Partners In Health Articleshttps://www.pih.orgFlorida Migrant Workers Among Hardest Hit by COVID-19

Migrant workers in Immokalee, Fla., not only endure long shifts, intense heat, and low pay—they face increased risk of COVID-19 due to systemic inequities.

Immokalee, a rural community of around 25,000 in Collier County, has emerged as a hotspot in southern Florida’s outbreak, which has worsened statewide following its reopening. Migrant workers make up the majority of Immokalee’s population and are especially at-risk for COVID-19 due to systemic inequities, ranging from occupational exposure to overcrowded living conditions.

Driven by the belief that health care is a human right, Partners In Health is collaborating with the Florida Department of Public Health in Collier County and community organizations to establish a community health worker program.

In mid-July, PIH trained Immokalee residents—the people who know their community best—to serve as health promoters, spreading vital health information and powering the fight against COVID-19.

This work comes as part of PIH’s U.S. Public Health Accompaniment Unit, a growing effort to stop COVID-19 across the United States, from Pima County Ariz., to Newark, N.J. Through this initiative, PIH offers states, counties, cities and community organizations technical expertise learned from decades of fighting infectious diseases around the world, including tuberculosis in Peru, cholera in Haiti, and Ebola in Liberia.

The initiative grew out of the Massachusetts Community Tracing Collaborative—PIH’s contact tracing effort in partnership with the State of Massachusetts and local boards of health. Beyond advisory services, the initiative also includes a Learning Collaborative, which serves as an open-source library and educational hub on everything from how to establish contact tracing to monitoring and evaluation.

Essential Workers

Immokalee’s harvest season typically runs from October through May, though some migrant workers live there year-round. Crops harvested include tomatoes, strawberries, and watermelon.

Months after the majority of migrant workers left for seasonal work in the North, the community has emerged as a hotspot for COVID-19. In early June, 611 people in the community had tested positive, according to state data. By late July, that number had surged to more than 2,000.

Migrant workers typically fill jobs for which U.S. employers often struggle to recruit Americans, such as seasonal agricultural work. “Immokalee is one of the most vulnerable and poor communities in all of Florida,” says Matt Hing, who is helping lead PIH’s work in the area. “Most of the people in this community are essential workers; if they don't work directly in the tomato picking, they work in construction, the service industry, or as landscapers for residents in Naples,” a nearby city and one of the wealthiest in the U.S.

The majority of Immokalee’s migrant workers come from Latin America—specifically Haiti, Guatemala, and Mexico. Some are guest workers on temporary visas, some are U.S. citizens and residents, while others are undocumented immigrants.

Hing previously worked with PIH in Chiapas, Mexico, where he saw firsthand the poverty and systemic injustice that prompted people to migrate to places like Immokalee, in search of work.

“There are global forces that determine who is poor, who is sick, and who is not,” he says. “So, in many ways, this is the same community we've always served.”

You Have To Go Door-To-Door

In Immokalee, PIH has focused on two goals so far: help develop the county’s community health worker program and assist community groups offering social support.

"It’s not enough to just do health messaging,” says Hing. “You have to go door-to-door and have that person-to-person contact and also address the social determinants – housing conditions, labor protections, financial precarity, documentation status – that enable someone to quarantine, self-isolate, or not."

As essential workers, migrant workers face systemic inequities on and off the clock that put them at increased risk for COVID-19.

Social distancing, for example, is nearly impossible for migrant workers who live in cramped trailers and apartments, travel shoulder-to-shoulder on crowded buses to get to and from work, and work closely in the fields. And personal protective equipment is far from a guarantee. Although some agricultural employers provide handwashing stations and masks, others do not; at least one has called COVID-19 a hoax.

When a farm worker, one of their family members, or one of their roommates falls sick, workers face systemic barriers that make quarantine and isolation challenging, if not impossible. Beyond the logistical nightmare of self-isolating in a trailer shared with five people, missing work for two weeks could drain finances and force a choice between rent or food, if adequate sick pay is not provided. And many migrant workers don’t know where to go for help or what resources are available near them.

In response, PIH has partnered with the county to develop and launch a community health worker program, hiring and training 10 Immokalee residents to share basic health information and social support resources. These health promoters come from within the community and speak Spanish and Creole.

Community health promoters sit around a table holding informational flyers about COVID-19.
Health promoters in Immokalee help connect people with health information about COVID-19 and social support in the community.

“The team's knowledge of the culture, languages, and residents of their hometown empowers the community to protect their health,” says Reggie Wilson, Healthy Communities Program Consultant with the Florida Department of Health in Collier County. “Bringing health with a personal touch to people at home makes messaging more accessible than ever.”

Insights gained from these one-on-one conversations feed back into the county’s strategy for how best to tackle the local outbreak.

Residents have the opportunity to ask questions and share their concerns with someone they trust,” says Mark Lemke, Health Center Administrator with the Florida Department of Health in Collier County. “They appreciate someone taking the time to help them understand how they can best protect themselves and their family.”

Joashilia Jeanmarie, an Immokalee resident and student at the University of Florida, chose to become a health promoter to help her community, which, despite its cultural diversity, resilience, and resourcefulness, she says, has been hit particularly hard by COVID-19.

“Without the ability to work from home or socially distance on the job, many of our agricultural, industrial, and construction workers have become vulnerable populations for COVID-19,” says Jeanmarie. “By going out in the communities that were hit the hardest, our health promotion team strives to alleviate this issue.”

Social Support

The team not only shares health information, such as about coronavirus symptoms and testing site locations, but also resources about social support, such as rental assistance. To do so, PIH collaborates with community organizations such as Misión Peniel and the Coalition of Immokalee Workers (CIW), which have worked in Immokalee for years and helped design creative and culturally appropriate public education materials, assemble and distribute essential PPE, and build crucial public support for key public health interventions, including mass testing, in the farm worker community.

“Having PIH join us in Immokalee has been absolutely invaluable,” said Gerardo Reyes Chavez of the CIW.  “From the very start of the pandemic, we have been sounding the alarm about the crowded and substandard housing and working conditions that would serve as a superconductor for the spread of the coronavirus here in Immokalee and in similar farm worker communities throughout Florida, but it was always an uphill battle to convince state and local authorities to take action because we are not a health organization. Having PIH lend its voice, expertise, and resources to that effort definitely opened doors that were far too hard for us to open alone.”

As health promoters go door-to-door, building trust is key. Importantly, they do not ask about immigration status.

Undocumented workers are often reluctant to use COVID-19 health services due to fears of deportation. These concerns come in spite of the health department’s assurances that it is not asking about citizenship or immigration status.

Health promoters also make sure to connect people with a host of resources that do not take immigration status into account.

Informational flyers about COVID-19 and social support resources available for people in Immokalee.
Health promoters speak Creole, Spanish and English; informational materials are available in all three languages as well.

The harvest ended in May and many migrant workers have left for work elsewhere. But PIH remains on alert, helping migrant workers who stayed behind and preparing for a potential surge of cases in the coming months, when thousands of workers return en masse from northern states, such as Georgia, North and South Carolina, Virginia, and New Jersey – some of which are also experiencing a spike in COVID-19 cases – for the winter growing season.

For health promoters like Jeanmarie, the work has only just begun.

I think the best part of my job so far has been listening to the experiences, concerns, and frustrations of the people I visit,” she says. “I think it’s important that these voices are heard."

COVID-19 Observation Center Ensuring Safety, Reducing Stigma in Liberia

Robert-Lee Dahn’s successful stay in a precautionary observation center for COVID-19 in Maryland County, Liberia, has enabled him to safely reunite with his family, rejoin his community, and improve local perceptions about quarantining during the pandemic.

Dahn, 43, is a regular volunteer in the non-communicable disease clinic at J.J. Dossen Hospital in Maryland County, in Liberia's south. Partners In Health supports J.J. Dossen, which provides comprehensive health services in collaboration with the national government and the Maryland County Health Team.

Dahn found himself receiving care rather than providing it, though, after a potential brush with COVID-19 this spring. A nursing student, Dahn was selected earlier this year for a three-month internship at Jackson F. Doe Memorial Regional Referral Hospital, in central Liberia.

On the last day of his internship, in April, a patient at Jackson F. Doe died of COVID-19. As a potential contact of the patient, the tragic loss bore implications for not only Dahn’s health, but also his ability to return home.  

A precautionary observation center made that return possible.

Opening of COVID-19 observation center in Harper, Liberia
Dr. Methodius George, government health officer for Maryland County, Liberia, addresses clinicians during the opening of a PIH-supported COVID-19 observation center in Harper, Liberia, in April. (Amy McLaughlin / PIH)

PIH worked with Liberia’s Ministry of Health, National Public Health Institute, and the county health team to set up the observation center in April. The 26-bed center is in a renovated school building in the coastal city of Harper, and supports the government’s COVID-19 response across Maryland County.

The center accommodates people who have traveled from high-risk areas, may have contacted someone with COVID-19, or who exhibit symptoms such as a cough, fever, sore throat, or difficulty breathing.

When Dahn arrived at the center, staff taught him how to follow the facility’s extensive safety protocols and receive the support he needed while in quarantine.

“The clinical team and psychosocial team were very friendly and provided counselling support, with so much care and attention,” Dahn said. “We also received three meals a day, safe drinking water, toiletries, and other supplies.”

Dahn said when he first learned he’d need to stay at the center in quarantine, he was nervous—but counselors assured him it was a precautionary measure, to protect himself and others.

After 14 days at the observation center, Dahn did not show any signs of infection. His successful stay meant that after traveling back to Harper from a high-risk area and an internship at a hospital with COVID-19 patients, he could safely return home and reunite with his family.

“My isolation sent a clear message out there that being quarantined is not a death sentence, but instead, a precautionary measure for the safety of yourself, your family members and the community,” he said.

Dahn now is heathy and has continued his volunteer work at J.J. Dossen, caring for patients in the non-communicable disease clinic.

“I was well-received by my family and friends. My community has embraced and accepted me with open arms, without any form of stigmatization,” he said. “Everyone expressed delight that I was finally out and released from quarantine. I also feel that I have sent a positive message to the public about the need to be quarantined, without any fears or anxiety, when necessary.”

COVID-19 Disproportionately Impacts Immigrants in Massachusetts

When a Cape Verdean family in Boston was diagnosed with COVID-19, the virus presented more than a health issue. They needed baby formula for their newborn, but could not leave the house due to the isolation period. And as recent immigrants, they had no relatives or social network in the area to support them. They needed help if they were to recover and ensure their baby remained in good health.

Theirs is just one of many cases where the Massachusetts Community Tracing Collaborative (CTC) was able to intervene with social support for immigrants, in this case connecting the family with formula and checking in with them throughout the quarantine period. Launched in April by Gov. Charlie Baker, the CTC is a statewide contact tracing initiative made possible through a partnership among several state bodies, local boards of health, and Partners In Health, which has decades of global experience responding to infectious disease outbreaks.

“It’s really, really critical that when any contact tracing initiative gets launched, to think about particularly vulnerable groups,” says Oscar Baez, a care resource coordinator with the CTC. “It’s been very clear nationwide that this pandemic has laid bare preexisting systemic inequalities.”

COVID-19 has underscored longstanding health disparities rooted in systemic racism. Black, Hispanic, and Native American communities nationwide have been disproportionately infected and killed by the virus due to risk factors (such as a higher burden of chronic health conditions or inconsistent access to health care) caused by decades of racist policies threaded into the fabric of society, from housing and employment to education and health care.

The hardest hit areas are home to not only historically marginalized communities of color but also to immigrant communities who face unique systemic barriers to care.

Grounded in the principle that health care is a human right, PIH and its CTC partners accompany immigrants as they navigate the daily realities of a pandemic that discriminates as much as it devastates.

‘A Perfect Storm’

In Massachusetts, the data reflect a national trend; COVID-19 disproportionately impacts communities of color. Hispanic residents account for 12 percent of the state’s population, but nearly 30 percent of COVID-19 cases; similarly, Black residents make up about 9 percent of the population, but 14.4 percent of cases.

“Even in a state like Massachusetts and a city like Boston, where we have premier academic and medical institutions, a thriving biotech hub, we haven’t achieved health equity across race and ethnicity,” says Baez. “That is applicable across the United States.”

Massachusetts’ hardest hit communities are home to large immigrant populations, such as Chelsea, Lynn and Lawrence. Chelsea, a predominantly Hispanic city where immigrants form nearly half of the population, has the highest positivity rate in the state.

Massachusetts' hardest hit cities are home to historically marginalized communities of color as well as immigrants.

Before COVID-19, immigrants in these marginalized communities already had to navigate a host of systemic barriers in their day-to-day lives, including low-wage work, language barriers and, for undocumented immigrants, the looming threat of deportation.

When the pandemic hit, these social and economic preexisting conditions created “a perfect storm for vulnerability,” says Baez.

The vast majority of immigrants in the workforce are essential workers who cannot perform their job from home. They face increased risk not only at work—where they often lack adequate personal protective equipment—but also on the commute, which typically involves public transit.

For those who live paycheck-to-paycheck, lack well-resourced social networks, and receive few, if any, welfare benefits, a COVID-19 diagnosis—and instructions to quarantine for 14 days—presents far more than a health issue.

“The virus itself can be life or death,” says Baez. “But for many people, quarantine and isolation can be life or death if they have no other kinds of social support.”

When asked to quarantine, many immigrants face a daunting choice—whether to put the little money they have toward rent or food. And for those who share overcrowded apartments with extended family, due to poverty, quarantine is a nearly impossible ask in itself.

The CTC aims to address these challenges with equity-based social support. Care resource coordinators like Baez have connected people with resources ranging from rental assistance to meal deliveries to cleaning products.

The CTC’s Immigration Working Group recently supported an immigrant released from detention who tested positive for COVID-19. They helped the man find housing where he could safely isolate, as well as health insurance and prescription medications.

The CTC has also connected immigrants with mental health support, as many have experienced depression, anxiety, and panic attacks following their diagnosis.

The team helped an undocumented woman, who was a survivor of domestic violence and had struggled with suicidal thoughts in the past, connect with a Spanish-speaking mental health specialist.

Community Accompaniment

As devastating as COVID-19 has been, many immigrants have seen hardship before, from being dislocated from their country of origin due to social-structural violence to the current punitive immigration policies and practices in the United States, particularly for undocumented immigrants from Latin America.

“When we talk about immigrants, we tend to think about victims. They are survivors rather than victims,” says Humberto Reynoso, a care resource coordinator. “They confront the hardships in both their country of origin and the US.”

With each call, Reynoso aims to provide a listening ear and connect people with culturally relevant resources.

PIH approaches contact tracing as a form of accompaniment, similar to how community health workers around the globe support patients in need. To that end, the CTC trains contact tracers to take immigration considerations into account in every interaction—specifically, legal, linguistic, financial, and digital barriers.

Language has been essential to providing that accompaniment. Nearly 40 percent of households in Boston speak a language other than English at home. In Chelsea, that number jumps to 70 percent.

The CTC works with translators and multilingual staff to converse with immigrants in the language they are most comfortable speaking. Baez—who speaks multiple languages—estimates that 90 percent of his phone calls are conducted in a language other than English, mostly in Spanish and Portuguese.

The CTC also partners with local organizations with deep ties to the communities, building trust and finding relevant solutions, such as culturally appropriate foods at a food bank.

For many CTC staff, the work hits close to home.

Berlyn Olibrice, a care resource coordinator originally from Haiti, has worked on several cases in the state’s Haitian American community and has seen people hesitate to get help due to the stigma surrounding coronavirus.

“In my role, I try to navigate that with people and tell them, ‘It’s okay to seek help within your own community,’” says Olibrice, who speaks Haitian Creole and Spanish. “We are not going to judge you because you have this virus. Local organizations are there to support you.”

Baez, too, brings first-hand expertise to his work, having immigrated to the U.S. from the Dominican Republic as a child. He once handled a call that came from a public housing building across the street from where he grew up. The caller had tested positive for COVID-19 at the same community health center where he went for physicals as a child.

Black and Hispanic residents in Massachusetts have been disproportionately impacted by COVID-19.

Building Trust

While the CTC’s work spans Massachusetts, it has focused its efforts where the virus has done the most damage and where it is most urgent to track the disease and stop the spread; these areas have disproportionately included immigrant communities.

Contact tracing is an entirely confidential process and participation is voluntary. Contact tracers do not ask about immigration status. No information is disclosed to the public or shared with other government agencies, including law enforcement. However, misinformation about the process has led to privacy concerns.

These concerns are especially heightened in immigrant communities, where undocumented immigrants live with the constant threat of deportation and those with green cards fear losing access to public benefits.

As a result, many immigrants are reluctant to pick up the phone when an unfamiliar caller ID appears, much less divulge personal information such as their contacts.

To address these concerns, contact tracers assure patients—sometimes, with the help of a translator—that all information is confidential and migration status will not be shared with anyone.

The CTC has also launched awareness campaigns, creating flyers and online resources in several languages to educate the public about contact tracing and dispel common myths. Additionally, it has partnered with local community organizations, health centers, and city councils to host virtual town halls in various languages, including Spanish.

“Trust is our greatest currency in this fight,” says Baez. “We really need trust, even in environments of fear, to get through this together.

Research: Adolescents In Peru Face Barriers to HIV Treatment Adherence

Globally, AIDS-related deaths among teens are on the rise, even as fewer adults and children are dying of the disease, despite monumental advances in treatment and research over the past decade.

UNAIDS estimates that 1.8 million adolescents worldwide are living with HIV. In Latin America and the Caribbean, as many as 74,000 adolescents live with the disease.

Although antiretrovirals are widely available, young people living with HIV face several barriers to treatment adherence. The issue is especially potent in North and South America—a recent meta-analysis of data from 53 countries found that the lowest treatment adherence among adolescents living with HIV occurred in the Americas.

Why are so many adolescents struggling to follow their treatment? And how can the barriers they face be addressed? A team of PIH researchers based in Lima and Boston set out to investigate just that in a study, “Barriers and facilitators to antiretroviral therapy adherence among Peruvian adolescents living with HIV: A qualitative study,” published in the medical journal PLOS ONE.

“People worldwide have a lot of concern for children with HIV, but few wonder what happens to these children once they grow up and become adolescents,” says Milagros Wong, RN, a co-author of the study and Project Manager at Socios En Salud, as Partners In Health (PIH) is known in Peru.

Understanding The Barriers 

In Peru, around 79,000 adults and children live with HIV, according to UNAIDS. Free antiretroviral therapy was only made available in 2004. As a result, adolescents living with HIV now are among the first generation to reach adulthood.

PIH researchers collected data through a series of support groups with 18 adolescents living with HIV – all receiving care at an urban hospital in Lima, Peru – and in-depth interviews with their families, caregivers and health care workers.

What they found was unsettling but not surprising: young people living with HIV faced barriers to treatment adherence at the individual, family or caregiver, and structural levels. Among the factors that interfered with treatment were life-stage and emotional issues, negative side effects from therapy, a lack of information about HIV, and a lack of economic resources.

For example, young people struggling to form their identity and navigate relationships sometimes choose to hide their HIV status—even if it means skipping treatment.

“HIV is highly stigmatized,” says Dr. Molly Franke, co-author of the study, Harvard Medical School epidemiologist, and longtime collaborator with PIH in Peru. “So a lot of the adolescents haven’t necessarily disclosed outside of their immediate family. In order to keep their diagnosis private, they may not take their medication when they are out with friends or with a boyfriend or girlfriend, out of fear of disclosure and rejection.”

PIH researchers also found that complicated family relationships or lack of familial support can make staying on treatment feel like an uphill battle for adolescents.

Add systemic barriers to the mix and it becomes even more clear how treatment adherence can be especially difficult for adolescents. Sometimes there are complications in health insurance registration, delays in accessing care, or a complicated and bureaucratic transition from pediatric to adult care. A routine HIV care visit, for example, can last an entire morning, preventing parents from going to work and creating financial difficulties for families living on the margins.

All of this overlays challenges that some adolescents living with HIV already face, as the HIV epidemic disproportionately impacts the LGBTQ+ community. Wong recalls hearing from a transgender patient who hesitated to participate in the research due to fears of rejection.

“The needs are pretty multi-factorial, and I think that was a major lesson for us,” says Franke. “We knew the needs were going to be complex to a certain degree, but I think we underestimated them.”

Finding Solutions

The study highlights the need for interventions that consider not only the individual but also their environment—from their families and caregivers, to the health system. And it has since paved the way for the team to investigate potential solutions, including an ongoing intervention funded by the National Institutes of Health.

Called The PASEO Project, the intervention aims to provide social and medical support to adolescents living with HIV who are especially at-risk for non-adherence to treatment. Guided by the model of accompaniment – a key pillar to PIH’s work around the world – the intervention involves training entry-level health workers and lay workers to help adolescents navigate a complex health system, serving as their liaisons with formal health services.

The PASEO Project draws upon PIH’s 20-year history of working in Peru, specifically its long-running, community-based accompaniment and social support programs for patients with HIV and tuberculosis. The intervention seeks to help adolescents bridge the transition from pediatric to adult care and to address the social and economic conditions that prevent them from adhering to treatment.

The work is ongoing, but the takeaway is clear: no adolescent living with HIV should die from AIDS when treatment is accessible and when support can be made available.

As COVID-19 Cases Mount in Peru, Medical and Social Support Are Key

From mobile clinics to chatbots, Partners In Health is bringing technologies old and new to the fight against COVID-19 in Peru – one of the hardest hit countries in South America, despite its early success in curtailing the virus.

