Zanmi Lasante has received 13 burn victims at hospitals in Hinche and Mirebalais within the past 72 hours following a gas tanker explosion late Monday night in northern Haiti, which killed more than 70 people and injured dozens more.

The hospitals supported by Zanmi Lasante, Partners In Health’s sister organization in Haiti, are among few facilities in the country with the specialized staff and services necessary to tend to burn victims. As of Thursday morning, nine patients had been transferred from Cap-Haïtien, the site of the deadly explosion, to Hôpital Sainte-Thérèse in Hinche and four to Hôpital Universitaire in Mirebalais—with more patients expected to arrive by Haiti Air Ambulance, a nonprofit organization that assists with emergency helicopter services. In Mirebalais, all four patients remain in serious condition, and most have a poor prognosis.

Zanmi Lasante staff confirmed that 10 burn victims remain in Cap-Haïtien, with five anticipating immediate transfer to Hôpital Universitaire in Mirebalais. While the facility does not have a dedicated burn unit, the hospital is home to an emergency department, multiple operating rooms, and an intensive care unit—the only such service in the public sector in Haiti. Clinicians said this and similar other incidents emphasize the importance of creating a burn center in the future to tend to victims’ specific needs.

Government officials continue to assess damage following the gas tanker explosion, which occurred around midnight on Monday. According to news reports, the tanker driver swerved to avoid a motorcycle, which caused the truck to flip and begin leaking fuel. Given the extreme and chronic gas shortages nationwide, passersby noticed the leaking gas and began filling containers, putting them in danger when the vehicle burst into flames.

Zanmi Lasante staff anticipate further patient transfers in coming days and say they are specifically in need of mattresses, bed sheets, mosquito nets, gauze, and analgesic cream to treat pain.

Four months after the devastating 7.2-magnitude earthquake, Haitians in the southern peninsula continue to rebuild their lives and seek health care—many at mobile clinics established in the wake of the disaster.

Zanmi Lasante, Partners In Health’s sister organization in Haiti, has worked closely with colleagues in the Ministry of Health and other partnering organizations to set up, stock, staff, and supervise mobile clinics across Grand’Anse, South, and Nippes departments—the hardest hit by the August 14 quake, which killed more than 2,200 people and wounded more than 12,000, according to the Pan American Health Organization.

While clinicians and health workers triaged patients with acute trauma to specialized facilities for emergency care and surgery, such as Zanmi Lasante’s Hôpital Universitaire de Mirebalais, they also provided basic services to residents who lack regular access to care. Such patients arrive at the clinics malnourished, suffering from hypertension, in need of mental health support, and much more.

The mobile clinics’ impact has been immediate. In a single month in Koto, for example, 7,000 people were attended by Zanmi Lasante staff and partners. The video below shares more information about that impact, the people providing care day after day—now months after the earthquake, and the remaining need for those seeking the right to health in Haiti.

{"preview_thumbnail":"/sites/default/files/styles/video_embed_wysiwyg_preview/public/video_thumbnails/e9w6Fhxk9Ww.jpg?itok=2Kikpc3A","video_url":"https://youtu.be/e9w6Fhxk9Ww","settings":{"responsive":1,"width":"854","height":"480","autoplay":0},"settings_summary":["Embedded Video (Responsive)."]}

In a hospital room in Lima, Kathy Morales stared into her daughter’s eyes for the first time. It was a moment the 29-year-old mother, after years of heartbreak, thought might never be hers.

Her daughter’s name is Victoria. Morales calls her “my miracle.”

She had wanted to be a mother for years. But loss after loss had kept the dream out of reach.

Her pregnancy with Victoria didn’t show until four months—and three pregnancy tests and a blood test—later. It was then that the reality began to set in.

“Some of us women dream of becoming mothers since we are very young. But once that moment arrives, we have no idea of all that lies ahead,” says Morales. “We have no idea.”

A Complicated Pregnancy

Morales is one of hundreds of mothers who have received maternal health care from Socios En Salud, as Partners In Health is known in Peru. For more than 25 years, Socios En Salud has provided medical care and social support in the impoverished hillside communities of northern Lima.

Morales first heard about Socios En Salud from an obstetrician at her local health center in La Flor, a community in Carabayllo District. At the time, she was four months pregnant. In the weeks that followed, Socios En Salud provided ultrasounds, medications and vitamins, and mental health support.

Essential to that care was Roxane Rivera, one of 90 community health workers with Socios En Salud, who was assigned to Morales’ case.

“Thousands of women like Kathy go through these types of complications during pregnancy and do not have support,” says Rivera. “The maternal and child health program [at Socios En Salud] has proven to intervene in a comprehensive way to ensure the health of the mother and child.”

That support proved crucial for Morales.

In the fifth month, she began to feel intense cramps and contractions and was rushed to the maternity hospital in Lima, where doctors told her she was going into premature labor—a condition that affects more than 30,000 pregnancies in Peru each year, according to the Ministry of Health.

She still remembers doctors in the emergency room discussing her daughter’s weight at the time: 1.07 pounds. Little more than a can of soup. Not likely to survive, if the labor led to a delivery.

“At that moment, I started crying,” she recalls.

She had already lost a son—born in late 2019, but passed away a month later—and had lost four others.

Fortunately, doctors were able to stop the contractions and prevent a delivery. Over the next several weeks, through Socios En Salud’s support, Morales continued her prenatal check-ups at the health center in La Flor, just 10 minutes from her home, commuting by motorcycle taxi. When she wasn’t at the health center, she was resting and eating as healthy as possible.

Still, the oxygen levels in her blood were dangerously low.

Socios En Salud helped her get a referral to the maternity hospital in Lima, where she stayed for three months, allowing for constant monitoring and care in the final weeks of her high-risk pregnancy.

On June 21, Victoria was born: 7.5 pounds and 20 inches. Perfectly average.

Care That Continues

These days, Morales wakes up at 4:30 am—that’s when Victoria wakes.

“My life has changed,” she says. “Now, it’s all about her.”

She continues to visit the health center in La Flor for postpartum care, where her health and Victoria’s are tracked. At first, she was not able to produce milk and had “a lot of pain,” so fed Victoria formulas. But these days, she is exclusively breastfeeding—a change she chalks up to Socios En Salud’s support.

“They are always communicating with me,” she says. “They are always asking me how I am feeling about my health.”

That communication has included her emotions, too, as she navigates postpartum depression—a condition that affects millions of new mothers worldwide.

Rivera has been there to listen.

“Kathy has shown that the love she feels for Victoria is unconditional,” says Rivera. “She is a champion.”

For mothers like her, Morales has a simple message: have faith.

“Thank to Socios En Salud, I can say that Victoria is my daughter,” she says.

The sweeping Build Back Better Act, an attempt to shore up the country’s social safety net, is currently under consideration by the U.S. Senate after its passage by the U.S. House of Representatives just before Thanksgiving.  

While the Senate debates the terms and details of the bill, it’s worth remembering that taken as a whole, many of the legislation’s provisions would transform public health, maternal health, and long-term care for millions of people across the nation. 

Here, we speak with Justin Mendoza, advocacy lead for Partners In Health United States about some of the bill’s high-impact provisions related to public health and equity, and which communities might benefit from the law’s passage. 

How is Build Back Better different from the American Rescue Plan Act? 

Build Back Better is intended to be a larger economic package, delivering longer-term childcare, expanded Medicaid coverage, health insurance primarily for low-income households and some people with disabilities, and major investments in policies designed to curb the impacts of climate change. It builds on programs that were passed, created, or extended in the American Rescue Plan, and also creates new funding for programs that fit the current moment. In addition, it builds on public health investments in the American Rescue Plan and funds programs to strengthen public health infrastructure through 2026.  

The legislation also includes new elements designed to support pregnant and postpartum women, with an emphasis on improving Black maternal health, which has lagged disgracefully in the U.S. Earlier this year, the U.S. Centers for Disease Control and Prevention reported that Black women face a three-fold higher risk of dying from a pregnancy-related cause than white women, due to multiple factors including health care quality, structural racism, and implicit bias.  

How about investments related to health insurance? 

Build Back Better includes language that would extend Medicaid postpartum coverage (health insurance for low-income new mothers) for a full 12 months after birth. This is huge for people who have children in states that have not expanded Medicaid, because prior to the American Rescue Plan, they could only receive six months of health coverage. Experts in maternal health believe this will address some major racial disparities in health outcomes in the United States.  

There’s more: Build Back Better proposes to close the coverage gap in Medicaid. In many states, individuals who earn above the federal poverty line, but below the subsidized private health insurance level (individuals with an income of 150% of the federal poverty line qualify for such a subsidy), are left without health coverage of any kind. As of 2020, that meant around 2.2 million uninsured, low-income adults in 11 states. The Build Back Better Act expands Medicaid to those individuals. 

Health care reforms do not stop at Medicaid. Build Back Better takes on health insurance costs through reductions in health care marketplace premiums, expanding access to Medicaid for people who are transitioning out of incarceration, and adjustments to Medicare—federal government-sponsored health coverage for individuals over 65— to cover hearing services and hearing aids.  

How might all of this impact health coverage, and by extension, care in the United States?  

If Build Back Better were to become law, millions of people who are unable to afford health care in the United States will have new pathways to affordable care. For people with disabilities, expanded home and community-based services would help provide care and support for those that need assistance navigating a system that is set up for able-bodied individuals.  

In addition, changes to public health will help prevent disease, respond to social determinants of health— the basics like food and housing that everyone needs to be healthy, and build out programs and training to combat implicit biases in health care.  

How much money will go into public health? 

Overall, the public health provisions, including those related to workforce development and system strengthening, would invest more than $3 billion in essential health equity work, enable communities to better address social determinants of health, and increase investments at the local and state level.  

Health departments can look forward to a portion of $1.5 billion (allocated through a formula) to state, territorial, and local health departments from 2022-2026; and $750 million in competitive grants during that same period. The CDC will also get a boost of $750 million to help implement programs, expand capacity, and ensure training for health departments across the country. These funds will be used to both bolster public health departments’ response to COVID-19 over the next few years and to build resilience, in the form of staff, systems, and technology, to better handle future outbreaks.  

How would the maternal health provisions benefit new moms? 

First and foremost, the Medicaid expansion for postpartum care is essential for low-income mothers: It allows new moms to secure health coverage for their newborn babies for a full year. But beyond that, Build Back Better focuses on maternal health outcomes based on a set of priorities outlined in what’s being called the Black Maternal Health MOMNIBUS.  

That includes more than $1 billion to help address systemic inequities that lead to worse health outcomes, particularly for communities that have high rates of maternal mortality and/or large maternal health disparities between racial and ethnic groups. The funds are allocated across different programs scaled to meet specific needs in maternal health. For instance, $100 million would go to community-based organizations, tribal organizations, Native Hawaiian organizations, or nonprofits that work with multiple community-based partners. The money can be used to hire and train staff, develop culturally and linguistically appropriate resource centers or materials for particular communities, create demonstration projects that address social determinants of health, and host community-led consultations. These funds will also give communities the ability to develop tailored plans that will address direct care from prenatal workers and build out culturally competent trainings.  

Other funding for maternal health includes $170 million to increase and diversify the nursing workforce in maternal and perinatal care, $75 million for the Office of Minority Health, $50 million to grow the doula workforce, $75 million to increase the maternal mental health and substance use disorder workforce, and $100 million for competitive grants that would allow educational institutions to train midwives, physician assistants, and others in maternal health.   

These grants will help organizations, community leaders, and educational institutions build a more diverse maternal and prenatal workforce across the board—from doulas and community-based workers to nurses and physician’s assistants—all trained with culturally competent tools, community-centered approaches, and programs coordinated with federal and state programs. If these provisions make it into the final version of Build Back Better, and it is implemented well, then the U.S. will truly start to turn the tide on maternal health disparities. 

How does Build Back Better get us closer to health care as a human right?  

Although affordable care alone does not provide health care as a human right, Partners In Health applauds these efforts as a step toward expanded care for those who need it most. To that end, PIH joined a sign-on letter with hundreds of national and state organizations to thank the U.S. House of Representatives for passing the legislation and to urge the Senate to pass the Build Back Better act swiftly. Read the letter here. In August, PIH worked led another letter with 40 organizational partners and allies to urge Congress to make critical public and community health investments. 

We believe now is the essential moment to invest in public and community health and a stronger safety infrastructure for new mothers, children, and families across the U.S. Build Back Better is an important step toward recovering from one of the most devastating periods in U.S. history, and reimagining a more equitable future. 

What can people do to support this? 

Get in touch with your Senators to push for them to support public health and maternal health investments in Build Back Better. We even made it easy to do with our online action tool, here. 

On December 10, Partners In Health (PIH), the University of Global Health Equity (UGHE), and the Rwandan government broke ground on the next phase of growth for PIH-supported Butaro District Hospital.

The ambitious, multi-year construction project is set to expand the hospital, located in Burera, from 150 to 240 beds and further establish it as a leading medical institution and teaching hospital in the region.

At the groundbreaking were leaders from PIH, including Dr. Paul Farmer and Dr. Joel Mubiligi; the Rwandan government, including Northern Province Governor Dancille Nyirarugero and Burera District Mayor Marie Chantal Uwanyirigira; and the University of Global Health Equity, including Professor Agnes Binagwaho and Professor Abebe Bekele. Also present were health workers, construction workers, and community members.

Shovels hit the ground at 11:05 am.

“The work we do in Burera demonstrates perfectly what settings like this have been deprived of and what we can do to make a change,” said Dr. Joel Mubiligi, executive director of Inshuti Mu Buzima, as PIH is known in Rwanda. “This hospital will allow us to save more lives, quicker.”

The construction, which begins this month, will take place in two phases and is expected to be completed in August 2023.

Such growth has been years in the making.

PIH has worked in Rwanda since 2005, in partnership with the Ministry of Health, to strengthen the country’s health system. Butaro District Hospital was one of the early fruits of that partnership—built by PIH, the Ministry of Health, and architectural partner MASS Design, with doors opened in January 2011.

Today, the hospital serves 345,893 Rwandans and hosts the country’s Cancer Center of Excellence, in a rural district that once had no hospital.

The expansion project aims to build on that progress.

The hospital’s growth over the years has been striking. In 2012, the oncology ward saw 561 new patients. By 2019, that number had soared to 1,770. Now, the oncology ward is at 120% of capacity.

Adding to its challenges, the hospital currently has no intensive care unit. There is only one operating room for all types of surgery, as is common for district hospitals in Rwanda. There is no CT scanner, despite the diagnostic tool being crucial for more than 75% of cancer patients. And the pediatrics ward is at 130% capacity, with some children forced to share beds.

All that is set to change with the construction.

Phase one will create a 4-bed intensive care unit with room for additional beds if needed, introduce CT scan services, and add an OBGYN-specific operating room for women. The first phase will also increase the pediatrics ward from 28 to 34 beds and the surgical ward from 26 to 44 beds, among other improvements.

The construction will double the number of surgeries the hospital can perform through two new operating rooms as well as add a new 10-bed emergency department with a procedure room.

Phase two will add 54 more beds for oncology patients, create a 16-bed isolation facility, and deliver additional lifesaving medical equipment, among other improvements. It will also improve the hospital’s supply of essential resources such as oxygen, with the installation of a dual-system oxygen plant.

These changes will improve the quality of care and, as a result, will save lives.

Additionally, the project aims to further establish the hospital as a leading medical and scientific institution in the region, paving the way for its accreditation as a teaching hospital and providing a fertile training ground for students from the University of Global Health Equity (UGHE), which sits just across the valley.

“Now that the university is growing, we need to transform this hospital into a teaching hospital,” said Professor Agnes Binagwaho, vice chancellor of UGHE. “Today is the beginning of this transformation.”

Most notable to Dr. Paul Farmer at the groundbreaking ceremony was the spirit of community.

“What today means for me is not just pride and not just nostalgia,” said Farmer, as he reflected on a moment made possible by years of partnership and coalition-building in Rwanda. “It’s that there’s a hope born of having high aspirations—not just on behalf of oneself.”

Those aspirations are shared by many, in Burera and beyond—from patient to doctors, elders to youth, agricultural cooperatives to architectural partners.

“What this moment is for me is not ‘you’re going to be important in the world’ but it’s that, collectively, ‘we’re going to be important in the world,’” Farmer continued. “We can make a difference. It’s not about I. It’s about us.”

Samal wasn’t showing up for therapy. But she had missed appointments before.

After filling out a depression questionnaire, the 21-year-old had missed her next two therapy sessions at the clinic where PIH works in Almaty, Kazakhstan. Social workers had tried calling her, but she hadn’t picked up. So it wasn’t a total surprise she was a no-show, again.

But for the next month, social workers heard nothing. The worry began to set in. They knew about the tuberculosis. The family estrangement. The sexual abuse.

And she had scored highly on the depression questionnaire. But there was little they could do but wait.

Samal is one of 160 of patients who have received mental health support from PIH in Kazakhstan, a landlocked nation of 18 million in Central Asia where PIH has worked since 2010 in partnership with the Ministry of Health. PIH provides these mental health services at the inter-district outpatient clinic in Almaty.

Kazakhstan has one of the highest burdens of multidrug-resistant tuberculosis (MDR-TB) in the world—a disease that takes a devastating toll on patients’ physical and mental health. PIH’s work in the country has focused on tuberculosis care and, recently, has expanded to include mental health support for patients living with the disease—most commonly, for depression.

That mental health support is provided as part of PIH’s Many Voices Collaborative, a cross-site initiative begun in 2018 to support the development of mental health services across the countries where PIH works—support that has become even more crucial amid COVID-19, as the virus puts patients like Samal at disproportionate risk and creates heightened fear and anxiety each day.

A Turning Point

After a month of no news, social workers finally learned Samal’s whereabouts: She had been re-admitted to the National Institute of Physiopulmonology, after test results had showed her tuberculosis worsening.

Fortunately, after months of constant care, her bacterial excretion stopped, her vital signs improved, and she was discharged from the hospital and able to continue treatment at the clinic in Almaty. That meant her mental health care could resume, too.

As the therapy sessions restarted, social workers learned more about her past, including how she had been raised by her mother’s relative, as is common for large families in the rural grasslands of the Kazakh Steppe, and how her parents hadn’t taken action to end the sexual abuse.

These sessions led to a diagnosis of complex trauma and depression—conditions linked to her past but compounded by her present, including her struggle with tuberculosis and its long, painful treatment regimen.

From diagnosis to treatment, PIH’s mental health team was there to support her, using common elements treatment approach (CETA)—a cognitive behavioral approach developed for non-mental health providers in low- and middle-income countries—to help her understand and manage her complex thoughts and feelings.

She is one of dozens of patients who received such care from PIH.

Over the past year, the PIH mental health team in Kazakhstan conducted 555 consultations by phone, visited 160 patients in person, and trained 238 health workers in psychological first aid. In May, PIH trained seven psychologists on staff and six from partner nonprofits in the CETA approach.

PIH also provided social support, including 2,100 food vouchers, removing systemic barriers such as food, housing, and transportation, which can prevent the poorest patients from accessing health care.

“The problem of mental health is very important for our country, because there are a lot of people in the country in need of psychological help,” says Serik Kozhabekov, mental health coordinator with PIH Kazakhstan. “As we can see from our experience, cognitive therapy is a very effective tool in the fight against depression.”

Through PIH’s support, Samal was able to reduce the intensity of her traumatic memories and clear her mind of stuck, unproductive thoughts. She completed her therapy in May 2021, after showing clinical improvement. More good news followed: she gave birth to a child and finished her tuberculosis treatment, making a full recovery.

Then, another tragedy struck: her mother died of COVID-19.

Samal was spotted by a social worker, through a bus window, wandering aimlessly down a city street in Almaty with her child in her arms. Worried, the social worker got off the bus at the nearest stop and led Samal, by the hands, to the clinic, where she was offered additional mental health care.

Now, Samal is in therapy to treat her depression. She is already showing signs of improvement, learning how to detect and manage negative thoughts related to her mother’s passing and her postpartum depression.

