciences, and social determinants of health. Just across a valley, the nearby, PIH-supported Butaro District Hospital will help students gain firsthand medical experience during the program, which will emphasize hands-on learning with patients and health systems in rural areas.

Incorporating UGHE’s existing Master’s in Global Health Delivery into the medical program will ensure that graduates not only gain a solid foundation in the health sciences and clinical practice, but also acquire the knowledge and management skills needed to build and maintain effective, equitable health systems.

Students will put that education and training into practice directly after graduating. Each of UGHE’s new medical students has signed an agreement known as umusanzu, which means “contribution” in the local language of Kinyarwanda. Under umusanzu, students pledge to work with the government of Rwanda in underserved communities for at least five years after completing their studies, in exchange for a full scholarship to UGHE. The scholarships are funded by private charitable contributions.

UGHE's campus, seen from Butaro District Hospital
UGHE's campus, seen from PIH-supported Butaro District Hospital. The hospital's proximity will enable medical students to gain firsthand experience and training at the hospital. (Photo by Mike Lawrence / Partners In Health)

Umusanzu is at the heart of UGHE’s mission of building the next generation of global health leaders. The university believes that financial capacity should not determine someone’s ability to pursue a career in global health, and that removing financial barriers to education will create a more diverse field of medical professionals and lead to more equitable health outcomes.

“We take pride in providing equitable access to health sciences education, as we believe that equity in education is the basis of equity in health care,” said Professor Abebe Bekele, UGHE’s founding dean of health sciences. “We do not want our students to pay us back for the education they receive here, but rather we want them to pay it forward by serving those who have lacked access to quality health care in the past.” 

That commitment seems to align closely with Mizero’s goals. She said she’s looking forward to the medical program’s community involvement and comprehensive curriculum, which extends beyond clinical care to develop humanitarian values, such as cultural literacy and social justice.

“I am highly concerned about the general well-being of the community, especially the least privileged, underserved, and most vulnerable,” Mizero wrote. “Thank you again, UGHE, for being a ladder on which I climb up to achieve my dream."

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Fri, 13 Sep 2019 16:32:55 -0400 https://www.pih.org//article/ughe-welcomes-inaugural-majority-female-medical-class
U.S. News Lauds Fabrice's Story, Rwanda's Revitalized Health Care https://www.pih.org//article/us-news-lauds-fabrices-story-rwandas-revitalized-health-care A new in-depth article by U.S. News & World Report praises Partners In Health’s “pivotal” role in the transformation of Rwanda’s health care system, particularly in child cancer care, which the online news magazine highlights through former Wilms’ tumor patient Fabrice Irakoze, now a healthy 11-year-old. 

The Sept. 5 article, “Rwanda’s Model: Progress, with More Work Ahead,” includes comments from several PIH and Rwandan health leaders and is part of an expansive special report on child cancer care around the world. The special report includes opinion pieces, a photo gallery, and vignettes from Hong Kong, Jordan, Lebanon and other locations, collectively titled, “Childhood Cancer: Seeking a Better Global Solution.” The package coincides with Childhood Cancer Awareness Month, recognized every September by cancer organizations around the world. 

The Rwanda article features treatment at the Butaro Cancer Center of Excellence, part of the PIH-supported Butaro District Hospital campus in the country’s rural north. PIH has worked in Rwanda since 2005 and is known locally as Inshuti Mu Buzima. PIH, Rwanda’s Ministry of Health, and other partners opened the cancer center in 2012. The facility now sees nearly 2,000 patients per year, from across Rwanda and nearby countries. 

Dr. Cyprien Shyirambere, director of oncology for PIH in Rwanda, told U.S. News that the center’s growth and success has defied expectations.

"When we started this cancer center people were saying that we would do harm, to treat cancer you need all the resources that are available in high-income countries," Shyirambere says in the article. "But a child like Fabrice shows it is possible to treat cancer in a country like Rwanda if you have a strong health system, if you have access to basic chemotherapy, a dedicated team of doctors and nurses and you have protocols and a committed government."

Fabrice Irakoze was 4 years old in 2013, when he developed a fever that wouldn’t go away. At a district hospital in Kigali, Rwanda’s capital, he and his mother, Cecile Nzamwitakuze, were given what she thought was a deadly diagnosis: a kidney cancer known as Wilms’ tumor, or nephroblastoma.