Known locally as Socios En Salud, PIH has focused its work in Lima and Carabayllo, a poor neighborhood stretched along the northern hills of the capital. For decades, PIH has strengthened these local health systems in partnership with Peru’s Ministry of Health, focusing on infectious diseases, community health, and mental health.

PIH’s systems strengthening over the years has paved the way for a quick and comprehensive response to COVID-19, even as the country scrambles for resources to stave off a stubborn pandemic and an alarming surge of cases. Since March, PIH has steadily fought COVID-19 and expanded its work through support from the United States Agency for International Development in Peru.

The country has seen more than 288,477 cases and more than 9,860 deaths since March, according to Reuters. PIH has conducted contact tracing for more than 41,000 people, tested 12,000 people, and donated 30,000 tests to Peru’s Ministry of Health—all of which helped identify North and East Lima as hotspots. PIH has also expanded beyond its typical reach in the North to fight COVID-19 in additional regions of Peru.

Rapid Response: Testing, Tracing, and Stopping the Spread

Daniela Puma spends her days knocking on doors in some of the most remote neighborhoods in North and East Lima. As supervisor of PIH’s Rapid Response Team, she leads a group of nurses and community health workers on the frontlines of PIH’s COVID-19 response in Peru. They go door-to-door in communities where COVID-19 cases have been identified and offer free screening and testing. She estimates her team runs about 120 tests per day.

If a person tests positive, the team asks them to quarantine for two weeks and educates them about the disease.

"We try to do education on washing hands, but there are many people who don't have water in the house,” says Puma. “It’s very difficult to do the work."

To address this concern, PIH provides families with a hygiene package, including hand sanitizer, bleach, and face masks. Puma’s team also connects patients in quarantine with social support, including money for food. Social support is especially crucial in Carabayllo, a district where extended families often squeeze into small apartments, making isolation nearly impossible. In response, PIH has rented rooms in nearby hotels for individuals who need to isolate and provided more than 366 families with social support since the start of the pandemic.

As cases are confirmed, Puma and her team begin the process of contact tracing. They ask for the name and information of anyone they’ve been in touch with over the past two weeks, and reach out to inform those individuals that they’ve been exposed to the virus. Then they test the patient’s contacts and track the spread of the virus.

The team mainly works in residential neighborhoods but has also looked for the virus in crowded areas, such as bus depots, food markets, and hostels.

People are often willing to take a test when offered one, Puma says, even when approached on the street. As the pandemic’s toll has mounted, testing – once stigmatized – has become a new normal.

Socios En Salud goes door-to-door in communities where COVID-19 cases have been identified and offer free screening and testing.
Socios En Salud goes door-to-door in communities where COVID-19 cases have been identified and offers free screening and testing.

A Moving Target

Despite its early successes in curbing the virus, Peru has been one of the hardest hit countries in South America.

Systemic inequalities have fueled the disease’s spread, says Dr. Marco Tovar, medical director of PIH in Peru. The virus is often initially spread by travelers who visit Peru and bring the disease with them. A large part of the PIH team’s initial response was focused on screening passengers arriving at the Jorge Chávez International Airport in Lima. The virus is then transmitted by workers who cannot afford to stay at home and commute to work in the city, especially from Carabayllo.

As the Rapid Response Team tracks cases at the community level, Tovar works to mobilize resources in Peru’s health system and tackle the systemic issues that have made the virus especially deadly for Peru’s most vulnerable communities, supporting hospitals across the country.

In hospitals, the situation is especially harrowing, as long lines form outside of facilities running low on beds and oxygen. PIH is supporting facilities in need by delivering personal protective equipment and oxygen across multiples regions in Peru.

Realizing this gap, Tovar and his team are working hard to find innovative ways to help more people in need of hospitalization. Meanwhile, they are closely watching the virus. Even as Lima has shown signs of improvement in recent weeks, the disease has spread to other regions of the country, creating new hotspots. And plans to reopen Peru’s economy have sparked concern.

"Now the economic activities are beginning again, you now have more people on the streets,” he says. “We are preparing our response in case we have a new wave of the disease.”

Technology and Innovation

In the fight against COVID-19, PIH has drawn from past lessons in fighting infectious diseases in Peru, specifically the multidrug-resistant tuberculosis epidemic of the 1990s. Again, PIH has turned to the old standbys of contact tracing and testing, but also employed technological innovation.

For example, mobile clinics – a staple of PIH’s TB program – have been revamped to respond to COVID-19 as well as tuberculosis, screening for both diseases simultaneously and helping health care workers reach even the most remote neighborhoods.  

Socios En Salud is screening for COVID-19 and tuberculosis simultaneously, with the help of mobile clinics from its tuberculosis work.
Socios En Salud is using mobile clinics - key to its tuberculosis work - in the fight against COVID-19, screening for both diseases simultaneously.

And as COVID-19 cases have mounted, PIH and government partners have turned to another innovative approach—a mobile molecular testing lab. Molecular tests are crucial for diagnosing COVID-19 and stopping the spread. Unlike antibody or antigen tests, they detect the virus’s genetic material and have a high level of accuracy. But despite the demand for molecular tests, Peru lacks enough labs to process them.

PIH’s lab in Carabayllo can process 100 tests per day. But with thousands of new cases emerging daily, more capacity is needed. So PIH teamed with Peru’s Ministry of Health to launch a new mobile molecular testing lab, a truck with lab technicians and equipment, that provides a way to scale up testing capacity and provide faster, more accurate results. The lab can process as many as 500 to 600 tests per day, according to Peru’s National Institute of Health.

Innovation in PIH’s COVID-19 response extends to mental health as well, through the creation of a phone app.

For years, PIH’s mental health program has helped patients with conditions ranging from anxiety to schizophrenia through innovative programming and resources. Now, as the death toll from COVID-19 rises, mental health has become even more critical, as Peruvians grapple with the loss of loved ones and the daily realities of a pandemic with virtually no end in sight.

To meet the demand for mental health resources, PIH has created an innovative new tool—the ChatBot App. The chatbot asks a set of mental health screening questions and notifies a team of 95 PIH- and government-employed psychologists about people with mental health conditions so they can follow up with a phone call and additional support. Of the 473 people who responded to the app in May, 76% were in need of mental health support.

The chatbot can communicate in Spanish and Quechua, an indigenous language spoken by around 13 percent of Peruvians. Most Peruvians who lack access to health services – around 60 percent – speak Quechua, according to a 2014 World Bank study.

Tovar hopes that technological innovations like this can help address systemic barriers that have prevented marginalized groups from receiving care.

PIH’s decades of work in Lima and Carabayllo have laid the groundwork for and ensured trust in its COVID-19 response, pointing to the value of strengthening health systems.

“Here, in the north of Lima, we know the leaders of that community,” says Puma. “If you say ‘Socios En Salud,’ people in the community know about Socios. I think it is an advantage that Socios has been here as an institution for many years.”

Statement on U.S. Withdrawal from WHO

Partners In Health joins the chorus of public health and human rights groups opposing the decision of the Trump administration to terminate its relationship with the World Health Organization (WHO) in the strongest terms possible. The irresponsible decision to withdraw funding to the WHO will have disastrous consequences, both weakening the collective global response to COVID-19 in the midst of an unprecedented pandemic and causing further unnecessary death and suffering by undermining other critical areas of the WHO’s five-year program of work. Withdrawing its membership from the WHO will serve to erode the U.S.’s global credibility and influence.

Never has it been more urgent to ensure the WHO is fully resourced to lead this global pandemic response. The indispensable work of the WHO in the COVID-19 response is in the interest of all Americans, just as it is in the world’s interest. This decision arrives after May’s World Health Assembly, one of the most important in the 73-year history of the WHO, in which all 194 member states voted to promote an equity agenda supporting access to diagnostics, treatment, personal protective equipment for health workers, and an eventual vaccine in the global pursuit to contain COVID-19. This is vital work, which PIH supports and advocates for on the international stage.

Call on Congress

We call on the United States Congress to take bipartisan action to ensure appropriations for contributions to WHO remain, and to fully consider the devastating consequences of this decision. Effective global coordination and capacity to prevent, mitigate and respond to health crises, including infectious disease outbreaks, requires a strong WHO.

"This is, above all, a human crisis that calls for solidarity."

As Secretary-General António Guterres has said, "This is, above all, a human crisis that calls for solidarity." Now more than ever, we need global solidarity and collaboration to contain the spread of COVID-19 and ensure that the most marginalized and vulnerable receive preferential access to these collective global goods.

Sierra Leone Ebola Lessons Shaping Massachusetts COVID-19 Response

While home to some of the best hospitals and medical schools in the U.S., Massachusetts was one of the hardest-hit U.S. states early in the COVID-19 pandemic. In looking to stop the virus’ spread, state leaders turned to world experts—and found significant help from Sierra Leone.

Seeing how the West African nation and its Ebola response in 2014-16 are informing Massachusetts’ response to COVID-19 requires a step back, to early this spring.

As Massachusetts became one of the first states hit by COVID-19, the rapid spread of the virus presented an enormous challenge for the state’s world-class Department of Public Health. Recognizing the gap in Massachusetts’ prevention strategy—with 20 percent of cases requiring hospitalization, but the other 80 percent spreading in communities—Gov. Charlie Baker announced that the state would join with Partners In Health, drawing on PIH’s decades of experience fighting Ebola and other outbreaks. To stop community-based transmission, the state and PIH established the Massachusetts Community Tracing Collaborative (CTC)—the first large-scale coronavirus contact tracing program in the U.S.

Gov. Charlie Baker and Dr. Joia Mukherjee at the State House
Dr. Joia Mukherjee, chief medical officer for PIH, speaks at the April 3 launch of the Massachusetts Community Tracing Collaborative, while Gov. Charlie Baker looks on, at the State House in Boston. (Joshua Qualls / Governor's Press Office)

Following an April 3 launch at the State House, PIH would rapidly hire and train more than 1,500 people, to support the state and its 351 local health departments in a broad scaling-up of case investigation and contact tracing. New CTC staff members began calling everyone who had tested positive for the virus, gathering details about people with whom they had been in close contact, and then calling those contacts to ensure they knew about their exposure and could quarantine safely.

The partnership between PIH, the Commonwealth, and local health departments introduced many Americans to contact tracing, a tried-and-true practice for public health practitioners. For PIH, contact tracing is foundational to placing equity at the center of an epidemic response, by ensuring that people who cannot quarantine safely get the material support to do so, and by directly engaging the community in response efforts.

Lessons from Sierra Leone became vital as PIH, the state, and local health departments worked to scale and launch the Massachusetts collaborative. Sierra Leone’s use of compassionate, community-based contact tracing to halt history’s worst Ebola outbreak has provided inspiration for Massachusetts’ COVID-19 efforts—and, now, for efforts by a growing list of other U.S. states and jurisdictions.

“We looked at our notes and were specifically referencing Sierra Leone,” said Dr. Joia Mukherjee, PIH’s chief medical officer and a leader of the organization’s U.S. COVID-19 response. “Contact tracing is something that allowed Sierra Leone to do well in the fight against Ebola. We need to take those lessons about tracing every contact and to think of strategies that will allow the most vulnerable to survive, while also enacting other public health measures.”

At the April announcement with Gov. Baker, Mukherjee talked about Tonkolili, a remote Sierra Leone district that was home to the country’s last person infected with Ebola. She recalled how teams checked every single person who entered the district.  

“Everyone would get out of the car, be screened, temperature written down, cell phone numbers recorded. Every single contact was traced,” she said. “If they can do this in a place like Tonkolili, how can we say it is too late in the Commonwealth?

“You cannot do control of infection without social support, solidarity, and protection for the vulnerable. Those public health principles we've all learned together in places like Sierra Leone should be at the forefront today,” Mukherjee continued. “That model going from, as we say, Tonkolili to Tewksbury [Massachusetts].”

PIH staff visit the home of Ebola survivors in Sierra Leone, in 2014
PIH staff visit a home of Ebola survivors in Freetown, Sierra Leone, in 2014, as part of contact tracing efforts to provide social support and make sure the people are remaining safe and healthy. (Rebecca Rollins / PIH)

Contact Tracing During Ebola 

Contact tracing proved essential to ending the historic Ebola outbreak that killed thousands of people in West Africa from 2014 to 2016.

“It was very helpful,” said Gbessay Safa, Sierra Leone’s national coordinator for contact tracing. “We were able to contact every person who’d come into contact with a probable or confirmed case [of Ebola], and follow up with them for 21 days. That prevented the spread of the disease in many ways, and prevented new hot spots.”

The country’s Ebola contact tracing program relied on a force of 2,250 community contact tracers, working alongside community health workers. Their joint efforts aimed to not only identify cases and notify contacts of their exposure, but also ensure people’s ability to safely, comfortably quarantine—a tricky endeavor throughout Sierra Leone, where a majority of families living on the margins can’t afford to lose a day, let alone two weeks, of work outside the home.

 “In Kono and Port Loko, PIH used community health workers to go to homes to actually see and understand the real needs of families,” said Dr. Bailor Barrie, who helped design Sierra Leone’s national contact tracing program and is currently a strategic advisor for PIH-Sierra Leone.

Meals were a top priority among quarantining households; PIH partnered with other organizations focused on hunger prevention to advocate for families’ needs.

“In Kono, we had a family whose breadwinner got Ebola and was taken to a treatment center,” Barrie recalled. “It was painful for them; his wife and four kids had no other means. But our community health worker flagged that, and we helped a partner organization distribute their food support accordingly.

“We know—the evidence proves it—that when you connect social support and contact tracing, it works very well,” he said. “That is the humane way to treat people.”

On to Massachusetts

Protection for the vulnerable is a cornerstone of the Massachusetts Community Tracing Collaborative.

CTC contact tracers not only inform people of their exposure to COVID-19, but also advise them on how to safely isolate, seek care, and obtain social services. Care resource coordinators then connect vulnerable patients and their families with local organizations that assist with needs like food, shelter, and mental health care.

Care resource coordinators connect patients to social services “A lot of inequalities in social services are becoming glaringly obvious through this work,” said Michelle Baum, a care resource coordinator. “People who are quarantining themselves might need food urgently, for example, or diapers or baby formula. Or rent money if they’re not able to work, or cleaning supplies if they’re sharing a space with someone who’s confirmed to have COVID-19.

“They call the CTC saying, ‘We’re going to leave the house’ because of these needs. And then contact tracers are able to say: ‘Hold on, a care resource coordinator is going to call you.’”

By the end of June in Massachusetts, contact tracers were reporting a median of two contacts per case (excluding people with zero contacts)—a low rate that speaks to the effectiveness of social distancing and pandemic response efforts led by the state’s Department of Public Health and local health departments. Relaxing such measures will inevitably increase transmission, especially among the majority of cases that are minor or asymptomatic and are “silently and unknowingly spreading the disease,” in Mukherjee’s words.

“We want to shine a light on that,” Mukherjee said. “A light with love and compassion, that can reach out to people and humanely let them know that they are at risk and help them to isolate themselves.”

Back to Sierra Leone

As a trusted government partner in Sierra Leone, PIH immediately began helping coordinate the country’s national response to COVID-19, which has now spread to all of the country’s 16 districts, including Kono, where PIH has worked for years to strengthen the overall health system.

Contact tracing has been a primary focus of the response, with Sierra Leone President Julius Maada Bio asking PIH to apply lessons from Massachusetts to Sierra Leone.

In so doing, Sierra Leoneans are using lessons from their own country and history.

Barrie coordinated with Safa and other government partners on a national contact tracing plan for COVID-19. Subsequently, PIH trained 1,540 contact tracers across Sierra Leone’s population of 7 million—a similar set up to the 1,900 contact tracers who cared for Massachusetts’ same-sized population at the height of cases in the state.

Currently, 110 contact tracers are assigned to each district in Sierra Leone, and PIH is providing specialized accompaniment to all 16 of those district efforts.

Kono District, Sierra Leone
PIH has helped train more than 1,500 contact tracers in Sierra Leone, to support COVID-19 patients and response efforts across the country, including in Kono District, shown here. (Courtesy of PIH Sierra Leone)

“What PIH will be able to do is coordinate surveillance in the country, because surveillance is very important in terms of disease outbreaks,” Barrie said. “If we strengthen the surveillance system, we’ll be able to get ahead of the curve.”

The government has also been providing food to all quarantining households. In Kono District in particular, social support is a robust part of stopping COVID-19.

When the country’s borders closed at the end of March, Kono was hosting an influx of Sierra Leonean families needing to immediately quarantine after returning from Guinea. PIH provided food and housing to allow them to do so.

Subsequently, the organization hired additional community health staff charged with educating households about the virus and linking patients and families with the resources they need to effectively quarantine. And when the district confirmed its first cases of COVID-19 on May 21, PIH began putting together social support referral plans and packages, which include soap and laundry detergent, food, and money for cellphone cards.

New Challenges for COVID-19

Yet as the pandemic begins to take hold in Sierra Leone and cases rise in Kono, limited funding threatens to stifle relief. There are now more than 50 cases in Kono, and more than 1,400 nationally—numbers that pale in comparison to Massachusetts’ more than 108,000 cases, but that likely reflect the challenges of widespread testing and, relatedly, of widespread social support.

“The key difference between the Ebola outbreak and the COVID outbreak is resources,” Barrie said. “Now we have the structures functionally in place, but resources to support them are lacking. This means that countries like Sierra Leone, all across Africa, are often unable to implement social support fully alongside contact tracing.”

Bailor Barrie, strategic advisor for PIH in Sierra Leone
Dr. Bailor Barrie, strategic advisor for PIH in Sierra Leone, says that while resources are lacking in the country's fight against COVID-19, he is confident that Sierra Leone will overcome the pandemic, as it did Ebola in 2016. (Courtesy of PIH-Sierra Leone)

Nonetheless, he added, “we’re doing a good job in Kono linking the two. We have budgeted to give around 500 households support; I’m cautiously optimistic we won’t get to that number.”

And while there’s a long road ahead, Barrie indicated he expects Sierra Leone eventually to see a similar sight to Tonkolili, where the last Ebola patient was identified four years ago—the country’s last COVID-19 patient, safely tested and quarantined.  

“These are difficult times,” Barrie said. “But I’m sure we’ll all fight it together and overcome it.”

Need To Know: Social Support

Partners In Health staff often talk about the five “S’s” essential to quality health care: staff, stuff, space, systems, and social support. Each piece is equally important in building a strong public health system and in caring for patients—not just their current illness or chronic condition, but their ability to thrive in their communities.

Social support, the fifth “S,” is an essential part of how PIH uniquely approaches patient care. It comes in many forms, but mostly entails the provision of food, housing, transportation, education, and job security to patients and their families.

The need for social support has been magnified as a result of the spread of COVID-19, globally and within the United States. Patients who test positive for the virus are asked to quarantine for up to 14 days, but that is a nearly impossible task for people who are “essential workers” or are part of the informal economy, live in close quarters with extended families, and do not have electricity or running water.

We spoke with Basimenye Nhlema, community health director for Abwenzi Pa Za Umoyo, as PIH is known in Malawi, and with Jorge Tamaki, deputy director of Socios En Salud, as PIH is known in Peru. They spoke about social support, the difference it makes in patients’ lives, and why it’s particularly essential in the time of COVID-19. 

What is social support?

PIH’s social support programming varies by country. Generally, though, we provide transportation to and from clinic appointments, food, housing, educational fees and supplies, and financial support, such as startup loans for small businesses.

The reality is that a high-quality health care system isn’t always enough, especially in the world’s poorest countries. Patients now battling COVID-19, tuberculosis, HIV/AIDs, malaria, non-communicable diseases, malnutrition, and mental and maternal health issues often lack access to amenities we take for granted.

Why is it important?

Our social support programming treats the whole patient, not just his or her disease. That difference means that patients will not only reach a cure for common illnesses or manage a chronic condition, but also maintain their good health over the long term.

Take as an example patients living with a chronic disease, such as diabetes or hypertension. Getting to and from regular appointments at a government hospital may entail walking hours along poor roads or taking crowded public transportation.

But if patients are too ill to walk far or can’t afford transportation fees, they don’t regularly make appointments. Helping them solve the transportation question ensures they remain in care and stay healthy.

Can you share an example of how social support has changed lives?

When PIH began providing social support seven years ago in rural Neno, Malawi, a seriously ill woman arrived. She was diagnosed with and treated for HIV. To ensure this woman was nourished and could provide for her family, PIH gave her goats to raise at home. In a region where most earn their income from small-scale farming, she went on to breed them and now has a herd of over 12 goats that she is able to use to support her family needs and to start a vegetable business in the market.

This extra income means she can grow or buy enough food for her family and purchase other goods they need to stay healthy.

Taking another example from Peru, Harold*, 27, had been supporting his parents and brother in a small home in one of the most vulnerable communities north of Lima, the country’s capital. He lost his job a week after Peru declared a state of emergency due to the COVID-19 pandemic and could no longer help his brother pay for school. His dad tested positive for COVID-19, and before long, with no space for social distancing, the virus had spread to the two brothers. They ran out of money and food, and without medication, his father’s health began to decline.

Harold reached out to PIH for help and was greatly relieved when staff showed up at his door with food, followed by two months of continued support until they recovered.

“If Socios En Salud had not provided me with the isolation guidelines and food, perhaps we wouldn’t be here,” Harold said.

We know PIH is reaching 90 percent of 132,000 households in Malawi’s rural Neno District, and that HIV outcomes have been better there than in districts across the country.

In Peru, where 72 percent of the population is informally employed, social support has assisted tens of thousands of people in the past two decades. Since the national government declared a state of emergency in March, PIH has provided social support to more than 2,000 households.

Why is social support crucial now, as we work to slow the spread of COVID-19?

Strengthening health systems and social support programming are the best defenses against a public health crisis.