“I am still very young,” she says. “Even if I stumbled…I have time to take a break and start fighting for life with renewed vigor.”

The recent discovery of the new coronavirus variant, Omicron, demonstrates what we have known all along: the only way to end the global COVID-19 pandemic is by ensuring equitable access to vaccines, treatments, and diagnostics to everyone in every country.  

Health systems around the world also require increased material support to deliver care and epidemic control services. To date, world leaders, including President Joseph Biden and his administration, have failed to do their part in meeting these global needs.  

While the United States government has expressed support for a waiver to intellectual property for COVID-19 vaccines since May, the administration has not taken significant steps to advance this policy at the World Trade Organization and fails to advocate for a waiver for COVID diagnostics and treatments. The United States has also not yet exhausted all available tools or authorities granted by law to dramatically scale vaccine supply to meet global need. This includes more than $16 billion appropriated by the U.S. Congress in March to increase vaccine production.  

Despite recent commitments to secure 300 million doses for donation to low-income countries by the end of 2021, and 1.1 billion by September 2022, we are severely disappointed in the Biden administration’s lack of accountability and leadership on vaccine equity worldwide. The emergence of yet another variant proves that these donation efforts are not meeting the scale or speed of the pandemic. In public statements this week, Biden suggested that the Omicron variant in South Africa is the result of weak health systems in poor countries alone, rather than acknowledging global vaccine inequities as a large driver of low global vaccination rates.  

While Partners In Health does know that impoverished nations need increased material health system supports, the health systems are not to blame for global vaccine hoarding nor the lack of action from wealthy nations to put equitable access before the profit margins of vaccine manufacturers. 

The rationale for inaction on the production of vaccines is reminiscent of those made by politicians two decades ago to oppose treating HIV in impoverished nations. In Africa alone, up to 12 million people needlessly died of AIDS in the time it took to make HIV treatment universally available. Sadly, with respect to COVID, world leaders are on track to oversee even more preventable global suffering. 

Partners In Health calls on the Biden administration to raise its aspirations such that the full power of the United States is mobilized to end this pandemic as soon as possible.

It is our position that the United States must immediately participate in negotiations to enact a waiver to the Trade Related Aspects of Intellectual Property Rights Agreement (TRIPS), and scale up mRNA vaccine production to close the gaps in global need. Without these pivotal steps, Omicron will not be the last variant of concern to lengthen the COVID-19 pandemic. 

In the late 1990s, Partners In Health delivered a message that no one in the global health establishment wanted to hear: thousands of miles away, in Peru, people were dying of a deadly infectious disease—and world leaders had turned their backs.

It wasn’t the first time PIH had challenged the status quo. And it wouldn’t be the last.

For more than 30 years, PIH has pushed for a simple yet radical idea: health care is a human right. No matter where people live, how much money they have, or what their background is, they should have access to world-class health care—for free.

Our mission, which is both medical and moral, has strengthened and inspired us, from the early days treating HIV in rural Haiti to the ongoing fight against COVID-19.

We focus on the needs of the most marginalized, providing a “preferential option for the poor,” and care for patients as if they were members of our own family. We do this because, as Co-Founder and Chief Strategist Dr. Paul Farmer put it: “The idea that some lives matter less is the root of all that is wrong with the world.”

Since 1987, PIH has been caring for some of the world’s most neglected patients and speaking truth to power—because we stubbornly believe a better world is possible. Our defiant optimism has changed global health policy and strengthened the movement for health equity worldwide.

Here are five ways PIH disrupted the status quo in global health:

1. MDR-TB

In the 1990s, a deadly, airborne infectious disease—multidrug-resistant tuberculosis (MDR-TB)—was sweeping through Carabayllo, an impoverished community just outside of Lima, Peru. But despite mounting deaths and suffering, the World Health Organization advised not treating these patients, dismissing the disease as too complicated and costly to fully address in impoverished settings.

That was a status quo that PIH founders refused to accept. Directly challenging WHO policy, the PIH co-founders and Peruvian clinicians began treating patients with MDR-TB—saving hundreds of lives neglected by the global health establishment and leading the WHO to revise its global treatment recommendations for MDR-TB—a story captured, among many others, in the award-winning documentary, Bending the Arc

2. HIV/AIDS

Amid the AIDS epidemic, PIH co-founders saw ripple effects of a longstanding injustice: even as awareness, action, and treatment began to spread in the United States, patients in rural communities around the world were being left behind. As PIH began caring for patients with HIV/AIDS in Haiti, global health experts said treatment wasn’t a sustainable option and advised to focus on prevention instead—a mindset that would have left millions of people worldwide without care.

PIH decided to treat patients anyway—launching the HIV Equity Initiative, providing anti-retroviral therapy, and hiring and training hundreds of Haitians to deliver basic health services in their communities, which helped pioneer the community health worker model. Our approach saved millions of lives and helped inspire the Global Fund, PEPFAR, and the WHO to fund HIV/AIDS care in rich and poor countries, alike.

3. Cholera

In the wake of the devastating 7.0-magnitude earthquake in Haiti in 2010, millions of people were left without housing, food, or access to health care. PIH immediately sprang into action, using our deep ties to the community—our staff in the country is 99% Haitian—to mount an emergency response. As we worked around the clock to care for patients, another crisis began to emerge in hospital wards: an influx of cholera patients.

The infectious disease had arrived in the country with a troop of United Nations peacekeepers and spread in a makeshift camp with poor plumbing. As contaminated sewage leaked into the Artibonite river, a water source for countless Haitians, an outbreak took hold. In response, PIH cared for the sick, taught communities how to prevent the disease’s spread, and—despite opposition from the global health establishment—vaccinated thousands of people against cholera. The innovative campaign saved thousands of lives and convinced the WHO to stockpile oral cholera vaccines, which have since been used to control outbreaks in Yemen and Sierra Leone.

4. Non-communicable diseases

In the early 2000s, PIH clinicians in Rwanda began to see a pattern: hospital beds filling up with patients living with chronic diseases such as diabetes and coronary heart disease—known as non-communicable diseases (NCDs). But connecting these patients with chronic care was a logistical challenge, as most lived in rural communities and such care required specialized staff and medical equipment.

That dilemma led to a solution that would change NCD care—training nurses and other health workers to provide chronic care at district hospitals. This approach, called PEN Plus, has since inspired WHO Africa to change its policy on NCD care in rural settings and has provided a model for other countries, such as Liberia.

5. Ebola

As Ebola began to spread in West Africa in 2014, patients in Sierra Leone weren’t receiving quality care. Instead, they were put in isolation rooms, given oral rehydration solution, and largely neglected due to fear of the little-known and deadly disease, a lack of training and resources for health workers, and decades of civil war and colonialism that had weakened the country’s health system. Due to this poor quality of care, the death rate from Ebola was 70%. PIH was one of few organizations to sound the alarm.

That set in motion a years-long effort to improve Ebola care in Sierra Leone and beyond, as PIH partnered with the Ministry of Health and local clinicians to build intensive care units, procure lifesaving resources, and train clinicians and community health workers to provide the highest standards of care. PIH’s response has since inspired the WHO to update its clinical guidelines on Ebola care for patients and survivors, which were used in recent outbreaks in the Democratic Republic of the Congo.

As Guerline Jozef stood under a bridge at the U.S.-Mexico border, she was surrounded by thousands of Haitian migrants and asylum seekers. In the sea of eyes around her, she saw--and felt--a sense of hope.

“I saw those 14,000 faces. Not only 14,000 faces there, but also 14,000 Guerlines,” said Jozef, co-founder and executive director of Haitian Bridge Alliance. “So as I was looking at myself in the faces of those [people]...the hope that I saw was overpowering the desperation in the conditions of our people.”

Jozef, who was at the border to provide legal and social services, says that moment—and many other similar instances—is what keeps her motivated to advocate for a sustainable society for all Haitians. 

During a livestream organized by Partners In Health (PIH) on November 15, Jozef shared her honest reflections and advice alongside Whenda “Wanda” Tima, CEO and founder of L’union Suite; Ancito Etienne, PIH trustee; and Jimmy Jean-Louis, actor, producer, and ambassador to The Barbancourt Foundation. The conversation was moderated by Christa Michaud, Haitian diaspora engagement and development officer at PIH. 

During the hour-long virtual conversation, panelists examined Haiti’s complex history, its challenging present, and the important roles played by the diaspora. United by their shared fight of pushing for justice, the panelists expressed pride in where they came from. 

“There’s a real will to put all our energy and strength into bettering the Haitian cause. That’s why we’re here. And that’s why I still remain. Because I truly believe that Haiti can come out of it,” Jean-Louis said during the event.

{"preview_thumbnail":"/sites/default/files/styles/video_embed_wysiwyg_preview/public/video_thumbnails/qHjS_TIPcUA.jpg?itok=yTU3csAA","video_url":"https://www.youtube.com/watch?v=qHjS_TIPcUA","settings":{"responsive":1,"width":"854","height":"480","autoplay":0},"settings_summary":["Embedded Video (Responsive)."]}

Etienne echoed Jean-Louis’ thoughts and encouraged viewers to look beyond the often negative portrayal of Haiti—which is what L’union Suite, which started as Tima’s passion project, does by sharing everyday stories and amplifying voices on her website. “We’re a melting pot of people. We’re not just the poorest this and the poorest that,” said Tima.

The panelists are among the more than three million Haitians living outside of the country, which includes an estimated two million people in the United States. As leaders in their respective fields, they aim to create a thriving community--in Haiti and beyond its border-- where all voices are heard.

“Haiti is in the process of becoming what it’s always meant to be,” said Etienne.

A recording of the discussion is available to watch above or on PIH’s Youtube channel. To learn more about our panel partners, visit The Barbancourt Foundation, Haitian Bridge Alliance, and L’union Suite.

As the pandemic raged in Pima County, Ariz., and the number of families in need of food assistance spiked, the Tucson Food Bank reached out for extra volunteers.  

That’s when Ruthann Smithrud, a former first grade teacher and executive director of the nonprofit, Faith That Works Tucson, stepped in. Smithrud’s small group of outreach volunteers had been organizing clothing drives and operating a mobile shower unit so that anyone in town could bathe in a safe, private place. Now, suddenly, a call from the Pima County Health Department brought the group into the region’s COVID-19 response operation. 

The health department, with support and technical advising from Partners In Health United States, had established a care resource coordination system so that COVID-19 case investigators and contact tracers could connect people with food, housing, and other needed services. When health department staff  told Smithrud about the food bank volunteer shortage, she immediately agreed to help, organizing a team to create custom-made food boxes for COVID-19 patients stuck at home   “This was a connection birthed out of desperate need,” Smithrud said.  

In cities and states across the nation, for people forced to isolate, quarantine, or care for a relative sick with COVID-19, perhaps the most frequently requested basic item was not a mask, or hand sanitizer, or even cash assistance to help pay the bills. It was food. 

Indeed, a recent federal report on food insecurity, defined as the lack of reliable access to enough food to live an active, healthy life, found that Black households, families with children, people in the South, and others teetering economically suffered far worse from food insecurity in 2020 compared to the previous year. Consider these numbers from the government report and various media analyses: 

• The gap between Black and white households widened further, with 21.7% of Black households experiencing food insecurity, compared with 7.1% of white households. That gap of 14.6 percentage points is up from more than 11 points in 2019. 
• In households with an adult who was either unemployed or prevented from looking for work due to the pandemic, 20.4% reported being food insecure for the 30-day period from mid-November to mid-December 2020. 
• Children in 2.9 million households were hungry, as close to 8% were food insecure in 2020, compared to 6.5% in 2019. Many of these households had very low food security among children, meaning they were hungry, skipped a meal, or did not eat for a whole day because there was not enough money for food. 

PIH-US seeks to eliminate such inequities. Working alongside public health departments and community organizations to set shared health and racial equity agendas, the organization provides technical advising and operational support in seven regions across the U.S. to deliver on those commitments. 

Emily Wroe, a PIH senior advisor on the COVID-19 response, said that even in a rich country like the United States, hunger remains a dire problem. 

“We know that many families in America don’t have enough food on their tables and that even more are one paycheck away from devastating food insecurity,” Wroe said. “The pandemic made this worse, but PIH was able to map out food resources and develop partnerships in the communities where we work, allowing us to make many connections to support these families.” 

Such connections, as well as broader initiatives to expand the food support network, were tailored in response to individual community needs, Wroe said. 

“Sometimes this was simply a matter of connecting people affected by COVID-19 to food banks in their communities; sometimes it involved making connections across town or county lines; sometimes it meant identifying gaps in access related to food delivery or languages spoken; and sometimes we identified larger gaps necessitating higher level advocacy. It also led to connecting people with long term benefits such as SNAP (previously called food stamps), for longer lasting support, and ultimately, this work set up invaluable pathways and partnerships for impact far beyond the pandemic.” 

Resource Coordinators Expanding Food Access 

The Massachusetts Community Tracing Collaborative (MA CTC), a contact tracing workforce, was launched in April 2020, as a partnership between PIH and the Commonwealth. Central to the mission was connecting people in need—those who tested positive for COVID-19 and their close contacts—to basic support, such as food. To support this effort, a team of care resource coordinators identified and helped build local networks to help people gain greater access to the essentials they would need to make it through quarantine and isolation.  To date, the MA CTC has connected more than 100,000 people in in the state with social services, often to combat food insecurity.

Anne Moller, assistant director for the MA CTC's care resource coordination program, said the team immediately began reaching out to partners who were scaling up food delivery and increasing other modes of food assistance in regions around the state. Care Resource Coordination Program Manager Odessa Holt described regular meetings and ongoing calls to ensure that all people in need— no matter where in the state they lived—would have access to food. Coalitions of community organizations worked alongside the MA CTC to monitor trends in food needs and offered tailored responses. 

For example, Holt and Moller said, in Mystic Valley, MA CTC data helped the local YMCA secure a grant to develop an Instacart-style app and delivery system from their food pantry. Further east, the New Bedford Immigrant Support Network partnered with the care resource coordination program and others meeting the food needs of hard-to-reach households.  

A Food Hub, and a Vision for the Community  

In Revere, a city of about 62,000 just outside of Boston, Charlie Giuffrida is a key point person for the care resource team. When the pandemic hit, Giuffrida, then assistant director of parks and recreation, was quickly named director of outreach, part of the mayor’s emergency response team managing the health crisis. “It became very clear we had to scale up the operation quickly,” Giuffrida said. “People needed PPE, transportation, help getting medications and then, instantly, food.”  

Before the pandemic, Revere’s 38-year-old food pantry at the First Congregational Church provided food to 60-80 households per week. That number jumped to 300-500 households after March of 2020. Overall, since the start of the pandemic, an expanded coalition—including the food pantry, Food for Free, FEMA, Farmer Dave, Cambridge Health Alliance’s Mobile Market, the Revere Farmers Market, and others—have distributed more than 135,144 food bags, boxes, and meals.  

While COVID-19's toll has been devastating, Giuffrida said, there is a silver lining. Revere’s city government “has been transformed” by the crisis, he said, shifting focus to become more community-oriented and attuned to the needs of residents in a region becoming increasingly diverse.   

For example, there’s a new Food Hub downtown, a 4,400 square foot building acquired by the city where volunteers arrive on Tuesday nights to help fill 500-600 bags with a variety of basic, healthy foods, from cereal and shelf stable milk, to pasta, bread, peanut butter and cheese. Each bag includes an insert with local resources listed in English, Spanish, Arabic, and Portuguese, the city’s dominant languages; separately, more than 200 boxes of produce are distributed weekly.  

Dimple Rana, Revere’s director of community health and engagement and leader of the city’s Emergency Response Team, said the long-term vision for the “Grow in Revere Food Hub” is to increase access to healthy food for residents while also establishing food and economic security  for low-income families, youth, seniors, newcomers, people with disabilities, and others.  Ultimately, she said, the bustling food center could include an outfitted teaching kitchen; space for a year-round farmer’s market; education and training on food, nutrition, and business development; and an expanded drive-through food pantry 

Megan Witter, a former volunteer and now co-coordinator of the Food Hub, said Revere’s shifting demographics—it's now a majority minority city—informs her decisions about ordering and distributing food. For instance, she said, she provided many bags of dates to Muslim families during Ramadan. 

“They break their fast with dates and milk,” she said. “I take that to heart. I want to be able to help all residents, all the different cultures here. Some people don’t want PB and J, but they might want dates.” 

A Statewide Safety Net in North Carolina  

In the state of North Carolina, a different kind of shift in government has been taking place.  

Addressing the social needs of residents in marginalized communities was already a priority of the North Carolina Department of Health and Human Services before the pandemic, but the COVID-19 crisis further exposed the vulnerability of these populations statewide. Indeed, more than 41,000 food boxes were distributed during the pandemic, as well as financial assistance and other basics under a DHHS program supported by the PIH-US team.

Idalia Arellano, a community health worker employed by Southeastern Healthcare of North Carolina, also a PIH-US partner, has seen those vulnerabilities up close. As she traveled from home to home to check on patients, she said almost “every conversation came down to food.” Even when the discussion started with questions about assistance paying a utility bill or arranging a COVID-19 vaccine appointment, it ended with the need for food, Arellano said.  

That’s partly why the department recently announced the expansion of its food support program in parts of the state where nearly 600,000 people face hunger. Working with the Food Bank of Central & Eastern North Carolina, the state began offering food assistance to residents in 34 counties—many in rural regions—who are experiencing food insecurity related to COVID-19 or are at high risk for severe cases. Last year alone, this regional food bank provided over 115 million meals to families and individuals.  

Undergirding the new, revised “Support Services” food program, as it’s called, is an expansion of the community health worker initiative from 55 to all 100 counties in the state. The PIH-US team provided technical assistance on coordination, resource development, integration, and strategy for these complementary programs.    

Maggie Sauer, with North Carolina’s office of rural health, said there are currently 462 community health workers statewide and the plan is to hire and train a total of 650.  Under the program, all requests for food assistance must come through a community health worker, Sauer said, adding that in the first five weeks, 184 food boxes have been delivered to 25 households. “There are a few intricacies we are trying to work through,” Sauer said, noting that NCCARE360, the platform for tracking community health worker referrals, will be modified to accommodate the new effort. Still, funding has been set aside to provide up to 40,000 food boxes over six months.  

‘I Saw So Much Need’ 

Back in Pima County, Smithrud’s volunteers are still packing three basic types of food boxes: regular, low-glycemic, and one for soft food diets. But Smithrud often included extras in the boxes. Some families needed baby food, others made special requests for beans, rice, and tortillas. Volunteers also contributed their own money, time, and transportation to provide families stuck with other crucial supplies, from pet food and toilet paper to household essentials. 

Over the past 18 months, Smithrud said, she learned a few new things about the region she thought she knew so well. 

“I’ve lived in Tucson all my life,” she said, “but I’d never been to some of the places we delivered to. I saw families living in trailers on rough dirt roads far out of town. The poverty level was much more noticeable.  

"I used to be one of these people who said, ‘Why doesn’t that person just get a job.’ I now see it in a different way," Smithrud added. "My eyes were opened when I did mission work in Mexico and saw poverty at a new level, then I realized there was poverty in Tucson at those levels, people who were homeless or living in motels with COVID-19. It gave me real insight.... I saw so much need.” 

Late last week, Smithrud's team delivered free turkeys for Thanksgiving along with the food boxes. “It’s been a huge gift to be able to work with the health department and the community and use my contacts in the city to help those in need,” she said. “If everyone does a little bit, we’ll all be better off.” 

Months after COVID-19 vaccines were widely administered in wealthy nations, billions of people worldwide still haven’t received a single dose.

In fact, less than 1% of doses have been administered in low-income countries, compared to 75% in high- and upper-middle-income countries.

That leaves 3.6 billion people unvaccinated—and puts countless patients, families, and communities at risk, as the virus continues to claim lives and mutate into new variants that threaten everyone.