But during six months of chemotherapy in Butaro, as PIH also supported the family with food packages, school fees and materials, and transportation costs, Fabrice steadily improved. He now has been cancer-free for six years, and returns to Butaro for annual checkups with Shyirambere.

U.S. News uses his story to show how strong health systems and comprehensive care can transform a country. Dr. Joia Mukherjee, chief medical officer for PIH, told the online magazine that wealthy nations must increase commitments to system-wide improvements in the global south.

"These problems are long-term problems that we need to solve together with international solidarity that's lasting," Mukherjee says.

Read the full article here.

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Tue, 10 Sep 2019 14:58:05 -0400 https://www.pih.org//article/us-news-lauds-fabrices-story-rwandas-revitalized-health-care
Students in Sierra Leone Share Stories as School Year Begins https://www.pih.org//article/students-sierra-leone-share-stories-school-year-begins On a rainy July day in Sierra Leone, children across the country walked to their local schools with pencils in hand, to take their end-of-year exams. If they passed, they would be accepted into the next grade level when school returned in September.

As children and young adults all around the world know, summer goes by fast, and many of those students now are beginning the new school year. But for students served by Partners In Health, challenges far greater than final exams could have stood in their way.

PIH has worked in the West African nation since 2014, when responding to the Ebola outbreak was the immediate need. But through a continuing partnership with the national government, PIH's role has only grown. Staff now supports comprehensive care for a population of more than 500,000 in the country's eastern Kono District, with two health facilities and more than 100 community health workers reaching families in their homes, every day. PIH also supports national tuberculosis and mental health programs based in two facilities in the capital, Freetown.     

In all of its work, PIH knows comprehensive care extends beyond physical health. That's why PIH also provides social, mental, and economic support, to help people, families, and communities thrive. Ensuring children can return to school after illness is a vital part of that care. Here, four children and young adults who have faced vast challenges—such as HIV, TB, and diabetes—share their stories and their spirit. And, as September arrives, they share their excitement to get back to school. 

Emric Ansu at his family's home near Koidu, Sierra Leone
Ten-year-old Emric Ansu, at his family's home near Koidu, Sierra Leone, says he hopes to be a doctor one day but right now, his favorite part of school is writing—and football, as evidenced by his notebook with Manchester United star Paul Pogba on the cover. 

Emric Ansu

In a village just outside of Koidu, 10-year-old Emric Ansu hides shyly behind the entrance of the home he shares with his aunty, Massah, and five cousins. But as soon as he sees the familiar faces of PIH community health workers arriving, he runs outside with a smile to welcome them.

Emric had lost both of his parents to HIV by the time he was just 3 months old. Massah immediately made the 155-mile journey to Freetown to collect him, and has cared for him since. Sitting outside their home, she briefly paused to go inside, and returned with a crumpled photo in a plastic sleeve.

“This is my brother, just before,” Massah said. 

Across Sierra Leone, HIV still carries a heavy weight of stigma. But that didn't deter Massah from doing everything she had to do to save Emric’s life.

As soon as he was in her care, she had him tested for HIV. The results came back positive. In Kono District at that time, a decade ago, HIV treatment wasn’t easy to come by, let alone pay for. But Massah repeatedly found ways to ensure Emric had the antiretroviral medication he needed to survive. Those efforts became increasingly difficult, though, as Massah started her own family—today, she’s raising five of her own children along with Emric, on her own, while also supporting her mother, who suffers from disabilities. Earlier this year, PIH stepped in to help, providing free medication and health care to make sure Emric could continue his treatment and stay in school.

“It’s always hard,” Massah said. “Sometimes we don’t have enough food for the family, and when Emric can’t eat I don’t give him his medication, because without food it’s too strong and it makes him sick.”

PIH’s Acute Needs Program is designed for this kind of situation, and provides cash or food supplies to enable patients like Emric to stay on medication.

Emric turned 10 this summer, a milestone for any child. But in Sierra Leone, most families don’t have the means to celebrate every year and instead recognize birthdays every five years, if they can.

“But we still danced,” Emric said, smiling.

John Suluku, manager of the Acute Needs Program for PIH in Sierra Leone, recently visited Emric and asked to see some of his schoolwork. The energetic youth ran inside to collect it and returned moments later, holding a small notebook with Manchester United footballer Paul Pogba on the cover and “Exam Book” written at the bottom.