We rely on social support now more than ever in Peru, where the government’s stay-at-home measures have paralyzed 60 percent of the economy. As a result, an estimated 80 percent of family businesses are projected to declare bankruptcy. The state also closed all primary health care, leaving patients without medication or treatment.

We are working tirelessly to provide food and basic needs to those who have lost their primary means of income. That way they aren’t forced to break quarantine to look for a way to support their families.

PIH staff load a truck with social support items in Neno, Malawi
Staff with Abwenzi Pa Za Umoyo, as PIH is known in Malawi, load a truck with social support items for patients and families in Neno District. (Photo by Karin Schermbrucker / Slingshot Media) 

In Malawi, PIH is working closely with officials in Neno District to ramp up screening and implement contact tracing and treatment protocols to keep the number of positives cases relatively low. PIH is providing food, supplies, and sanitation products to individuals and their families who’ve contracted or been in contact with the virus.

*Name has been changed for privacy.

Innovation: Malawi Critical Care Study Adapted for COVID-19 Response

In January and February, when Partners In Health and the Malawi Ministry of Health conducted a nationwide survey of hospitals’ ability to provide emergency and critical care, they didn’t realize how vital that work was about to become.     

The Malawi Emergency and Critical Care Survey was created with the ministry’s Non-Communicable Disease (NCD) Unit, as part of efforts to support PIH’s broad mission of health systems strengthening—working with countries long-term to install “staff, stuff, space, and systems,” as PIH co-founder and chief strategist Dr. Paul Farmer often says.

In this case, the survey would help Malawi’s health system save lives during emergencies, provide critical care with infection control procedures, and meet ongoing needs for a range of infectious and non-communicable diseases.

PIH is known locally as Abwenzi Pa Za Umoyo and has worked since 2006 in Malawi’s mountainous, rural Neno District, where it supports Neno District Hospital and Lisungwi Community Hospital, along with 12 health centers.

The survey assessed capacity at all four of Malawi’s central hospitals and nine of the country’s 23 district hospitals, interviewing 13 administrators and 101 clinical staff. Neno District Hospital was included in the survey.

“The original plan was to present the data to the Ministry (of Health), disseminate it to the districts, get feedback, and eventually write it up,” said Dr. Paul D. Sonenthal, a pulmonary and critical care specialist at Brigham and Women’s Hospital in Boston, and PIH collaborator.

“But we realized that the information was too valuable to take that approach.”

As the COVID-19 pandemic escalated around the world, the colleagues pulled out the data most relevant to a COVID response, quickly analyzed it, presented it to Ministry of Health officials, and drafted a manuscript.

The final product, published in May in The Lancet Global Health, paints a detailed picture of emergency preparedness—which tracks very closely to COVID-19 preparedness—and provides one of the few published, facility-level assessments of critical care capacity in a low-income setting.

Assessing Gaps for COVID-19 

The survey revealed “crucial gaps in resources” needed to treat COVID-19 patients in Malawi, which had 11 deaths and more than 800 cases as of June 23. Co-authors of the published study, including Sonenthal, noted that just three of the 13 hospitals surveyed early this year had an intensive care unit; that all four central hospitals, but none of the nine district hospitals, could administer non-invasive mechanical ventilation; and that oxygen was adequately available in just five of 13 outpatient or emergency departments.

The survey also showed a severe lack of personal protective equipment, including eye protection, N95 respirators, and access to handwashing facilities. Co-authors highlighted the substantial risk those shortages create for health care workers. Media reports around the world at that time, in late May, said tens of thousands of health care workers had been infected with COVID-19 and thousands had died.   

Identifying those gaps in the first months of 2020, and creating plans to fill them, has proven crucial for the government’s COVID-19 response nationwide.

The study published in May also calls attention to “the crucial importance of early containment in Malawi and other low-income countries” through a combination of widespread testing, outpatient treatment, contact tracing, isolation, and physical distancing.

“A lot of people might look at Malawi and say, well, it’s a low-resource country, they don’t have anything that they need to care for people with coronavirus,” said Dr. Emilia Connolly, chief medical officer for Partners in Health in Malawi and a co-author of the study. “But before coronavirus, even the United States didn’t predict well how many ventilators it would need. This kind of information is vital for everyone, globally—for identifying weaknesses in the health system and developing a long-term plan to strengthen them.”

An ambulance on the road near Neno District Hospital
An ambulance leaves a cloud of dust on the main road near PIH-supported Neno District Hospital, where a recent emergency care assessment will inform planning and improvements for COVID-19 and far beyond. (Zack DeClerck / PIH)

A Model for Emergency Care

The hospital survey could create a needed assessment model for governments and health leaders outside Malawi.

Sonenthal said that at the outset, the question was: “How can we apply a PIH model of health system strengthening and sustainable growth to critical care? And we soon realized, after surveying the literature and speaking to a lot of people, that there just isn’t much known about care patterns in low-income countries.”

For all of its importance, he said, critical care often goes overlooked, largely because it doesn’t always fit into existing global health support structures.

“It’s not disease-based like tuberculosis or malaria; it’s not systems-based like cardiology or nephrology; and the actual people who do it vary,” Sonenthal said, noting that at many hospitals, clinicians who specialize in other areas often fill gaps in critical care.  

“It bleeds into a lot of different groups and structures, and we’ve made sure to keep in mind that the care of very sick patients happens across every space in the hospital—in the emergency room, in the wards, in the operating rooms and the post-operative units,” he said.  

The study’s co-authors knew that a needs assessment could help Malawi officials chart a path forward, not only by identifying gaps, but also by informing interventions to help facilities care for their sickest patients—a growing demographic amid COVID-19.

Sonenthal said one of the survey’s main strengths is its holistic view of ventilators, which are key equipment for the care of critically ill patients.

“If I were to hand a ventilator over to someone in a district hospital in Malawi, they still wouldn’t be able to accomplish mechanical ventilation,” he said. “The stuff is not the only barrier; it’s also about having staff and the infrastructure to use it,” including piped oxygen and reliable electric power.

Noel Kasomekera, a technical assistant with PIH who also works with the Malawi Ministry of Health’s NCD unit, noted that any epidemic will expose weaknesses in a health system.  

“So when we think about responding to an epidemic, we’re thinking about building capacity that will last well beyond it,” Kasomekera said. “We see the coronavirus as a major challenge, but also as a catalyst for system-wide change; being ready to treat COVID-19 patients is also being ready to treat patients made critically ill by tuberculosis, or severe pneumonia, or any number of other infections.”

COVID-19 Contact Tracing Explained

Contact tracing is key to stopping the spread of deadly, infectious diseases around the world. A tried-and-true public health practice recently used to curb Ebola, it's now a critical part of the fight against COVID-19. 

In April 2020, Partners In Health launched the first statewide coronavirus contact tracing program in the United States—the Massachusetts Community Tracing Collaborative (CTC)—in partnership with the Commonwealth of Massachusetts and local boards of health. PIH is also providing technical advice on contact tracing to other states and municipalities through its newly established U.S. Public Health Accompaniment Unit.

Contact tracing has been crucial in the global fight against COVID-19, too—countries from Peru to Sierra Leone have turned to contact tracing as a way to track and stop the spread of the novel coronavirus.

But how, exactly, does it work?

Register Now: Free Online Course on Pandemic Preparedness in Time of COVID-19

As leaders worldwide pivot to respond to the COVID-19 pandemic, Partners In Health and the University of Global Health Equity (UGHE) in Rwanda are jointly offering a free online course on an equity-based approach to pandemic preparedness and response, starting in early July

The course will run from July 7-16 in four sessions, totaling six hours of class time. Participants who complete all four sessions will earn a certificate. For those who can’t virtually attend, the content will be available online for self-learning after the course has ended.

Course instructors will include: PIH Co-founder Dr. Paul Farmer; Dr. Agnes Binagwaho, UGHE vice chancellor and former Minister of Health of Rwanda; PIH CEO Dr. Sheila Davis; Dr. Joia Mukherjee, PIH chief medical officer; Dr. Abebe Bekele, UGHE’s deputy vice chancellor and dean of health sciences; and Dr. Anatole Manzi, PIH deputy chief medical officer and director of clinical quality and health system strengthening—among many other PIH and UGHE leaders.

The course will draw on PIH’s deep expertise in fighting infectious disease outbreaks around the world and share insights from its role in the COVID-19 response, both in the United States and globally. Participants will also benefit from UGHE professors’ research and practical experience in pandemic response and control.

Registrants will be assigned readings and videos in preparation for each lecture. Case studies will include the COVID-19 response in Rwanda, integrated and human-centered contact tracing in Massachusetts, and the role of health equity and its implications for the COVID-19 response in Navajo Nation. The course will equip participants with a practical, interdisciplinary, and equity-driven approach to pandemic preparedness and response.

PIH CEO: Pride Month a Time to Celebrate, Commit to Equality for All

Partners In Health CEO Dr. Sheila Davis recently sent this letter to PIH staff, in celebration of Pride month and in recognition that, this year more than ever, the spirit of Pride is “fundamentally intersectional” with the fight for racial justice and equality for all.  

PIH CEO Dr. Sheila Davis
PIH CEO Dr. Sheila Davis 

Each June marks Pride month – a time to celebrate the incredible progress the LGBTQ+ community has made over the past 51 years in pursuit of dignity, equality, and acceptance. In recent decades, Pride has shifted from its roots as a radical liberation movement to a more cheerful celebration, from Liberation to Pride. With the Supreme Court’s landmark June 15 ruling that federal civil-rights law prohibits workplace discrimination against LGBTQ+ workers, there is yet another success to celebrate.

We must hold this celebration alongside a deepened commitment to the fight for equality for all. As with all the communities we serve, the most marginalized within the LGBTQ+ community, especially BIPOC trans women, remain actively oppressed around the world. In 2020, at least 14 transgender people have been killed by violent means; in the past week alone, Dominique Fells and Riah Milton, two Black trans women, were murdered with little to no media attention. Although Black trans activists paved the way for today’s Pride celebrations, Black trans women continue to be some of the most vulnerable people in our society today. Since 1987, the LGBTQ+ founded and led activist group AIDS Coalition to Unleash Power (ACT UP) has revolutionized the fight against the global AIDS pandemic. Their rallying cry of “Silence = Death” is a powerful slogan to reclaim for today. 

The progress in LGBTQ+ rights and acceptance was made possible thanks to the courage and revolutionary spirit of Black and Brown trans women at the Stonewall Riots against police brutality and oppression in 1969. Fifty years on, the greater purpose of Pride is to center and elevate the voices and stories of the most marginalized within the LGBTQ+ community. Pride is fundamentally intersectional with the fight for racial justice and the Black Lives Matter movement. Two of the three BLM co-founders are queer women and one of them, Patrisse Cullors, said:

“[Black Lives Matter] was created from not just a politic of ‘blackness,’ but it was created from the intersections of blackness, womanness, and queerness." 

Real, systemic change and progress is often a result of painful, awakening moments such as now.

Let’s celebrate our LGBTQ+ colleagues and loved ones by standing in solidarity with them, and gain inspiration from the Pride movement’s important history as we work toward a more just and equitable future.

Amid the growing calls around the world for an end to systemic racism, racial profiling, and police brutality, Pride this year is an opportunity to focus on its intersectionality with racial justice.

In the spirit of Pride, the fight for racial justice, equality, and acceptance for all has never been more important than now.

In celebration & solidarity,



PIH’s Statement in Honor of Juneteenth

Today, we remember and celebrate the freeing of the last slaves in the United States on June 19, 1865, and reflect on the continuing struggle for equal civil rights. Worldwide protests sparked by the brutal murders of Rayshard Brooks, George Floyd, Breonna Taylor, and Ahmaud Arbery, only the latest in a long line of unjust killing, are a powerful call for the collective denouncement of racial injustice in the U.S. and across the globe.

Freedom was technically won on the battlefield more than 150 years ago, but it did not surface in everyday life for African Americans. Instead, slavery’s hallmarks of racism and hatred spread like viruses through all structures of society. White supremacy, in all its manifestations, continues to impose an unequal distribution of power, wealth, and opportunity by marginalizing, terrorizing, and killing Black people–limiting their access to justice, quality health care, housing, education, and employment.

We’ve learned there can be no social justice without the active resistance to dismantle these exploitative systems; and there will be no global change without local activism.

In other countries PIH serves, like Sierra Leone and Haiti, the wounds left by slavery are painfully kept open by centuries of colonial, postcolonial, and neocolonial abuses, such as the pilfering of natural resources, labor exploitation, international debt, and economic discrimination. Western countries continue to enrich themselves by further exploiting the very countries some now claim are “aid dependent.”

We’ve learned there can be no social justice without the active resistance to dismantle these exploitative systems; and there will be no global change without local activism.

In honor of Juneteenth, we are using our platforms to amplify and learn from the voices of Black activists and organizations that are at the forefront of the movement for racial justice in the U.S.

Learn More

Here is a list of the organizations we are listening to and learning from:


Q&A: Michelle Baum, Care Resource Coordinator for PIH in Massachusetts

While contact tracers are on the frontlines of tracking the spread of COVID-19, colleagues known as care resource coordinators are leading an equally vital charge: connecting patients with the social support they need to quarantine safely and stay healthy.

Michelle Baum, 24, is a care resource coordinator for the Massachusetts Community Tracing Collaborative (CTC). The statewide program of community outreach, virtual contact tracing, quarantine, and patient accompaniment is a key part of comprehensive efforts to control and end transmission of the novel coronavirus in Massachusetts.

Care resource coordinator Michelle Baum
Care resource coordinator Michelle Baum

Partners In Health and state government launched the CTC in April, as the first large-scale coronavirus contact tracing program in the U.S. The Massachusetts Department of Public Health and local boards of health continue to lead contact tracing efforts, with ongoing support from the CTC.

The CTC has hired and trained more than 1,900 staff members since it launched. As of June 1, that staff had reached out to more than 26,000 people with confirmed cases of COVID-19 and made nearly 275,000 calls.

The CTC estimates that 10 to 20 percent of people contacted are in need of some kind of social support.

As a care resource coordinator, Baum speaks every day with people who have tested positive, as well as those at high risk for infection, to connect them with support and resources in their community. A resident of Boston’s Fenway area, Baum recently spoke with PIH about her role, what needs she’s seeing, and what COVID-19 is revealing about gaps in the social support network.

Q: What drew you to the CTC?

I come from a background of social work and public health, so I was excited about the CTC, because it combines those two fields—and I feel like you can't really separate them.

Care resource coordinators provide links to social supportSpecifically, I just graduated from Boston University with my master's in social work and have one more year finishing my master's in public health, as a part of BU's dual degree program. I had internships at a women's center in Dorchester as well as a residential eating disorder program for my social work program. Additionally, I worked as a research assistant on a project working with Spanish-speaking Latinx adults in the Boston area, in recovery from substance use disorders. I'm passionate about the intersection between social work and public health, especially as it relates to mental health and the social determinants of health. 

I first got involved with COVID-19 contact tracing in Massachusetts as a volunteer with the Academic Public Health Volunteer Corps, while the PIH CTC was getting started. I worked on the team that assisted the city of Lawrence.

I was really happy that Partners In Health and the state of Massachusetts felt it was important to do this social support and connect people with resources. I felt like most of the conversations I was having with people who were skeptical of contact tracing or quarantining were like, "Well, yeah, you can tell people to stay at home, but what happens when they need food or they need money for work or things like that?" I was just really grateful and excited to see that the state and Partners In Health would be addressing those needs directly.

Q: How are things going?

So far, it's been a really great experience working on the Boston team. I think being in my role, specifically, makes the inequitable distribution of needs very apparent. And we're always working in specific locations. For my team and I, it’s East Boston, Dorchester, Roxbury, Mattapan.

A lot of the time, it's people whose first language is different than English. So, I think a lot of inequalities in social services are becoming glaringly obvious through this work.

Q: How does your role as a care resource coordinator fit into the CTC as a whole, and how does it interlock with contact tracing efforts?

People who are quarantining themselves might need food urgently, for example, or diapers or baby formula. Or rent money if they’re not able to work, or cleaning supplies if they’re sharing a space with someone who’s confirmed to have COVID-19.

They call the CTC, saying, “We’re going to leave the house” because of these needs. And then contact tracers are able to say: “Hold on, a care resource coordinator is going to call you.”

There are cases where people don’t know how to get things delivered to their house, or where people need financial assistance or help with food. I recently was working with a client who had just been discharged from the hospital and lived alone. I called him and said, “Do you have any food for today?” He said, “No, I have nothing.”

A lot of the groups that we work with take a few days, understandably, to get food delivered. So, luckily, I was able to connect him with an organization that does emergency GrubHub deliveries for free, and then we were able to get him food delivered the next day to sustain him more.

It was stressful, because this man has no food at home, and he just got released from the hospital and food is such a basic need to restore health in all circumstances, but especially in this.

Care resource coordinators provide links to social supportQ: Is there another example that comes to mind?

I was just working with a family who had a lot of concerns around rent and utility payments. One of the sons who was a contact (of someone positive for COVID-19) was just like, "I need to go out and work." And so, I was able to call them and help them apply for pandemic unemployment assistance and refer them to different organizations or funds to apply for, so the son could stay home and safely quarantine.

Sometimes we also provide an organization to call for help with legal rights, or renters’ rights. People often don't know about the eviction moratorium or that their utilities can't be shut off right now. So, even just letting them know about that can be helpful.

Q: How much follow up do you typically do with families or with a patient?

For people in isolation, contact tracers make follow-up calls daily. For people in quarantine, I believe it's every other day.

Usually, when I follow up with someone as a care resource coordinator, I’ll set something up, like a food delivery or whatever is needed. Then I confirm that it was delivered and, when I do that confirmation, I ask, "Is there anything else that you need, are you going to need another food delivery?" And then, kind of just keep following up.

Care resource coordinators help COVID-19 patients access a variety of resourcesQ: When do you stop following up with someone? Is there any kind of transition, or handoff?

When someone’s quarantine or isolation period ends is when I let them know, "OK, it's ending, I'll refer you off to these other services if you need help in the future."

Or, let’s take a more simple case of just setting up a referral to a primary care physician. Someone I called recently was about to go to the emergency room that day, and I said, "Well, hold on, I could set you up with a (physician) referral."

But then, even after confirming appointments like that, contact tracers or case investigators might continue to be in regular contact with the person. So, frequently they’ll kind of re-task me, and I’ll go back on a case if a new need has popped up.  

Q: What’s the difference between quarantine and isolation?

Basically, the difference is whether or not you're a positive case.

If you have tested positive for COVID-19, we ask you to stay in isolation, and we do whatever we can to make that possible.  

Quarantine is for people who are contacts of people who have tested positive, and who ideally are able to stay home while they wait to see if symptoms develop.

Q: The person you mentioned earlier who was about to go to the emergency room when you called—were they seeking care because of COVID-19?

Yes. That person was a positive case. He had tested positive previously and had just retested positive, so he had some clinical questions, but he also needed to get another letter for his employer, saying he had to stay home in extended isolation because he had retested positive.

I was able to connect him with a local health agency—and there was a language barrier, too.

He spoke Portuguese and Haitian Creole, so I was able to connect him with providers who speak those languages, get him set up with an appointment and then get a letter to him.

But before I even went down that route, I asked him, "Is there something that's a medical emergency right now?" And he said, "No, it's not really that urgent." I think his sense of urgency was coming from needing the employment letter.

Q: What's the most common type of support that is asked for, and then what's the most common type of support that is fulfilled?

Food and rent money are the most commonly asked. Most commonly fulfilled would be food and cleaning supplies.

For a lot of people and families, instead of pursuing temporary housing to safely quarantine, they're just asking for a lot of cleaning supplies. People who live with several family members or roommates are thinking, "OK, well, I have to clean down this bathroom after every time this person uses it."

And so, local organizations have been really great in terms of being able to donate cleaning supplies and get those delivered, too.

Connections with local aid groups are vital to contact tracing Q: How instrumental are local organizations, like food banks and aid groups, in the CTC’s work?

I think about this all the time. We could do literally nothing without them. We don't have our own stock (of supplies), we don't have our own resources. We're just kind of connecting people. So without them, we could do zero of our job.

Q: Anything else you’d like to talk about, regarding your role as a care resource coordinator?

Just more about financial assistance. A lot of people are having a lot of worries about rent or utility payments, or having problems with their landlords.

And that's probably the most frustrating part of my job, because I've spent so much time trying to find funds, or whatever the case may be, and they're all closed or not taking applications or whatever the case. It's very frustrating because I know the need is so great, and I know that money is out there somewhere, but I feel I just keep reaching dead ends and then telling families, "Oh, hi, I guess you can get on this waiting list."

And then, finally, I just have an awesome team. I just want to shout out everybody who's involved. Contact tracers, case investigators, and care resource coordinators. Everyone's working really hard and they're great to work with.

Contact Tracing: Fact vs. Fiction

As the COVID-19 pandemic continues, contact tracing has been in the news as a way to stop the spread. But how does it work? And what does it mean for you?

Partners In Health launched the Massachusetts Community Tracing Collaborative (CTC) in partnership with the State of Massachusetts in April 2020. The CTC is a key part of comprehensive efforts to control and end transmission of the novel coronavirus in Massachusetts, and the first large-scale coronavirus contact tracing program in the U.S.

The Department of Public Health and local boards of health continue to lead contact tracing efforts, with ongoing support from the CTC.

We reached out to CTC staff and PIH leaders to clarify some common misconceptions.


MYTH: If I test positive, my identity and those of my contacts will be shared with the public.

FACT: If you test positive, your identity will not be shared with your contactsthey will only be told they may have been exposed in a certain date range.