With the flick of a pen, President Joseph Biden could invoke the Defense Production Act to compel United States-based drugmakers to share vaccine technology and know-how for the COVID-19 vaccines with capable manufacturers to ramp up production worldwide, according to legal experts at Yale Law School and Public Citizen. But so far, he has refused to take this action.

“For ten months now, the president has chosen to ignore calls from global health experts to dramatically expand vaccine supply,” says Garrett Wilkinson, government relations and policy officer with PIH’s Advocacy team, which has pushed the U.S. Government for over a year to expand COVID vaccine supply.

Biden’s inaction comes in spite of his own advisors, including Dr. Anthony Fauci, supporting calls to share COVID vaccine technology with the world to scale supply, says Wilkinson. It also comes in spite of a $16 billion appropriation from the U.S. Congress in March that could have been used to scale vaccine supply.

According to the activist organization PrEP4All, just $12.5 billion of this appropriation could have funded the drastic scaling of manufacturing capacity and put the U.S. on track to produce 1.3 billion extra doses per month by October and 4 billion extra doses in total by the end of January—enough to fully vaccinate the entire populations of Africa, Latin America, and the Caribbean.

But instead, by September, the Biden administration had spent less than 1% of the $16 billion appropriation on scaling up vaccine manufacturing and has currently pledged to donate just 300 million doses by January 1—hardly enough to meet global need. By contrast, by this date, China had heavily invested in ramping up its vaccine manufacturing capacity and aimed to export 2 billion doses this year.

“PIH is disappointed that most of the U.S.’s global vaccine deliveries will come sometime in 2022 or 2023,” says Wilkinson. “If President Biden had listened to global health experts and scaled vaccine supply, we’d be vaccinating the entire world with our best vaccines by now.”

To work toward that end, in 2020, PIH joined the People’s Vaccine movement, a coalition of global organizations and leaders mobilizing in support of a free, accessible vaccine. Over the past year, PIH’s Advocacy team and PIH Engage—a grassroots network of students and community organizers—have met with policymakers in the U.S. Congress and the Biden administration to call for global vaccine equity.

Those calls have only grown louder in recent months.

For health advocates like Wilkinson, the stakes are crystal clear. As the world waits for Biden and U.S. drugmakers to take the action necessary, people needlessly die.

For much of this year, the world saw 10,000 COVID-19 deaths per day. The vast majority of those deaths were among the unvaccinated.

The president’s inaction comes with other costs, too. The longer vaccines remain out of reach for large swaths of the world’s population, the greater the threat of variants, according to experts like Dr. Anthony Fauci—a threat that could only escalate under the administration’s current willingness to wait until late 2022 or 2023 to vaccinate just 70% of people in impoverished countries.

“Not only is this a racist, inequitable policy,” says Wilkinson, “it’s also terrible epidemic control, if you’re letting a virus circulate for three years before even trying to inoculate everyone.”

Still, he’s hopeful that the president will begin to listen to his advisors, public health and scientific experts, and the public, as momentum behind the People’s Vaccine campaign continues to build and as COVID-19 continues to exact a deadly toll worldwide.

“The pandemic is far from over,” he says. “The administration still can and must act to meet global vaccine needs.”

It all began when Dr. Ana Laura Rodríguez received a call in mid-September: Compañeros En Salud, as Partners In Health is known in Mexico, would receive a total of 2,000 COVID-19 vaccines to be distributed in 10 rural communities in the highlands of Chiapas.

The news came as a welcome turning point—but also a challenge. Chiapas was where the most remote and vulnerable villages had been hard hit by COVID-19 and lagged behind in vaccine access, despite vaccinations beginning in Mexico in early 2021.

Rodríguez, infection prevention and control coordinator with Compañeros En Salud, would have just seven days to organize a vaccination campaign—a process that usually takes months to plan—and to mobilize personnel, supplies, and systems, including a cold chain to keep vaccines an appropriate temperature.

It was a race against the clock and an effort overshadowed by global vaccine inequity: for a population of 85,325, Compañeros En Salud received just 2,000 vaccines.

But after weathering several waves of the pandemic—seeing parents, sisters, aunts, and grandparents pass away—Rodríguez and her team at Compañeros En Salud were determined to get vaccines into the arms of as many people as possible.

A team effort

The next seven days would put Compañeros En Salud to the test.

"It is generally thought that a vaccination campaign requires only clinical staff," says Mineo Yanome, head of operations at Compañeros En Salud, "but for one clinical person, you need four more support staff, including drivers [and] community managers."

As many as 60 staff members and volunteers at Compañeros En Salud—from nurses to drivers—paused their usual activities on short notice and mobilized to help deliver vaccines to patients in 12 rural communities—10 where Compañeros En Salud has worked for more than a decade, in partnership with the Mexican Ministry of Health, and two nearby communities.

To spread the word about the vaccination campaign, Sandra Vázquez, community manager with Compañeros En Salud, and her team hung flyers throughout the communities, broadcast announcements on the streets,  and went house to house knocking on doors, sharing information with community members and listening to any questions or concerns.

Those concerns, Vázquez found, remained a hurdle to vaccination.

"One big surprise was that the stigmatization was much stronger than we thought," says Vázquez. "Some people didn't want to get vaccinated because they have acquaintances who haven't been able to work for a few days because of arm pain or discomfort from the vaccination. The fact is that missing even one day of work in the highlands of Chiapas means a loss of economic resources that affects the entire family.”

Vázquez has also noted how myths surrounding the pandemic remain pervasive. In various communities, the vaccine is rumored to be a mark of the devil, a sign of the apocalypse, or a government conspiracy to sterilize people. As sensational as some of the rumors are, it is not uncommon for people to distrust the government in Chiapas, since these communities have been systematically oppressed for decades.

To counter the spread of misinformation, Vázquez turned to a time-tested approach: relying on the expertise of community health workers, known locally as acompañantes. These workers are neighbors, friends, and community members who are from the communities and have been trained to provide basic health services. Community health workers visited dozens of families at their homes, sharing information about the upcoming vaccination campaign and following up with suspected cases of COVID-19 to provide support.

Inequity kills

In Mexico and around the world, it’s not just COVID-19 killing patients—it’s inequity.

COVID-19 mortality is 50% higher in rural areas compared to urban areas in Mexico, according to Dr. Hugo Lopez-Gatell, the nation’s undersecretary of health. This is due to social inequality, lack of access to specialized health services, poverty, and the long distances people have to travel to even reach a primary care clinic.

In July, the Frailesca region of Chiapas experienced the devastation of the third wave of COVID-19—a crisis that brought Compañeros En Salud’s Center for Respiratory Diseases in Jaltenango to 80% capacity. Had vaccines been available in Chiapas months earlier, those numbers would have been significantly reduced.

The evidence so far, says Rodríguez, suggests that epidemiological change will come when 70% of a population is immunized. Signs of that trend have already emerged in Laguna del Cofre, a rural community where part of the population had been vaccinated and, when faced with the third wave in July 2021, had a very low rate of positive cases.

Change remains an uphill battle, due to global vaccine inequity and reluctance among patients whose trust of the health system has been broken.

The situation is just one of many instances where the urgent need for universal access to vaccines becomes abundantly clear—uncovering the inequity that exists around the country and the world, where rich countries such as the United States, Spain, and Canada have more than 70% of their population vaccinated, while countries such as Nicaragua, Liberia, and Iraq have not even reached 10% vaccination coverage. This situation is due to the unequal distribution of vaccines worldwide.

In just seven days, Compañeros En Salud was able to vaccinate 460 people in the communities—a modest percentage of the population—and returned the remaining doses to the Ministry of Health. But amid a pandemic that continues to cause death and destruction worldwide, every win, no matter how small, counts.

"There is still a lot of work to be done,” says Yanome. “But at the end of the day, it gives us great satisfaction to know that we can support people who otherwise would not have had access to vaccines."

National Native American Heritage Month, which has been celebrated every November since 1990, is a time to recognize and celebrate the contributions of Native American and Indigenous peoples and honor their traditions and cultures. In honor of the month, we’re highlighting several ways Community Outreach and Patient Empowerment (COPE), Partners In Health’s sister organization on Navajo Nation, tie Navajo culture into their health programs.

Through a patient-focused and community-based approach, COPE colleagues are committed to eliminating health disparities and improving the well-being of American Indians and Alaska Natives. COPE programs are driven by community member input that reflects Navajo (Diné) culture, language, and traditional teaching.

Below are three COPE programs that demonstrate this approach:

Making Traditional Foods More Accessible

Food is medicine. This belief lies at the heart of Diné cultural traditions. Food is viewed as an important component and balance of oneself—physically, spiritually, and mentally. Navajo people traditionally consumed a variety of corn, squash, and other vegetables native to the southwest region.

Through the Fruit and Vegetable Prescription Program (FVRx), COPE provides vouchers to help enrolled Navajo families reintroduce healthy traditional food into their diet. More than 1,000 families have participated in FVRx since 2015.

Empowering Growers to Succeed

While it is convenient to purchase food at a grocery store, there aren’t many on Navajo Nation. In total, there are 13 grocery stores across 17 million acres of land—roughly the size of West Virginia. This is why supporting Navajo growers to improve access to locally grown food is vital to a healthy food system.   

The health of the people, community, and land are all connected. Navajo growers face many challenges, including water access, land disputes, invasive weed species, and drought issues. And for most, growing traditional squash, corn, melons, and other produce isn’t enough to earn a living wage. However, for Navajo people, growing these foods reinforces their resiliency and sovereignty, while ensuring these traditions are passed on to future generations.

COPE’s Growers Initiative supports local Navajo producers as they revitalize sustainable food systems.  The informal program is a collective effort and works with individuals based on interest, need, and capacity.

Promoting Physical, Spiritual Benefits of Water

Water, or Tó, is a central part of Diné values and teachings. However, many people on Navajo Nation lack access to clean drinking water due to decades of uranium mining, well contamination, and fracking, which has led to unsafe levels of contaminants in sources of drinking water. The introduction of sugary beverages, such as soda and juice, has also disrupted the diets of people on Navajo Nation.

COPE is working to highlight the importance of water for personal health, gardens, and livestock. Through Water is K’é, COPE promotes healthy beverage consumption by creating and distributing beverage kits, conducting healthy beverage demos, and hosting community workshops about the importance of choosing water over sugar sweetened beverages. As of November, COPE has completed around 50 healthy beverage demonstrations and distributed around 15 Tó kits Navajo schools and businesses.

Every other Friday in Kono District, Sierra Leone, the quiet, serene campus of Wellbody Clinic’s birth waiting home erupts with noise. Women chat. Toddlers squeal. A wood fire crackles. And a metal grinding machine whirs as it blends together buckets of sesame seeds, rice, dried fish, beans, salt, and sugar—creating a highly-nutritious mix to be cooked into a porridge and fed to the crowd of caregivers and their children, who are suffering from malnutrition.

Malnutrition is a daily threat in Sierra Leone, where 76% of people live on less than $3.20 per day and food insecurity is high. The resulting health impacts are devastating and long-term: As a result of poor nutrition and starvation, nearly one-third of children younger than five suffer from stunting, or impaired growth, that can permanently damage cognition and overall physical health.

Since PIH began its work to strengthen Kono’s health system, combating malnutrition has been a priority. In addition to launching the inpatient feeding program at Koidu Government Hospital, which provides intensive care to malnourished children, PIH-supported clinicians established the severe acute malnutrition program at Wellbody to treat and support children on the brink of needing inpatient care.

But these initiatives, while critical, left out children experiencing a specific kind of malnutrition: moderate acute malnutrition. Children with moderate acute malnutrition were classified as sick, but were not considered sick enough to be enrolled in and benefit from the severe acute malnutrition program.

So in 2019, PIH established a new program to catch these kids at risk of falling through the cracks: the moderate acute malnutrition program (MAM). In the years since, that program has been expanding malnutrition treatment, providing support to hundreds of families in Kono each year and ensuring that children have access to the care they need to restore their health.

Now well into its second year, the MAM program has proven prescient, as food insecurity and malnutrition have been on the rise throughout the COVID-19 pandemic. While Sierra Leone has recorded comparatively low rates of COVID-19 infections and deaths, the virus’ ripple effects have, unsurprisingly, proven serious and long-lasting in the country’s context of extreme poverty, few formal safety nets, and already rising food prices.

According to one study, 67% of Sierra Leonean households have seen their incomes decrease from last year, as three-day lockdowns enacted throughout the pandemic caused catastrophic losses for families surviving on daily wages. Relatedly, between June and August of this year, nearly 2 million people—a quarter of the population—fell into the category of severely food insecure.

In the face of this mounting injustice, now, more than ever, equitable malnutrition care is essential. Below, spend an afternoon in Kono at a MAM feeding session and learn how the program works:

Although starving, malnourished children show little interest in food. They also suffer from symptoms like fatigue, limited growth, and a weakened immune system, making other illnesses easier to contract and harder to heal from.

Clinicians at Wellbody screen their pediatric patients for malnutrition by measuring their upper arm circumference and taking their z-score—a comparison between their weight and the weight of a healthy child their same height. Those who meet the criteria of malnutrition are enrolled in the either the severe acute malnutrition or the MAM program. They’re also tested for malaria and respiratory viruses and given amoxicillin, deworming medication, and vitamin A tablets, to ensure the absence of other underlying infections and to boost their immune system.

The MAM program lasts six weeks, by which time the vast majority of toddlers regain their health with feeding support and family nutrition education. In the program’s first year, 61% of children gained weight, with an average weight gain of more than two pounds.

Every two weeks, children and their caregivers in the MAM program gather at the clinic to prepare mass amounts of homemade Bennimix—a blend of entirely local ingredients, provided by PIH, that contain the carbs, protein, calcium, and iodine children need to restore their health and nutrition. The mix is named after the sesame seeds it contains, which are called benni in Krio, the most widely spoken language in Sierra Leone.

To make Bennimix, Wellbody staff and caregivers of enrolled children sift through the ingredients—rice, sesame seeds, fish, beans, iodized salt, and sugar (for taste)—and feed them into a metal grinder to blend them together.

Some of the Bennimix is saved to cook into a porridge that day, as a demonstration for caregivers on how to create these specialized meals at home—from how to measure the ingredients to how long to let the porridge simmer.

“When they go back home, they’re going to apply what we’re teaching them—how to prepare the food, how to cook it properly,” says Mariama Mansaray, a Wellbody Clinic nurse who oversees the nutrition department and leads MAM feeding sessions. “It’s reducing malnutrition across the district, and drastically reducing relapse cases.”

Enough Bennimix is made for every family to take home a two-week supply, ensuring children have the daily nutrients they need to recover.

Mansaray calls caring for children “her calling.”

“Since I was a little girl, I had this vision of taking care of children,” she says. “We have a lot of orphans in the program—referrals from the special care baby unit [at nearby PIH-supported Koidu Government Hospital] and directly from communities of babies who have lost their mothers. I have a special passion for these children since I, too, am an orphan. They say ‘She who knows it, feels it.’”

Mansaray has more kids in her care than ever before. Last year at PIH-supported facilities in Kono, nearly 800 children received treatment for malnutrition, the last step of which is enrollment in the MAM program.

The steady growth of the MAM program is a testament to not only how widespread the problem of malnutrition is in Sierra Leone, but also to the program’s success. Women whose children have been discharged from the program and have regained their health often promote the MAM program to their friends and neighbors—leading to a line of patients actively seeking enrollment.

“When they see this program is very good, that their child is well fed, they go back and bring their neighbors who are going through the same constraints,” says Mansaray.

And the program has served to build community among some of Kono’s most marginalized, isolated people—often, teenage and single mothers.

“She [the mother] will tell you, ‘I don’t have anything. I’m just giving my child glucose powder,’” Mansaray says. “We try to let them know that all is not lost. We, the nurses, are encouraging them, talking to them as equals, receiving them with open arms. They’re happy to be around the other women.”

At the beginning of each session, Mansaray leads a health talk covering early childhood nutrition, including the benefits of breastfeeding, what to add to a child’s diet as she grows older, and how to access ingredients without going to the market, such as through gardening and fishing.

But recognizing that, for many caregivers, it is an extreme lack of material resources—not knowledge—that prevents their child from eating, Mansaray and Wellbody staff take note of each family’s health and economic status and refer the most vulnerable to PIH’s social support program.

Through this additional form of care, families receive money to continue buying the ingredients they’ve learned about, plus clothing, toiletries, and goods to sell for profit, helping them start small trading businesses and get back on their feet financially.

In this way, the MAM program also acts as referral center, connecting families with other forms of support beyond nutrition. Mansaray also often directs young mothers to the adolescent and youth-friendly services clinic at Koidu Government Hospital, where they can get specialized health care as well as educational and career counseling.

By the end of each session, the hustle and bustle of children playing, women cooking, and clinicians teaching calms as everyone comes together for one final activity: eating. Caregivers feed the Bennimix porridge to their children, taking a spoonful for themselves here and there and unlocking the healing power of sharing a meal.

Late in the evening of Friday, November 5, the phone calls began between Partners In Health staff in Sierra Leone: A car and a fuel tanker had collided in the capital city of Freetown, resulting in an explosion and a widespread fire. Hundreds of people were engulfed in flames. Many of them had already been on the road, in their cars commuting, or on foot selling goods. Many others had rushed over from home, empty jerry cans in hand, looking to capitalize on the leaking tanker as a free source of fuel.

Officials report that 98 people died on the scene, and 158 were transported to hospitals across the city, in critical condition with up to 95% of their bodies severely burned.

And the news didn’t stop there. Among the injured, PIH staff learned, was a colleague: Fleet Manager Hassan Bunduka, who had been driving home to his family when he was caught in the blast.

PIH’s response to the disaster began immediately. At 3 a.m., a vehicle departed Kono District, where the majority of PIH clinicians work in the eastern part of the country, to bring Clinical Services Lead Dr. Marta Patiño and General Surgeon Dr. Kilongo Papy Mulailwa to Bunduka’s bedside and then to Connaught Hospital, Sierra Leone’s largest public hospital, where the vast majority of victims were taken for care. A vehicle loaded with medical supplies from PIH’s warehouse in Kono, such as central IV lines and gauze, followed soon after, to donate to the hospital’s intensive care unit.

Relief efforts have only grown from there. Now entering its second week, PIH’s response is centering on all five pillars of our work—staff, stuff, space, systems, and social support—in partnership with the government of Sierra Leone and other nonprofits.

The goal: to ensure survivors of this disaster have the resources they need to heal in the short and long term.

Tragically, on November 7, Bunduka succumbed to injuries sustained from the disaster. As of November 16, he is one of 148 people who have passed away, with 52 still receiving care across five public and private hospitals in Freetown—none of which have the resources to offer specialized care for burns.

“Emergencies tell you something about the health system,” Dr. Bailor Barrie, executive director of PIH in Sierra Leone, said, sharing an idea often cited during the country’s struggle with Ebola. “There is no burn unit in the country; the expertise of burn care is not available. So it tells you that the health system is weak, and incapable of handling such an unexpected crisis.”

Staff in Sierra Leone are grieving while also managing the complexities of an ever-evolving medical crisis and putting together a social support program for survivors that will carry over into 2022.

Six Days, Six Weeks, Six Months

PIH staff have divided the fire explosion response into a rough timeframe, captured by the phrase “six days, six weeks, six months.” The phrase represents a response that is immediate, mid-range, and long-term, with each stage overlapping with the next to ensure that survivors—and the clinicians caring for them—have the right resources.

“I really see PIH’s utility in the mid- and long-term, ensuring that patients have comprehensive, lasting support,” Barrie said. “We’re positioned to provide services to patients to make their chances of survival increase and to holistically help them be functional and reduce their suffering.”

Such support would include financial aid to make up for lost wages, as many survivors are the primary or only earner in their family; food packages, so that survivors have the nutrition required for continuous healing; mental health care and counseling; and accompaniment through ongoing medical care from specially hired community health workers (CHWs) trained to provide logistical and moral support amid a difficult healing journey.