Emric’s dream is to be a doctor, but for now, what he loves most is exactly those two things—football and writing. He said he's not nervous at all about returning to school in his village. 

“I love school. I’m excited," Emric said. "My best friend is Philip. He’s not in my class, but we play together.”

Bintu Bailor
Bintu Bailor was diagnosed with tuberculosis this spring, just days before her end-of-year exam. She received treatment at PIH-supported Koidu Government Hospital, took the exam, and passed, clearing the way for her return to school this fall.  

Bintu Bailor

Bintu Bailor, 17, sat on the doorstep of her family’s home earlier this summer with her sister and cousins, in their home village near Koidu, waiting for PIH community health workers to arrive for their regular visit.  

They had been seeing the health workers often. Two months prior, just weeks before Bintu’s end-of-year exam, she was diagnosed with TB at PIH-supported Koidu Government Hospital.

Immediate treatment and support got her back on her feet. Bintu had a short hospitalization at Koidu, and took the exam just days after her release. She passed.

“Now I can be in secondary class one when we go back to school next month,” she declared proudly on that day earlier this summer, at her family’s home. “I just love to study, even when I’m not at school. I really like math.”

Her care has continued. PIH supports Bintu with transportation to and from the hospital, for medicine refills and regular checkups. The experience has left a lasting impression on Bintu.

“I’m feeling much better,” she said. “Now, I want to be a nurse and work for PIH. I like the way people treat me in the hospital when I go there. That’s why I want to study to become a nurse.”

Anita Bungura
Anita Bungura, 14, became critically sick last year, and became one of the first patients in Sierra Leone to be diagnosed and treated for type 1 diabetes. She now knows how to administer her own insulin and check her blood sugar, and has returned to school.  

Anita Bungura and Joshua Kamara

Anita Bungura sat patiently with her parents on a July day, on a bench outside the non-communicable disease clinic at Koidu Government Hospital, waiting to see the doctor.

Late last year, the 14-year-old had become critically ill.

“I wanted to drink a lot of water and needed to go to the bathroom very often,” Anita recalled.

In November, Anita and 20-year-old Joshua Kamara became two of the first patients in Sierra Leone to be diagnosed with, and treated for, type 1 diabetes. In a country with a high prevalence of infectious diseases such as HIV and TB, patients like Joshua and Anita—with non-infectious diseases—often had gone unnoticed.

During initial treatment, PIH provided transportation to and from the clinic for Anita and Joshua twice every day, so they could get insulin and blood sugar checks. The support saved their lives.

Joshua Kamara, 20, has learned to manage his diabetes with support from PIH
Joshua Kamara, 20, has learned to manage his diabetes with support from PIH, and has graduated from secondary school. 

Gradually, PIH doctors taught Anita and Joshua to administer lifesaving insulin and check their blood sugar levels on their own. PIH staff also arranged for Anita’s insulin to be stored at a local clinic, where it could be kept cold, and provided Joshua with a clay pot to store his insulin and keep it cool, as well. Community health workers have continued to make regular home visits to each family, and both Anita and Joshua were able to return to school this spring. 

Six months after his diagnosis, Joshua graduated from secondary school—an achievement he had long thought was out of reach.

“When my father died in 2010, I had to look after myself by doing labor to get myself food. I had given up hopes of completing school,” Joshua said. “I didn’t know about diabetes before, but (a PIH doctor) taught me about it. He showed me how to use a syringe, the amount of insulin I needed to use in an injection, and how to measure my sugar levels.”

With his health vastly improved, Joshua now hopes to continue his education even further.

“I used to lie in bed and feel like I was going to die,” he said. “But I feel happy and good now. Getting a good education is the way forward for me. That is my priority.”

The support from PIH has given Anita dreams of a bright future, as well.

“I’m in Form Three now and I want to be a nurse," she said. "I have learned a lot from the nurses and I feel a lot better now, so that’s what I would like to become.”

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Thu, 29 Aug 2019 15:12:08 -0400 https://www.pih.org//article/students-sierra-leone-share-stories-school-year-begins
Q&A: SE Liberia's Only Surgeon Describes Lifesaving Role(s) https://www.pih.org//article/qa-se-liberias-only-surgeon-describes-lifesaving-roles Dr. Gerald Ekwen is not only the sole general surgeon at Partners In Health-supported J.J. Dossen Hospital in Harper, Liberia. He’s also the only surgeon in all of southeastern Liberia, where in Maryland County alone, PIH serves a population of about 170,000.