If you test positive, your identity will not be shared with your contacts—they will only be told they may have been exposed in a certain date range.


MYTH: I am an undocumented immigrant and fear that, if I answer the phone, I may be turned in and get deported.

FACT: Your information is strictly confidential and will not be shared with immigration officials or other agencies. Additionally, your identity will not be shared with any contacts you’ve listed.

Your information is strictly confidential and will not be shared with immigration officials or other agencies. Additionally, your identity will not be shared with any contacts you’ve listed.


MYTH: If I answer the call and learn I've been exposed to COVID-19, I will face challenges isolating at home or will be forced from my home.

FACT: Quarantine is a crucial part of stopping the spread of COVIDthis includes staying home, maintaining social distance, self-monitoring for symptoms, and notifying public health staff. If you face challenges or concerns around isolating at home, you will be connected with resources in your area, including for housing, food, domestic violence and economic support.

If you face challenges or concerns around isolating at home, you will be connected with resources in your area, including for housing, food, domestic violence and economic support.


MYTH: Contact tracing doesn’t seem to be making a difference. Positive cases keep rising.

FACT: Without contact tracing, COVID-19 cases will rise further because we can’t track the virus and test, treat, and isolate patients.

FACT: Without contact tracing, COVID-19 cases will rise further because we can’t track the virus and test, treat, and isolate patients.


MYTH: I don't answer the phone, because I don’t think I speak English that well.

FACT: Language won’t be a barrier. Contact tracers speak several languages and have access to professional translation.

Language won’t be a barrier. Contact tracers speak several languages and have access to professional translation.


MYTH: I hear contact tracers will require me to download an app that will track my locations and behaviors.

FACT: We do not require you or your contacts to download apps that track your locations or behaviors. We only need you to answer the phone. Contact tracers use digital tools to capture necessary information during phone calls to monitor infected people, trace their contacts and help connect them with care and support.

We do not require you or your contacts to download apps that track your locations or behaviors. We only need you to answer the phone. Contact tracers use digital tools to capture necessary information during phone calls to monitor infected people, trace their contacts and help connect them with care and support.


State of Massachusetts


Fighting a Growing COVID-19 Pandemic in Mexico

Patients walking into Jaltenango Hospital are now greeted by a nurse in a face shield and surgical mask, sitting at a desk, and flanked with bottles of disinfectant and hand sanitizer. She asks their name, where they’re from, and what symptoms they’re experiencing. Then she directs them to a waiting area—green, yellow, or red—based on whether their symptoms match with those of COVID-19.

Life has changed in this region of Chiapas, and triage is just one example.

Partners In Health, known locally as Compañeros En Salud, has worked in this southern Mexican state since 2011. The work focuses on strengthening local health systems, which includes supporting a hospital, 10 rural primary care clinics, and a maternal home.

As COVID-19 has spread throughout Mexico, that mission hasn’t changed. But it’s taken on a new urgency.

“Support is very important for places like Chiapas,” said Dr. Diana Sánchez, a newly minted physician in PIH’s pasante program. “It’s one of the most vulnerable places in Mexico.”

From PIH-supported Jaltenango Hospital to rural health clinics, COVID-19 is changing day-to-day health care in Chiapas. PIH is responding with compassionate care—the same ethos that has driven its work in the area for nearly a decade.

Education and Resources

The negative impact of COVID-19 across Mexico magnifies daily. The country’s death toll has been projected to almost quadruple over the next two months, with nearly 52,000 people estimated to lose their lives to COVID-19 by August 4. By early June, the Mexican Ministry of Health’s “stoplight” map, predicting risk of infection, had placed every state at the maximum “red light” level.

For Chiapas residents, the stakes become higher each day. While COVID-19 cases remained relatively low for several months, the number of confirmed cases began to rise at the end of May, as testing capacity improved. By early June, at least 49 people had tested positive in the areas surrounding the communities where PIH works.

PIH staff on the frontlines, such as Dr. Karla Saldivar, suspect there are many more cases to be found, so they’re coordinating a massive response.

Saldivar heads the Infection, Prevention & Control team, which is spearheading PIH’s COVID-19 response in Chiapas. For Saldivar, a gynecologist whose past experience includes emergency response with Médecins Sans Frontières, the COVID-19 response requires two critical components: education and resources.

Her five-person team educates the public about the importance of handwashing, COVID-19 symptoms, and where to go for help if they believe they’ve contracted the virus. They also develop and lead trainings for health care workers on how to use personal protective equipment (PPE) and help patients with symptoms of COVID-19, among other topics.

But education is only one part of the COVID-19 response; resources also are critical.

Hospitals and clinics must have triage areas, sufficient PPE, and care protocols in place. Saldivar works with local and national authorities to mobilize resources and send them to PIH sites. But that has been a sticking point.

Most of the PPE so far has come from private donations. Saldivar and her team have been scrambling to secure more PPE, so hospitals and clinics have the resources they need to fight the pandemic.

There also aren’t enough tests.

Dr. Doris Altuzar giving training to a nurse on how to manage triage areas in the clinic of the community of Honduras.
Dr. Doris Altuzar giving training to a nurse on how to manage triage areas in the clinic of the community of Honduras.

Testing, Treating, and Isolation

By early June, Jaltenango Hospital had just one confirmed case, but there are likely more out there, according to Dr. Erick González, the hospital’s interim director.

The hospital has only been able to test a handful of people for COVID-19, even though dozens have shown symptoms. That’s because there aren’t enough tests. In order to get one test, a hospital must have at least 10 suspicious cases.

Jaltenango Hospital has not seen enough such cases to acquire the tests it needs—in part because many patients are scared of setting foot in a hospital.

“There are probably more cases than the one we have confirmed,” González said. “People are scared of getting sick, of getting stigmatized.”

By contrast, Villaflores Hospital, a couple hours away by car, had 18 confirmed cases as of early June. Villaflores has seen more patients, detected more suspicious cases, and therefore acquired more tests from the government.

Despite Jaltenango’s low case count so far, González and staff know that an influx could happen virtually at any moment. They’ve worked hard to ensure that the hospital has protocols and procedures at the ready.

That includes a triage area, set up at the hospital’s entrance and staffed with nurses. The space is divided into three sections—a “green” area for patients with no respiratory symptoms, a “yellow” area for patients with one respiratory symptom, and a “red” area for patients with more than one respiratory symptom.

Nurses identify suspected cases based on COVID-19 symptoms and refer the patients to a health center next to the hospital where they receive public health guidance, including quarantine instructions.

So far, the hospital’s one confirmed case was told to go home and isolate, since the patient’s symptoms were mild. For more serious cases, the hospital plans to provide in-patient care.

COVID-19's Impact on Care

Rural Chiapas residents with COVID-19 symptom are more likely to visit a health center or local clinic first and not a hospital. Even as hospitals scramble for resources and draft response plans, these smaller facilities are also preparing for COVID-19—and are already feeling its effects.

The health center where Sánchez works used to see dozens of patients each day. Now, it sees around five.

Sánchez, a first-year doctor completing her social service year with PIH, says that much of the Jaltenango Health Center’s usual programming has been put on pause. The center has moved to limit appointments for patients with chronic illnesses, such as diabetes and hypertension, to once every two months. She estimates the center now sees only 25 percent of the patients it used to.

Not all PIH programs in Chiapas have seen such drastic changes; some have simply been modified.

Casa Materna, the home for new and expectant mothers, continues the bulk of its operations, with nurses and midwives following public health guidance to prevent the spread of COVID-19 as they conduct prenatal appointments and assist with labor and delivery.

Similarly, community health workers still make house calls in the rural communities where PIH works, while taking additional safety measures, including wearing face masks.

Dr. Fátima Rodríguez (left) and psychologist Luis Fabricio García (right) during a training for nurses of the Basic Community Hospital
Dr. Fátima Rodríguez (left) and psychologist Luis Fabricio García (right) during a training for nurses of the Basic Community Hospital

COVID-19 and the Vulnerable

PIH’s vital work in Chiapas continues, both in spite and because of COVID-19. The need for strong health systems could not be more urgent, especially for Chiapas’ most rural communities.

“There are sometimes four to six people sleeping in one bedroom,” she said. “The idea of quarantine or social distancing is pretty much non-existent.”

Saldivar shares these concerns. While PIH-supported clinics are equipped with PPE and triage areas, people in Chiapas’ most remote areas—not supported by PIH—still don’t have access to a health facility equipped to handle COVID-19.

She also worries about patients who have comorbidities such as diabetes or hypertension, which put them at increased risk.

“We are really worried about vulnerable populations,” Saldivar said. “I’m afraid of the virus really getting into the community. A lot of our population are really vulnerable for other diseases. So this pandemic is really challenging for patients.”

In addition to the health concerns, a stream of misinformation surrounds COVID-19. Not everyone believes the pandemic is a real threat. Some think it’s a political conspiracy; others turn to religion as an explanation for the disease and, sometimes, as a reason not to fight it.

Health care workers must walk a fine line between listening to community members’ concerns while also educating them about the facts of COVID-19 and correcting misinformation.

Despite the challenges, PIH is fighting to mobilize resources and accompany patients each step of the way.

“It hasn’t been easy and we hope everyone gets quality health care,” said González. “Hopefully this will help us build better health systems and, as an organization, we will be able to know where we can improve.”

Now Answering Calls: A COVID Case Investigator’s Story

When a Massachusetts family was struck by COVID-19, their immediate concern wasn’t simply recovering—it was not getting evicted.

Both parents had tested positive for the disease. They had two young children, and had been laid off from their hourly jobs in the service industry. As they worried about how to make ends meet in an economy already devastated by the pandemic, the prospect of losing their apartment loomed.

When they called the Massachusetts Community Tracing Collaborative, Alex Cross and her team of case investigators and contact tracers were ready to respond.

To help the family, Cross and her team pulled in care resource coordinators, who contacted the local board of health. The triage worked. When her team checked in with the family later—Cross said her team conducts daily follow ups with people who are positive cases, and her final call with this family was a week after the first—their landlord was allowing them to stay and their quarantine window had passed.

As a case investigator supervisor, Cross sees cases like this all the time. She knows firsthand that contact tracing is about much more than picking up the phone and tracking cases; it’s about connecting people with social support and accompanying them, often in their darkest moments.

Partners In Health and the Commonwealth of Massachusetts launched the CTC in early April in collaboration with other state partners, as part of the statewide COVID-19 response. The CTC is a key part of comprehensive efforts to control and end transmission of the novel coronavirus in Massachusetts, and the first large-scale coronavirus contact tracing program in the U.S. The Department of Public Health and local boards of health continue to lead contact tracing efforts, with ongoing support from the CTC.

The collaborative has since grown – at the height of the pandemic, the team included more than 1,900 contact tracers, case investigators and care resource coordinators.

The expansion has been massive, and critical.

“Data and experience from countries that have been successful in bending the COVID-19 curve downward have shown us that we have no choice,” says Dr. Jim Yong Kim, PIH co-founder and board member, who initially reached out to Gov. Charlie Baker to offer PIH’s assistance in Massachusetts. “It’s time to go on the offense against the virus.”

‘Frontlines’ of contact tracing

Cross’s team—known as the inbound line—began with around 15 people, but grew within weeks. Now, her team includes 130 contact tracers and fields as many as 500 calls per day.

Unlike the CTC’s outbound lines, where contact tracers call people to share their test results and have case files at the ready, the inbound line fields incoming calls, including everyone from people asking about their COVID-19 status to tenants worried about eviction.

“We see them as the frontlines of the CTC,” Cross says.

She hadn’t expected to be a part of this fight. If you had asked the Tennessee native a year ago—or even a few months ago—about her plans following grad school, leading a team of contact tracers likely wouldn’t have been Cross’s answer. But as COVID-19 took hold, the Tufts University graduate felt a strong desire to help, especially given her public health training.

“I had all this energy and time I wanted to funnel into helping with the COVID-19 effort,” Cross says. “I saw this job posted and thought, ‘This is perfect.’”

Case investigator Alex Cross supervises a team on the Community Tracing Collaborative, launched by PIH in partnership with the State of Massachusetts
Case investigator Alex Cross supervises a team on the Community Tracing Collaborative, launched by PIH in partnership with the State of Massachusetts

On the inbound line for COVID-19

Her day starts at 7 a.m., when she catches up on news and sets an agenda for the day. The inbound line opens at 8 a.m. As soon as her contact tracers mark themselves “available,” calls start pouring in.

“My team are the people out there every day, talking to hundreds of Massachusetts residents and being their guide through this really scary, uncertain time,” Cross says.

People typically get the CTC’s inbound line phone number at COVID-19 testing sites. But the number also is shared by local health boards and on voicemails from CTC contact tracers.

For most incoming calls, Cross and her team follow a standard approach. First, they conduct a symptoms interview, asking callers if they have experienced shortness of breath or other COVID-related symptoms. Then, if callers know they have symptoms, tested positive, or were exposed, contact tracers ask callers whom they have been in contact with, and then get information for those contacts to set up future interviews, and link the cases for the state’s epidemiological database. (The data is kept confidential and participation is voluntary.)

The last step is often the most complicated. After the symptoms interview and contact questions, the contact tracers make sure callers have the resources they need to safely and effectively quarantine.

If not, they connect the callers with care resource coordinators—CTC staff who can connect them with local support for a variety of needs, including housing, food, and mental health services.

Because COVID-19 is rarely the only concern on callers’ minds.

Empathy required

Her team has helped people with mental health crises, families running low on food, and mothers needing to buy formula. For the most urgent cases, supervisors like Cross and care resource coordinators are pulled in immediately.

“To work on the inbound calling line, it really takes an emotionally intuitive, really empathetic person,” Cross says.

“You have to really be able to read the situation you’re in, because when you pick up the phone, you really just don’t know what you’re getting. When that phone line rings, you just have no idea.”

She recalls speaking with a woman who was living in a tent and had tested positive for COVID-19, but didn’t have a primary care doctor. The woman also was reluctant to go to a shelter, because she was in recovery for addiction and didn’t want to be around people who could be using. With the help of care resource coordinators, Cross and her team found a way to connect the woman with treatment and shelter.

For Cross, cases like this make the work rewarding. But for every success story, there are many more people in need. And that knowledge takes a toll.

“Sometimes when I go to bed, it’s all I dream about,” she says. “You encounter so many people each day. It's hard to just turn it off at night. I think about it all the time.”

A step toward healing

Her contact tracers have to manage not only the needs of callers, but also the fast-moving world of COVID-19—from updated national guidance to protocol changes. Additionally, contact tracers field a steady stream of concerns about the CTC itself, and often give additional information to callers, such as people who are concerned about privacy or think the effort is a scam.

Cross said it’s important for her team to “meet callers where they are” emotionally, and help them feel understood.

Her team reassures callers that their participation is voluntary, their identity is confidential, and that any personal information already on file comes directly from the Massachusetts Department of Public Health. And they emphasize that every symptom tracked and every person contacted is a step away from quarantine and lockdown, and a step toward a vaccine and healing.

For callers who don’t speak English, including undocumented immigrants, the team works with interpreters and staff members fluent in numerous languages. All information is confidential, treated as a private medical record, and not shared with other, non-health agencies, including immigration officials.

Keeping the inbound line running is no small task, but Cross knows each and every call makes a difference.

“It requires a lot of trust in your team and also just having to know that you can’t personally touch each case,” she says. “The system is built in a way that the needs are getting met every day. It’s just been amazing to see what a bunch of people can come together and do.”

The Rise of a Lifesaving Blood Bank in Sierra Leone

“Limitless,” said Nurse-Midwife Isata Dumbuya, describing the access she had to blood as a clinician working for the United Kingdom’s National Health Service. “As many units as you needed would be available at the drop of a hat.

“It’s a real life-changer in the maternity unit,” she continued. “When a woman starts bleeding, whether it's during or after pregnancy, there are a lot of drugs and maneuvers that can hopefully stop the bleeding. But if she's still bleeding, she needs to have replacement. If you cannot get her this blood, then ultimately she would die.”

Nurse Midwife
Nurse midwife Isata Dumbuya, pictured in the KGH maternity ward.

In wealthy nations with well-resourced health systems, where blood banks are stocked, and transfusions are an unremarkable part of clinical practice, this fatal consequence is rare. In a poor country like Sierra Leone, it’s an unjust norm. One key fact behind the country’s unmatched rate of maternal mortality—women in Sierra Leone face a 1 in 17 lifetime risk of dying in pregnancy or childbirth—is that most health facilities are without a functional blood bank. And even if such a facility exists, clinicians often lack the training on how to properly perform a transfusion, let alone enough blood to freely provide one to every patient in need.

Limited is the best descriptor for blood bank services in Sierra Leone.

But for clinicians like Dumbuya, who since 2018 has managed the maternity ward at Partners In Health-supported Koidu Government Hospital (KGH) in Kono District, this reality is changing. And for the women she and her team care for—as well as patients in the pediatric and emergency wards, the other departments most in need of access to blood—health outcomes are changing, too.

Thanks to PIH's partnership with the Sierra Leone Ministry of Health, and its  investments in the KGH blood bank, safe transfusions are widely available. What once was a single, unreliably cold refrigerator has turned into what Dumbuya called “a real game changer for us.

“Nine times out of 10 that we need emergency blood, we have it,” she said. “It’s saved countless lives.”

Multiple refrigerators now stock KGH's blood supply.
Multiple refrigerators now stock KGH's blood supply.

A mere 10 units

Before PIH’s support, blood transfusions were few and far between at KGH, regardless of how many patients needed blood to survive, such as women suffering postpartum hemorrhage, victims of car accidents, and severely anemic children. The refrigerator kept in the hospital’s clinical lab typically held only a handful of units of blood at any given time—up to 10, if clinicians were lucky.

“Imagine,” Dumbuya said, “you’ve only got 10 units of blood for the month, for the whole hospital. There was always a limit on how much one department could use without having it replaced.”

A lack of staff, stuff, space, and systems were to blame for the constant shortage. Served by the national power grid, KGH had spotty access to electricity, so blood often went too long unrefrigerated. Supplies like reagents, blood bags, and tubing were often out of stock, preventing safe blood collection and screening. Blood bank staff had to share a space with other lab services. Too few systems were in place to ensure the blood’s adequate collection, safe delivery, and transfusing. And the one community blood drive held every six weeks didn’t collect enough blood to comfortably stock the bank.

Momodu Mansaray, a leb tech at the blood bank, handles a bag of blood.
Momodu Mansaray, a leb tech at the blood bank, handles a bag of blood.

Meanwhile, Dumbuya recalls the era when clinicians, without a specialized blood warmer, would run a bag of blood under hot water, ruining the integrity of the cells and the overall safety of the transfusion. Or the countless times clinicians would give a patient blood at the wrong time.

“There wasn’t any sort of formal training,” Dumbuya said. “Cleaners could go and get the blood. And any person, whether they’re trained, untrained, volunteer, was being allowed to put up blood. Somebody would write down vitals that were blatantly worrying, but because the person writing it didn’t even know what they were writing, they would carry on. The blood transfusion would continue until the woman had an adverse reaction, and all hell would break loose.”

“Now, we have a system”

Investments in KGH’s blood bank were inherently urgent, and became even more so as patient levels increased. PIH’s efforts to encourage more of Kono’s population, pregnant women in particular, to seek health care required an improved and expanded blood bank.

“The KGH medical superintendent approached PIH and asked us to fully get involved in supporting the blood bank,” said Musa Bangura, PIH laboratory manager in Sierra Leone. “We replaced the faulty, broken-down fridge. We expanded the blood bank space. Now, it has a phlebotomy room, a testing room, a room for the refrigerators, and a reception area. And then of course we added full support with supply chain,” including items such as blood bags and reagents.

Laboratory Manager Musa Bangura helped lead the revitalization of the blood bank.
Laboratory Manager Musa Bangura helped lead the revitalization of the blood bank.

Relocated directly next to the maternity ward and powered by PIH generators ensuring 24-hour electricity to the hospital, the blood bank could help save more lives than ever before.

“We established a lot of standard operating procedures and did a lot of refresher trainings on how to manage a blood bank, ranging from the screening process, to storage, to cross-matching, to the distribution of blood in the wards,” Bangura said. “And we did some crash training on how you can identify and mitigate blood transfusion reactions.”

“Now,” Dumbuya added, “we have a system before you are allowed to do blood transfusions. You have to have gone through the training that Musa and the team organized. We have a better check-off system between nurses and blood bank staff to reduce the incidence of somebody being given the wrong blood. And there are forms that must be completed before transfusion.”

Blood bank staff and clinicians feel newly empowered, Dumbuya said. And, last but not least, they no longer have to ration blood, thanks to an ever-lengthening list of local blood donors and regularly held blood drives.

KGH blood drives have grown so much as a program that they require a dedicated staff member: Ansumana Morine, blood donor mobilization assistant.
KGH blood drives have grown so much as a program that they require a dedicated staff member: Ansumana Morine, blood donor mobilization assistant.

“We have mobile blood drives two or three times a month throughout Kono District,” Bangura explained. “We normally target 50 donors, and can get 35 units minimum. Then we have static drives—people from our database of donors we call and transport to KGH to donate when we are in need of fresh, emergency blood.”

All told, these system-wide changes enable KGH to have between 50 and 80 units of blood on hand at all times. Whereas before 10 units had to be split amongst the whole hospital each month, Dumbuya said, “now I know we can transfuse 10 units a week just in maternity.

“It’s truly not comparable,” she continued. “It’s going from being able to use one unit of blood per week, to performing three or four transfusions a week—and a transfusion can be up to four units.”

These numbers should only go up. “Because of the impact we’ve created in the district and the donor groups we’ve set up,” Bangura said, “we should try to increase the donor target to 70 [people per blood drive].”