“Plastic surgery, dealing with mobility, you’ll need a lot of physical therapy. All of which are very difficult to get in Sierra Leone,” Mulailwa explained to The New York Times. “You can anticipate that the next three months, for the ones who survive, will be very difficult.”

PIH staff are currently devising a program to provide all of these resources as more patients begin to recover. PIH has already hired nine mental health CHWs and two CHW supervisors to work with patients upon their discharge from the hospital, connecting them with continued medical care and helping them through their trauma. Two specially hired psychosocial counselors will provide additional counseling and support. After completing their training this week, their direct work with patients will begin on November 22.

But, as Mulailwa suggested, even for patients who have survived this long in the hospital, nothing is guaranteed. This is partially due to the severity and extension of their burns, which make them susceptible to fatal dehydration, sepsis, and illnesses like pneumonia, which spread in hospital settings, especially those with poor ventilation and inadequate capacity for infection prevention and control.

Providing Medical Personnel, Essential Supplies

PIH clinicians are currently working alongside Connaught Hospital staff to prevent these conditions. Since November 10, Patiño, alongside Frank Rogers, a scrub nurse at PIH-supported Koidu Government Hospital in Kono District, and Sarata Sillah, PIH Sierra Leone’s interim director of nursing, have been working at Connaught Hospital, providing clinical support and expertise in the intensive care unit, where 27 burn patients remain as of November 16. (Four remain in critical condition at Connaught, and nine remain in critical condition across all hospitals.) On November 13, they were joined by Dr. Sterman Toussaint, a surgeon with experience in burn care and PIH Liberia’s clinical services lead, who was dispatched to the site along with other medical personnel by the government of Liberia.

These clinicians’ direct experiences in the hospital each day are informing how PIH is assisting with Connaught’s space and supplies. Amid an outpouring of donated medical supplies—including from the government of Liberia, enabled by PIH Liberia—PIH staff in Kono have been sending equipment to the hospital, with vehicles regularly driving from the PIH warehouse to Connaught to fulfill requests for supplies: 10 vials of glucose here, 300 blood bags there.

Also, in response to the hospital’s severely limited laboratory and blood bank capacity, PIH loaned Connaught a refrigerator to store more blood safely; an ambulance to transport blood between hospitals for the next month; and reagents for lab technicians to be able to carry out tests, as well as a cutting-edge, portable lab testing device that can conduct vital tests at patients’ bedsides.

PIH staff are continuing to monitor how best to support the disaster response, attending government emergency response meetings and providing strategic insights on how to overcome persistent obstacles, which include the availability of antibiotics and nutritional support for patients prone to infection and in need of more calories than ever before, especially two weeks into their hospital stay.

“Every team is working to make possible the best support for the patients,” Patiño said. “I see this is having a clear impact in the care we are providing. This extraordinary work is even more remarkable with the terrible and devastating loss of our colleague Hassan.”

Patiño also noted that the government’s response, which PIH and other partner organizations have been supporting, has been “swift and organized,” clearly informed by its experience with Ebola and bolstered by international teams of clinicians visiting to provide expertise in burn management and rehabilitation. Still, critical medical gaps remain—a familiar story in Sierra Leone, where centuries of injustice have left health facilities direly under-resourced and ill-equipped to handle even some routine health problems, let alone a mass influx of burn patients.

“Sierra Leone has people who are well-trained and who really know what to do” Patiño said. “Given the resource constraints, the care being delivered [in Connaught’s intensive care unit] is outstanding.

“But there are not enough of them, and they don’t have the supplies and the facilities necessary to do a high-quality job,” she continued. “There are two plastic surgeons in the whole country, and they’re very good. But how are you going to manage this situation with two plastic surgeons? It’s impossible.”

In 2014, when the Ebola outbreak was declared in Liberia and other West African countries, people were warned that the disease was devouring everything in its path.  For many, it seemed like madness to stand against such a lethal virus. But not for Julius D. N. Kpoeh, who was then working as a transport nurse with African Humanitarian Action in Nimbe, one of the 15 counties of Liberia.   

Guided by the sense of duty, Kpoeh joined other frontline health workers who were determined to do everything to stop the virus’s deadly spread. For months, he helped transport patients with Ebola symptoms in ambulances from their villages to treatment centers for emergency care.   

“I was just performing my duty,” he says. “I had no other choice; something had to be done.”    

Kpoeh again feels compelled to respond, but this time in tending to cancer patients arriving at facilities supported by Partners In Health Liberia, where he currently works as the palliative care coordinator. He was drawn to PIH’s mission to strengthen and rebuild Liberia’s health systems, using an approach that had proven successful in countries like Haiti and Rwanda.  

Growing Cancer Burden, and Response, in Africa  

According to the WHO data, poor countries endure a bigger burden of cancer, with approximately 70% of deaths from cancer occurring in low- and middle-income countries. 

In Liberia, 3,552 new cases of cancer and 2,603 deaths occurred in 2020. And the numbers are expected to rise because of the aging and growth of population.  

In his role, Kpoeh helps cancer patients manage stress and pain, but knows more can be done.    

“We have cancer patients who were diagnosed earlier and have a chance to be treated and survive,” Kpoeh says. “But in Liberia we don’t have an advanced cancer treatment center and skilled oncology nurses to support in the treatment of patients.” The critical shortage of health care workers in sub-Saharan Africa has meant that nurses are taking on additional roles in busy hospitals, but often lack specialized training to provide quality care. 

Inshuti Mu Buzima, as PIH is known in Rwanda, has made efforts to nurture medical professionals who will become major players in the next generation through training and mentorship programs, in collaboration with the Rwanda Ministry of Health and Dana-Farber Cancer Institute. 

Recognizing this gap in cancer care training, Partners In Health Liberia and Inshuti Mu Buzima worked together to arrange training for Kpoeh and Dehcontee M. Hardy, another nurse working in the pediatric department and part of the palliative care team at PIH-supported J.J. Dossen Hospital in Maryland County, Liberia.    

Since its opening, The Butaro District Hospital has been greatly successful in delivering robust cancer treatment and care to patients from not only Rwanda, but across Africa. From 2012 to 2019, the hospital admitted 11,107 patients diagnosed with cancer, with the number expected to exceed 13,000 in 2021. 

Plans are in the works to expand the facility so that it will eventually serve as the district’s first teaching hospital.  

"In order to deliver holistic cancer care, a multidisciplinary team approach that involves trained physicians, nurses, and social workers is a must," says Jean Bosco Bigirimana, Inshuti Mu Buzima’s oncology program manager. “Since 2012, Inshuti Mu Buzima has collaborated with the Dana-Farber Cancer Institute, the Rwanda Ministry of Health, and other partners to implement training programs for the oncology staff. The knowledge we have gained in cancer care will be beneficial to Kpoeh and Dahcontee."  

Holistic Training in Cancer Care 

In September, Kpoeh and Hardy arrived in Butaro, Rwanda, intending to learn and return home to train other nurses involved in the care of cancer patients.   

“When Partners In Health approached me to come to Rwanda to learn more about oncology nursing, I was very happy. I want to learn about chemotherapy and holistic approach to cancer care,” says Hardy. 

Kpoeh and Hardy’s eight-week intensive training began with an assessment of their skills in oncology.  The training was facilitated by Espérance Benemariya and Olivier Habimana, nurse educators at Butaro District Hospital, who were trained by specialized nurses at Dana-Farber. 

“Kpoeh and Hardy’s training began with a general orientation and overview of Butaro Cancer Center of Excellence and oncology protocols, and they also shadowed the team at the ambulatory oncology clinic to learn about different services provided in the oncology program,” says  Habimana.  

The Butaro Cancer Center of Excellence consists of an inpatient department with an adult and pediatric oncology ward, an outpatient department with an infusion center, and a support center to host patients and their families during extended treatment stays.  

Other parts of Butaro District Hospital also play a crucial role in the treatment of cancer patients. The pathology lab delivers results that help clinicians provide accurate and timely diagnoses.  And surgeons are available to remove tumors or perform such specialized care as mastectomies for breast cancer patients.   

Weeks into their training,  Kpoeh and Hardy had acquired fundamental knowledge of oncology program services and were ready to dive into complex topics.  

“Before coming to Rwanda, I had limited knowledge about chemotherapy,” says Hardy. I was relying on the instructions stated on the label.”   

Under the supervision of nurse educators, physicians, and their fellow nurses, Kpoeh and Hardy spent the second part of their training shadowing the everyday routine of an oncology nurse. They became better at mixing, administering, and safely handling chemotherapy drugs. They also learned more about cancer, its epidemiology and prevalence in developing countries, cancer treatment protocols, and treatment options, including palliative care.   

“We have gained a lot of knowledge about cancer care that we will share with others when we go back to Liberia,” says Kpoeh. “This will help to reduce the workload of our doctors and improve the quality of care provided to the patients.”   

Kpoeh and Hardy are not the first to come to Rwanda to learn about Inshuti Mu Buzima’s approach to addressing health equity. And surely, they will not be the last.   

Over the years, more than 100 nurses and 20 doctors from Rwanda, Liberia, and other countries have gone through the training program to learn about Inshuti Mu Buzima's holistic approach to care in oncology. 

“Partnership in knowledge sharing is paramount and much needed in Africa,” Bigirimana says. “Each country has different expertise that others can learn from and help to promote PIH’s mission to provide a preferential option for the poor in health care.”  

Tina Thomas was first diagnosed with type 1 diabetes at age 26 after months of feeling unwell. She had lost weight, was urinating frequently, drinking water, and sometimes eating excessively.

“My complexion changed and people kept saying I looked like someone who was pregnant,” Thomas said. “I got concerned because I didn’t know what was happening to me and I still wasn’t feeling well. People started asking me to go to church and all sorts of places for treatment but I decided to go to the hospital.”

The hospital Thomas visited was J.J. Dossen, supported by Partners In Health (PIH) Liberia, which began working in rural Maryland County during the 2014 Ebola outbreak and remained to help the Ministry of Health strengthen and build the health system. Hospital staff listened to her concerns and ordered a battery of lab tests to pinpoint a diagnosis.

“They did my HIV test, sugar level, malaria, and some other tests,” Thomas said. “Everything came back negative, except the sugar test. It was very high, so the doctor asked that I should be admitted and put on some fluids immediately.”

A diabetes diagnosis is relatively uncommon in Liberia—mostly because clinicians lack the training, lab tests, and medications to identify and treat the condition effectively. Prevalence among people ages 20 to 79 who have type 1 or type 2 diabetes stands at 2.4% in Liberia. Type 2 diabetes is the most common and accounts for about 90% of all diabetes worldwide. In sub-Saharan Africa, type 2 diabetes affects about 8% of people above the age of 25. 

The number of patients living with type 1 diabetes is much lower. The chronic condition typically appears during childhood or adolescence, but it can develop in adults. There is no cure and, without access to insulin to control blood sugar levels and a proper diet, people with type 1 diabetes could face disabling or life-threatening complications.

Thomas stayed at J.J. Dossen Hospital for two weeks. While there, she met Diana Culbertson, former non-communicable disease (NCD) and malnutrition clinical lead at PIH Liberia, who was administering her medications, checking her sugar levels daily, and constantly encouraging her.

“For me to accept that I had diabetes was hard because, as a young person, I had not seen it in my family,” Thomas said. “I never heard about it in my family or that somebody had diabetes, so I was doubting it.”

In time, Thomas did accept her diagnosis. After being discharged, she visited the hospital twice daily for her insulin shots and other medications. The journey was taking a toll on her. Culbertson noticed and decided to train her and other patients to administer their insulin shots at home. Being the youngest among the patients, Thomas received extra training and was guided to support other diabetic patients.

Seeing a growing number of patients diagnosed with chronic conditions, such as diabetes, PIH opened a specialized outpatient clinic at J.J. Dossen Hospital in June 2017 to manage both severe and common NCDs, in partnership with the Ministry of Health’s NCD Division and the County Health Team. The NCD team treats type 1 and type 2 diabetes, chronic heart failure, chronic kidney disease, advanced hypertension, and other complex NCDs. Care for these conditions is often only available in Monrovia, the capital city, not in rural hospitals such as J.J. Dossen. The goal is to decentralize access and improve the quality of NCD care by sensitizing communities, training and mentoring primary care providers, procuring essential medicines and diagnostics, building fit-for-purpose spaces, developing referral and electronic medical record systems for patient tracking.

Liberia is among several PIH-supported countries working to integrate NCD care within the primary health system, using an expanded version of the World Health Organization’s Package of Essential Non-Communicable Diseases.   

Currently, 228 type 2 diabetes patients and 37 type 1 diabetes patients are enrolled in the NCD program across Maryland County. PIH provides medical supplies and social support for all type 1 diabetes patients and some type 2 diabetes patients. PIH has also supported the Ministry of Health to develop national diabetes guidelines, while also building the capacity of health workers in diabetes management in Maryland County and around Liberia.

Today, Thomas is a PIH community health worker and a member of Maryland County’s patient advisory board, constituted in June 2021, to provide guidance on diabetes management in facilities across the county. She also assists the NCD clinic at J.J. Dossen Hospital and holds talks in communities to raise awareness for diabetes prevention and treatment, as well as other non-communicable diseases.

“Now I am well, I make sure I eat right and take my medicines,” she said. “I sometimes share my story with some of the people I engage in the communities and, because I look healthy, they believe me and follow the advice we give them.”

A vaccine can change the course of global health—and not just amid COVID-19.

After 100 years of research and clinical trials, the first-ever malaria vaccine was approved by the World Health Organization on October 7, a historic moment that marked a turning point in the longstanding fight to end one of the world’s deadliest diseases.

Malaria kills about 500,000 people each year, with children in Africa accounting for around half of those deaths. The disease is highly prevalent in Rwanda, Liberia, Sierra Leone, and Malawi—countries where Partners In Health works and where community health workers can do little more than hand out bed nets as a preventative measure.

Even as the vaccine ushers in a new era for millions of people worldwide, questions remain about its cost and accessibility, especially for those who need it most.

To explore these questions and others, PIH sat down with our Africa Regional Policy and Partnerships Advisor Dr. Evrard Nahimana for his insights on this scientific breakthrough and how it could change the course of global health.

A vaccine for malaria has been a long time coming—100 years, to be exact. How does this historic moment resonate with you, on a professional and personal level?

Malaria is a disease I have grown up with. I had a couple episodes of malaria during my childhood and during my clinical years. I also cared for many patients with severe malaria, particularly children under 5 and pregnant women. Some of them unfortunately died from the disease. The burden of malaria goes beyond the number of patients affected and/or deaths related. Malaria has a huge negative impact on a family’s finances and a country’s economy. 

Clinical trials on the malaria vaccine started decades ago. I had the opportunity to meet researchers directly involved in the trials in Kenya and Tanzania. And so hearing about this scientific milestone in my lifetime is so exciting. A vaccine is and could be a powerful tool in the fight against malaria.

However, the fight is far from over. Malaria is a “poverty disease” and so, only relying on drug/vaccine/commodities-based interventions to control and eliminate the disease is a big mistake. Its elimination should go hand-in-hand with poverty reduction strategies, including improving housing and building strong and equitable health systems.

The story of this vaccine is quite different from others; it was developed in Africa, by African scientists, which is major. Can we talk about the development of this vaccine—what makes it unique and what lessons can we learn from it?

Over the past century, clinical trials in infectious diseases have been led by researchers and agencies from the western countries. However, the research and development of malaria vaccines present a different scenario. African scientists have been closely involved and leading clinical trials for the malaria vaccine, including the one that led to RTS,S (the new malaria vaccine), which was recently approved by the World Health Organization. Although the process involved a collaboration with a British drug manufacturer, with funding from the United States and United Kingdom, scientists born, raised, and trained in Africa led the clinical trial that occurred in Ghana, Malawi, and Kenya.

This means a lot for the scientific community across Africa. For the scientists involved in the trial, it is about fighting a disease that is killing them, their families, and communities they live in. But most importantly, when it comes to scale, you are not relying on data from studies conducted elsewhere on other populations by other researchers. This is also a message of hope for other scientists from Africa involved in similar trials—their work may lead to even more efficacious drugs and vaccines.

The vaccine has modest efficacy—30% among children under five—and requires a complex regimen of doses—4 shots. What do you make of this, from a clinical perspective?

It is true that the vaccine has a modest efficacy of 30%. However, the evidence from a recent study shows that the vaccine RTS,S combined with other existing methods (use of antimalarial drugs and bed nets) could reduce under 5 mortality and hospitalization up to 70%. Also, 30% of efficacy might seem modest, but applying that to the millions of children affected by malaria every day could save so many lives.

Across most African countries, vaccination coverage among children was high (around 90%) before COVID-19. Countries like Rwanda achieved 98% coverage for the overall complete basic childhood vaccination among children aged 12–23 months. Even for countries with low coverage, the issue is less hesitancy but more related to accessibility due to structural barriers. I am confident that adding a malaria vaccine into routine immunizations for children will be met with a lot of enthusiasm and the uptake will be high. Producing the vaccine at a large scale and making it available to the people who need it most will be the critical next steps.

Now that the vaccine has been approved, what would it take to make it free and accessible to the world’s population, especially those who need it most?

Developing a lifesaving product (vaccine or drug) is one important step; ensuring large production, fair distribution, and administration to everyone, particularly those who need it most, is challenging—but possible. Recent history has taught us, through so many examples (HIV, Ebola, COVID-19), that without global collaboration to fund the production, distribution, and administration of vaccines, we could be waiting years and even decades before those vaccines, already approved, are available to those who need them most. It would be a tragic, global, moral failure if that happens again with the malaria vaccine.

The COVID-19 Vaccines Global Access (COVAX) facility was established as a mechanism to support low- and middle-income countries in accessing vaccines doses for their populations. We need a similar mechanism for the malaria vaccine. And the right time to do it was yesterday! A study shows that countries with moderate to high malaria transmission will need about 110 million doses per year by 2030. I don’t know how much this will cost, but it is nothing compared to the lives of children we can save. This is a call for governments, multilateral agencies, donors, philanthropists, and the entire global health community to work together to mobilize resources for universal access to malaria vaccines. Again, it should be clear that a vaccine is not a magic bullet to control malaria. Vaccination should be integrated into broader strategies for health system strengthening and economic and human development.

What does this vaccine mean for the sites where PIH works and where malaria has long been prevalent?

Malaria kills half a million people every year and the majority of them (more than 90%) live across the African continent. Access to malaria vaccines will help save lives and prevent the hospitalization of millions of people. It is good news for people living in malaria endemic areas, including countries supported by PIH.

Countries with weak health systems will struggle to distribute and administer the vaccine once it is available, and its impact on malaria control will be very limited. Improving supply chain systems will be essential for effective vaccine distribution. With PIH’s efforts over the past two decades to build a robust, resilient health system through our 5S model (staff, stuff, space, systems, and social support), the sites we support are well-positioned to embark into the effective distribution of the malaria vaccine, and PIH will continue to support governments with that.

Any insights on what the vaccine could mean for the Global Fund—the international partnership between governments, civil society, and the private sector to fight malaria, HIV and TB? Do you think the Fund will be used to buy vaccines? Will it be as needed as before if this vaccine proves to be revolutionary?

The Global Fund has been essential in the fight against malaria, TB, and HIV. In some countries, the Fund contributed to building a horizontal health system. It has been supporting the procurement of commodities, including malaria drugs. It is not clear what the Fund’s strategy will be toward procuring malaria vaccines and facilitating distribution and administration. But that’s what we hope to see.

The WHO endorsement of this vaccine is a huge win in the long-running fight against malaria, but that fight is far from over. What do you think is the next chapter in the global push to end malaria? What must the global health community do now?

Malaria is a good example of a “poverty disease.” Over the past decades, most of the strategies to control it have been focusing on commodities (bed nets, drugs, etc.) which are effective but limited in the long-run.