People also come to J.J. Dossen from neighboring counties and neighboring countries, such as Côte d'Ivoire. Ekwen has boosted obstetric services, too, helping his PIH colleagues track and reduce maternal deaths and increase the rates of women giving birth in a health facility, rather than at home.

PIH’s medical director for Maryland County, Dr. Abdissa Kabeto, said nearly 70 percent of expected deliveries occurred in a health facility in 2018, up from 35 percent just three years earlier—a vital improvement in Maryland, where PIH also supports the Pleebo Health Center.

“The southeast of Liberia is underrepresented and underdeveloped, and requires a lot of support from all of us,” Kabeto said.

Ekwen is an essential part of those efforts. He began his surgical career in 2014 at hospitals in his native Cameroon, and now works with 12 operating room nurses or support staff at J.J. Dossen, performing about 15 surgeries per week. Since Ekwen joined the PIH-Liberia team in 2018, he has conducted about 400 lifesaving surgeries, covering everything from endoscopies to emergency procedures.

His work addresses a need that extends far beyond Liberia. Five billion people worldwide lack access to safe surgeries, according to the World Health Organization. The shortage is most severe in low- and middle-income countries, where nine out of 10 people have no access to basic surgical services.

Ekwen sat down recently to talk about surgery in a rural setting, a daily routine that often extends late into the night, and how he couldn’t find J.J. Dossen’s operating room during an eventful first day on the job.        

Why did you become a surgeon?

After working in rural Cameroon for a while, I saw the challenges and burdens of surgical diseases in rural settings. I realized that, to make a difference in people’s lives, I needed to do more than just prescribe drugs. I needed to do surgeries also. That’s what caught my attention and my interest. I saw people suffering from treatable conditions because there was no surgeon.

Dr. Gerald Ekwen at J.J. Dossen Hospital
Dr. Gerald Ekwen at J.J. Dossen Hospital. (Kyle Daniels / PIH)

How is practicing surgery in a rural area different from an urban setting?

Here in rural Liberia, you’re expected to work as a urologist, as the orthopedic surgeon, the gynecologist, the obstetrician, and the general surgeon. There are even times when you’re called to do internal medicine and infectious disease care.

Many times, you find that you are alone in terms of support. You have to either connect to others through email or phone to discuss cases. When you work in a city or in teaching hospitals, you have all of these people around you. So when you have a case, you put your heads together and come up with a solution. In a rural setting, there’s no other surgeon, so you have to make the decision.

Working in a place with limited resources, you can make quite a huge difference in people’s lives. If you hadn’t been there, lots of people would have died, or would have had disabilities, because there was no surgeon. You are needed more than in a city.

You’ve certainly been needed, and welcomed, here. What brought you to Liberia?

I had read about the work of PIH in Rwanda and their push for global surgery equity. Our visions intersected in many areas, including the provision of a preferential option for the poor in health care. While reading through the PIH website, I came across a new job listing for Liberia.  I saw it as an opportunity to positively impact lives where I was needed most. The opportunity to build local capacity also prompted my interest and, ultimately, my decision.

I hear you had a case from the moment you arrived in Harper. Can you tell me about that day?

In the morning, I was going around the hospital with PIH’s medical director for Maryland County, Dr. Abdissa Kabeto, to introduce myself to the team. We had just finished in the x-ray unit and were in the PIH office in the hospital, talking with another director, when we heard shouts from the ER. We were like, “That is not normal. People are screaming and shouting. Is someone dead? What’s happening in the ER?”

We stepped out to see what was happening, and there was a crowd gathering. We saw a man in a pool of blood, sitting on the floor in the ER. What really scared me was that I had just seen him a few minutes ago in the x-ray room. They said there had been a small explosion, and a piece of metal got into his hand and caused a laceration of his artery.

He was pouring blood, so I had to jump in immediately. I couldn’t allow him to just die in front of me. I compressed the artery and wrapped it in a bandage. But I didn’t know where the operating room was yet, so I asked, “Can you take me to the OR?” We rushed into the OR, and I borrowed some scrubs. They were too big for me, but I just put them on. It was an emergency. 