A bag of blood
A bag of blood

Poverty and mythology

The success of KGH’s blood drives is notable in Sierra Leone, where fear, mistrust, and mythology characterize a common sentiment against blood donation.

“Some people are so spiritually embedded in their tradition, they believe when you take their blood, you have taken their soul out of their body,” Bangura said. “Others say we are taking their blood to do research. Or, just after Ebola, people were saying we wanted to take their blood to put Ebola in their bodies.”

In response, blood bank staff begin every mobile blood drive with a community education event. “Every blood drive lasts 48 hours,” Bangura explained. “Once you get there, you call a town hall meeting. You talk to communities. ‘We are PIH. This is the importance of donating your blood. These ae the kinds of lives you are going to save.’

“The following day, people donate voluntarily.”

The  blood bank now has a dedicated space for blood collection.
The  blood bank now has a dedicated space for blood collection.

Slowly but surely, a cultural shift is taking place in Kono—one that promotes a new vision of blood donations, and a new trust in health care in general.

In a country like Sierra Leone, though, poverty remains the largest barrier to blood donation, as well as the biggest driver of demand. Dumbuya has witnessed instances in which a patient needed emergency blood, but family members were often not healthy enough to donate, for lack of proper nutrition and overall poor health. Other times, hospital visitors would offer to donate, but only for a price.

Meanwhile, maternity ward staff often see pregnant women so severely anemic—with hemoglobin levels half of what is normal in a healthy adult—that they suffer complications.

“Women come to the hospital in a state of collapse—without enough red blood cells to take oxygen around the body, which eventually affects your lungs and other organs, and with this baby trying to survive,” Dumbuya said. “It’s a lot about nutrition, and that resting is a theoretical concept for someone whose daily meal for their family depends on what she earns that day.”

This reality “still amazes” Dumbuya, even after two years working full-time in Sierra Leone, her country of birth. “I can still stand their gawking and thinking, ‘How did she die?’ I understand the physiological how,” she said. “But it’s how, in this day and age, a woman, a human being, can be allowed to deteriorate so badly.”

A healthy diet, encouraged by a mural in the KGH maternity ward, is key to a safe pregnancy--but is often unattainable for women in Kono District.
A healthy diet, encouraged by a mural in the KGH maternity ward, is key to a safe pregnancy--but is often unattainable for women in Kono District.

”We never gave up on her”

And yet, in the nick of time each day, KGH’s revitalized blood bank saves patients’ lives, particularly those of expectant mothers.

“The most rewarding part is when you see those lives saved,” Bangura said. “The blood bank is functioning, the staff are doing their best, and we’re contributing to reducing maternal death.”

Dumbuya echoed this sentiment, recalling numerous patients she and her team have saved with easy access to safe blood.

We had a patient, Margaret, who had choriocarcinoma—a cervical cancer,” Dumbuya said. “Today, she’s healthy and happy. The drugs helped, the other care helped, but there were times that Margaret would stand up and lose two, three liters of blood. Had she been in a place—this includes some of Sierra Leone’s other bigger hospitals—where you cannot access a safe blood bank, she would never have survived. Or if it was a few years ago, when there was one fridge with hopefully 10 units.

Margaret's life was saved by the KGH blood bank.
Margaret's life was saved by the KGH blood bank. (Click the photo for more on her story.)

“She has been the biggest user of the blood bank in the history of KGH,” Dumbuya continued. “Forty-two units over her weeks of treatment. We are in a really privileged position at KGH. In settings without blood banks, the value of one person’s life eventually has to be measured in terms of availability of resources—not using up more than your fair share. But we never gave up on her.”

Reaching higher

Now, the KGH team has higher aspirations for their blood bank. “We’re not yet able to separate blood components. This has got to be one of the things we start thinking about, because too much blood is also not good; you can overload the system,” Dumbuya explained. “Sometimes you only need parts of it—platelets, plasma, packed red blood cells.”

Bangura looks on as a blood bank staff member, Moses, screens blood.
Bangura looks on as a blood bank staff member, Moses, screens blood. Photo by Maya Brownstein / PIH

This new function would further increase the quality of care at KGH, and allow clinicians to save even more lives. The investments needed are familiar: the supplies and machinery that separates blood, staff training on when and how to do so, and systems to ensure safety.

“We’ve passed that sort of beginner’s level. So now we want to move to the intermediate stage and aim for the advanced stage,” Dumbuya said. “I truly believe we’ll get there some day.”

Need to Know: OpenBoxes and Supply Chain

The 2010 Haiti earthquake hit, and offers of in-kind donations came pouring in overnight. The need was unthinkable, and as charitable response grew, PIH staff quickly set up space in Miami and Port-au-Prince to stage shipments and manage stock of orthopedic equipment, IV fluid, wound care supplies, and many other donations and purchases.  

Supply chain staff in Boston and at Zanmi Lasante, as PIH is known in Haiti, would need more than a simple spreadsheet and paper forms to track this new volume of supplies, medications, and equipment; they needed a comprehensive electronic system to manage the increasingly complex supply chain. This need became all the more apparent as a growing number of patients began arriving at PIH-supported facilities from the damaged capital of Port-au-Prince in search of open clinics and hospitals. Soon, planning began for a reimagined University Hospital in Mirebalais, the state-of-the-art, 205,000-square-foot, 300-bed teaching hospital in the Central Plateau that would need to be stocked for referral-level care.

University Hospital in Mirebalais in Haiti
University Hospital in Mirebalais, Haiti, opened in March 2013, three years after the devastating earthquake in Port-au-Prince. Photo by Cecille Joan Avila / Partners In Health

So PIH set out in search of a new inventory software system to manage the massive volume of supplies required to maintain a high-quality healthcare system in Haiti. When it became clear that existing software solutions did not align with needs, PIH turned to its Medical Informatics team to develop OpenBoxes, an open source software used to manage and track the movement, consumption, and storage of supplies.

Today, OpenBoxes helps PIH staff track orders and donations not only heading to health facilities in Haiti, but also to Malawi, Liberia, Sierra Leone, Rwanda, and to PIH’s transit locations across the United States. Inventory, requests, and deliveries are updated by the minute, and supply chain, pharmacy, and clinical personnel can view the status of supplies in real time.

“Having more accurate forecasts and fewer stock outs saves lives every day by making sure clinicians have the supplies and medications they need to treat or diagnose each patient,” says Jesse Greenspan, PIH director of supply chain and logistics.

Pharmacy stock inside Neno District Hospital in Malawi
Inside a pharmacy at Neno District Hospital in Malawi. Photo by Zack DeClerck / Partners In Health

Below, Greenspan, Kelsey Nagel, supply chain manager for systems and reporting, and Remy Pacifique Ntirenganya, pharmacy department lead in PIH Liberia, explain the basics about OpenBoxes and how it makes a difference in day-to-day work around the world.

How exactly does OpenBoxes work?

OpenBoxes provides PIH staff all over the world with a detailed snapshot of the entire global supply chain. Our team uses the software to track stock from initial purchase, to arrival at a warehouse, to delivery inside a hospital, pharmacy, or laboratory. Users can adjust inventory and generate reports of what comes and goes. By recording requests, we can see the difference between what we sent to a facility and what that facility truly needed and adjust for those gaps in the future.

How has OpenBoxes made PIH operations more efficient?

The major challenge for any supply chain system is getting information to the right people at the right time. Before OpenBoxes, inventory and shipment information were largely stored on paper or simple spreadsheets, and remained inaccessible to staff outside the warehouse. Now, anyone can access information about shipments and utilization to help with decision making every day. We’ve also linked OpenBoxes to our financial data to have one streamlined system. The results are fewer stock outs, data-informed decisions, less waste, and big savings overall.

What are the financial benefits of OpenBoxes?

Before OpenBoxes, we didn’t have an accurate read on the number of supplies we consumed globally. With better forecasting, not only can we prepare more accurate budgets, we can now negotiate lower prices with vendors based on our estimated global volumes. The software's automation ensures we are using resources as efficiently as possible. This year, for example, on insulin alone we saved PIH $150,000. We used the difference to purchase lifesaving drugs we would not have otherwise been able to afford.

The software's automation ensures we are using resources as efficiently as possible.

Having visibility into our inventory as well as automations in the system related to inventory management also help us save money. For example, when a program needs a new piece of equipment, staff can quickly check OpenBoxes to see what we already have in stock before placing a new order for an item we may not need. Before we had an electronic system, it was very difficult to verify this information among the thousands of items in our multiple warehouses. Now, we can notify the requestor right away if the item they need is already in the warehouse.

OpenBoxes also tracks where each item is located in the warehouse, making it easier for staff to quickly find the item and send it out. In addition to warehouse location, the software tracks expiration date, so as staff prepare shipments, OpenBoxes automatically prioritizes the delivery of medications and supplies with the soonest expiration dates to prevent waste.

How has a software program saved lives?

We can now proactively work to make supplies available at the right time and in the right place, so patients are more likely to receive lifesaving medications and supplies right away. OpenBoxes has this amazing feature, called stock lists, that enables those in the warehouse or a hospital ward, laboratory, or pharmacy to keep an electronic list of all the items they need to keep in stock. Staff use these lists to make requests to replenish their stock on a regular basis, ensuring that staff get the supplies they need.

In Liberia, for example, improvements resulting from OpenBoxes are visible on a daily basis. One of our main goals is to ensure uninterrupted, timely delivery of medications and supplies to patients. OpenBoxes makes this work easier. We can track our use of all items to anticipate and replenish our stock in a timely manner, including at J.J. Dossen, a public district hospital that PIH Liberia supports. Moreover, we can anticipate expiration dates and avoid stock outs to ensure availability and accessibility of medicines and supplies that improve the quality of care and clinical outcomes for patients.

Does PIH hold a patent for OpenBoxes?

OpenBoxes, like all software designed by PIH, is open source. This means we make the software publicly accessible to anyone who is interested in using or modifying it, free of charge. From the start of the project, our Medical Informatics team came in with expertise they gained from building another open source software program for electronic medical records, called OpenMRS. The organization is a strong supporter of making resources available to anyone who needs them, and is now consulting to help other organizations implement OpenBoxes.

PIH Liberia, Government Partners Establish New COVID-19 Center

In collaboration with Liberia’s Ministry of Health, National Public Health Institute, and Maryland County Health Team, Partners In Health Liberia is operating a 26-bed quarantine center in the coastal city of Harper, supporting the government’s COVID-19 response across Maryland County in Liberia’s southeast.

The center will accommodate people who have traveled from high-risk areas, along with those who have potentially contacted someone positive for COVID-19, or exhibit symptoms including a cough, fever, sore throat, or difficulty breathing.

In addition to the 26 isolated beds, the center is equipped with hand-washing stations, water tanks, gender-friendly washrooms, blood pressure equipment, oxygen saturation machines, medical thermometers, and more. PIH is operating the center alongside national and county partners, supporting their efforts to identify COVID-19 cases and minimize spread of the viral disease.

“A well-equipped and dignified Precautionary Observation Center is an essential part of community-based infectious disease management and prevention,” said Dr. Maxo Luma, executive director of PIH Liberia. “Using this space, we are able to quarantine COVID-19 contacts to keep our communities safe, while ensuring those exposed to COVID-19 receive the medical attention and psychosocial support they need.”

Melvin Tamba of PIH Liberia sorts supplies for the quarantine center
Melvin Tamba, clinical mentor coordinator for PIH Liberia, sorts supplies for the new quarantine center in Harper. (Photo courtesy of PIH Liberia)

Clinicians at PIH-supported Pleebo Health Center, north of Harper, reported their first confirmed case of COVID-19 in April. Shortly after, PIH and the county health team set up the quarantine center at Harper’s Cape Palmas High School, which the national government had designated for use in the country’s COVID-19 response. 

Managing cases at the center is a joint effort between PIH Liberia and the county health team, with PIH clinicians and mental health staff providing care and social support alongside technical support from the county team.

Clinicians at the center had monitored 21 patients total as of June 1 for COVID-19 symptoms, regularly checking their temperature, blood pressure and oxygen levels, while sending samples for testing in Monrovia, Liberia’s capital. By the end of May, Clinicians had designated a group of 17 patients as stable and ready to be discharged, enabling them to safely return to their families and communities.

As of June 1, the confirmed case from April remained Pleebo’s only positive case. Four people who had traveled into Liberia were under observation at Pleebo Health Center as of that date.

Melvin Tamba prepares mosquito nets for the center
Melvin Tamba of PIH Liberia sorts mosquito nets for the COVID-19 quarantine center in Harper. (Courtesy of PIH Liberia)

Melvin Tamba, clinical mentor coordinator for PIH Liberia, said it took the team a week to set up the quarantine center in Harper, with help from volunteers. But the group also faced initial public sentiment against using the school for COVID-19 care, because of concerns about infection risks. 

The county health team and local authorities addressed those concerns with a public awareness campaign about the health protocols implemented to prevent spread of the virus among the public.

“In order to prepare the quarantine center within a week, PIH, the county health team and volunteers from the Red Cross and Integrated Development Youth cleaned and disinfected the center before setting up,” Tamba said.

The group partitioned a block of six classrooms into safe, isolated spaces of about six beds per room, to limit exposure and safely provide hygiene and infection control supplies for each patient.

The group also set up hand-washing stations with clean water and soap at every entrance and exit, to limit the spread of the virus and help patients safely meet health protocols and social distancing measures.

The center is staffed 24 hours a day by medical clinicians, psychosocial clinicians, and security personnel, who work in shifts to check vital signs, monitor new patients and give care when necessary. Two custodial workers also are on duty, cleaning all surfaces and washrooms to ensure patients’ safety.

Dr. Francis Ketah, Liberia chief medical officer, opens the center in Harper
Dr. Francis Ketah, Liberia's chief medical officer, formally opens the quarantine center in Harper. (Photo by Amy McLaughlin / PIH) 

Dr. Francis Ketah, Liberia’s national chief medical officer, received keys to the quarantine center on behalf of the county health team, at a ceremony marking its opening. Ketah expressed his appreciation for PIH’s continuous work to strengthen the country’s health system, and for its leadership role in fighting COVID-19 in Maryland County. Also at the opening ceremony were PIH Liberia staff, leadership of PIH-supported J.J. Dossen Hospital and of Tubman University, local authorities, and community leaders.

Isaac Dolo, senior clinical mentor for PIH-Liberia, emphasized that the quarantine center will offer psychosocial support to patients, as well as medical care.

“We seek to give the utmost care, including psychological counseling, and the unit will keep people from high-risk zones and situations under close observation, until they clearly manifest symptoms or are safely discharged, in order to ensure public safety,” Dolo said.

Celebrating New Possibilities at Sierra Leone’s Only Psychiatric Hospital

In Freetown, Sierra Leone, June 4 was a day of celebration at Sierra Leone Psychiatric Teaching Hospital (SLPTH), the only dedicated mental health facility in a country of 7 million people and the oldest psychiatric hospital in sub-Saharan Africa. Partners In Health staff, hospital staff and patients, and country leaders—including President Julius Maada Bio and Minister of Health Dr. Alpha Wurie—gathered to recognize and rejoice over the completion of renovations and improvements to the hospital.


Since its opening in 1820, SLPTH had been without electricity, running water, or an adequate supply of medications. For safety reasons and lack of proper resources, many patients spent days and nights chained to their beds.

Led by PIH’s partnership with the government of Sierra Leone, SLPTH has transformed into a dignified, well-resourced hospital in which to deliver and receive care for severe mental health conditions. PIH’s introduction of plumbing and electricity, establishment of a supply chain for never-before available psychiatric medications, and reconstruction of wards mean that clinicians now deliver care to patients in a clean, comfortable space.

Chains are no longer used, or even necessary.

The ceremony included speeches from President Maada Bio, SLPTH Medical Superintendent Dr. Abdul Jalloh, and Executive Director of PIH in Sierra Leone Jon Lascher. And while it marked a milestone for mental health care in Sierra Leone, other news weighed heavily, too. With attendees clad in masks, the threat of COVID-19 was an obvious presence. What couldn’t be ignored, either, were the ongoing protests in the United States and around the world over systemic racism and continued police brutality and murder of Black Americans.

President Julius Maada Bio delivers his speech at SLPTH.
President Julius Maada Bio delivers his speech at SLPTH.

Lascher’s remarks covered all three topics, and reflected upon the connection between America’s long history of slavery and anti-Blackness and the resource extraction and deprivation that have helped give way to poor health outcomes in Sierra Leone.

“Our two nations are bound by a history of injustice, the consequences of which are still being felt on both sides of the ocean that separates us,” Lascher said.

A lack of high-quality mental health care is certainly one such consequence—one that PIH and the government have made much progress in counteracting. Below, read Lascher’s full speech:

A Binding Injustice

Jon Lascher
Jon Lascher, masked to prevent the spread of COVID-19, at SLPTH.

"His Excellency, Mr. President, Honorable Minister of Health, CMO, Medical Superintendent Dr. Jalloh, Matron, SLPTH staff and patients, staff of PIH, especially the tireless infrastructure team that has helped amplify the beauty and dignity of this sacred ground, members of the community, partners, and media: Thank you.

Thank you, first, for welcoming me to this country. I arrived here in October 2014, and not a day has passed since that time that I have not been a welcomed guest in this country no matter where I travel, and for that I thank all of you, for making Sierra Leone a home for me, and for welcoming Partners In Health into this country.

It has been my great privilege over the last six years to build out PIH’s work here in collaboration with the Ministry of Health and Sanitation. We are facing yet another health crisis in Sierra Leone, and by many measures, Sierra Leone has responded with leadership and resolve that most countries, so many months into this outbreak, wish they had followed. 

We are here today to celebrate the rehabilitation of the oldest psychiatric hospital in sub-Saharan Africa. The remarkable transformation you all see here would have been impossible without the hospital leadership and the leadership of the Ministry of Health and Sanitation. 

SLPTH's new lecture hall, where the speeches were delivered, was filled with the infrastructure team who built it and clinicians who will teach and learn in it.
SLPTH's new lecture hall, where the speeches were delivered, was filled with the infrastructure team who built it and clinicians who will teach and learn in it.

As a white American, I feel it important to also comment on what is happening in my country. And what is happening in the United States cannot be delinked from what happens in Sierra Leone. The shameful history of America’s slave trade is inextricably connected to the story of Sierra Leone. Our two nations are bound by a history of injustice, the consequences of which are still being felt on both sides of the ocean that separates us. Sixteen percent of slaves that were stolen from Africa and forcibly brought to America were from Sierra Leone. Though some argue slavery in America ended long ago, and that it is now time to move on, the systemic racism that persists in the United States is directly related to the very recent history of slavery and Jim Crow segregation.

The shameful history of America’s slave trade is inextricably connected to the story of Sierra Leone. Our two nations are bound by a history of injustice, the consequences of which are still being felt on both sides of the ocean that separates us.

The aftershocks of slavery and colonization are still playing out today. Americans aren’t alone in grieving the senseless murder of George Floyd. Americans are taking to the streets in order to demand justice from those in power in the United States to dismantle the racist systems that allow white police officers to carry out state-sponsored murder without consequence. My only regret in being here with all of you today, is that I can’t be marching in the streets in my home country.

The campus of SLPTH.
The campus of SLPTH, whose building facades, pathways, and greenery were also renovated.

And so we are here now at the Sierra Leone Psychiatric Teaching Hospital. A place where a few years ago, patients were chained to beds. It would be easy as an outside observer to think that Sierra Leoneans were okay with this. But at PIH, we reject simplistic analysis. We know that systemic racism also plagues global health and international aid. The same countries that have benefited from centuries of bounty from Sierra Leone are the ones suggesting what is and what is not possible for the progress in this and other impoverished nations. It is possible to unchain patients if you have support that is directed towards your priorities. Mental disorders dramatically impact people in low- and middle-income countries, where 80 percent of the world’s population live. However, greater than 90 percent of mental health resources are spent in high-income countries.

A ward at SLPTH.
A ward at SLPTH--renovated with 24-hour electricity and running water;  ceiling fans, a television, and new beds for patient comfort; and new paint and flooring. Photo by John Ra / PIH

At PIH, we reject simplistic analysis. We know that systemic racism also plagues global health and international aid. The same countries that have benefited from centuries of bounty from Sierra Leone are the ones suggesting what is and what is not possible for the progress in this and other impoverished nations. It is possible to unchain patients if you have support that is directed towards your priorities.

Patients need doctors and nurses who are trained, medication, electricity, running water, and good infrastructure. And this hospital stands as a pragmatic example of how NGOs can partner effectively with the government and people of Sierra Leone. And PIH will continue to challenge the rich world on what they think is possible for poor people. Here we gather in this new lecture hall where the next generation of mental health professionals will be trained.

Over the past two years, PIH has worked directly with Dr. Jalloh and the Ministry of Health to fill gaps. Our effort and commitment here is long-term, as long as Dr. Jalloh and the Ministry will have us. The time for long-term partnerships in Sierra Leone has come. PIH is special because with limited resources, we direct them to public priorities for the long term.

SLPTH pharmacy
The SLPTH pharmacy is filled with mood stabilizing drugs never before available at the hospital, which have transformed  patient care. Photo by John Ra / PIH

And so we are extremely grateful to be able to build lasting partnerships in the places where we work, and one of the lasting partnerships that we have that I am proudest of is our partnership with the Sierra Leone Psychiatric Teaching Hospital. 