Shifting our methodology by embedding these existing tools and new ones into a broader development agenda, including proper housing and improving health systems, will help to eliminate the disease. And resource mobilization for mass production of the vaccine—including building capacity within developing countries to manufacture the vaccines for themselves—should happen as soon as possible.

Partners In Health remembers Hassan Bunduka, who tragically died on November 7 from injuries sustained in the November 5 fuel tanker explosion and fire in Freetown, Sierra Leone.

Hassan was a longtime member of PIH Sierra Leone’s fleet team, responsible for coordinating transportation for staff, patients, and medical supplies.

As PIH Sierra Leone staff work to respond to the urgent medical and psychosocial needs of the hundreds of people affected by this accident, they also grieve the loss of their beloved colleague and friend.

On behalf of all the PIHers who knew and love Hassan, Dr. Bailor Barrie, executive director of PIH Sierra Leone; Dr. Sheila Davis, chief executive officer of PIH; and Jon Lascher, former executive director of PIH Sierra Leone, provide this reflection.

It is with great sadness that we share the news of Hassan Bunduka’s tragic, untimely passing.

In 2014, when PIH began its work in Sierra Leone at the height of West Africa’s historic Ebola outbreak, Hassan was the second member of our staff, hired as a driver in Port Loko District, the epidemic’s hotspot. Transporting our staff around Port Loko, Hassan was willing to shoulder incredible personal risk, all in support of patients and our growing organization. When there was a difficult mission, Hassan never shied away, and his commitment never wavered even through the most harrowing of days. In fact, Hassan shared in a recent staff highlight that he looks back on these times with fondness. “My favorite memory with PIH is being part of the achievements made in Port Loko,” he said. “Seeing Ebola survivors discharged from our treatment centers and providing them a startup package to go back home and reintegrate with their families and communities gave me a joy money can’t buy.”

With his unparalleled optimism and determination, it was an easy decision to promote Hassan to fleet manager in Port Loko. After the end of the Ebola epidemic, Hassan brought these same gifts to his work as our fleet manager in Freetown, ensuring every day that staff, patients, and supplies safely got where they needed to go. His work often went unseen, but without a doubt was the glue holding together PIH Sierra Leone’s operations and our mission to make health care a human right.

Of course we are devastated as an organization to lose Hassan’s many talents that helped make our lifesaving work possible. But more so, we are devastated to lose Hassan as a colleague and friend. Hassan was funny, gentle, smart, and fiercely loyal, an engaging conversationalist with a knack for making people feel included. Some of our favorite memories are from his wedding party, where he was surrounded by so many people who loved him, including everyone at PIH Sierra Leone who was so excited to celebrate with him.

Hassan was always there for us when we needed him—so we will be there for his wife, son, and two daughters, supporting them during this terrible time and beyond.

Hassan’s passing is a stark reminder that life is fragile. And it further grounds us in the importance of our work to improve health care in Sierra Leone, where the specialty medical services needed by the victims of this horrific accident are in short supply, if they exist at all.

No one was a bigger believer in the equity we must continue to fight for, in health care and beyond, than Hassan. Again in a recent staff highlight, Hassan shared what social justice meant to him: that “every human is important, and that we should see ourselves as one and equal.”

Beautiful words from an amazing son, brother, husband, friend, colleague, and father, who we miss so much and will never forget.

Dr. Paul Farmer, co-founder and chief strategist of Partners In Health, was featured on CBS’ 60 Minutes in a segment about the Boston-based nonprofit MASS Design Group, PIH’s architectural partner in building Butaro District Hospital in Rwanda.

In the segment, which aired on October 31, Farmer shared stories from the early days of working with MASS in Butaro and contended that hospitals should be beautiful, honoring patients’ human dignity, in addition to providing world-class medical care and strengthening local communities.

PIH partnered with MASS in 2008 to design and construct the 150-bed hospital in Butaro, a rural district of 350,000 people who at the time didn’t have access to health care. The project provided jobs for more than 4,000 residents and used locally sourced materials, including volcanic stone.

The hospital opened its doors in January 2011 and provides a range of specialized services through an emergency department, a surgery ward with two operating rooms, and a neonatal intensive care unit.

Watch the 60 Minutes Segment

Ángela Velasco had tried everything: Herbal tea. Acetaminophen. Another pill from the medicine cabinet. But her daughter’s fever was only getting worse.

“I didn’t know what to do,” she recalls. “It was about 5 or 6 o’clock in the evening and the girl did not get any better.”

Ariadna had started to vomit. She could no longer walk. And the pain, once confined to the 9-year-old’s stomach, had spread throughout her body.

Then the rain started to fall. During the rainy season in Chiapas, Mexico, rain often meant a torrential downpour, turning the dirt roads of Plan de la Libertad into mud and making any travel on the side of the mountains dangerous.

Velasco rushed her daughter out of the house and, with her husband’s help, put her on a relative’s motorcycle.

Reaching the nearest open clinic—nearly an hour away—felt like a race against the clock. But they had to try.

An Unexpected Diagnosis

Plan de la Libertad is one of nine communities in Chiapas, Mexico, where Compañeros En Salud, as Partners In Health is known locally, has worked for more than a decade, providing medical care and social support in partnership with the Mexican Ministry of Health.

Although Mexico provides universal health care, costs like transportation and lodging near advanced hospitals in major cities make accessing that care difficult, especially in Chiapas, where 1 in 3 families lives in poverty. That’s a reality that Compañeros En Salud is working to change.

“Compañeros En Salud is an organization that fights for universal access to health,” says Dr. Valeria Macías, Compañeros En Salud’s executive director. “We fight for health as a human right.”

For many—like Velasco—that fight is personal.

“Getting medical attention should be a right, but unfortunately it is not,” she says.

After rushing her daughter to the health center, Velasco and her husband were sent from clinic to clinic and passed from doctor to doctor—all of them private, out-of-pocket services—leading to a series of tests, consultations, and even a surgery, but ultimately no answers. The diagnosis wouldn’t come until months later, during a follow-up appointment—this time, at a public clinic run by Compañeros En Salud and the Ministry of Health: Ariadna had ovarian cancer.

Velasco still remembers the moment doctors told her.

“It was like a bomb had exploded in my face, without me realizing it,” she says. “The whole situation made me sad.”

Ariadna would need six rounds of chemotherapy—immediately. At some point, maybe a blood transfusion. Maybe platelets.

“The doctors at the time were worried,” says Dr. Alejandro Hernández, Right To Health Care coordinator at Compañeros En Salud. “The family was very worried about Ariadna.”

‘We Didn’t Have One Peso Left’

Doctors were adamant: Every three weeks, Ariadna would have to travel to Tuxtla for chemotherapy at the advanced hospital for specialized care, at least five hours from Plan de la Libertad. After each round, she would have to return to the hospital within three to four days for follow-up testing.

To save time and money, Velsaco decided to stay with her daughter in Tuxtla during the chemotherapy. But the bills were stacking up.

She asked everyone for help in those days—friends, family, even strangers. The savings from the family’s coffee farm and her husband’s seasonal work were running out.

“We didn’t even have one peso left,” she says. “My husband said, ‘Well, at some point we’re going to have to sell, whether it is the coffee plantation, the house or whatever, to be able to support the girl.’”

It wasn’t just the finances weighing on her. The chemotherapy was taking a toll on Ariadna. As she watched her daughter lose her hair, pass out, and struggle to breathe, Velasco didn’t know how much longer she could cope.

“She told me she felt like she was dying,” Velasco recalls. “It was a really distressing moment for me. How do you think straight? How do you respond to a situation like that?”

‘They Never Left Her Side’

But even in her darkest moments, Velasco wasn’t truly alone.

From diagnosis to chemotherapy, Compañeros En Salud was there to support her and Ariadna—and not just medically. A clinician at Compañeros En Salud's clinic in Plan de la Libertad referred Velasco and her family to the Right to Health Care program.

Since 2013, the Right to Health Care program has helped 1,787 patients in the rural communities where Compañeros En Salud works get referrals to advanced hospitals for specialized care. The program has also connected patients with social support—essential resources such as food, housing, and transportation that are often barriers to health care for patients living in poverty.

Guided by PIH’s value of accompaniment, the Right to Health Care team helped Velasco schedule each of Ariadna’s chemotherapy sessions and arrange for food, transportation, and lodging in Tuxtla, free of charge.

“We started mobilizing all the resources and talking to hospitals to follow up in a third-level hospital with oncology,” says Hernández. “This is how we managed to get them to follow up at the pediatric speciality hospital in Tuxtla.”

Compañeros En Salud helped Velasco navigate a complex health system and communicate with clinicians, even sending a pasante, a first-year clinician completing their year of service with Compañeros En Salud, to attend chemotherapy appointments with her and Ariadna—accompanying them through each step of the process.

“As soon as the medication started, they were there to be with her, to watch her,” Velasco recalls. “They never left her side, not even for a second.”

There were other signs of hope, too.

As the rounds of chemotherapy progressed, Ariadna was starting to respond to the medication. By the fifth round, her side effects had become mild and her body was recovering.

In December 2020, the moment Velasco had long awaited—had prayed for—finally arrived: Ariadna was declared free of cancer.

“For me, it was a lot of emotions,” Velasco recalls. “I was standing up. I sat down. I cried with joy.”

The journey wasn’t over. Ariadna’s condition would have to be monitored for five years to make sure the cancer did not return. The family currently sees an oncologist once a month to track her progress, with transportation, lodging, and food supported by Compañeros En Salud.

But Velasco, who has since returned home with Ariadna, is breathing easier.

“The support that Compañeros En Salud has given us has been very valuable,” she says. “I really don’t know what we would have done.”

As COVID-19 continues to devastate communities across Peru, Socios En Salud—as Partners In Health is known locally—has delivered more than 120 oxygen concentrators and 90 oxygen tanks to hospitals nationwide, as well as installed 260 oxygen outlets directly into hospital walls, beside patient beds.

The lifesaving equipment couldn’t have come fast enough.

Peru has the highest COVID-19 deaths per capita in the world, as of early November, with more than 2.1 million cases and more than 200,000 deaths. Carabayllo, an impoverished community where Socios En Salud has worked for decades, has seen more than 10,155 cases—the highest rate of infections in northern Lima.

Socios En Salud has worked in Carabayllo for more than 25 years, ever since responding to an outbreak of multidrug-resistant tuberculosis. Amid COVID-19, Socios En Salud mounted a comprehensive response in partnership with the Ministry of Health, including testing, triage, and isolation, as well as connecting patients with mental health support and essential resources like food and transportation.

As the pandemic has taken a deadly toll on communities in Lima and beyond, Socios En Salud has doubled down on its efforts to deliver another essential resource: oxygen.

Helping Patients Breathe

For thousands of COVID-19 patients across Peru, medical oxygen can mean the difference between life and death. It’s one of the last lines of defense against a virus that attacks the respiratory system and, in its most severe form, requires intubation.

Patients are given oxygen in hopes that it will prevent them from needing an ICU bed.

Hospitals and health centers typically access medical oxygen through oxygen plants (standard-size shipping containers), oxygen tanks, and oxygen concentrators (bedside or portable machines).

Among the essential medical equipment provided by Socios En Salud were 260 oxygen outlets, installed directly into hospital walls—allowing the lifesaving resource to flow continuously from oxygen plants to patients’ bedsides.

"[Before the oxygen outlets] each patient used about 3 or more oxygen tanks, which had to be refilled regularly,” says Dr. Marco Tovar, medical director of Socios En Salud. “But with the installation of these oxygen outlets on the wall alongside each bed for COVID-19 patients, it will now be easier to maintain a continuous flow of oxygen, which will help everyone.”

Socios En Salud installed the oxygen equipment in health centers in eight communities, following inspections of the facilities to evaluate their needs and challenges, such as irregular access to electricity. The equipment was delivered after months of supply chain challenges, including finding manufacturers of oxygen concentrators that could meet Peru’s electrical specifications.

Training Clinicians, Saving Lives

As that process unfolded, Tovar and his team discovered another challenge: health workers at the clinics weren’t trained on how to use the equipment or maintain it.

To address this, Socios En Salud, with the support of its Center for Global Health, developed courses for health workers to learn how to operate and maintain oxygen equipment—technical expertise that is critical in making the efforts sustainable for the long-term. So far, the courses have enrolled and trained 116 health professionals. Three more trainings are scheduled to take place in the coming weeks, with 80 more professionals invited to participate.

And the equipment is already saving lives.

Carlos Quispe, 57, is one of dozens of patients who received care at a temporary oxygen center in Carabayllo, where Socios En Salud delivered 51 portable oxygen concentrators and 51 beds.

"I arrived [at the health center] in a bad state…I couldn’t breathe well,” says Quispe. “Today, I feel much better. The doctor and nurse in charge are constantly checking on me.”

More than 115 patients have been discharged from the center since its opening in February. After leaving the center, they receive support 24/7 from community health workers, who track their progress and teach them physical therapy techniques to help them recover from the virus and its side effects.

Quispe was able to return home and reunite with his family, with Socios En Salud’s support. It’s a success story that Dr. Carolina Muñoz, a physician at the oxygen center, hopes will continue, as COVID-19 remains a threat across the country, alongside other respiratory diseases, such as tuberculosis.

“Oxygen concentrators are a huge help in caring for patients with respiratory difficulties and prevent them from landing in an ICU bed,” she says. “With this technology, we can save the lives of thousands of people.”

As COVID-19 struck and millions of people worldwide quarantined at home, health workers did the opposite—they walked straight through hospital doors, ready to care for patients, even as little was known about the deadly new virus.

Isaac Mphande, primary care nursing manager at Abwenzi Pa Za Umoyo, as Partners In Health is known in Malawi, was among those health workers.

“Everyone was not safe,” he recalls. “Being a public place, everywhere you stood was a potential risk of contracting the virus. But we knew we had to help in saving lives. So, we continued doing our work.”

Even as case counts rose, along with uncertainty, Mphande led Abwenzi Pa Za Umoyo’s team of 19 nurses through the COVID-19 response, providing the medical care and social support that define PIH’s work around the world.

This year, he is one of 10 recipients of PIH’s Global Nurse Executive Fellowship—a program launched in 2017 to equip nursing and midwifery leaders at PIH’s clinical sites with the knowledge and skills to respond to global health challenges and transform health systems, from the ground up.

A Commitment to Service

Nearly 50% of the world’s health workers are nurses and midwives.

Yet, nurses and midwives are systemically undervalued compared to doctors and health care management, receiving lower pay and fewer leadership opportunities. And when they are placed in leadership roles, they don’t receive the necessary tools, skills, or support to be successful. That’s a reality that the fellowship aims to change.

Each year, 10 awardees are selected from among senior and executive nurse leaders at PIH’s clinical sites around the world. Mphande was chosen for the year-long program following his outstanding leadership in response to COVID-19. The program includes three, weeklong intensive bootcamps, a yearlong executive-style curriculum, and a capstone project which seeks to improve patient outcomes and care delivery.

Originally from Mzimba, a district in the northern region of Malawi, Mphande holds a Bachelor of Science in Nursing and Master of Science in Midwifery from Kamuzu University of Health Sciences in Blantyre, Malawi. He first began working as a nurse in December 2008 at Chitipa District Hospital.

He joined Abwenzi Pa Za Umoyo in September 2018, drawn to its mission.

“I love PIH because of the commitment to serve people who live in challenging situations,” he says.

Now, as primary care nursing manager, he supervises a team of 19 nurses in rural Neno District, where he manages clinical care, making sure patients are supported from screening to outpatient services, and mentors Abwenzi Pa Za Umoyo’s nurses, midwives, and support staff, investing in their professional development.

Abwenzi Pa Za Umoyo has worked in Malawi since 2007 in partnership with the Ministry of Health and has expanded to support two hospitals, 12 health centers, and a network of about 1,300 community health workers. Its clinical programs include HIV, malnutrition, and mental health.

In an area where more than half of families live below the poverty line, Abwenzi Pa Za Umoyo provides food and housing assistance to more than 4,500 patients each year, tackling the structural barriers that prevent patients from accessing health care.

It’s work that Mphande finds fulfilling on a personal and professional level. But it’s not without hurdles.

“The biggest challenge is resource constraints in the environment where we work,” he says. “We have few staff members and not enough medications or supplies.”

Another obstacle, he says, are poor roads in Neno, which can lead to delays in medical supplies reaching the health centers as well as for patients seeking referrals for advanced care.

Nurses as Leaders

When COVID-19 struck, those challenges were compounded—fearful of coming to the clinic, patients canceled their check-ups and attendance dropped, even among pregnant women, leading to complications in maternal care, including some that persist to this day.

But Mphande and his team were determined to respond as fast and as comprehensively as they could, despite limited resources and a staffing shortage. Over the course of the year, with Mphande’s support, Abwenzi Pa Za Umoyo trained more than 1,225 community health workers to educate the public about COVID-19, continued its health services for thousands of patients, and provided key insights that informed the Ministry of Health’s nationwide pandemic response.

That work has continued to this day.

As wealthy nations hoard vaccines and COVID-19 puts patients’ lives at risk in Malawi and other low- and middle-income countries, Mphande is continuing to press forward with the pandemic response, strengthening Neno’s health system and leading his team by example, as a nurse and midwife—leadership that he hopes to see more of.

“There are more nurses practicing in health facilities [now] compared to the time I started working as a nurse,” he says. “I hope to get more nurses into leadership roles at PIH.”

A key goal of Partners In Health United States is to help strengthen and expand the network of community-based organizations carrying out the day-to-day work of supporting the health and well-being of people living in economically and socially marginalized regions. The importance of this on-the-ground work has been highlighted during the COVID-19 pandemic, but it remains central to building healthy communities for the future.

To that end, PIH-US applied for and was recently awarded $11.1 million from the federal Health Resources and Services Administration (HRSA) to invest in community-based organizations -- some already focused on public health while others were not involved directly -- to help more people in hard-hit communities get vaccinated. More broadly, the work is intended to help close the race and income gaps in vaccination laid bare by COVID-19, and advance health equity overall.

We spoke with Project Director Dr. Wilfrid Cadet, Deputy Director Annie Zhou, and Coordinator Alicia Krewer, members of the PIH-US team overseeing the HRSA project (officially called Reaching Equity through Community-based Vaccination Engagement and Resourcing or RECOVER) to find out more about this important work.

What is PIH-US’s role in this project?

PIH-US is unlocking access to federal funding for many of our partner organizations for the first time and supporting organizations in managing the funds according to federal requirements. These funds support frontline vaccine education and outreach for vulnerable communities, and our learning team provides the latest scientific research and best practices related to COVID-19 response. Big picture, we are working to make connections between community-based organizations to further learning and collaboration.

What's the overall aim here?

First, we are helping to spark the mobilization of local, community-based outreach workers who can pave the way for more people to gain easier access to COVID-19 vaccines. To do this, we’ve invested in training this community-based workforce; developing much more accessible and culturally aware health education materials; and trying to address and eliminate every possible barrier that might prevent someone from getting vaccinated, from scheduling and appointment issues to translation and transportation support. Taken together this is what we mean when we talk about equitable vaccine outreach.

A key to achieving equity here involves tapping into the underused, but critical, community-based workforce. These are folks who grew up and live in the communities they serve and are deeply knowledgeable about the defining cultures and customs. These local health workers are trusted messengers, and our hope is that as they reduce barriers, and address hesitation, vaccine uptake will increase. Each of our partner communities was selected because of their populations’ social vulnerability, paying close attention to the percentage of residents who are Black, Indigenous, and people of color, and the number of residents living below the federal poverty line. That’s no accident—those are the people we want to support and build up during the lifespan of this project. We also try to tighten the collaboration between state and county health departments and community-based organizations to strengthen support for marginalized populations.

Where are the participating community-based organizations located?

They’re located across the country, including at sites where we already have work underway: New Bedford, Mass.; Newark, N.J.; North Carolina; Immokalee, Fla., Montgomery, Ala.; Chicago, Ill.; Navajo Nation; and Pima County, Ariz. Through partner organizations, we are also conducting outreach activities across Los Angeles, California; New Orleans, Louisiana; Washington D.C.; Baltimore, Maryland; Maine; and Ohio.