We finally got the artery and bleeding controlled. A major challenge now was how to reconstruct the artery; since I’d never worked here before, I didn’t know what instruments I had, what sutures. So it was a little challenging for me on the first day. But despite the stress and the tension, we composed ourselves, repaired the artery, and saved the life of this patient.

What does a typical day look like for you?

I start around 7:30 a.m. I’m already in the hospital and want to see patients. I begin by going to the ER to get a quick round of what happened overnight and see any patients who came during the night—those having abdominal pain or surgical emergencies that the ER staff have not identified.

Then I do ward rounds. Afterwards, on Mondays and Wednesdays, I go to the surgery clinic, where we see patients for consultations. New patients are first, then we have those who are pre-op, and lastly those who are post-op and coming for review. Tuesdays and Thursdays are mainly elective days.

By 4 p.m., we often start getting emergency cases. For some reason, patients often come later in the day or at night. You see the ambulance start dropping patients. We operate until maybe 9 or 10 p.m. on Tuesdays or Thursdays. Sometimes until 2 a.m., if it’s a particularly complicated patient.

On Fridays, I try to scale down and give some breathing space for the OR team to recover, because obstetrics has a lot of emergencies and cesarean sections on Thursdays.

J.J. Dossen Hospital campus in Harper, Liberia
PIH-supported J.J. Dossen Hospital serves 170,000 people in Maryland County, Liberia, as well as people from neighboring counties and countries. (Photo by Rebecca E. Rollins / PIH)

You have an impressive track record of ensuring safe surgeries at J.J. Dossen Hospital. To what do you attribute this success?

Our team is working hard to make sure our surgeries are safe. Sometimes I see the OR team, after I’m done with a case, sitting there and waiting with a patient. They become the recovery or ICU nurse, sitting there until the patient comes around, before they transfer the patient to a ward. This is making a lot of difference in reducing deaths.

I’ve seen our anesthetist stay with a patient until 2 a.m., sitting with him after a surgery that finished at 9 p.m., giving him fluids and making sure he has oxygen, until he was fully awake and transferred to the ward. Our team follows patients even when they’re on the ward, through phone calls and text messages. All of this is helping to ensure the patient has continuity of care. That is what is making the difference.

Surgery is a team sport. You have to rely on your anesthetist, your scrub technicians. You have to motivate your ward nurses. That is what we can say we are winning on. We’re getting more involved in the management of the patient. Team members begin to feel like it’s our patient. If the patient gets well, it’s our success—not the surgeon’s.

How do you maintain your optimism in the face of difficulties?

Touching and transforming people’s lives, and bringing high-quality health care to those who are truly in need, is a great thing.  Many times, all they can tell you is “thank you,” but that’s more than enough. My perspective on life, doing to others what I expect to be done to me, and my deep love for fellow humans all keep me optimistic, in the face of any difficulty.

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Tue, 27 Aug 2019 12:34:01 -0400 https://www.pih.org//article/qa-se-liberias-only-surgeon-describes-lifesaving-roles
Research: Haiti Training Program Propels Vital Emergency Care https://www.pih.org//article/research-haiti-training-program-propels-vital-emergency-care Haiti’s growing network of emergency doctors has its roots in an innovative program that pioneered emergency medical training in the Caribbean nation, paved the way for Haiti’s ongoing expansion of lifesaving critical care, and created a model for filling a severe gap in care found in developing countries around the world.

BMC’s International Journal of Emergency Medicine published results of the program in April 2018, in a study titled: “Addressing the Immediate Need for Emergency Providers in Resource-Limited Settings: the Model of a Six-Month Emergency Medicine Curriculum in Haiti.” The program addressed a well-known but hard-to-tackle problem: Short, quick trainings of a week or two helped meet immediate needs for some emergency and critical skills, but did not give doctors enough hands-on experience or expertise to manage the breadth of emergency care needs. Meanwhile, multi-year residency programs trained highly skilled specialists, but took too long to fill immediate demands and gaps in care. 

Haiti’s devastating 2010 earthquake, which killed nearly 300,000 people and injured hundreds of thousands more, made the dire need for emergency care in Haiti starkly clear.

Dr. Shada Rouhani, Partners In Health senior adviser for clinical operations, said she and colleagues in Haiti developed the six-month training program in the years immediately following that disaster, at a time “when there was no in-country emergency care capacity.”