Our mission as an organization is to make a preferential option for the poor in health care. That means we prioritize those who are suffering the most. We say that the most marginalized should be first in line to receive the benefits of our society. Those suffering from mental illness are some of the most marginalized people on earth, and so we prioritize them. This mission of a preferential option for the poor shares common cause with those demanding justice across America, as part of the Black Lives Matter movement. Your Excellency, Honorable Minister of Health, Superintendent, thank you for welcoming us into your health system, and thank you for showing the rest of the world what health leadership looks like in the face of unfathomable challenges and scarcity."

Sheriff and Alpha Sesay, who supervised the infrastructure remodel of SLPTH, pose with another plaque at the hospital. It reads: "Ministry of Health and Sanitation in partnership with Partners In Health, improving mental health care in Sierra Leone since 2018."
Sheriff (right) and Alpha Sesay, who supervised the infrastructure remodel of SLPTH, pose with another plaque at the hospital. It reads: "Ministry of Health and Sanitation in partnership with Partners In Health, improving mental health care in Sierra Leone since 2018."


Mental, Emotional Toll of COVID-19 on Haitian Teen Girls and Young Women

The Women and Girls Initiative (WGI) promotes adolescent girls’ social protection, empowerment, and leadership. Under the hospices of Partners in Health, WGI has worked to empower the most marginalized and disadvantaged adolescent girls and young women in Rwanda and Haiti through scholarships, youth resource centers, and summer leadership academies. Since 2008, it has served over 600 beneficiaries aged 10 to 24 years old in both countries

The below essay was written by Didi Bertrand Farmer, who leads WGI and is PIH’s senior adviser on community health and strategist for adolescent youth’s health, gender, and development.

“I’m mentally exhausted by fear, stress, and anxiety as days pass by and the cases rise. It's a matter of days before my mother or myself contract this thing, since we have to go to the streets every day to keep our family going.”

PIH’s Public Statement in Response to Death of George Floyd

For more than 400 years, structural racism has been and continues to be a public health emergency in the United States—a virus requiring a systemic response. The horror of George Floyd being brutally choked to death demands outrage and pragmatic solidarity from all individuals and organizations.

As we experience collective grief, we must side with the black and brown communities who have been terrorized by racial inequity and state-sponsored violence in the United States, and with community organizers who have been fighting these issues on the ground for years. PIH will consult with community leaders to understand how our organization can best support their efforts to mobilize for change and justice in the immediate and long-term future.

This is a defining moment. Our collective fight for justice is intensifying. We must continue to stand tall with vigilance and hope alongside leaders from communities most impacted by injustice, leaders who have continuously struggled and forged ahead with commitment to a just, more inclusive world, where dignity of all and for all is ensured.

Research: Rwanda Referral Program Saving Cancer Patients’ Lives

Clinicians for Partners In Health in Rwanda saved more than 100 lives with a vital referral program that enabled cancer patients to access radiotherapy when none was available in the country, a study shows.

The program at a PIH-supported hospital in Rwanda’s Northern Province supported patients’ care, transportation, and housing at the Uganda Cancer Institute in Kampala, Uganda’s capital.

Without the referral, patients may not have been able to access radiotherapy, often a crucial component of cancer treatment.  

Dr. Cyprien Shyirambere, director of oncology for Inshuti Mu Buzima, as PIH is known in Rwanda, said nearly 60 percent of cancer patients need radiotherapy at some point in their care.

“Radiotherapy is just as important as the other modalities of cancer treatment, and with this study, we’ve shown that, even for a rural facility, referring patients outside the country is a feasible option, through rigorous selection and effective collaboration with radiotherapy centers in the region,” Shyirambere said.

The referral program began in 2012, shortly after the Butaro Cancer Center of Excellence opened its doors at the PIH-supported Butaro District Hospital.  The cancer center provides patients from across the country, and even from neighboring countries, with access to comprehensive cancer care, including histopathology services (microscopic examination of tissue) for diagnosis; chemotherapy; surgery; palliative care; and psychosocial support.

Due to cost constraints and an initial lack of a radiation therapy staff, the cancer center was not able to offer radiotherapy services when it opened. Clinicians tried to fill that gap by referring patients elsewhere, and providing them with financial support to access that care.

At the time, Rwanda was one of 28 African countries without a radiotherapy facility. So every month, Butaro clinicians selected 10 to 15 patients for referral to the cancer institute in Kampala, the nearest center with the capacity to provide radiotherapy services.

Testing for COVID-19 Along the Haiti-Dominican Republic Border

Following the first confirmed COVID-19 case on March 19, the Haitian government announced the closure of the country’s main point of entries, including ports, airports, and the border with the Dominican Republic.

For more than 15 years, Zanmi Lasante (ZL)—as Partners In Health is known in Haiti—has been providing health care at the border in Belladère at the Hôpital Notre Dame de la Nativité. In early March, ZL collaborated with the region’s health director to place a medical team at the Elias Pina-Belladère crossing, where migrants pass daily. As part of those efforts, the team has collected demographic and health information related to COVID- 19 and taken migrants’ temperature.

Despite the official closure of both sides of the border, native Haitians have self-deported by the hundreds daily in cramped buses, where they are unable to maintain social distancing and often travel without personal protective equipment, such as masks and gloves. Health experts fear that this unprecedented migration could fuel transmission of the virus throughout Haiti.

ZL has been involved in all aspects of the fight against COVID-19, but is uniquely positioned to respond to this need for screening along Haiti’s eastern border. Leadership and staff believe that prevention, especially stopping transmission through rigorous testing and contact tracing, remains essential for control of the pandemic.

Below, ZL staff working in Belladère talk about the process travelers undergo at the border, the reactions they’ve received so far, and why they believe this work is important in stopping the spread of COVID-19 in Haiti.

a mural in Haitian Creole educates about COVID-19 prevention
A mural in Haitian Creole in Belladère educates the public about staying at home, maintaining social distancing, and washing hands with soap and water to prevent the transmission of COVID-19. 

When did border testing in Belladère begin?

Testing at the border began on April 7.

Tell me about the COVID-19 screening process for travelers arriving in Haiti.

Upon arriving at the border, they are welcomed and invited to disinfect their shoes and wash their hands. Those who don’t have a mask are given one. Then they sit down in order of arrival while giving priority to pregnant women, travelers with children, and the elderly. They receive an educational session on COVID-19.

Afterwards, travelers go see a service provider, who is equipped with a tablet and a thermometer, and respond to a questionnaire. After the questionnaire is completed, they are invited to come to the lab, where pre-test counseling is done, and the test is completed.

Using rapid diagnostic tests (RDTs), trained personnel place a drop of the traveler’s blood onto a device that tests for antibodies, which are produced in individuals whose immune systems have successfully fought off the virus.

After about 15 minutes, RDT test results are available. If the test is negative, ZL staff reinforce advice on how to prevent the transmission of COVID-19, and the traveler is able to leave.

How many people have already been tested? And how many have tested positive?

As of this week, more than 1,750 people have been tested, with 39 positives. Of this last group, four travelers were confirmed positive for COVID-19 through a PCR, or polymerase chain reaction, test conducted later at a higher-level facility.

What is the process for those who are positive?

We proceed with meticulous counseling, while informing them that they are suspect cases and that another confirmatory test is mandatory. For this reason, they must be referred to ZL’s University Hospital in Mirebalais or to the ZL-supported hospital in Hinche to be quarantined and await results from a PCR test. PCR tests are only being analyzed by the National Lab in the capital of Port-au-Prince.

lab staff train on proper use of rapid diagnostic tests for COVID-19 in Haiti
Zanmi Lasante staff train on how to properly conduct a rapid diagnostic test for COVID-19.

Why did ZL decide to start testing at the border?

ZL leadership wanted to determine the maximum number of suspected cases passing through the Belladère border and, using that knowledge, help stop or reduce the spread of the virus throughout Haiti.

What type of reception has ZL staff received to this border screening?  

In general, people accept being tested. However, they often arrive in large numbers from a long journey—sometimes lasting several hours or even several days. If they could, they would avoid all screening to be able to continue on their journey home. We did have a case were two people who were in quarantine in Hinche escaped. But luckily, we were able to find them, talk to them about the importance of quarantine, and welcome them back into care.

What are people's reactions to being tested? 

This only poses a problem when the people being tested are asymptomatic, get a positive result, and must be placed in quarantine. They don’t want to be placed in quarantine, because they don’t think they are infected and just want to go home.  

Do staff feel nervous about being exposed to people who may test positive?

Staff doing the tests aren’t nervous about being infected, because they have proper personal protective equipment. Nevertheless, some are precautious and want to know their status before returning home so that they don’t put their families in danger on infection.

How do staff feel about the importance of this work?

Knowing that there are a lot of people who are infected in the Dominican Republic, they believe the work they are doing at the Belladère border is extremely important. It is important to know travelers’ status, because there is an imminent risk that they may be infected and subsequently may spread it to the Haitian population.

PIH Calls for Continued U.S. Funding of WHO

U.S. Sen. Rand Paul of Kentucky has proposed an amendment to terminate all United States funds to the World Health Organization, a plan that would have disastrous consequences and further erode U.S. credibility globally.

We believe Paul's proposal comes at a disastrous time amidst the global fight against the COVID-19 pandemic. It also arrives on the heels of one of the most important World Health Assemblies in the 73-year history of the WHO, in which all 194 member states voted to promote an equity agenda supporting access to diagnostics, treatment, personal protective equipment for health workers, and an eventual vaccine in the global pursuit to contain COVID-19. This is vital work, which PIH supports and advocates for on the international stage.  

Now more than ever, we need global solidarity and collaboration to contain the spread of COVID-19 and ensure that the most marginalized and vulnerable receive preferential access to these collective global goods.

Call your elected official

Contact your state officials to voice your concern for Paul's plan and make sure this doesn't receive Congressional approval.

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PIH Staff Picks: Essential Reading and Watching As You Stay At Home

As Partners In Health staff continue the organization’s vital work of strengthening health systems around the world—a mission that’s especially critical amid COVID-19—they’re drawing inspiration from a host of books and films. These stories of strength, struggle and perseverance reflect the passion for social justice that lies at the core of PIH and its work. PIHers around the world contributed to this list of recommended books and films—stories that uplift us during these uncertain times and shine a light on the challenges that they bring. We hope they can inspire and inform you, too.

Directed by Nadia Hallgren

“An inspiring, joyful, honest, behind-the-scenes look at Michelle Obama’s book tour—this is a “must see” for all! I enjoyed reading the book. Seeing this behind-the-scenes account was even more inspiring. As we are faced with so much negativity and adversity around us, Ms. Obama brought hope and inspiration to my heart and soul!  A very inspiring & uplifting documentary. If you have the opportunity to watch, please do!”

—Mary Cooper, Accounts Payable Accountant, Finance

The Undocumented Americans
Written by Karla Cornejo Villavicencio

“I’m currently reading The Undocumented Americans—a beautiful, raw and, above all, honest account of what it means to be an undocumented person in America. Through a series of essays covering over a decade of reporting, Karla Cornejo Villavicencio tells the stories of people who are all too often absent from journalism and writing about immigration today. There are the “second responders,” undocumented workers who responded to 9/11, stories of underground pharmacies/botanicas in Miami catering to persons whose legal status blocks them from receiving adequate medical care, the struggle for acknowledgment—and clean water—via a state ID in Flint, Michigan. Through it all, she weaves her intensely personal story of struggles with mental health, love, life and hope as an undocumented American. Inspiring and highly recommended.”

—Matias Iberico, COVID-19 Strategic Planning Coordinator, Compañeros en Salud (PIH in Mexico)

LAVIL: Life, Love and Death in Port-au-Prince
Edited by Peter Orner and Evan Lyon

“Through the direct voices of residents of Port-au-Prince, Haiti, you can hear a heartwarming message of courage, hope, pride and determination. With the struggle, crises and hardship they have been through, that message that couldn’t be any more relevant for me as a reader than during this pandemic craziness.”

—Jean Claude Mugunga, Deputy Chief Medical Officer, Population Health Planning and Financing

The Worst Hard Time: The Untold Story of Those Who Survived the Great American Dust Bowl
Written by Timothy Egan

“A powerful and highly engaging narrative about the Dust Bowl, Egan’s work tells the tale of the people who stayed and survived in Oklahoma through the 1930s. A tribute to their courage and the power of the human spirit, this book is also a frightening documentary of the damage that misguided government policy can do to an ecosystem, public health, and society itself.”

Andy Wilson, Chief Development Officer, Development

Directed by Rachèle Magloire & Chantal Regnault

“This interesting documentary touches upon social justice, immigration, culture and identity. The film follows several Americanized Haitians—who have never been to Haiti and are unfamiliar with the culture and language—before and after their deportations, capturing their struggles as they try to adapt to their new environments. Deported highlights the discriminatory policies within the American justice system toward foreign residents with minor offenses. Today, despite the COVID-19 pandemic, ICE continues to deport Haitians—some who have tested positive for the virus—putting the Haitian population at higher risk for transmission. This is a growing concern among human rights advocates as the number of COVID-19 cases continues to rise in Haiti."

—Coralie Noisette, Senior Development Officer, Zanmi Lasante (PIH in Haiti)


On Fire: The Burning Case for a Green New Deal
Written by Naomi Klein

"This collection of longform essays by journalist and non-fiction author Naomi Klein offers a detailed, powerful, and accessible account of the climate crisis, possible solutions, and its inevitable effects upon all members of society, but particularly on the most marginalized. With an eye toward the systems and practices that have created this crisis, Klein captures the deep-seeded need to fight this issue, not just for Earth, but for ourselves.  As we face a crisis of our own that requires sacrifice, expert consultation, and broad cooperative action, Klein's viewpoint and catalyzing words hopefully will serve for inspiration to come out of the COVID-19 crisis with a mindset toward rebuilding our systems with a sustainable focus.”

—Will Cleveland, Liaison Officer and Partnership Coordinator, UGHE, Rwanda

Long Way Down
Written by Jason Reynolds

“This book simply demands that you give it your full attention and read it cover to cover in one sitting. Written in verse, Long Way Down melds the power of poetry with the capacity to cultivate compassion in a way that is unique to narrative storytelling. Touching on the themes of racial justice, courage, and resilience, this book will leave a lasting imprint in your mind and heart.”

—Lauren Spahn, Senior Advisor to the CEO

Taika Waititi, Global Stars to Read Roald Dahl Classic to Benefit PIH

Partners In Health is thrilled to announce that Oscar-winning filmmaker and actor Taika Waititi will lead a glittering line-up of global stars in a multi-week reading via YouTube of the Roald Dahl classic James and the Giant Peach, to benefit PIH’s global work and response to COVID-19.

In the 10-episode series, the Thor: Ragnorak director will lead viewers through the beloved children’s story with help from megastars, including: Meryl Streep, Ryan Reynolds, Benedict Cumberbatch, Cara Delevigne, Chris and Liam Hemsworth, Cate Blanchett and Lupita Nyong’o.

The first two episodes are now available on the Roald Dahl YouTube channel. New episodes will be released every Monday, Wednesday, and Friday at 1 p.m. EDT.

Viewers will be encouraged to donate. The Roald Dahl Story Company has committed to matching the first $1 million donated and has a history of supporting PIH’s work. Ophelia Dahl, PIH co-founder and board chair, is the daughter of Roald Dahl, who was among the organization’s first supporters.

He believed deeply in the power of imagination to fuel important change, whether a vastly better health system, a more effective vaccine, or jobs for the most vulnerable,” Dahl said of her father. “Creativity and partnership are at the root of our organization.”

The campaign will support PIH’s critical work globally in the fight against COVID-19. Having successfully confronted infectious disease outbreaks for more than 30 years, PIH is uniquely positioned to respond to COVID-19, building on deep experience in treating epidemics and responding to emergency situations around the world.

In addition to its global efforts, PIH recently announced the expansion of its national efforts to fight COVID-19 with the launch of a new unit aimed at helping under-resourced public health entities in the U.S. build and refine contact tracing programs. The U.S. Public Health Accompaniment Unit follows the launch of PIH’s Community Tracing Collaborative  in Massachusetts.

PIH knows that the best way to defeat any new disease is to rely on and invest in local health systems that deliver high-quality, dignified care. Through health system strengthening and long-term partnership, PIH offers an antidote to despair and demonstrates that injustice has a cure.

PIH to Support COVID-19 Response Across U.S.

Despite its vast clinical infrastructure, the United States’ struggle to respond to COVID-19 has exposed weaknesses in the public health system, which are proving to be particularly devastating for vulnerable populations. For the past three decades, Partners In Health (PIH) has been at the forefront of global health interventions in the most resource-poor settings around the world, including widespread response to epidemics such as HIV, tuberculosis, cholera, and Ebola.

When the novel coronavirus pandemic swept the globe in early 2020, PIH was asked by the Commonwealth of Massachusetts to mount an unprecedented contact tracing initiative to help local boards of health cope with the expected surge of positive cases of COVID-19, the resulting disease.

PIH recognized the opportunity to share its decades-long and unique expertise with many U.S. partners, who are desperately struggling to implement complex interventions such as contact tracing not only to flatten but to shrink the curve of the virus, help protect communities and health care workers, and return to normal life.

A Vision For the Future

Since its very beginning, PIH has brought the benefits of modern clinical expertise to the most resource-poor settings around the world. Over the years, PIH has built, in close partnership with local ministries of health, a vast and unique experience implementing nimble and effective public health interventions.

PIH leaders have always known that such experience could be valuable to many other governments across the globe, including resource-rich nations like the U.S. The replication of those hard-earned lessons at the global level is the ultimate step in PIH’s theory of change, which is built on the integration of direct provision of care, rigorous research, and professional training.

This moment is a perfect opportunity to shift the paradigm of global public health towards an inclusive and equitable redistribution of health resources.

And that is why PIH is launching the U.S. Public Health Accompaniment Unit, which will engage U.S. government agencies, local jurisdictions, and their implementing partners with two interrelated components: 1) direct technical advisory services and 2) a newly formed Learning Collaborative.

Caring for a Campus: Nurse Andre Ndayambaje Leading Health Services at UGHE

Andre Ndayambaje said the first baby he ever held was his sister’s—in a tragic setting that he will never forget.  

“It was during the 1994 Genocide against the Tutsi in Rwanda, and my sister gave birth in the forest,” Ndayambaje said. “It was raining and cold, and I didn’t know what to do when I held the newborn covered in blood. We were saved by the loud sounds of my crying for help. From that moment, I wanted to be a nurse or midwife, someone who could help another in times of need.” 

Ndayambaje has more than fulfilled that ambition.

Andre Ndayambaje trains a midwife in newborn care
Andre Ndayambaje teaches a midwife how to help a newborn baby breathe.

He’s worked for 11 years as a senior nurse midwife in critical care units, providing neonatal care, and has been a master trainer, educator, activist, and project manager for maternal and newborn health programs. He’s held executive positions with organizations supporting nurses, including serving as president of the Rwanda Association of Neonatal Nurses. And he’s a 2019 graduate of the master’s in global health delivery program at the University of Global Health Equity (UGHE), a Partners In Health initiative in northern Rwanda.

Now, as UGHE’s health services coordinator, Ndayambaje provides mental and physical checkups for the nearly 100 staff, students, and faculty living on the university’s campus in the rural community of Butaro.  

As the world celebrates International Nurses Day, the World Health Organization continues its ongoing Year of the Nurse and Midwife, and, of course, amid the global COVID-19 pandemic, the role and contributions of nurses like Ndayambaje have never been more important.

Ndayambaje said the pandemic has revealed the extent of nurses’ and midwives’ work, and their vital roles in health care.

“It has greatly added to the workload for nurses and midwives,” he said, of COVID-19. “Mothers are still coming for care as the cycle of life continues, and nurses are still handling other conditions (and) routine health problems, on top of caring for patients with COVID-19. It doesn’t go away in times like these.”

Personal sacrifices to keep patients safe also are increasing, unfortunately, during the global battle against COVID-19.

“There are nurses in almost every country who have lost their lives at the hands of this pandemic, nurses suffering physical and mental hardship in the face of long hours and emotionally draining patient circumstances, and nurses’ families who will suffer either the absence of a mother or father, or else risk increased exposure to transmission at home,” Ndayambaje said.

Andre Ndayambaje, center, with colleagues in eastern Rwanda
Andre Ndayambaje, center in black jacket, stands with colleagues while serving as a maternal and newborn specialist for a USAID project in Rwanda's Eastern Province. 

But that doesn’t change his dedication, or his optimism.

“As a nurse-midwife, I feel so proud of my colleagues across the world who are reaching patients where others don’t dare to reach,” Ndayambaje said. “By fostering collaboration between health workers, investing in fragile health systems, and providing the right tools to nurses on the frontline, we will beat this virus, and outbreaks to come.” 

Read more about Ndayambaje and the university’s new Center of Nursing & Midwifery, via UGHE.

UGHE Student Mothers Balancing Studies and Family, Amid COVID

Balancing full-time academics and raising a family is hard enough. Amid the global COVID-19 pandemic, student mothers at the University of Global Health Equity, a Partners In Health initiative in northern Rwanda, are facing additional pressures and difficult decisions felt by families everywhere: How to continue studies while also supporting children and spouses who live far away, including in different countries; whether to stay on campus or return home; and above all, how to keep themselves and their loved ones healthy and safe.

For Mother's Day, three UGHE students share their stories of perseverance amid the pandemic, and how they are working harder than ever to become future global health leaders. Their full profiles will be shared Sunday by UGHE. Here, we present introductions, of Sosina Dessalegn, Salome Sijenyi, and Grace Chinelo Okengwu. 

New Mom Holding Baby Daughter Close After Early Birth in Liberia

As Liberians celebrate Mother’s Day throughout May, on different dates according to different religious leaders and churches, one new mother in particular is thankful for her first child and newfound joy.