Can you talk about some of the various efforts underway?

The community-based organizations we work with are engaged in hyperlocal approaches that meet people where they are. Our partners have hosted “Back to School” vaccine forums; supported outreach workers traveling to Tennessee, Virginia, and New Jersey to provide “Know Your Rights” training, including COVID-19 and vaccination information, to hundreds of tomato farmworkers; teamed up with Uber to reduce language and transport barriers to getting vaccinated; distributed 9,000 masks and vaccine education materials at Seventh Day Adventist Church of New Orleans; and sponsored Facebook and Instagram Live events sharing information on the Delta variant as well as personal vaccine experiences in Washington, D.C.

The community-based organizations have used a variety of supports and incentives to improve the vaccination experience: from offering gift cards and food at events to providing childcare. One group in North Carolina, called “Helping All People Excel,” found that conducting vaccine information sessions in the break room of a local manufacturer was particularly effective; people felt comfortable at their workplace and asked a ton of questions. This community-based organization also found that providing candy at outreach events is an incredibly effective motivator to get children and parents to approach them to learn more about the vaccines.

What’s the long-term vision, and what do you expect will be the greatest impact from this investment?

In the short term, we hope to reach 700,000 with accurate, accessible information about the COVID-19 vaccines. Additionally, we hope to leverage the current activities for longer-term impact by highlighting the importance of community health workers in the public health infrastructure, building capacity in historically underserved communities by funding community-based organizations to implement locally identified solutions, and connecting them to other like-minded organizations locally and nationally. We hope that this work elevates the influence of community-based organizations and positions them for future longer-term funding opportunities. Each of these organizations has proven that the people they serve are their priority; we hope that investing HRSA funds in this way helps our partner organizations to advocate for robust, long-lasting support for their communities.

Note: This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $11,169,572. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

In Haiti, breast cancer is the most common form of the disease among women, as it is worldwide. But there’s a key difference: a higher percentage of women will die from breast cancer in the Caribbean nation than most other countries.

While many factors may contribute to this, including that Haitian patients are often diagnosed at later stages, there is limited research detailing how these factors play a role in Haiti. To gain a better understanding of the situation and to assess care delivered at Hôpital Universitaire de Mirebalais (HUM), researchers from Zanmi Lasante—Partners In Health’s sister organization in Haiti—alongside co-collaborators from several institutions in the United States, conducted a comprehensive assessment.

Their findings, which were published last year in The Oncologist, include many important takeaways, with the most encouraging being that basic breast cancer treatment can lead to better outcomes in Haiti, especially when patients are diagnosed and treated early.

“We wanted to highlight the fact that we can treat cancer in Haiti. It’s feasible but you need the right resources,” says Dr. Ruth Damuse, clinical care coordinator in HUM’s oncology department and co-author of the study.

Their research is the first published assessment of cancer care at HUM since the program (which began in Cange in 2011) moved to the hospital in 2013, the same year the 350-bed, world-class teaching facility opened its doors. HUM has the country’s only public oncology center capable of diagnosing and caring for patients and offering both therapeutic and surgical treatments.

As the oncology department at HUM becomes more widely known, patients—80% of whom have breast cancer—have come from all around the country for care.

A Closer Look

The study included data from 341 female patients with nonmetastatic breast cancer who started treatment at HUM from 2012-2016. Damuse and her colleagues measured “event-free survival” in patients, meaning how much time elapsed before the patient had either a recurrence of cancer, a new tumor, disease progression, or death from any cause. They also reviewed the type of care provided by HUM, taking into consideration what treatments were administered, the time it took for patients to receive that treatment, and the treatment’s duration.

Of those patients, 81.5% received curative surgery, or removal of the breast where a tumor was found. (Breast-conserving surgery is not performed in Haiti at this time since it requires patients to receive radiation therapy, which is not available in the country.) Pre- and post-surgical therapies such as chemotherapy were provided to shrink the tumor, and some patients also received further chemotherapy and hormonal therapy after surgery. During the follow-up period, 28 patients died, 77 had disease recurrence, and 10 experienced progression of the disease.

Of the patients that had up to 3 years of follow up, over 60% were alive and free of disease.

Most patients tended to have more advanced disease at the time of diagnosis—a rate that was even higher than previous studies conducted across Haiti had indicated. The authors believe one reason was the lack of nationwide breast cancer early detection programs. And many of the patients appeared to get breast cancer at an earlier age than patients in the U.S., which previous studies have also found.

Lead author Dr. Temidayo Fadelu, PIH’s oncology advisor, says an explanation is illusive and needs further research. “You have an overall younger population, and then you have the possibility that the biology of cancer might be different in a population of African descent. Overlaying that is likely referral bias.”

In other words, he wonders: “Is it possible that older patients are having cancer but not making their way to our facility?”

The study helped researchers pinpoint several important obstacles to care that will be useful in identifying areas of improvement. For example, researchers found that many patients experience delays when they go to other facilities. When patients wait until their disease has advanced, it becomes more difficult to treat their cancer and more likely that they will have a negative outcome.

Damuse said that patients are oftentimes resistant to seeking care for several reasons: stigma related to breast cancer, fear that a mastectomy will make them less feminine, or because they believe breast cancer is a death sentence. In some cases, patients are skeptical of modern treatments. And in rural areas, she says, people tend to be unfamiliar with hair loss associated with chemotherapy or have never heard of a breast being removed to save a patient’s life.

Diagnosis is also challenging. For most of the study period, there was very limited access to pathology services and patient samples had to be sent to the U.S. for a diagnosis. In Haiti, clinicians evaluate the extent of the cancer using a chest x-ray and ultrasounds, but other tests common in higher-income  countries such as CT scans, nuclear studies, MRI, and PET scan machines are not readily available.

Implementing Changes at HUM

Since conducting the study, the team has worked hard to improve the scheduling system and follow up with patients, with the goal of making sure patients continue treatment.

Dr. Joarly Lormil, oncology care coordinator at HUM, has seen thousands of patients in his practice. He estimates that, at the moment, about 150 patients are actively receiving chemotherapy at HUM. Lormil treats patients with all kinds of cancers, but the majority are patients with breast cancer. He has seen firsthand how harmful it can be when patients delay treatment.

Lormil recalls seeing a patient in her early 30s who was diagnosed with breast cancer and was a candidate for surgery. However, she was newly married and reluctant to have her breast removed. Nearly a year later, “we finally convinced her to receive the care,” he says. But then the earthquake struck, further delaying her surgery. Two more months passed. Finally she had the surgery and is doing well now, but is at higher risk for further complications and recurrence of her disease.

As the oncology team continues to increase its capacity to care for and treat patients in Haiti, increasing its staff and eventually bringing in new technology and treatments will improve patient outcomes, but all this comes at a significant cost.

Nonetheless, Lormil is optimistic: “Most men and women with breast cancer can get cancer care, including palliative care.”

Take the recent example of a nurse working in HUM’s maternal health unit, who discovered she had breast cancer. When she first got treatment, she felt ill from chemotherapy, but is doing better now. She is free from cancer, says Lormil, adding that the nurse has been sharing her experience with her co-workers and patients.

“She is the embodiment that, if you receive care early,” he says, “you can be free of cancer.”

Moving Forward

The research team identified gaps and areas for improvement, such as increasing the percentage of patients who receive surgery, the proportion of patients who get estrogen receptor testing, and the use of chemotherapies before and after surgery. The team also hopes to reduce the number of patients who fail to follow up and decrease system delays for patients.

As a result of the study, HUM staff are now working with local partners on initiatives to teach women how to perform self-breast exams. Clinicians are also providing information and support to patients with the goal of overcoming stigma around cancer care. Further studies are recommended to better understand why there are high rates of breast cancer in Haiti, and why Haitian women seem to get breast cancer at a younger age.

The study’s findings have already helped raise the standard of care for breast cancer patients at HUM. For example, the hospital now has a full-time surgeon integrated in the oncology team and dedicated to providing expedited access to surgery.

Damuse says the study has given the team confidence and proven the success of HUM’s oncological care model, which can serve as a blueprint for cancer care across Haiti and other developing countries.

“The study,” she says, “shows that we can improve cancer care in Haiti going forward.”

Monument to ‘Mothers of Gynecology’ Unveiled in Montgomery, Alabama 

A new monument by artist and activist Michelle Browder aims to tell the other side of the Marion Sims story by honoring the “Mothers of Gynecology,” -- Anarcha, Lucy and Betsey, three of eleven enslaved women who were the unwilling subjects of Sims’ experiments in the 1840s. 

Read the full AL.com story here. 

Vaccines and Tamales: NC Pharmacists Bringing COVID Shots to Farm Workers, Families 

The News & Observer reports that “since July...health care volunteers have spent their weekends at the Episcopal Farm Workers Ministry vaccinating hundreds of migrant workers, their families, and another Spanish-speaking immigrants at pop-up clinics at the ministry’s headquarters and nearby businesses.” 

Read the full article here. 

‘This is the Dream Team’ Coalition of Immokalee Workers, Partners In Health, and the Healthcare Network address unique partnership to fight Covid-19 

“While the pandemic has been disruptive to nearly every aspect of life over the past year and a half, it hasn’t actually disrupted the persistent problem of inequality in health.” 

Read the full CIW article here. 

Katie Bollbach of Partners In Health:  In Light of the Pandemic, Here are the 5 Things We Need to do to Improve the U.S. Healthcare System 

“Accompaniment is rooted in solidarity, compassion, and most importantly, shared experiences. To truly accompany patients, providers must listen to their patients and care for the whole person rather than just the acute clinical needs. Health is inextricably linked to the systems around us. Providers should be able to not only treat a disease or a broken bone but be able to help patients navigate services and receive support to address the social determinants of health — housing, food, education.” 

Read the full Authority Magazine article here. 

While he was still a high school student, Devonta Boston founded TGI Movement hoping to create a safe space on the southwest side of town where kids could relax and connect with each other.  Now, Boston’s community-based organization has quickly pivoted to pandemic response, using spaces to help youth better understand COVID-19 and the importance of vaccination.  

 “A lot of youth won’t come out just to get vaccinated,” said Boston. “So, we try to make the vaccine a ‘plus one’ or add on to big things that draw out the youth.” From open mic nights to toy drives and fashion shows, TGI Movement hopes to make vaccination more alluring to youth, sending the message that getting the shot can be part of a larger, more compelling activity.  

TGI Movement is one of 60 Vaccine Community Mobilization grantees funded by the Chicagoland Vaccine Partnership, an organization staffed and managed by PIH-US, that brings together public health experts, government officials, community groups, and philanthropists to focus on equitable vaccine uptake and closing stark health equity gaps that have become more apparent during the pandemic. The latest round of grants aim to expand the range of organizations involved in vaccine outreach; several of these groups recently gathered virtually to discuss their work, and the work ahead.  

With winter on the horizon and vaccination rates hovering around 50% in Chicago's Black and Latinx populations, the Vaccine Partnership took a unique approach to awarding grants.

Funds went to local organizations with a track record of impact in their communities, but not necessarily in the public health sphere; groups include food pantries, youth boxing programs, affordable housing providers and violence prevention organizations.  

“Each of these organizations has gained deep trust within their communities,” said Anand Balasubrahmanyan with the Chicagoland Vaccine Partnership. “Their outreach workers are skilled at connecting and communicating with neighbors because of years of on-the-ground work.”  

GAP Community Center, another grant recipient, hosted a Health and Resource Fair at Cragin Park recently that included a job fair, free children’s clothing, food, and entertainment – as well as a chance to get vaccinated. CEO Angelina Zayas said she wanted to offer families a little fun, and a needed break from the health crisis.  “With everything going on, we wanted to give [families] a sign of hope, that this too will pass,” she said. 

Addressing a Broad Range of Needs

For many people of color on the South and West sides, COVID-19 is just one of many pressing concerns they live with daily; residents struggle to gain reliable access to nutritious food, jobs and housing. That’s why grantees say they are working to attract community members to events that serve a broad range of needs and include vaccination as another free resource. 

As part of the grant process, each organization is offered flexibility to design the type of outreach plan that will best meet the needs of their community. For example, Something Good in Englewood, another grantee, saw that access to food was one of the biggest challenges in the community. They responded by using grant funds to host drive-through food pantries where they also provided COVID-19 safety resources. Their staff also knew how important personal connections are for establishing trust, so they used grant funds to hire community members as outreach workers. 

 “In Englewood we have some of the highest rates of positive COVID tests and lowest rates of vaccination,” said Justin Morgan, Director of Operations for Something Good in Englewood. “We’re putting money in the pockets of the young people in our programs by training them to do vaccine canvassing. Because we have people of the community speaking to the community, it kind of has trust already built in. They talk the talk and walk the walk.” 

Years later, Estefanía Monterrosas still remembers the girl.

How she came in the middle of the night. How she came alone. How she had crossed the border from Guatemala to Mexico with little more than identity documents, stating her age was 18—documents that turned out to be her sister’s.

The girl was only 15. She had run away from home. And no one in her family, but her sister, knew she was pregnant.

Monterrosas was on duty at Casa Materna that night. She had never seen the girl before. But she recognized her.

“I was a teenage mother,” says Monterrosas. “So I kind of understood and felt everything she felt. No woman should have to go through what I went through.”

Casa Materna is the maternal health center at the community hospital in Jaltenango, a town in the rural, coffee-growing Sierra Madre region of Chiapas, Mexico. Compañeros En Salud, as Partners In Health is known locally, has worked there for more than a decade in partnership with the Ministry of Health, providing medical care and social support to thousands of families.

That night, Monterrosas, then a first-year clinician, recalls watching in awe as nurses and midwives sprang into action, staying by the girl’s side for hours and helping her give birth safely.

It’s an experience that has stuck with Monterrosas through the years. And it ignited a passion for respectful childbirth that she has carried with her to this day. Now, as clinical supervisor of Casa Materna, Monterrosas aims to instill that passion in her team of nurses and midwives every day.

“Casa Materna is an example that things can be done differently,” she says. “In the end, it is possible.”

Respectful Childbirth

Since 2016, Casa Materna has helped more than 821 women give birth safely and has provided more than 10,000 prenatal consultations. But safe deliveries weren’t always so achievable in Chiapas.

Before the maternal health center opened its doors, women in labor in the rural, mountainous communities of the Sierra Madre region often had nowhere to go if they wanted a facility-based delivery, even after traveling for hours to Jaltenango, where the community hospital lacked the space to accommodate them.

That challenge set in motion a series of talks between Compañeros En Salud and the Ministry of Health about expanding the community hospital’s maternal ward into a maternal health center, which would provide the space, staff, and resources for women to give birth safely.

In 2016, Casa Materna was born.

“I remember it now and it makes me very nostalgic,” says Monterrosas. “It was always something we had dreamed of.”

At Casa Materna, Compañeros En Salud provides care for women at all stages of pregnancy, connecting new and expectant mothers with medical care, including consultations and tests, and social support, such as free housing and transportation. Staff includes traditional midwives, since many women in Chiapas have historically chosen to give birth at home and feel more comfortable with midwives. At every stage of care, clinicians put the mother and her needs at the center.

Since its earliest days, Casa Materna has been guided by a model of respectful childbirth, which recognizes the woman’s autonomy to make informed decisions about her body and birthing process—a stark contrast to the experiences of many women in labor in hospitals throughout Mexico, where childbirth is viewed through a strictly medical lens and women often aren’t listened to. Instead of assuming to know what is best, clinicians at Casa Materna educate the woman about her options, ask what she would prefer, and then act accordingly.

Those decisions include everything from what birthing position she would prefer to whom she would like present in the delivery room, including any family members. Additionally, following birth, newborns are immediately held to the mother to facilitate bonding between mother and child.

“At Casa Materna, we try to make sure that women have the information they need, so they can make decisions,” says Monterrosas. “We fully believe that labor should evolve according to each body and each woman.”

‘I Leave Here Feeling Alive’

Casa Materna is not only proving that respectful childbirth is possible in Chiapas—it’s also proving that seasoned doctors aren’t essential to delivering it.

Most staff at Casa Materna are first-year clinicians—recent graduates completing their mandatory year of social service with Compañeros En Salud—and traditional midwives. The model has shown what’s possible for maternal health services in rural contexts, where experienced doctors are often hard to find.

Just 27% of deliveries at Casa Materna and the community hospital were supervised by first-year clinicians in the center’s second year of operation. But by December 2020, 86% of all deliveries were supervised by first-year clinicians, demonstrating that, even with limited staff and resources, lives can be saved and new life, welcomed into the world.

María Avendaño, a recent graduate in nursing, is one of the first-year clinicians currently completing her year of social service at Casa Materna.

“Despite having only a little time here, I feel like I’ve learned a lot,” she says. “I’ve learned a lot about dignified care. I’ve also learned how to engage with people in the community.”

That learning cuts both ways.

“I think that Casa Materna is a safe space for all of us who are dedicated to the care of pregnant women,” says Monterrosas. “We always learn something new from everyone.”

Monterrosas spends her days learning. Before she starts her shifts, she knows which women are in labor, which are staying in town as they approach their due date, and which are waiting for a referral to an advanced hospital.

It’s a process that has become more arduous lately, amid COVID-19. As the pandemic has surged in Mexico, filling ICU beds and consuming already scarce resources, Monterrosas has had to fight to get her patients with pregnancy complications access to advanced hospitals—a journey that takes several hours and depends on the availability of Compañeros En Salud’s only ambulance, which is also used to transport COVID-19 patients.

Amid all the uncertainty, Monterrosas does what she can to stay grounded—leading her team by example and continuing to advocate for the respectful care at the heart of Casa Materna.

“There are days that are heavier than others. There are days that are calmer than others,” she says. “But at the end of the day, I leave here [feeling] alive.”

Like many countries around the globe, Liberia has a shortage of nurses and midwives. In an effort to address this, Partners In Health (PIH) Liberia created the Nursing Center of Excellence in 2019 to recruit more health care professionals, while also providing high-quality training and research opportunities. Investing in the next generation of nurses and midwives—who account for nearly 50% of the global health workforce—is vital to developing strong health systems.

Daniel Maweu, nurse-midwife and reproductive health care educator, has played a key role in the development of the Nursing Center of Excellence. For nearly a decade, he has worked in education roles and across clinical settings in Kenya and Liberia to help build resilient maternal health systems while advocating for dignified maternity care for all women. Since 2018, Maweu has worked with PIH Liberia at J.J. Dossen Memorial Hospital and Pleebo Health Center.

In the interview below, which has been edited and condensed for clarity, Maweu discusses the importance of the Nursing Center of Excellence, its impact on staff and patients, and the challenges they face.

What is the Nursing Center of Excellence?

The Nursing Center of Excellence was designed to be a model for the nursing practice and it’s built on a foundation of compassionate, high-quality, evidence-based, and interdisciplinary care. It encompasses five pillars: leadership; clinical education and mentorship; research and innovation; advocacy, practice, and quality improvement.

Why was it created?

Liberia faces a severe shortage of nursing specialists and midwives—health workers who are critical to the nation’s progress toward universal health coverage and the United Nation’s Sustainable Development Goals. As frontline workers, nurses are often the first and sometimes the only contact patients have at all levels of the health system. We expect that shifting specific roles and tasks to nurses and empowering them will go a long way toward achieving universal health coverage. The center is therefore investing in strengthening Liberia’s nursing capacity through innovation and development in health and health care—particularly in primary care, the management of non-communicable diseases, and the development of new approaches to health promotion, prevention, and literacy. Ultimately, the goal of the center is to build excellence in nursing care through education and promotion of research in nursing.

Who qualifies for the program?