The situation reflected chronic shortages of emergency care found in low-resource settings worldwide.

The 2018 study described the “tremendous need for improved emergency services in low- and middle-income countries, to reduce the burden of infectious diseases, non-communicable diseases, and injuries.” Citing numerous sources, including the World Health Organization, the study added that up to 90 percent of trauma-related deaths worldwide occur in low- and middle-income countries.

“Like all specialties, there are too few emergency care providers,” said Dr. Regan Marsh, director of clinical systems for Partners In Health. “In many ways, emergency care (still) is relatively new on the global health stage, in terms of importance.”

Dr. Cassandre Edmond, left, and Dr. Regan Marsh review an ultrasound in 2014
Dr. Cassandre Edmond (left), then an attending physician in the University Hospital emergency room, and Dr. Regan Marsh, then the hospital's co-director of emergency medicine, review an ultrasound for a patient who had been struck by a motorcycle in January 2014, about two months before Marsh and colleagues launched an emergency medicine training program that would galvanize care across the country. (Photo by Rebecca E. Rollins / PIH)

Rouhani and Marsh are two of the study’s co-authors, and worked together for several years as co-directors of the emergency department at Hôpital Universitaire de Mirebalais, or University Hospital, in Mirebalais, Haiti. Zanmi Lasante, as PIH is known in Haiti, opened the 300-bed teaching hospital in 2013, in partnership with Haiti’s Ministry of Health.

The training program was a national partnership, as well.

“This program was successful because it was done with the Ministry of Health and it was done within the national system,” Rouhani said. 

The study’s co-authors also include Dr. Fernet Leandre, former co-executive director and current chief of programs for PIH in Haiti, and Dr. Kerling Israel, former director of medical education at University Hospital.

Leandre said prior to 2014, medical professionals received basic training in emergency care at the Hospital of the State University of Haiti, in Port-au-Prince. Equipment and standard-of-care protocols were not up to date, creating challenges with handling medical emergencies across Haiti’s health system, from primary care to hospital levels.   

Leandre said that in the absence of strong systems, lifesaving equipment, and specialized staff, many emergency medical situations—such as road accidents or strokes—can become “a death sentence.”

He and his colleagues knew that a better emergency system began with better education.

The group developed and implemented a six-month emergency medicine training program, designed to provide substantive instruction and experience in an efficient timeframe to boost staffing for emergency care. Fourteen physicians from across Haiti joined the program, held from March to August 2014, and received classroom instruction as well as supervised clinical time.

Israel said Marsh and Rouhani’s experience working with local staff in emergency settings at University Hospital, and with the hospital’s medical education department, gave them a strong understanding of local context that was invaluable in designing the program’s curriculum, and ensuring it was relevant in Haiti.  

All 14 physicians completed the program successfully, the study notes.

“All improved from their pre-test to post-test. At the end of the program and nine-month post-program evaluations, participants rated the program highly, and most felt they used their new knowledge daily,” the study states.

Marsh said the majority of the program was spent on the job, as each participant had to spend 180 hours in University Hospital’s emergency department, working in conjunction with herself, Rouhani and other visiting faculty in emergency medicine.

“Everyone said that was a key component of the learning,” Marsh said.

Dr. Mirrielle Bien-Aime at University Hospital in 2013
Dr. Mirrielle Bien-Aime checks on a patient in University Hospital's emergency room in July 2013. The following year, she would complete the hospital's six-month emergency medicine training program, which combined classroom lessons with extended time in the ER. (Photo by Rebecca E. Rollins / PIH)

The program’s effectiveness continues to resonate today, as the six-month training paved the way for a three-year emergency medicine residency program at University Hospital. The program is thriving, and remains the only emergency medicine residency in Haiti.

“The six-month training was very important in the preparatory phase of the residency program,” Israel said. “It allowed leaders to anticipate specific needs and hurdles to overcome, and plan accordingly.”

Israel added that two family physicians who participated in the course were able to continue in-depth emergency medicine training, and have become key players in the residency program.  

The residency began in 2014 and graduated its first class in 2017. The latest group will graduate in coming weeks.

“We now have 12 fully fledged Haitian emergency docs—and we’re about to have 18,” Marsh said.

Marsh said the training program and residency have improved services and resources not only at University Hospital, but at health facilities across the country.

“The training program strengthened the first network of emergency medicine providers (in Haiti),” she said. “It’s a great success story.”