Because for Jacqueline Bedell, 23, motherhood did not come easy.

Bedell was six months pregnant when she visited Pleebo Health Center, one of the facilities supported by Partners In Health in southern Liberia’s Maryland County. Pleebo District is home to more than 55,000 people, who visit the health center for care and treatment in areas ranging from hypertension and diabetes to tuberculosis, HIV, and emergency needs.

Bedell was visiting for her regular prenatal checkup, part of the health center’s maternal and child health services. Her visit became far from routine, though, when clinicians diagnosed Bedell with preeclampsia, a condition associated with high blood pressure during pregnancy.

World Needs Public Health, Nursing to Lead Way in Global Pandemic

This is not the celebratory Nurses Week I had imagined for 2020. This being what the World Health Organization named the Year of the Nurse and Midwife, I had visons of a week filled with celebrations and social media highlights of the amazing nurses who work at Partners In Health (PIH) globally. This year will instead be remembered as the time of the COVID-19 pandemic and talk of isolation, quarantines, and a different life for all of us. 

All over the world, we are seeing people honoring and celebrating nurses and all frontline health workers. There are music, lights, horns blowing, and pots and pans making a cacophony of sounds every evening in some cities—all to pay respect to our essential workers. The word “hero” is being used a lot, fitting I think in many circumstances.

But there is also an uprising of health care workers who do not want to be called heroes; they want a safe place to work and provide care for their patients. These frontline workers make sacrifices every day. There are many things that cannot be controlled in a health care environment, but access to protective equipment is not one of them. This can happen with the right strategy, planning, and prioritization by those in power.  

We also need to acknowledge and give thanks to all of the frontline workers who are risking their lives, including those who work in stores, those harvesting and hauling our produce, firefighters, police, and countless others who make the machinery of our lives function. 

COVID-19 and health disparities

The United States spends the most per capita on health care, yet trails other countries in many health indicators, including life expectancy and infant and maternal mortality. The disparities that underlay those statistics—such as access to care along racial and economic lines—are becoming even more pronounced during this pandemic. People living in small spaces with many others are not able to safely quarantine or isolate themselves if exposed or infected with COVID-19, leading to high rates of familial transmission. Food insecurity and the reliance on public transportation are most likely increasing risk for infection, while the disappearance of many service industry jobs is further compounding the disease’s assault on communities.

COVID-19 is not the great equalizer, and those who say viruses are equal opportunity infectors are wrong. APM Research Lab is tracking mortality rates from the 38 states that are releasing that data. The existing data are deeply disturbing and reveal deep inequities by race, especially for Black Americans. The latest available COVID-19 mortality rate for Black Americans is 2.3 times higher than the rate for Asians and Latinos, and 2.6 times higher than the rate for Whites. 

patient is tested for COVID-19 at a shelter on Navajo Nation
A patient is tested for COVID-19 at St. Joseph's Shelter on the Navajo Nation. Photo by Robert Alsburg / COPE

We also know that Navajo Nation has been severely impacted. As of May 4, the Navajo Nation had reported a total of 2,373 cases and 73 confirmed deaths from COVID-19.  With a rate of 46 deaths per 100,000 people, the tribal nation has a higher coronavirus death rate than every state in the country except New York, New Jersey, Connecticut, and Massachusetts.  PIH’s sister organization, Community Outreach and Patient Empowerment (COPE), is working hard to provide support to the Navajo Nation.

For the first time, many people in the U.S. are worrying about whether hospitals have enough ICU beds, whether their loved ones working there have enough gloves and masks to protect themselves, and whether they themselves have enough food at home as income evaporates. These worries have always existed for vulnerable populations living in this country, and even more so for those who work in the PIH global sites in Africa and Latin America. 

Global North learns from Global South

With the first reports of the arrival of a new virus, we at PIH looked to our global experts in Rwanda, Haiti, Peru, Liberia, and beyond for guidance in responding to this pandemic and lessons learned from others. Rwanda has an aggressive COVID-19 strategy and has had a lot of success keeping transmission under control with comprehensive public health measures. Our colleagues in Haiti treated and hunted down cholera in 2010. In Peru, our community health workers conducted contact tracing for multidrug-resistant tuberculosis cases and prevented countless deaths. And to eliminate Ebola in Libera and Sierra Leone, we employed survivors who helped track down the virus’s spread in their communities to stop transmission and end the epidemic there.

nurse puts on protective equipment before treating Ebola patients in Sierra Leone
Nurse Musa Sillah, who grew up in Sierra Leone and returned to the country to help PIH combat the Ebola epidemic in 2015, dons personal protective equipment at a treatment unit. Photo by Rebecca E. Rollins / Partners In Health

Technology is great; we push for access to the best tools to monitor and evaluate care. But these tools can only support the most crucial players in the battle against a global pandemic—human beings.  At times of stress, sadness, and fear, we all seek human connection, compassion, and empathy. There is no app for that.

In the vast majority of PIH sites, we do not have access to ventilators, but are doing the best we can while we continue to fight for more. Alongside our colleagues in the ministries of health, we are working hard to improve hospitals and make sure there is 24-hour electricity, running water, oxygen, and essential medications to try and stabilize critical patients.

But we are not there just to respond to COVID-19. We have already been there for years, in some cases decades, because PIH made a long-term commitment to the countries where we work. And we will stay there, as long as we are needed. Just as with HIV, TB, Ebola, and other challenges to the health system, we need to fight the immediate danger in front of us AND continue to build or strengthen national health systems. 

Lessons from a pandemic

When working in West Africa during the 2014 to 2015 Ebola outbreak, home was a place of refuge for me each night. This feels very different to me now, as home can feel often like a fortress to keep the world out and not a place for rejuvenation. This has increased my awareness of and empathy for my colleagues, whose homes are in the communities where we work globally. As much as I thought that I had appreciated the duality of working and living in the same place in the midst of an epidemic, I know now that my experience was surely different than my West African colleagues. Just as we turned to our colleagues to teach and guide us through large-scale contract tracing, I am also relying once again on my mentors and teachers from PIH country sites to learn how to respond to crises in my own backyard.

Dr. Sheila Davis consults with colleagues during the Ebola epidemic in West Africa
Dr. Sheila Davis (center), PIH's CEO and an expert nurse, and Dr. Anany Gretchko Prosper, who led PIH's Ebola response in Liberia, speak with an MSF colleague during the epidemic in October 2014.

As the pandemic has run rampant throughout the U.S., it is painfully apparent that this country is ill-prepared, despite spending the most on health care in the world. Our health care system has been built around high-tech solutions in elaborate hospitals that provide the most advanced level of acute care. There is no doubt that that is very much needed. But what we do not have is a robust public health system that can identify and address pathogens and illnesses where they appear—within the community. We need a system that strives to address health and illness and relies on an interdisciplinary team to provide care in people’s homes, schools, places of worship, and community gathering places.

Lilian Wald & Florence Nightingale

We need Lilian Wald. Lilian was a 26-year-old nurse who settled in the lower east side of New York in 1893 and who, two years later, opened the Nurses Settlement (later called the Henry Street Settlements). She believed that poverty was the result of societal structural forces and worked with the most vulnerable communities to connect them with health care. She saw people in their homes, saw their challenges, and fought to provide a dignified approach to care for all.

Lack of access to clean water, electricity, food, and quality health care is not just an example from Lilian’s days; it is an issue in the U.S. and globally today. We need a strong public health nursing presence today during COVID-19 and long after.

For decades our public health systems have been defunded and dismantled. If there is even a sliver of a silver lining to this pandemic, it is that a light has been shown on the U.S.’s lack of a comprehensive health care model that connects a community to a clinic to a hospital and back again. We need health care that is embedded in communities as the norm. Epidemic control is local and needs local solutions supported by a strong network at the state and federal levels. We need excellent hospitals, but as a part of a continuum of care delivery, much of which can be done more effectively, efficiently, and less expensively in the community.  

Nightingale fellows at graduation ceremony in Boston
The first graduates of PIH's Nightingale Fellowship, which provides professional development for global nurse leaders. From left to right: Viola Karanja, Graciela Cadet, Angeline Charles, and Emmanuel Dushimimana.

Nursing as a profession must answer this call. Let us lead the way and shift the locus of health care away from the hospital and bring it back into the community. Lilian would be proud.

May 12 is the birthday of Florence Nightingale, the modern-day founder of nursing, and the last day on which we celebrate Nurses Week. On that day, I will stop, remember her and Lillian Wald, and think about the PIH nurses and midwives who are working hard combatting COVID-19 and delivering all of the other amazing care they provide every day.  I will then do what nurses always do—I will go back to work. 

Q&A: Combating Sierra Leone’s Maternal Health Crisis Through COVID-19

As the novel coronavirus continues to spread, patients aren’t just at risk of contracting its resulting illness, COVID-19. They also face higher risk for all other health issues, as many facilities must divert resources from routine medicine to emergency care. What’s more, COVID-19 is preventing families from seeking the care they need. Fear of the virus is spreading alongside the virus itself—and could prove just as deadly.

Expectant mothers across the globe find themselves uniquely impacted by these new barriers to health care. Nowhere in the world is the situation more acute than in Sierra Leone, where a woman’s lifetime risk of dying in pregnancy or childbirth is already 1 in 17 during non-pandemic times—the world’s worst maternal mortality rate.

Isata Dumbuya, a nurse midwife and manager of reproductive, maternal, neonatal, and child health for Partners In Health in Sierra Leone, has been working to combat these barriers in the maternity wards at PIH-supported Wellbody Clinic and Koidu Government Hospital in Kono District. Last year, the facilities provided more than 2,200 safe deliveries—a number that rises annually.

Isata Dumbuya stands in the maternity ward at Koidu Government Hospital. Photo by John Ra  / Partners In Health
Isata Dumbuya, pictured in the maternity ward at KGH.  

COVID-19 case numbers are also rising. PIH has been preparing Kono for a possible outbreak, as well as assisting the government with national response efforts, as the number of known cases increases past 200 in the country of seven million people.

“What we don’t want,” Dumbuya said, “is fear of COVID preventing women from coming into the hospital to access normal services that would improve their health and prevent them from having other morbidities that have nothing to do with COVID.”

We caught up with Dumbuya to hear more about the intersection of a longstanding epidemic—maternal mortality—and the new pandemic of COVID-19, and the measures PIH is taking to fight even harder to protect women and infants in Sierra Leone.

What impact has the coronavirus pandemic had on maternal health at Wellbody Clinic and at Koidu Government Hospital?

Dumbuya: Like most of the departments in the hospital, we did see a reduction in the number of women who came in, primarily for prenatal care. They are probably thinking, "This is not an emergency. I'm well, and I would rather save myself a journey into the hospital." Because there was a lot of uncertainty and fear around coronavirus, there was a common misconception in communities: "Don't go to the hospital." Women who might want to come for prenatal checks were being told, "Don't come."

We also saw, in the initial periods at least, that women who did come into the labor ward were much further along in their labor than we would like, so we didn't have a lot of time to monitor them or put interventions in place to have a better outcome. Women come in late most of the time, but this was just getting to later, critical stages, and there were fewer of them. For the first couple of weeks, almost every woman who came in ended up with a cesarean section.

A delivery room at Koidu Government Hospital. Photo by John Ra  / Partners In Health

And were fewer patients arriving for care generally at the hospital?

Before, you would come into Koidu Government Hospital and there's usually a crowd of people. Some are patients, some are waiting, some have accompanied patients. That stopped. The few that had to come in were the ones that had no choice. And when they came in, they came in with one person. Usually the average rate of accompaniment is three people per patient. They were coming in with one person at a time and trying to get out as soon as they possibly could.

That was the same during Ebola, too. Most people in Sierra Leone never had Ebola, but were dying from malaria, tuberculosis, HIV, car accidents—everything that was affecting people before Ebola.

But it's getting better. We're getting more women to come in. We’re almost back to normal. In the prenatal clinics, especially at Wellbody, the numbers have started to increase. It's good to see that they're willing to come back. Patients are walking back in and seeking care, which is one of the things that we feared the most, one of fallouts: "These people are not gonna come to the hospital, and when they do come, they're gonna be critically sick, and we're gonna have more and more poor outcomes."

Pregnant women wait for their prenatal care appointments at Wellbody Clinic in 2018. Prenatal services at the clinic saw a drop in patients after COVID-19 was confirmed in Sierra Leone. Photo by Emma Minor / Partners In Health
Pregnant women wait for their prenatal care appointments at Wellbody Clinic in 2018. Prenatal services at the clinic saw a drop in patients after COVID-19 was confirmed in Sierra Leone. Photo by Emma Minor / Partners In Health

Before coronavirus, you were going out to the different chiefdoms around Kono District to educate community leaders and families about the services available at KGH and Wellbody. Have you been doing any outreach since the coronavirus pandemic started?

I was really lucky to be part of the engagements with community health workers and other community stakeholders, explaining step-by-step what coronavirus is, the impact that it's having all over the world, how we are preparing to minimize the potential for us experiencing the same level of infection and death. And also just trying to get people to understand that the hospital is still open. Having that interaction, it allayed a lot of the people's fears. It generated a lot of questions. They seemed to understand a lot more about COVID by the time we were done and were willing to take the message forward and say, "Now we know, we are also less fearful, and we will let our people know and encourage them, 'You have to come to the hospital.'"

Maternal mortality in Sierra Leone has been an emergency for decades for women and children. What would you say to those who may be worried about COVID-19’s impact on plans and strategies to radically reduce maternal mortality?

With COVID, yes, this is the foremost thing, not just in Sierra Leone, but in the whole world at the moment. But there will be life after COVID. Maternal mortality in Sierra Leone still continues to deteriorate despite COVID, until we get more and more structured systems in place.

We're still pushing forward and realigning our plans with COVID. We're getting more and more ideas about things that we perhaps hadn't thought about or hadn't put very high on the list. We need more isolation units. We need more staff trained in high-dependency care. We're going to need more equipment, so that in the future, whether it's COVID or anything similar, we need to build in more critical care intervention for pregnant women.

The maternity ward at KGH, empty of patients.
The maternity ward at KGH during an abnormally calm weekday with few patients. 

One of the biggest differences between coronavirus and Ebola times is that health care in Kono has come such a long way; patients will still have access to the care they need in a way they didn’t during Ebola. What are some of the standout improvements you've seen in the maternity wards and in reproductive and maternal and child health care in Kono since you arrived?

There's so much. I remember when I first started here in 2018—the difference from then to now with staff motivation. We've had a few new staff, but most of them I met when I started. They now come to work because they really want to. They come in determined to do a great job and to enjoy doing their job.

We recently did a weeklong training, because we're opening up a high-dependency unit in maternity. This is also something new. We are able to look after critically ill women in a dedicated space—with staff that are now happy to come to the training. There’s a higher level of motivation, of pride that they take in their work, and of interest.

A woman recovers in the maternity ward at Koidu Government Hospital.
A woman recovers in KGH's maternity ward. 

That transformation makes sense—going from having no resources and not being able to intervene to save a woman’s life to having resources, training, supplies, electricity, and a blood bank.

Women should not die in pregnancy. She should not die when she comes to give birth. This is not something that we should just take lightly anymore. This is something that we should do everything, with the resources, knowledge, finances that we have, to prevent from happening.

What's keeping you motivated and energized during this moment?

Every day I come in to work determined to support the staff I'm working with, both PIH staff and the Ministry of Health, to do the best they can in terms of patient care to help women and babies. The care that we give is intended to not just save lives, but also to improve their whole reproductive journey, to make it special and different from anything they've ever experienced.

Meet the Mental Health Warriors of Sierra Leone

At Partners In Health (PIH)-supported Koidu Government Hospital (KGH) in Kono, Sierra Leone, PIH’s mental health care team gathers in their office, the walls covered with evidence of their work: posters detail their schedules and contact information; fliers bear educational messages about the hospital’s mental health care services; and shelves reveal tomes of records for each patient they’ve treated.

Their efforts began just over one year ago, but have already made a world of difference.

In partnership with the government of Sierra Leone, PIH formally established mental health care programs through KGH and nearby PIH-supported Wellbody Clinic in February 2019. The mental health team—comprised of eight community health workers (CHWs) trained in mental health care, three psychosocial counselors, a program manager, and a psychiatrist—works to destigmatize mental health conditions within communities around Kono and provide essential therapy and medication to people living with conditions like depression, psychosis, and bipolar disorder.

Posters in the mental health office at KGH
Posters destigmatizing epilepsy--which falls under the purview of mental health in Sierra Leone--and encouraging  people to pursue care like group therapy hang in the mental health office at KGH.

Such services had never been as robustly available in Kono, an eastern district located hours away from Sierra Leone’s only dedicated mental health facility in the capital of Freetown. Beyond the biological roots of mental health conditions, which disregard history and geography, Kono’s population of 500,000 contend with ongoing trauma from Sierra Leone’s decade-long civil war, historic Ebola outbreak, and day-to-day reality of extreme poverty.

As the mental health team supports individuals and their families during regular home visits and connects patients with the district’s first and only psychiatrist, more people than ever before are accessing the care they need to live independent, healthy, productive lives. By December of last year, more than 750 patients were receiving mental health care at KGH—up from 115 patients in December 2018.

Patient records at KGH
Patient records stored in the mental health office show that 2019 was the year with the highest volume of mental health patients receiving care at KGH to date.

Alongside the longtime need for mental health services in Kono, personal experience drives the work of each PIH mental health care provider in Sierra Leone. Below, meet some of the team members, and learn about the inspiration behind their efforts to make mental health care a human right.


John Kamara

*John Kamara, mental health CHW at Wellbody Clinic: I was an Ebola patient. I managed to survive with help from people really caring for me, spending their time with me, talking to me, building my confidence. That kind of love, and the hope and courage they built in me—it’s the same thing I want to extend to my patients. I was run down like them. I want to give back to them the mental support that was given to me.

Kumba Judith Conteh

Kumba Judith Conteh, psychosocial counselor at KGH: I was once a refugee. When the [civil] war broke out, my family and I went to Guinea. Being a refugee, you also have mental illness, because you leave your home forcefully and go to another man’s country. But people were caring for me; there were NGOs that were going around to talk to us about how to adjust to our situation as refugees. When I came home to Sierra Leone, I found myself in the mental health program. I’m really happy about it. I’m passionate about giving care to other people, helping somebody who is in need.

David T. Mafinda

David T. Mafinda, psychosocial counselor at KGH: During the war, as a refugee in Guinea, the Center for Victims of Torture’s program trained and employed me as a psychosocial counselor. When I came back to Sierra Leone, my colleagues from Guinea and I started a local version of that program. We called it the Community Association for Psychosocial Services. During Ebola, I volunteered as a counselor at Koidu Government Hospital. And this year, PIH came and took me on board as a full-time, paid staff member. This is my field—I love giving help to my people.

Mary Kargbo

Mary Kargbo, psychosocial counselor at KGH: I was one of the refugees in Guinea. Because I didn’t have any relatives there, and because of what I saw during the war, I wanted to kill myself. But I worked with some angels who taught me how to take care of myself and others, and when I returned to Sierra Leone, I was trained by the Center for Victims of Torture as a psychosocial counselor. I was a volunteer at Koidu Government Hospital, and then PIH hired me. I see myself in my colleagues and patients. I empathize with them and know the pain they are going through or have gone through, and that compassion drives me to take care of them. I know the benefits that mental health support gave to me, so I love this work and our program.

Lansana Kamara

Lansana Kamara, mental health CHW at KGH: I feel relieved to work on [mental health care with] my fellow human being, who to me has lost his senses and cannot concentrate. I enjoy working with such an individual to regain his consciousness. I feel passionate that if I achieve that, I will be rewarded in the kingdom of God.

Cathy Conteh

Cathy Conteh, community health officer at KGH: If we think about the horrors that have happened here—from the war in 1991 to the Ebola outbreak—and looking at our people, they have really been suffering. Now, with support from PIH, people have the knowledge that mental illness is a condition, just like malaria. It can be treated. Seeing people on treatment, who now fit into their community, they are really grateful.


*Comments were edited and condensed for clarity.

Going on the Offensive to Stop COVID-19

Global Situation in the Time of COVID-19

Recommendations for Next Stimulus Package -- Necessary Funds to Rebuild our Public Health Infrastructure

Closing non-essential businesses and services and implementing stay-at-home orders and lockdowns has not been easy. Yet these steps are working in flattening the curve and reducing the number of contacts that each person who tests positive has had. It is essential we take advantage of the time these measures have bought us, and fully implement four key elements of a robust public health response: testing, contact tracing, supporting those of us who have been exposed to successfully quarantine, and helping isolate and care for those of us who have the disease.

Moving too quickly to re-open non-essential services without all of these four key elements in place will spark a resurgence of the epidemic, cost more lives, and wreak even more economic damage than the first wave of this outbreak. Moreover, every state needs to implement these strong public health strategies in unison: failures to contain the virus in one state will impact all states. We thus urge the federal government to provide strong incentives for all states to invest in and rapidly scale these public health measures.

1. Testing

The slow ability to increase testing capacity nationally has been our Achilles heel in our ability to contain the spread of COVID-19 in the U.S. We are happy to see provisions of $25 billion for increased testing capacity in the stimulus package approved on Thursday, April 23rd, and hope that additional testing will come online rapidly in the upcoming weeks. All positive test results must be linked to public health surveillance database so that case investigators and contact tracers can do their jobs. Moreover, testing needs to be expanded in an equitable way, such that those communities with the highest numbers of cases and most vulnerable populations are prioritized.

2. Contact Tracing

We recently worked with U.S. Rep. Andy Levin and U.S. Sen. Elizabeth Warren to inform their Containment Corps strategy announced on April 22, focused on addressing the shortage of public health jobs for the long term and rapidly putting community members who lost jobs due to COVID-19 back to work for the public good.