Every registered nurse, midwife, and new nursing graduate in the hospitals we support qualifies for the program, which is in its formative stage. Structures are still being laid down to build partnerships with other institutions and to recruit nurses for various scholarships. The program will utilize J. J. Dossen Memorial Hospital [for clinical training], and Tubman University will be the main hub [for medical education and theory]. An additional network of facilities, including the Deanna Kay Isaacson School of Midwifery, Phebe College of Health Sciences, and various sites across PIH’s network, will be involved. Priority nursing specialty programs are oncology, anesthesia, critical care, midwifery, and neonatology. A scholarship for high school graduates interested in enrolling in nursing and midwifery programs was introduced in September.

How many people are enrolled?

Currently, 50 nurses and 20 midwives at J.J. Dossen Memorial Hospital and Pleebo Health Center are enrolled in the program. All nurses working within the facilities we support receive mentorship and support from partner institutions.

How does the center impact health care delivery?

One of the challenges identified in Liberia's health workforce is not simply the shortage of health professionals but also the level of training and experience in the current workforce. The lack of health care professionals has led to an increased demand for skilled nurses to fill positions in nursing, which is the largest sector in the healthcare industry. Developing the competencies to become an excellent nurse relies on the education and mentorship the nurse receives in their baccalaureate program and, therefore, quality education is a must. The Nursing Center of Excellence seeks to create nursing specialists who can adapt to ever-changing health systems. Currently nurses are forced to take on more responsibilities, which were previously assigned to doctors. Maryland County has only four doctors for its population of about 174,441 people.

What has been the impact of the center since its inception in 2019?

PIH, in collaboration with the Maryland County health team, conducted several non-communicable disease short courses for nurses and physician assistants. The training focused on diagnosis and management of cardiac diseases and diabetes. Some of the key areas addressed were electrocardiogram, basic echocardiography, laboratory tests, management of congestive cardiac failure, hypertension, and diabetes. That short-term work has translated to long-term programming that aims to strengthen patient care on a systemic level. The nurses and physician assistants from this cohort have since been running the non-communicable diseases clinic at J. J.  Dossen Memorial Hospital and Pleebo Health Center.

Through on-the-job clinical mentorship of nurses, we’ve been able to ensure that medical surgical ward nurses have basic critical care nursing skills. The ward is now able to provide basic critical care to very sick patients. The Post Anesthesia Care Unit has since established a short stay critical care unit for critical post-operative patients. Nurses and midwives have also been trained in basic life support.

We’ve also started laying the foundation to create specialized training opportunities for nurses in critical care, neonatal care, nursing anesthesia, and oncology through cross-site collaboration. Four nurses have already received neonatal care and oncology training at the Butaro Cancer Center of Excellence in Rwanda. Upon returning to Liberia, the two neonatal care nurses used their newly acquired skills and knowledge to open the first neonatal care unit at J.J. Dossen Memorial Hospital.

Training scholarships for nurses have also played a role. Two nurses and one midwife are currently enrolled in a master’s in nursing and midwifery program at Mother Patern College of Health Sciences. This team will be expected to provide expertise in nursing and midwifery training at Tubman University upon their return. This has opened the door for discussions on the possibility of having more scholarship opportunities for Liberian nurses in key nursing specialties.

What has been your most memorable experience at the center?

The opening of the J.J. Dossen Post Anesthesia Care Unit has made a big impact in care for critical post-operative patients. My most memorable experience in that unit was working on a case where the team cared for a mother in critical condition, experiencing postpartum hemorrhage following her C-section. The patient had to undergo three major surgeries to control the internal bleeding. In addition, the team was forced to transfuse her with more than 10 units of blood while utilizing other devices like the anti-shock garment to keep her alive. It took three days for the patient to regain consciousness. This type of success was previously unheard of at J. J. Dossen Memorial Hospital, where in the past critical patients would die due to lack of basic care.

What are the challenges you face at the center or in your role?

Apart from anesthesia nursing, there are no other nursing specialty training programs in Liberia. This means that nurses have to travel to other countries for training in specialties such as critical care and oncology. Additional limitations are funds to support future nurses, limited space to create a critical care ward, and a lack of adequate diagnostic and therapeutic equipment at J. J. Dossen Memorial Hospital, which is a major barrier for providing quality nursing care to patients with special needs.

What does the future of the center look like?

We envision that the Nursing Center of Excellence will serve as a beacon of clinical care excellence not only at J. J. Dossen Memorial Hospital, but also Liberia and the West African region. We’re focused on developing and fostering clinical specialties; improving leadership, mentorship, and clinical education; and providing a better educational experience for students.

Ideally, specialties will include critical care nurses, oncology nurses, nurse anesthetists, neonatal care nurses, and a leadership team, as well as programs for nursing advocacy, clinical education, and mentorship. We would like to increase the number of educators and improve the faculty-to-student ratio from 1-to-30 to 1-to-10. This will help provide high-quality nursing and midwifery training at J. J. Dossen Memorial Hospital and Tubman University, as these institutions grow into research and innovation hubs.

The race to find a safer, shorter treatment for one of the world’s deadliest infectious diseases just advanced to the next level.

The endTB project has enrolled 750 patients across four continents in a clinical trial aiming to find safer, shorter, and effective treatments for multidrug-resistant tuberculosis (MDR-TB).

Partners In Health is among the organizations leading the clinical trial, along with Médecins Sans Frontières, Interactive Research and Development, and financial partner Unitaid.

The clinical trial comes as part of the endTB project, which was launched in 2016 to revolutionize treatment for MDR-TB patients. Enrollment was completed earlier this month, even as COVID-19 paused hundreds of clinical trials and caused a reduction in TB diagnosis and treatment worldwide—making the milestone even more notable.

New Treatments

MDR-TB is an airborne, infectious disease that has become resistant to standard antibiotics. Each year, 500,000 people fall sick with MDR-TB and nearly 200,000 die, according to the World Health Organization.

Existing treatment regimens for MDR-TB are long and painful, requiring daily injections and taking as long as 2 years to complete.

The clinical trial compares five new treatment regimens, which include bedaquiline and delamanid—two new TB drugs developed in recent years—in combination with other existing oral TB drugs. While these new drugs were approved by regulators as individual medications, they hadn’t yet been tested in combination with other drugs, as a treatment for MDR-TB.

These new regimens could shorten the treatment timeline to as little as six months and wouldn’t require daily injections—an outcome that would be revolutionary for patients living with MDR-TB.

“Shortened regimens, which don’t require daily injections, represent a major advantage to patients and health systems,” says Dr. Carole Mitnick, senior TB researcher with PIH and co-principal investigator of the trial. “We launched the endTB trial to ensure that we have the strongest possible evidence for safe, effective, shortened, injectable-sparing regimens that can be made available worldwide.”

A Global Effort

EndTB’s movement to discover safer, shorter treatments for MDR-TB spans four continents.

Patients were recruited for the Phase III randomized controlled trial from seven countries, including Kazakhstan, Lesotho, and Peru—countries where PIH works and where MDR-TB is an ongoing threat.

“In Peru, we are very proud to be part of the endTB clinical trial and to actively contribute, so Peruvian patients have access to oral and shortened treatments for multidrug-resistant TB,” says Dr Leonid Lecca, executive director of Socios En Salud, as PIH is known in Peru. “Every day we see a growing interest from health care professionals and among the community to access these treatments.”

The clinical trial aimed to enroll a diverse group of patients to ensure that clinicians would have the data they need to best care for vulnerable populations.

“The endTB clinical trial from the initial design strived to have high diversity in terms of different ages, geography, cultures, and ethnicity,” says Dr. Michael Rich, endTB project leader for PIH. “The endTB trial takes place across the African, Asian, European, and South American populations and enrolls people affected by comorbidities like HIV, Hepatitis C, or diabetes.”

The trial also aimed to shorten the research and development process, where scientifically prudent, getting potentially lifesaving drugs to patients faster. Instead of testing the different regimens sequentially—a process that could take 10 years or longer—PIH and partners used adaptive randomization, a method that allows for a relatively small sample size, requires fewer resources, and may enable dramatic improvements in treatment over shorter periods of time.

To further strengthen the research process, PIH and partners also helped train staff at clinical sites, allowing for more research, faster recommendations, and better treatment in the future.

The results of the clinical trial will be available in 2023 and will be relevant for a wide range of patients living with MDR-TB.

For more information, read endTB’s press release.

Diane Mukawera was diagnosed with stage one breast cancer at the age of 42.  As a practicing nurse, she was aware of the disease, but a discussion with a friend who was diagnosed with breast cancer is what she believes saved her life.  

She was among the first oncology patients admitted at Partners In Health-supported Butaro District Hospital, which opened its doors in 2012 and is reimagining equitable cancer care not only in Rwanda—but across Africa. From 2012 to 2019, the hospital admitted 11,107 patients diagnosed with cancer, the most common type among adults being breast cancer. 

Butaro District Hospital provides free cancer care services to all, including: pathology-based diagnosis, chemotherapy, surgery, referral for radiotherapy, socioeconomic support, a 68-bed hostel for patients and their families, and screening and early detection services.  

While not all of these services were available at the time Mukawera arrived in 2013, she fondly remembers the quality care she received at the hands of staff at Inshuti Mu Buzima, as PIH is known in Rwanda. This is her story, which she chose to tell to convey a lifesaving message: Breast cancer is not a death sentence; early diagnosis saves lives. 

In Her Own Words 

“In 2013, I went to visit a friend who had breast cancer surgery. I was informed about cancer because I was a nurse, and at the nursing school we learned about cancer and steps for self-examination of breast cancer.  When I got home, I felt motivated to self-examine my breasts to know my status. After breastfeeding my second child, she was 4 months then, I performed a breast cancer self-exam and felt a small lump in my breast. I neglected it because it was small and felt completely normal.  

There was one risk factor. In my family, my older sister was diagnosed with cancer, so I was a bit worried. One day after my rounds at University Teaching Hospital of Kigali, I decided to go for screening at a private hospital. The doctors ordered many tests, but I was only interested in breast cancer screening.  

I remembered a friend who was working at Butaro District Hospital. I called her and asked if I could go to Butaro for breast cancer screening.  

I went for my screening at Butaro with no symptoms whatsoever. One month later, I got a call to go pick up my results.  

My husband and the rest of the family thought I was going to die. 

In May 2013, I found out I had breast cancer. 

The news was welcomed with shock, fear, and disbelief in the family. My husband and the rest of the family thought I was going to die. I was the head of my department; all my coworkers were sad.  

Despite the fear of a disease that, by then, was believed to have no cure and extremely fatal, I started by treatment journey. I used to travel many hours to Butaro, drive through impassable roads, and leave my breastfeeding 5-month-old daughter at home crying. It was depressing.  

In late May, I had surgery and then chemotherapy for the next six months. After those months of full spectrum of treatment, I started to feel normal again; my hair grew back and I started meeting my doctor once in a while.  

Those first months of treatment were difficult times, giving up seemed like an easier option, but I didn’t.  

During my course of treatment, I kept going to work, and I never missed any single doctor appointment.  

My husband gave me hope, my family members were there to offer their support, and my friend I mentioned before who had cancer was my companion throughout the whole journey—together we gave each other hope. Above all, I had faith in God that made me go for screening very early, despite not having any warning signs. It was a miracle.  

I can’t forget doctors and nurses who supported me at Butaro District Hospital. Their names live forever in my mind. I still remember Nurse Rachel, who is still my friend. I remember a nurse we called Mama Mugisha, Gilbert, a doctor who spoke Kirundi, Nurse Claude, Dr. Cyprien, and everyone who did what seemed impossible to save my life.  

During my treatment, Partners In Health covered all related costs, medication, and provided other support like food, transportation money, and supplementary foods for my daughter. I didn’t even pay for my first screening test.  

I believe that breast cancer is not a death sentence. 

After 13 months of treatment, I tested negative for breast cancer.  

Up to now, Partners In Health continues to provide free medication and consultation until I finish my 10-years regimen. It’s been eight years since I was diagnosed with breast cancer, and I can say I am living proof that breast cancer is not a death sentence.  

I can’t sugarcoat it; some patients I shared a bed with died. But I have seen many people who went on to lead a healthy life after their breast cancer treatment, including my friend Rachel, my older sister, and patients I met at Butaro District Hospital.   

My breast cancer diagnosis came as a shock to me and my family, but that was in 2013. Today a lot has changed in terms of treatment, but awareness about breast cancer needs to be stepped up. Some people still believe that a breast cancer diagnosis means the end, which is false. There are patients who seek traditional healers, this is also wrong.   

I believe that breast cancer is not a death sentence. When you seek help early, you can beat cancer. This is the message I share with other women and girls at my church, workplace, and whoever comes to me for advice about breast cancer.”  

Editor’s Note: 

Diane Mukawera, now 50, is drawing close to the milestone 10-year mark for breast cancer care. She still receives medication to reduce the risk of cancer recurrence. Like other women living near the capital who have been treated for early-stage breast cancer, the pills are provided by Partners In Health and sent to Rwanda Military Hospital, which is less than five miles from her home in Kigali. 

After her first negative result for breast cancer in 2014, she has been going for screening regularly and all the results have shown that she doesn’t have breast cancer.   

In 2017, she retired from her 16-year nursing career to become an entrepreneur. Today, she runs a successful event decoration company. Her daughter, who was breastfeeding when she was diagnosed with breast cancer, is now a beautiful and smart 13-year-old girl completing her primary education. Her friend, who also received breast cancer treatment at PIH-supported Butaro District Hospital, is cancer free. 

These days, Justin Mendoza could be found meeting with senators and representatives in the halls of Congress, advocating for legislation to strengthen public health in the United States and beyond. As advocacy lead for PIH-US, it is part of his job to track legislation and keep up with lawmakers, always looking for an opportunity to advance PIH’s mission—health care as a human right—at the highest levels of government.

But his career in advocacy began somewhere else: on college campuses.

Mendoza started out as a community organizer with PIH Engage—PIH’s grassroots network of college students and young people in the U.S. and Mexico, organizing campuses and communities in support of global health initiatives. That time with PIH Engage was formative to Mendoza’s approach to advocacy now, helping him understand how to mobilize people and push for change—together.

In honor of Hispanic Heritage Month, we sat down with Mendoza for our Working In Global Health series, which spotlights PIH staff who have dedicated their careers to making a global impact. In this wide-ranging conversation, we chatted about what drew Mendoza to a career in public health, how his roots in community organizing shaped his approach to advocacy today, and what he has been up to outside of work.

Since July 2020, you’ve been a key member of PIH’s Advocacy team, pushing for policies to advance global health at the national level. How did you come to join the team and what is your role?  

I joined PIH because I believe strongly in our mission and vision: to deliver a preferential option for the poor. I believe that we need an equitable health care system all over the world, and I am driven by the work PIH does to strengthen health care systems and develop policies that can help. Before PIH, I was working in Washington, D.C., on legislation to improve health care broadly, and the COVID-19 pandemic convinced me I needed to find a mission to serve that was more centered on equity.  

Now, as our U.S. Health Care Advocacy Lead, my role is to build advocacy strategy designed to advance health equity and policy. I represent PIH with decisionmakers mostly at the federal level and guide a team of skilled experts to build out campaigns and strategies that improve the policy landscape for the communities we serve.  

You started out as a community organizer with PIH back in 2015. Can you share more about that experience and how organizing at the grassroots level shaped your perspective and approach to advocacy today? 

I believe firmly that anyone who aspires to advocate for change should start out as a community organizer. When I worked as a community organizer with our grassroots volunteer team, PIH Engage, I helped co-design advocacy campaigns, fundraising work, and community-building practices. As an organizer, it was my job to help empower people that care deeply about our mission and give them a way to help us build a broader movement for the right to health.  

The key to being a community organizer is to understand the way that power flows in our society, politics, and communities and to channel that power for the issues you care about. It means building relationships with neighbors, friends, colleagues, and strangers in order to push for the right to health. At its core, community organizing with PIH Engage gave me an inside look into what it means to be a part of the accompaniment, walking side by side with those we serve or partner with, that is core to PIH’s work. 

Now, PIH Engage is even more essential than it was during my days on the team. PIH Engage is made up of volunteers ranging from high school students to young professionals. Engagers are helping us shape the public's understanding of health equity, raise essential funds for the Maternal Center of Excellence in Sierra Leone, and advocate for health equity.   

What is your favorite part about working at PIH?   

I don’t even know where to start on this one. PIH has a mission I love, too many talented colleagues to count, and a leadership team that is dedicated to making our vision a reality. I also really like the opportunity to be creative with our work. For instance, we now host a monthly Health Justice Call, which my team and I put together, and we get to bring social movements from around the country to a space where they can share perspectives and strengthen their movements together. (P.S., you can sign up for our October call here).  

What does Hispanic Heritage Month mean to you?  

Hispanic Heritage Month is a moment for me to reflect on what my culture is and what my connection is back to that culture. My family is from the Dominican Republic and has a history of resistance. In the days of the former President Trujillo, family members fled the country out of fear of retaliation because they opposed his violent punishments and practices in the country. A family rumor even says that one of our relatives was on a government list of enemies of the state at the time. Now, as an advocate, I carry on our time-bound tradition of pushing back against policies that are oppressive to those around me. This month also coincides with important dates in my life, including my father’s birthday and the day he passed. I feel like during this month, I take a few more minutes than usual to connect, breathe, and pay attention to where I came from and where I am going. It definitely helps to work at an organization with fantastic colleagues from all over the world who celebrate and reflect during this month as well.   

How does your culture affect your work and how you approach it?  

My culture is all about family, closeness, and caring about the people around you. It is a part of my own empathetic approach to work and guides my value system. I think about what the policies I advocate for would mean for my family.  

Representation in the public health, political, and advocacy fields is growing. I find that when you look across the Hispanic culture, broadly, you find many people working in health care from promotoras (community health workers), to nurses and doctors, to health policy professionals—like Xavier Becerra, director of the U.S. Department of Health and Human Services. I am happy to be one among many others with shared cultural priorities and values. 

How can public health professionals better serve Hispanic and Latino communities in the U.S.? 

There are two key principles that every public health professional should remember when working with Hispanic and Latino communities. First, we’re not one simple culture; we represent many types of people, with many hopes, dreams, and values. So you should still get to know the community you aim to serve at a local level, rather than generalizing across everyone who checks the “Hispanic/Latino” box on the census.  

Second, remember that in many communities, language remains a key barrier, particularly for older generations. We have to plan for the translation of materials to the language spoken by the communities we serve, and the best way to do that is to work with a local. 

What do you like to do in your spare time? We heard you have some pretty adorable dogs at home and fun wall art in your office. 

Well, the dogs do take up a lot of my spare time. They have their own Instagram, and they’re both Husky mixes, so you can imagine the amount of fur there is to clean. I also spend time engaging with social justice movements that I care about. Living in Washington, D.C. means there are always protests and gatherings to attend, so I like to do that as much as I can. I also hold a position on the board of directors for Universities Allied for Essential Medicines, which is a student-driven nonprofit that works to make sure medicines are affordable for all.  

My wife and I really love to entertain as well, so we’re constantly having gatherings (particularly pre-COVID) with friends in the area for holidays, sports seasons (hockey and football), and big political events (like the State of the Union). During all of these, I get to test my cooking skills with new recipes and ideas!  

Beyond that, I enjoy running seasonally and recently picked up my guitar after letting it sit in storage for far too long. As far as I am concerned, as long as family and friends can be involved, any hobby is worth doing!  

In Rwanda, “impinja ntizigapfe” captures a mother’s prayer—that no baby ever dies. The phrase is part of a folk song in Kinyarwanda, one of the country’s four official languages. And it inspired an innovative program intent on saving newborns’ lives.

The program, All Babies Count, was launched by Inshuti Mu Buzima, as Partners In Health is known locally, and the Rwandan Ministry of Health in 2013, focused on reducing newborn deaths in Kayonza and Kirehe, two rural districts where neonatal mortality was high.

The results were striking: in just 18 months, the program reduced neonatal mortality by 35%. Among high-risk preterm and low-birth weight newborns, that drop was even greater—49%.

Since then, PIH staff have been determined to understand what made All Babies Count so successful—curiosity that led to new research published last year in Global Health: Science and Practice.