The program could lead to success stories in other countries, as well, as a model for filling vital gaps in emergency care. Rouhani, Marsh and others held an emergency medicine training with the PIH team in Liberia in May, for example, and will return in October for additional instruction.

“There is growing momentum at a number of our sites, and Haiti is a nice example of fulfilling the potential,” Rouhani said.

International awareness and recognition of the need for emergency care is growing, as well.

At a May session of the World Health Assembly, the decision-making body of the World Health Organization, attendees created a resolution that noted, “the lack of investment in frontline emergency care is compromising effectiveness, limiting impact and increasing cost in other parts of the health system.”

Additionally, the resolution called on all member states to, “create policies for sustainable funding, effective governance and universal access to safe, high-quality, needs-based emergency care for all, without regard to sociocultural factors.”

Outside the emergency department at University Hospital in Mirebalais, Haiti
The emergency department at University Hospital in Mirebalais, Haiti, has become a hub for emergency medicine training and resources that are improving services at health facilities across the Caribbean nation.  (Photo by Rebecca E. Rollins / PIH)

Rouhani said the lasting impacts of the Haiti training program—and the nationwide growth of emergency services—serve as a real example for others.

“The speed at which it has developed, the fact that it has become self-sustaining, and the fact that over the course of a short time you’ve seen huge impacts for patients, who are now receiving higher quality emergency care,” she said, listing positive results. “There are patients who are alive today who would not have been alive if these emergency care programs and systems hadn’t been there.”

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Tue, 27 Aug 2019 10:59:39 -0400 https://www.pih.org//article/research-haiti-training-program-propels-vital-emergency-care
Dr. Paul Farmer Talks Health Equity, Empathy with Bay Area NPR https://www.pih.org//article/dr-paul-farmer-talks-health-equity-empathy-bay-area-npr In a Bay Area NPR interview this week that ranged from Congo and Rwanda to Palo Alto, Harvard and Haiti, Dr. Paul Farmer focused strongly on a common thread that connected the diverse topics.  

“If you don’t have an equity agenda in mind….I think you’re looking at the wrong target,” Farmer, co-founder and chief strategist for Partners In Health, said to host Michael Krasny on KQED’s Forum radio show.

Farmer returned Tuesday to KQED and Forum, spending a full hour on the San Francisco NPR affiliate’s call-in news program. Farmer has appeared on the show previously in recent years, and he and Krasny enjoyed a familiar, friendly rapport as they discussed the ongoing Ebola outbreak in the Democratic Republic of the Congo, how to build trust and stronger health systems in communities where PIH works around the world, and how simple acts of empathy can improve health care equity for all.

Farmer had returned less than two days earlier from a visit with PIH teams in Rwanda. During his time there, Farmer spoke at the Aug. 11 graduation at the University of Global Health Equity, a PIH initiative in the country’s rural north; attended the opening of the nearby Cancer Support Center, which will provide housing and supports for patients in extended care at Butaro District Hospital; and met with health leaders helping Rwanda prepare for potential Ebola cases, should the deadly virus cross the border from neighboring Congo.

Farmer’s whirlwind schedule led Krasny to ask, in a lighter moment, if Farmer ever worried about burnout. Farmer joked that he’d be more worried if he had become a banker, or another profession outside of health care.

“I happen to have chosen a vocation,” Farmer said, referring to his leading role with PIH over more than three decades. “I find it very bracing and fun, so the chances of burnout are much lower.”

Farmer also took questions from listeners during the hourlong program, with people calling locally from around the Bay Area and from as far away as Toronto.

Listen to the full interview and conversation here.

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Fri, 23 Aug 2019 14:13:35 -0400 https://www.pih.org//article/dr-paul-farmer-talks-health-equity-empathy-bay-area-npr
Meet New CEO Dr. Sheila Davis: "Firefighter," HIV Advocate, and Nurse Poet https://www.pih.org//article/meet-new-ceo-dr-sheila-davis-firefighter-hiv-advocate-and-nurse-poet Dr. Sheila Davis knows about her reputation as a firefighter at Partners In Health. She led the organization’s Ebola response in West Africa from 2014 to 2016, then helped transition the teams to rebuilding the health systems in Liberia and Sierra Leone. She was the first one called to help the Haiti team when Hurricane Matthew wreaked havoc in Haiti in October 2016, and when flooding wiped away entire neighborhoods in Lima in the spring of 2017.