Currently there are only 2,200 contact tracers on CDC payroll in the United States. Roughly 50,000 public health jobs have been lost since the Great Recession, and public health departments simply don’t have the resources to hire the people they need; in 2019, the federal government spent $265 million less on public health preparedness than in 2002.

What we’re left with is a hollowed out public health system that knows how to beat this virus, but doesn’t have the resources to do it. Short-term surge capacity for contact tracing must work to reinforce existing departments of public health in each state and incorporate federally qualified community health centers (CHCs), and link to their existing public health data collection systems, rather than creating a completely parallel, privatized system.

This is what Gov. Charlie Baker and the Commonwealth of Massachusetts’ Contact Tracing Collaborative (CTC) commenced on April 3rd.

Tech-enabled solutions for contact tracing, such as those announced by Apple, Google, and Novid, can be strong complements to the human-to-human components of the MA CTC approach. As stand alone solutions, the technology may have limitations, especially when it comes to helping to provide psychological first aid for people learning of their positive status or that they were in contact with someone who tested positive, and in linking contacts to necessary resources to ensure they can safely quarantine or isolate.

3 & 4. Supported Quarantine and Isolation

Identifying positive cases and their contacts is essential, but it is a first step. People who have been exposed to the virus, but who are not yet sick, need to be in quarantine for a minimum of 14 days. Those who become infected need to receive medical care and remain out of physical contact with others for three days after the resolution of fever, for a minimum of 7 days.

Many people need support—financial, material, medical and social—to successfully complete stints of quarantine and isolation. It is worth emphasizing that if people are unable to adhere to quarantine and isolation, and go on to infect others, the testing and contact tracing program will be  ineffective, and the outbreak will not be brought under control. It is imperative that people be given the supports they need to be successful in this regard.

Studies from past quarantines demonstrate consistently that quarantine and isolation failures are driven primarily by food and job insecurity. We anticipate people will require a range of supports including food and cash assistance, home delivery services, medical support, and social services like dependent care, mental health and substance abuse counseling. Careful attention to the needs of marginalized communities will be necessary. Social support specialists from communities with highest need and highest case burden should be hired to add to existing social worker numbers and work to identify community resources and connect each case and contacts to these resources.

Already the MA CTC is finding that people are afraid to receive calls from contact tracers due to their immigration status. Given the inequities that exist in our society, many immigrant communities remain key hot spots for coronavirus spread. All people currently in the U.S., regardless of their immigration status, must be treated equally and provided the same access to testing, isolation and treatment if we are to succeed in stopping the spread.

A further consideration is that many people’s homes are not conducive to quarantine or isolation. They are too crowded to avoid spreading the infection to others in the household, or they are not safe. Establishing safe non-residential quarantine and isolation facilities in local hotels and universities can further reduce transmission and should be considered.

We are in the process of modeling the costs of home and non-homed based quarantine and isolation, as well as the costs of not providing these supports. We expect federal investment in these measures will be well worth the price, given the alternative of the high cost in lives and livelihoods that will result from an unchecked epidemic, especially among our most vulnerable communities where we’re already seeing the correlation between poverty and COVID-19 transmission.

Financing the Public Health Response

The federal government can provide financing for the public health response in a number of ways. For example, channeling public health financing to states through expansion of TANF, SNAP, SSI, or Medicaid or other federally subsidized programs, or creating a new one, should be considered.

War Bonds are one potential mechanism we also think has potential. War Bonds are a funding concept that have enjoyed wide popularity since they were first issued in 1917, particularly in times when citizens are motivated to show their patriotism and willingness to pull together as one nation. Using the War Bond model, “COVID Victory Bonds” would be long dated (30 years) debt instruments issued in small denominations for the retail public and backed by the credit of the U.S. Government. The bonds would be issued at below face value, with little or no annual interest, but would be guaranteed to double in value on or before maturity.

Our proposal would be for the federal government to disburse this funding to states to distribute solely for the purposes of stopping the COVID epidemic. This would entail funding state-operated testing and contact tracing programs and providing funds for individuals asked to quarantine or isolate themselves, including sufficient subsidies for food and housing, means-tested income replacement, and a range of support services.

If you believe this is a solid plan for battling COVID-19 and funding a national response, please reach out to members of Congress and share this proposal.

Look Up Your Elected Official

Keeping the Flame: UGHE Student Reflects on Rwanda's Post-Genocide Growth

Orietta Agasaro is a student in the master's in global health delivery program at the University of Global Health Equity (UGHE), a Partners In Health initiative in northern Rwanda. 

When I think about what Rwanda has surmounted in the last 26 years, I’m reminded of a passage from A Tale of Two Cities by Charles Dickens: “I see a beautiful city and a beautiful people rising from this abyss. I see the life for which I lay down my life, peaceful, useful, prosperous and happy.”

I, like many others in my generation, have the immense privilege of enjoying security, peace, and freedom in my daily life. As I reflect on this year's Kwibuka ("to remember" in Kinyarwanda), the 26th annual commemoration of the 1994 Genocide against the Tutsi, I have a heightened awareness of what was sacrificed – toil, suffering and even lives – to put a stop to the genocide.

I was born after the 1994 Genocide against the Tutsi, and am one of the post-genocide generation acutely aware of the suffering endured by more than 1 million victims, and of those who compromised their health and even gave their life to end the violence. I am also indebted to the valiant men and women who have, in the years that followed, given their all for Rwanda’s rebirth and reconstruction. 

Unity, Community in Rwanda's Rebirth

Growing up, I remember being taught about the ethnic divide that led to the genocide, but also about the concept of Ndi Umunyarwanda ("I am Rwandan"). Ndi Umunyarwanda is a national program that aims to promote unity and reconciliation by encouraging conversation about the causes and consequences of the genocide, and about how to rebuild the country by focusing on the national theme, “Remember-Unite-Renew." 

Rwanda was able to advance significantly in its pursuit of unity and reconciliation through several home-grown solutions, implemented at the community level. Those include the gacaca (local community courts); abunzi (community mediators); itorero (youth civic education camps); ingando (solidarity camps); and many more. I had the opportunity to attend an itorero camp in 2015. It not only broadened my knowledge of Rwanda’s history, but also reinforced my Rwandan values, namely Ndi Umunyarwanda. 

UGHE students are participating in this month's Kwibuka remembrances with on-campus activities, discussions, and more.
UGHE students, staff, and faculty are participating in this month's Kwibuka remembrances with on-campus discussions and activities, including lighting candles to symbolize Rwandans' hopes for a bright future. 

The national adherence to, and application of, Ndi Umunyarwanda and home-grown solutions have driven Rwanda’s rapid and impressive development.

Looking at the milestones my country has achieved, I cannot help but feel overwhelmed by a sense of pride and thanksgiving. As a young woman, I take pride in knowing that women have been, and currently are, important actors in Rwanda’s reconstruction and development. It gives me hope and confidence for my future, and for the future of my female friends and classmates.

Gender Equity

In my country, the promotion of women is one of the many milestones birthed through this focus on unity, particularly in decision-making and leadership positions. Rwanda has been recognized globally for its tireless efforts in promoting gender equity across all sectors; we are proud to have the highest percentage of women in parliament anywhere in the world.

Our health sector is exemplary in this regard, and its systems were revived and rebuilt by many strong and resilient women in Rwanda, including UGHE’s Vice Chancellor, Prof. Agnes Binagwaho.

When she gave a lecture to my master's in global health delivery class, I was inspired by her clear dedication to improving health care delivery, upon returning to a devastated country and finding innovative ways to promote health for all, and especially for the most vulnerable, in the post-genocide era. Her lecture reminded me why I wanted to study global health delivery in the first place: to contribute to my country’s efforts to improve the health and well-being of the poor and vulnerable.

I also look up to other pioneers in the rebirth of our health system, including Rwanda's First Lady, Her Excellency Mrs. Jeannette Kagame; Dr. Yvonne Kayiteshonga, the national director of mental health at Rwanda Biomedical Center and the Ministry of Health; and the many, many female health providers and community health workers on the frontlines, who tirelessly work to improve the health of Rwandans daily.

UGHE at sunset
The national flag flies over the University of Global Health Equity in northern Rwanda, with Mount Muhabura in the background. April is an annual time of genocide remembrance in Rwanda. (Photo by Nick Carney / UGHE) 

Health Care for All

Rwanda’s strong national governance, paired with leadership at the community level, has been key in finding equitable health solutions that promote health care for all.

From the examples set by these women, I’ve learned that a focus on social justice and a strong moral compass are two cornerstones to success. With scarce resources, Rwanda has managed to transform a broken health system into one that is acclaimed worldwide, through its evidence-based, community-oriented, and equity-driven approach to health.

After the complete devastation the health system experienced in 1994, some would call it a miracle that 15 years later, more than 90 percent of all Rwandans were medically insured, with the poor receiving free health coverage through Rwanda’s Mutuelle de Santé (Community Health Insurance) program.

This achievement has been paired with significant national strides in reducing HIV and malaria rates, decreasing infant and maternal mortality, and increasing access to vaccination. 

Solidarity and COVID-19

The strength and effectiveness of Rwanda’s health care system is now more apparent than ever, as the country is tackling the COVID-19 pandemic.

The multiple measures the country has taken to protect its citizens are testaments to our government’s belief in the value of strong health systems. Additionally, the commitment of Rwandans across the country to follow recommendations from the Ministry of Health and the World Health Organization speaks not only of the importance of good leadership, but also of the values of Rwandans themselves.

Each year, Kwibuka is a time of national solidarity. This year, the Rwandan people stand in solidarity with one another, and with the multiple frontline health workers, police, immigration officers, ministries and health organizations working to combat this destructive virus. 

We can surely hope that if the country continues to deploy its efforts in combating this pandemic, alongside the world, we will undoubtedly win this battle, as we have won many battles before.

I feel a surge of pride for belonging to a nation as bright as mine, and a surge of hope for what the future holds for Rwanda. My hope is greatly inspired not only by Rwanda’s good leadership but also by Rwanda’s highly motivated and socially conscious youth, including my UGHE colleagues.

I admire the audacity that members of my generation have in bringing up difficult conversations, and their ability to find creative and critical ways to arrive at solutions.

Furthermore, these past couple of months at UGHE have shown me what is possible when brilliant minds, driven by humanity, join to contend for health equity. 

I feel a deep sense of responsibility to keep the flame that was lit by courageous Rwandan men and women burning. As a young woman and future global health leader, I strive to contribute to my country’s development by being an advocate for equity and social justice, by treating all with the same compassion shown by those who’ve come before me, and by ensuring that voices long silenced are finally heard.

This reflection originally was published by the University of Global Health Equity

PIH Breaks Ground on New ER Facility at Liberia Health Center

Construction has begun on a new emergency care facility that will dramatically improve care and services at Pleebo Health Center in Liberia—so much so, Joseph Lusaka said, that it will feel like a long-held, angry stare finally is looking elsewhere.

“We are committed to giving patients the health care they need with the resources we have,” said Lusaka, PIH’s senior physician assistant at Pleebo. “But the challenges of inadequate beds for people with acute conditions; a lack of gender-friendly spaces; not enough space for standard protocols, quick referrals in emergency cases, or prevention of infection during sterilization procedures; and a shortage of patient-examination rooms, always have been glaring at us.”

Construction of Pleebo’s new emergency facility is making that glare go away.

In collaboration with Liberia’s Ministry of Health and Maryland County Health Team, PIH recently broke ground on the new emergency care block at the PIH-supported Pleebo Health Center. When completed, the facility will expand Pleebo’s capacity to provide health services and treatment in a wide range of areas, including hypertension, diabetes, hepatitis B, tuberculosis, HIV, maternal health and child health, in addition to emergency needs.

PIH previously renovated Pleebo Health Center in 2015. The health center serves Pleebo District, which is the most populated in Maryland County and home to more than 55,000 people in southeastern Liberia. Because Pleebo also is a regional commercial center, people from the neighboring counties of River Gee and Grand Kru, and from the neighboring country of Ivory Coast, also visit Pleebo frequently for health care.

Lusaka, affectionately called Joe, said the health center offers primary care in areas including maternal, newborn, and child health; adolescent reproductive health; mental health; and communicable and non-communicable diseases, while seeing about 200 patients and 20 emergency cases every day.

Patients talk while waiting for care at Pleebo Health Center
PIH-supported Pleebo Health Center offers a wide range of health services for people from Maryland County, neighboring counties, and even the neighboring country, Ivory Coast. The new ER facility will greatly expand the center's capacity to provide care, far beyond emergency needs. (Photo by Kathleen Towns/PIH) 

More than Emergency Care

Providing all of those services has been challenging without a dedicated emergency facility.

Lusaka said he and his team have been using a makeshift emergency ward to accommodate patients brought in with immediate needs such as injuries from accidents; severe hypertension; and acute respiratory infections, requiring oxygen. All of those patients need safe, high-quality spaces to receive lifesaving stabilization before referral or surgery.

The new emergency facility is designed to meet those needs.

When completed, the facility will include five beds for general admission patients, a trauma bay, an isolation room, utility rooms, storage areas, bathrooms, a reception and triage space, an inpatient ward with eight beds—four for males and four for females—an expanded outpatient consultation area, and a non-communicable disease clinic with three consultation rooms, a waiting area and storage.

Additionally, the new facility will provide outpatient services, therapy for palliative care patients, and emergency care for children, people with acute conditions, and people with emergency surgical needs such as trauma care.

All of those services will benefit patients from more than 30 vulnerable communities in Maryland County.

“When completed, the new ER block will further enable Pleebo Health Center to have adequate space, equipment and capabilities, such as ultrasounds and electrocardiograms, to improve treatment of ‘our bosses’ tremendously,” Lusaka said, using his team’s term for Pleebo patients. 

Wellington Kyane, mayor of Pleebo District, attended the recent groundbreaking ceremony along with the county health team and expressed his commitment to smooth construction of the new facility.

“Today’s groundbreaking demonstrates PIH and the government of Liberia’s efforts to strengthen health systems, through the provision of ancillary spaces, administrative spaces, and consultation spaces—including restroom facilities, a kitchen, storage, waiting areas and central waste management—to give long-term patient care to the people of Liberia,” Kyane said.

How Natural Disaster Response Links to Global Health

Clinicians and staff at Partners In Health see every day how climate change and natural disasters can have direct, devastating impacts on the lives of the most vulnerable around the world.

Severe droughts wither crops, forcing subsistence farmers to worry when, not if, their families will suffer hunger. Increasingly powerful and unpredictable rainy seasons cause flooding and mudslides, which wipe out fragile homes built along hillsides and riverbanks, leaving thousands homeless and scrambling for clean water. And more frequent hurricanes—with their gale-force winds, heavy rains, and tidal surges—multiply the number of hungry and homeless by destroying crops and homes.

At these moments, PIH’s long-term work to strengthen health systems and social support enables global teams to provide immediate relief through food packages, temporary shelters, clean water, and emergency health care at mobile clinics. These efforts help meet residents’ needs in the short-term, but are a small part of what PIH does on a daily basis.

PIH leaders and their government partners focus most of their efforts on building permanent, sustainable solutions that address the root causes of poverty. That work begins with universal access to quality health care, from prenatal appointments for expectant mothers to palliative care for the dying, and from lifesaving surgeries to cancer treatment.

Across 11 countries, PIH is working to build strong public health systems, train the next generation of health care professionals, and inspire global leaders to follow PIH’s example so that more people will benefit when empathy and solidarity join the fruits of modern medicine.

Below, and in honor of Earth Day, find examples of how PIH has responded in moments of climate crisis to ensure the most vulnerable have access to the care they need, and deserve:

patients are transferred to a dry facility following Hurricane Matthew in Haiti
Patients are moved to higher ground after torrential rains flooded the courtyard of a hospital in Les Cayes, two weeks after Hurricane Matthew crushed already fragile communities in southern Haiti. Photo courtesy of Hospital of the Immaculate Conception

Hurricane Matthew in Haiti

Zanmi Lasante, as PIH is known in Haiti, partnered with the Ministry of Public Health and Population to respond to Hurricane Matthew in the fall of 2016 by assisting with cholera prevention and response, mental health care, and aid for colleagues who had lost their homes, crops, and livestock across southern Haiti.

Floods in Peru

Socios En Salud, as PIH is known in Peru, sent at least 50 medical brigades throughout Carabayllo District, north of Lima, to deliver emergency aid and medication, distribute baskets of food, and tend to the mental health needs of flood victims in the spring of 2017.

Mudslides in Sierra Leone

In the fall of 2017, PIH in Sierra Leone partnered with the Ministry of Health to conduct a record-breaking cholera vaccination campaign that delivered two doses of oral vaccine to 500,000 people living throughout Freetown, the nation’s capital, following heavy rains and landslides that left residents susceptible to the deadly, bacterial disease.

Earthquakes in Mexico 

Leadership and staff at Compañeros En Salud, as PIH is known in Mexico, mobilized across 10 communities in rural Chiapas to assess damage from two earthquakes in the fall of 2017, helping residents clear roads, find temporary housing, and connect with care in the midst of the crisis.

Floods in Malawi 

Abwenzi Pa Za Umoyo, as PIH is known in Malawi, partnered with local and national governments to bring emergency relief to residents following particularly devastating rains and floods in the spring of 2019, delivering food, financial support, and temporary shelter to those affected.

Need to Know: WASH

The world is seeing now more than ever, how washing hands with soap and water has become one of the most important ways to prevent the spread of infections leading to illness. However, in lower-income countries, access to clean water is a luxury that most cannot afford. This is an incredible shame, because when people have regular access to potable water, it can lead to increased productivity, healthier communities, and decreased spread of water-borne and diarrheal diseases. That is why WASH—or water, sanitation, and hygiene—is such a vital part of improving people’s quality of life.  

For more than three decades, Zanmi Lasante (ZL), as Partners In Health is known in Haiti, has worked in close collaboration with the Haitian Ministry of Health to improve the lives of the less fortunate in the Central Plateau and lower Artibonite regions. In addition to clinical care, ZL started a WASH program to educate the public, provide clean water treatment, and conduct a variety of community projects to improve water and sanitation.

doctor provides care to cholera patient in Mirebalais, Haiti
A doctor provides patients with care in a cholera treatment center in Mirebalais, Haiti, in 2012. Photo by Rebecca E. Rollins / Partners In Health

Since the cholera epidemic began in October 2010, ZL established 12 cholera treatment centers to care for the sick and help stop the spread of the bacterial infection. Staff also disinfected homes, distributed hygiene kits, which included soap and water purification tablets, and made patient referrals to local cholera treatment centers. ZL trained teachers and community health workers on how to communicate about and encourage proper hygiene. And ZL staff led the construction or rehabilitation of dozens of public water sources, including protecting natural springs, covering wells, and repairing pumps.

At University Hospital in Mirebalais, ZL built a sanitation block—called Kay Liz—where an average of 500 people each day access bathrooms and showers, where this a regular stock of clean water and soap. This was key considering many patients arrive with family members or friends, who sometimes travel from far away to stay and accompany their loved ones through care. The sanitation block ensures they will remain healthy themselves throughout their stay.

Below, Saskya Vitiello, ZL's partnership relations officer, provides a definition of WASH, explains its importance in quality health care, and talks about its link to climate change:

community education on proper handwashing outside Mirebalais, Haiti
Rose Marie Renati (center), a local PIH health agent, teaches children at an orphanage in Fond Michel about the importance of handwashing to prevent illness. Photo by Cecille Joan Avila / Partners In Health
  1. What is WASH exactly?

WASH is the intersection of access to water, sanitation, and hygiene. A complete WASH program ensures individuals have access to safe water to drink, bathe in, wash clothing, and perform all bodily care. It means people have access to a toilet, where fecal waste is properly disposed of and cannot contaminate individuals or water sources.  In addition, it means that everyone has basic hygiene knowledge, including the importance of washing hands thoroughly with soap and water.

  1. Why is WASH important in places like health care facilities?

Just as there is an intersection among the three components of WASH, there is an intersection between WASH and health care. According to the British Medical Journal, the invention of sanitation is the greatest medical advancement in 150 years, surpassing the inventions of antibiotics and anesthesia.

Health facilities should exist in an environment that helps individuals recover from illness not makes individuals sicker. As such, a health facility cannot properly function if infection is not controlled. Health care professionals cannot control the spread of infection without clean water to wash their hands and clean surfaces, nor without toilets for proper disposal of human waste. Moreover, when health facilities do exist in the absence of good WASH, patients and health care workers suffer.

  1. What are the positive impacts of strong WASH programs in health facilities?

Having access to adequate WASH services in a hospital creates environments that are safer for both health care workers and the patients who visit facilities. This includes reduced risk of infection in surgical spaces, safer labor and deliveries—including cesarean sections, and reduced transmission of infectious diseases among patients.

  1. When WASH is not in place properly, what are the negative impacts?

Infection can spread among health care workers and patients. Patients can spread disease to other patients. Surgery cannot take place safely. In addition, labor and delivery can lead to complications for the woman and child, even leading to higher mortality rates from uncontrolled infections.

  1. How is WASH linked to environmental and climate change issues?

A poorly planned or executed WASH project can negatively impact communities and ecosystems when, for example, improperly collecting and disposing human waste—especially when that waste contaminates public water sources. This is most important in countries where open defecation due to lack of sanitation facilities is the highest.

Water-related climate change, such as more severe and frequent droughts or floods, will have the greatest impact on the most vulnerable. During those droughts and floods, the lack of water and sanitation in emergencies leads to increases in diarrheal diseases, such as cholera, and other health problems.