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

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

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

What drove you to become a nurse?

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

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

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

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

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

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

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

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

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

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

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

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

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

What attracted you to PIH’s work?

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

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

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

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

What are you most proud of having accomplished so far?

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

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

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

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

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

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

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

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

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

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

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

Tell us about your life outside of work.

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

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

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

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Mon, 12 Aug 2019 11:03:33 -0400 https://www.pih.org//article/meet-new-ceo-dr-sheila-davis-firefighter-hiv-advocate-and-nurse-poet
'We Get to Set the Tone': UGHE's First On-Campus Students Reflect on Landmark Year https://www.pih.org//article/we-get-set-tone-ughes-first-campus-students-reflect-landmark-year Nicole Jabo, 25, assessed the financial burden of type II diabetes on adult patients in her home country of Rwanda.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

One of many firsts for this year’s class.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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Fri, 09 Aug 2019 10:14:30 -0400 https://www.pih.org//article/we-get-set-tone-ughes-first-campus-students-reflect-landmark-year
NPR Highlights PIH Child Cancer Care in Rwanda https://www.pih.org//article/npr-highlights-pih-child-cancer-care-rwanda A recent piece in “Goats and Soda,” National Public Radio’s global health and development blog, shows how Partners In Health is leveraging strong collaborations to provide low-cost, lifesaving care for children with cancer in northern Rwanda.

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

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

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

Read the full NPR piece here.

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Tue, 06 Aug 2019 14:43:00 -0400 https://www.pih.org//article/npr-highlights-pih-child-cancer-care-rwanda
New Hepatitis B Clinic Launches in Sierra Leone https://www.pih.org//article/new-hepatitis-b-clinic-launches-sierra-leone Mariama Alieu was heavily pregnant when she was admitted in June to Koidu Government Hospital in eastern Sierra Leone. The 30-year-old mother of four said she’d suffered ill health for more than a year without receiving the correct diagnosis and felt like she would “always have the flu.

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

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

A new hepatitis B clinic

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

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

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

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

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

Screen, treat, monitor, repeat

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

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

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

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

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

Preventing transmission of hepatitis B

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

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

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

 

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Thu, 01 Aug 2019 10:58:06 -0400 https://www.pih.org//article/new-hepatitis-b-clinic-launches-sierra-leone
Research: Hepatitis C Trial Shows Strong Results in Rwanda https://www.pih.org//article/research-hepatitis-c-trial-shows-strong-results-rwanda A recently published study showed strong success for treating hepatitis C with new antiviral medicine in Rwanda, potentially creating a model for broader treatment plans across the region.

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

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

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

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

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

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

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

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

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

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

Personal stories emerged from the study.

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

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

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

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

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

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

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Fri, 26 Jul 2019 10:54:25 -0400 https://www.pih.org//article/research-hepatitis-c-trial-shows-strong-results-rwanda
Listen: Paul Farmer on podcast, "Why Am I Telling You This?" https://www.pih.org//article/listen-paul-farmer-podcast-why-am-i-telling-you Dr. Paul Farmer, Partners In Health co-founder and chief strategist, recently sat down with Chelsea Clinton for a full episode of the Clinton Foundation’s new podcast, “Why Am I Telling You This?” Clinton has followed Farmer's work for 20 years, since she was a student at Stanford University, and sits on PIH's Board of Trustees. 

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

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

Listen to the full podcast episode, here.

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Thu, 25 Jul 2019 13:01:55 -0400 https://www.pih.org//article/listen-paul-farmer-podcast-why-am-i-telling-you
Goats, Gardens, and Business Training Empower Mother in Neno https://www.pih.org//article/goats-gardens-and-business-training-empower-mother-neno On most days, Dalitso Mkango is busy selling her vegetables in the market in the central village of Neno District, Malawi. And if she’s not selling her produce, then she’s at home working in her gardens. Rumor has it that she has some of the best produce around—likely because of the fertilizer she uses, a homemade mixture of manure from the goats she cares for at her home. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

When asked about Mkango, POSER officer Edwin Kambanga smiled.

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

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

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

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

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Thu, 25 Jul 2019 09:01:54 -0400 https://www.pih.org//article/goats-gardens-and-business-training-empower-mother-neno