The study examines how All Babies Count reduced neonatal mortality and what those findings could mean for efforts to save newborns’ lives throughout Rwanda and worldwide, especially in rural contexts.

“What All Babies Count did is to provide knowledge and skills,” says Dr. Erick Baganizi, director of maternal, newborn, child and adolescent health at Inshuti Mu Buzima and co-author of the study. “It has had a huge impact on premature babies.”

‘These Achievements Are Possible’

Over the past two decades, Rwanda has made remarkable progress toward reducing child mortality. But neonatal mortality has not seen the same level of progress and has remained alarmingly high in rural areas such as Kayonza and Kirehe, where 30 out every 1,000 newborns died in 2013, compared to the nationwide ratio in Rwanda of 19.5 and United States’ 4.

Since its inception in 2013, All Babies Count aimed to change that. Launched by Inshuti Mu Buzima and the Rwandan Ministry of Health as an 18-month pilot, the program had one mission: end preventable neonatal deaths by equipping hospitals with resources, training, and national protocols for neonatal care.

Caring for newborns with health complications is costly and challenging for any hospital, but especially for those in rural communities where access to resources, staff, and expertise is limited. Having the right medical equipment can mean the difference between life or death for a baby born prematurely, or with other complications—a reality that clinicians routinely saw in Kayonza and Kirehe districts.

To address this critical gap, All Babies Count helped hospitals and clinics in these districts procure lifesaving medical equipment, such as delivery tables, incubators, suction machines and infant scales, improving their capacity for neonatal care and providing safe, clean infrastructure for both mothers and babies.

The program also invested in training and mentoring clinicians, offering “learning collaborative” sessions for health professionals to meet and share best practices and partnering with the Ministry of Health to develop national protocols for neonatal care and strategies to onboard clinicians—strategies that could be as simple as hanging a flyer on the wall of a clinic, or as complex as implementing mandatory trainings.

“Having the entire country on the same message for neonatal care really played a big role,” says Merab Nyishime, a neonatal nurse specialist who managed All Babies Count from 2013 to 2017.

That unified message saved lives.

After the 18-month pilot, neonatal mortality in Kayonza and Kirehe dropped from 30.1 to 19.6 deaths per 1,000 live births. Overall, 139 nurses and midwives were trained in essential newborn care, and more than 150 health workers were trained in the management of pre-eclampsia and eclampsia—both potentially life-threatening conditions for expectant mothers and, by relation, their newborns. Every hospital in the program received a full-time nurse or midwife mentor to provide specialized training.

All Babies Count was so effective that it was expanded to seven hospitals and 69 health centers across Rwanda from 2016 to 2019 and its elements—such as trainings, data sharing, quality improvement projects, and the learning collaborative—were integrated into Rwanda’s national strategy for neonatal care, which continues to this day. And it has served as a model for health workers elsewhere—PIH Liberia is applying elements of the program to its own maternal and neonatal care.

“This type of project helps in spreading knowledge and also increases the confidence of people who see the project working,” says Baganizi. “It’s a good way to show that this is doable, even if you are in a low-resource setting. These are the achievements that are possible.”

Growing up, Tiffany Treviño remembers struggling to breathe.

To doctors in her hometown of Kingsville, Texas, the problem was simply an infection—treatable with medication. But Treviño knew it was much deeper than that.

“In my town, many people live at or below the poverty line,” she says. “There’s pretty low college education rates and tons of health burden.”

In Kingsville, where 110-degree weather is a typical summer day, those inequities looked like houses with cheap insulation, forcing families to run air-conditioning units nonstop and causing mold to develop—mold that made breathing difficult and led to health conditions like asthma.

“Many of the physicians that we had were not from the area,” she recalls. “They were not versed in systemic inequities.”

For Treviño, who has since controlled her asthma, those days serve as a reminder of the health disparities she and so many others had to deal with, routinely—and what she’s now determined to change.

A Personal Connection

Treviño is a Learning and Impact associate with Partners In Health United States (PIH-US). Launched in May 2020, PIH-US grew out of PIH’s work in Massachusetts in response to COVID-19. That work has since expanded to several states, cities, and counties across the United States, focused on strengthening health systems through technical advising, a learning collaborative for public health professionals, and advocacy.

In her role, Treviño supports the Learning and Impact team, which provides resources for public health departments, community-based organizations, and health care organizations as they respond to the pandemic in their communities.

It is work that Treviño finds rewarding—and deeply personal.

As the daughter of an immigrant, she recalls the story of how her father’s family came to the U.S. from Mexico, because of a relative’s health condition.

“They all moved to the United States because my dad’s younger sister contracted polio while they were living in Mexico,” she says. “And they were really poor. I mean, like dirt poor.”

Galveston, where her father’s family relocated, offered the chance to start a new life—her relative was able to access treatment, and the family found some stability.

But quality health care was far from a guarantee—especially in Kingsville, where Treviño grew up.

Most doctors weren’t from the community. And, unlike many families in Kingsville, most hadn’t lived paycheck-to-paycheck, skipped meals to save money, or had the lights shut off over an unpaid bill. And few spoke Spanish—a language spoken at home by 38% of residents.

“I feel like the doctors and the health care system in general tended to overlook those things, despite living in an area that is over 70% Hispanic and where many people lived at or below the poverty threshold,” says Treviño.

Asthma—though often tied to systemic inequities—was treated as an infection. Obesity—though often connected to poverty and food deserts—was pegged to poor lifestyle choices.

As she watched clinics with revolving doors of patients, their health needs never fully met, Treviño knew something had to change—an instinct that led her to a career in public health and, ultimately, PIH.

A Passion for Public Health

It was in a grad school classroom that Treviño was able to put words to some of the things she had seen growing up—situations where single moms working two jobs and feeding their kids fast food, because it was all they could afford or had time to prepare, were now understood through the lens of academic concepts like the “double death.” New to Treviño, it was a term one of her professors used to describe malnutrition among patients living in poverty: how some were too poor to eat and others could only afford unhealthy foods.

Learning about the cycle of poverty and related poor health outcomes helped Treviño understand the systemic inequities behind the health disparities she had grown up around—ultimately fueling her drive to change them. As she worked toward her master’s in public health from the University of Otago in New Zealand, Treviño knew she wanted to pursue a career focused on health equity—a decision that led her to PIH.

Now, just months later, she is an integral part of her team, supporting public health professionals nationwide in accessing the resources they need, amid a fast-moving pandemic. It is work that inspires her. Though the cities in her day-to-day projects are varied, the work—with local communities—often reminds her of home.

“I think of it from a small-town perspective,” she says. “Whenever I think about the work I’m doing, I’m like, ‘Okay, what would it take for me to do this kind of work in my town?’”

Kingsville comes to mind in other ways, too.

PIH-US works in several communities, from Immokalee, Fla., to Pima County, Ariz., with significant Hispanic and Latinx populations—a cultural identity that, while vastly different depending on location, is familiar to Treviño.

“There’s this community feel that the Latinx community has,” she says. “We trust our families. We trust our friends. We trust our people. We’re very tight knit...I feel like public health workers, whether they’re from that area or from the outside looking in, need to understand that.”

That cultural understanding has been critical amid the COVID-19 response, as Hispanic and Latinx communities in the U.S. have been disproportionately impacted by the pandemic due to decades of systemic racism, xenophobia, and inequities in the health care system.

As a Latina public health professional, Treviño is determined to call attention to these systemic inequities—and find solutions.

One of those solutions, she says, involves a program at the heart of PIH’s approach, both in the U.S. and worldwide: community health workers.

Community health workers are recruited from the communities they serve and trained to provide basic health services, such as medications or screenings, to patients at home. Since hiring its first community health workers in Haiti nearly three decades ago, PIH has built a workforce of nearly 11,400 community health workers worldwide—delivering care to thousands of patients, when and where they need it most.

“I feel like community health workers, specifically, are like the golden key right now,” says Treviño. “There’s a need for public health organizations to utilize their community health workers—the people who are doing the groundwork, who can speak the language and that know the culture—to just get the work done.”

For Treviño, the impact of community health workers resonates more than anything learned through a class lecture or textbook reading—it’s a concept she can understand on a personal level.

“My abuela and my abuelo are not going to understand what my white supervisor is saying,” she says. “But they will understand what I’m saying, both as their granddaughter and as a member of the community—as a member of the Hispanic, Latinx community.”

Mental disturbances from delirium are usually temporary, but they can be life-threatening—which is why it’s critical to recognize and diagnosis the condition. At PIH-supported J.J. Dossen Memorial Hospital, 16 nurses recently received delirium and agitation training and are now equipped to provide better care to patients.

During the three-day course in Maryland County, Liberia, nurses learned how to identify, assess, refer, and effectively treat patients with delirium, which is a serious disturbance in mental abilities that can come on suddenly and results in confused thinking and reduced awareness of the environment. Nurses also learned about core psychotherapy approaches, such as Common Elements Treatment Approach and one-on-one daily counseling; and how to gather information to obtain a comprehensive overview of a patient’s mental health history.

The goal of the training was to equip nurses with skills and, ultimately, reduce the number of patients who die from delirium.

“From January to June 2021, we lost seven patients because of delirium. We also had nine patients diagnosed with delirium during ward rounds specifically for mental health support, which I think the nurses didn’t recognize. We decided to have this training because of that,” says Willis Yansine, PIH Liberia’s mental health coordinator, who co-led the training alongside Dr. Kurcine Kollie, an emergency medicine physician at J.J. Dossen Memorial Hospital.

Delirium can often be traced to one or more contributing factors, such as a severe or chronic illness, changes in metabolic balance (such as low sodium), medication, infection, surgery, or alcohol or drug intoxication or withdrawal. In some cases, patients experience hallucinations, anxiety, and have fluctuating levels of consciousness, all of which can lead to accidents or self-harm causing death.

Patients usually experience delirium at night, but the cases often aren’t diagnosed until the morning or later, explains Kollie. And in many instances, it’s not diagnosed at all.

“We’ve had patients who began to get more confused and the health worker thought it was psychosis or some other mental health condition. They could not identify it as delirium,” says Kollie.

Nurses are now able to identify behavior change and signs and symptoms of delirium because of the PIH training, led in collaboration with the Ministry of Health. Ideally, the nurses will be able to identify and address it early on in care, then consult with the attending doctor. Delirium is usually managed by addressing the underlying causes and adjusting environmental factors, such as lighting in the ward. Health care workers also help reassure patients by orienting them to the time of day and their location.

Previously, the lack of knowledge affected the team’s ability to address delirium. Now, “with this training and information, we can help reduce the death rate (due to patient agitation and delirium) in Maryland County,” says Samuel Nyenkpor, director of nursing services at J.J. Dossen Memorial Hospital.

Partners In Health has officially formalized its U.S. arm, Partners In Health United States (PIH-US).

What began as a time-bound initiative in response to a spiraling public health crisis has now catalyzed a long-term commitment to reimagining community health systems in the U.S.--a fundamental component of PIH’s mission to realizing health as a human right. With a visionary investment from The Audacious Project, PIH launched the United States Public Health Accompaniment Unit to support pandemic response in some of the hardest-hit areas in the country through contact tracing, connecting patients and families to vital resources like food and housing, and accessing lifesaving vaccines. PIH-US will build on the infrastructure and lessons learned over the last 18 months during the COVID-19 pandemic to advance a long-term vision of building stronger public health systems, a more robust community health workforce, and a more just health system overall.

“When Partners In Health launched its U.S. COVID-19 response in March 2020, we called upon our experience fighting epidemics and strengthening health systems around the world,” said PIH CEO Dr. Sheila Davis. “This work has laid the foundation for a long-term arm of Partners In Health that will focus on strengthening U.S. community health systems and, ultimately, shift the paradigm of public health towards a more inclusive and equitable redistribution of health resources.”

Unlike many of the countries where PIH works around the world, health care in the U.S. is abundant and heavily resourced. But people of color and the poor are systematically excluded from those resources and, in many parts of the U.S., there exists a 20-year gap in life expectancy between low-income communities of color and their wealthy white counterparts. U.S. health systems are built to maximize the delivery of profitable health care rather than to sustain the health and well-being of communities. When COVID-19 hit the U.S. in early 2020, these inequities were laid bare, and the devastating consequences of our fragmented health system became even more apparent.

Seeking to rectify that imbalance, PIH-US works alongside public health departments and community organizations to set shared health and racial equity agendas and provide technical advising and operational support to deliver on those commitments. PIH-US distills scientific evidence and on-the-ground experience to mobilize funding, advance policy change at the local, state, and federal levels, and lay the groundwork for stronger community health systems across the country.

As partners shift from emergency COVID-19 response to rebuilding U.S. health and social systems, PIH-US is supporting their evolving and emergent needs, with a focus on the following three priority areas:

Strengthening Public Health Departments for the Future

Since April 2020, PIH-US has supported the Newark Department of Health & Community Wellness to monitor and analyze test positivity rates and COVID-19 clusters, estimate COVID-19 workforce needs, inform reopening and response policies, and stand up a care resource coordination program which has connected more than 8,500 Newarkers to resources for safe isolation and quarantine. We also supported the city’s efforts to expand vaccination and bring vaccines directly to residents through static and pop-up sites.

As Newark moves beyond emergency COVID-19 response to focus on the greatest drivers of excess mortality and morbidity, we are helping to support long term public health planning that focuses on building back stronger and mobilizing resources to ensure sustained commitments to Newark’s ambitious health equity goals.

Investing in Community Health Workers as a Core Component of Public Health

In North Carolina, PIH-US has partnered with community-based organizations and the Department of Health and Human Services to strengthen contact tracing and case investigation; expand care resource coordination; and establish more equitable vaccine access. Now, PIH-US, is working closely with the state’s DHHS to assist the expansion of a successful community health worker program from 55 to all 100 counties statewide with more robust community relationships and connections to social supports.

As of August 2021, North Carolina CHWs had reached over 465,000 people with vaccine education, supported over 1,900 vaccination events, and scheduled over 30,000 individuals to receive a COVID-19 vaccine.

Building Collaborative Infrastructure that Serves as the Cornerstone of a More Resilient Health System

The Chicagoland Vaccine Partnership (CVP), supported by PIH-US, brings together a coalition of 160 community-based organizations, public health experts, government and philanthropists committed to closing health equity gaps. As the pandemic highlighted many glaring inequities in Chicagoland’s public health and social infrastructure, the CVP supported community-led engagement and vaccine access among Chicagoland's most vulnerable communities. The CVP worked with local funders to provide rapid response grants that allowed organizations that had focused on mitigating youth violence in pockets of the city to pivot and conduct vaccine outreach in those same neighborhoods. Similarly, organizations that ran food pantries and youth programs were funded so that people could get vaccine information and social support at places they knew and trusted. The team also partnered with Malcolm X City College and the Chicago Department of Public Health to offer a free online course that trained more than 3,000 community members to speak to their neighbors about vaccination. The CVP used grants and convening to expand the role of community organizations in health crisis response. This work has led to thousands of vaccinations and provides a cohort of community leaders who can serve as the backbone of more equitable response to health emergencies in the future.

In addition to embedded advising teams, PIH-US also includes a Learning Impact Team that provides up-to-date public health guidance, protocols, and research made available to peer organizations and community leaders throughout the country. And the U.S. Advocacy Team works with lawmakers in the top ranks of government to develop and adopt policies that lead to stronger public health systems that meet the needs of under resourced, neglected communities.

“This crisis has offered an inflection point to reimagine U.S. health and social systems,” said Katie Bollbach, executive director of PIH-US. “At this critical moment, PIH-US is committed to accompanying visionary public health and community leaders to rebuild community-based health systems that work to repair generations of harm inflicted through systemic disinvestment and structural racism, and to attain true health equity in this country.”

The headaches began in July 2019—but up until then, 13-year-old Emma* Gbonbor was living a healthy, happy life at home in Kono District, Sierra Leone. 

She and her twin sister, Kadie*, are the second youngest of seven siblings. Entering her second year of high school, Emma chose math as her favorite subject, inspired by Kadie, who excelled at it and tutored her at home. She played soccer with her friends. In the evenings, between homework and chores, Emma danced to the pop music blasted by her next-door neighbors. 

Then came the headaches—always accompanied by fever, weakness, and, as the family discovered one night around 3 a.m., seizures. 

Immediately, Emma’s mother, Rebecca, took her to nearby Koidu Government Hospital (KGH)—the only hospital in the district, supported by Partners In Health (PIH)—where clinicians in the outpatient department suspected malaria. Soon Emma was home with antimalarial pills and experienced some relief. But less than a week later, she was back in the hospital, admitted to inpatient care after having experienced more seizures—sometimes three per day. She’d begun to anticipate when they were coming on. 

“It was the headache that started and then the convulsion started to affect her. She was complaining about her head. She would say, ‘Mother, it is that sickness that is about to affect me,’” Rebecca said.

"Whenever she said that, I would see her fall down and lose her senses.” 

Over five days at KGH, clinicians stabilized her and sent her back home. But yet again, one week later, she returned—this time in critical condition. After a particularly intense seizure, she’d fallen unconscious. 

“She was on the verge of death,” Rebecca said, recalling bringing her daughter to KGH for a third time—despite those telling her not to. 

“People were calling me, saying, ‘This is not a disease for the hospital,’” she said, referring to neighbors who suspected witchcraft, the only cure for which lay with one of Kono’s traditional healers. 

“I said, ‘We are not going any other place. We pray. And then the medical.’” 

“This isn’t just ordinary malaria” 

It was Dr. Ikechukwu Nnanna’s first week of work at KGH, as a pediatric medical officer hired by PIH to bolster the hospital’s pediatric care, when he met an unconscious Emma in the emergency ward. A community health officer—akin to a physician’s assistant in the U.S., far outnumbering medical doctors at KGH and across Sierra Leone—had put Emma back on antimalarial drugs, as a rapid diagnostic test for malaria returned positive. It was the height of rainy season, and pediatric staff see upwards of 90 patients per day, 85% of whom have malaria. 

Nnanna, however, had other suspicions: meningitis and, likely, a brain tumor. 

“I examined Emma and found that she had neck stiffness and hemiparesis – or partial paralysis,” he said. “I thought, ‘This isn’t just ordinary malaria.’ So I asked for more tests to be done.” 

KGH lab technicians ran a battery of tests, from blood tests for HIV and kidney function to a chest X-ray to search for tuberculosis (TB). All came back normal—meaning all that was left to do was examine Emma’s brain. 

A computerized tomography (CT) scan—an advanced machine producing highly detailed images of inside the body—is rare in Sierra Leone, and one of the three that exist countrywide sits at a private health facility in the capital city, Freetown. So, shortly after admitting Emma, PIH staff made the five-hour journey from Kono with her and Rebecca.  

There, on the scan, staff observed a huge mass on Emma’s brain, along with three smaller masses. 

But they weren’t tumors. Nnanna and his fellow PIH clinicians—including pediatrician Dr. Naphtal Nyirimanzi, Dr. Marta Lado, PIH Sierra Leone’s former chief medical officer, and Dr. Joia Mukherjee, PIH’s chief medical officer—realized they were abscesses, consistent with extrapulmonary TB. 

Extrapulmonary TB is an increasingly common form of tuberculosis, one of the world’s deadliest infectious diseases, in which the bacterium causing TB travels outside the lungs and lodges itself in another part of the body. In Emma’s case, TB was living in her brain—causing her seizures, as well as secondary infection of meningitis. But without advanced medical equipment, it is impossible to detect the condition. KGH’s clinicians weren’t able to diagnose Emma’s it using a chest X-ray or tests. 

“Tuberculosis comes in many forms now,” Nnanna said. “If you are not vigilant, you think TB is only [indicated by] coughs. But TB disguises itself. If you are not precise in your diagnosis, you might miss it.”  

“Crying and praying” 

Emma remained unconscious and was put on a feeding tube. 

“I was not feeling good,” said Rebecca. “A kind of sickness that my child never had, all of a sudden it has affected her. I was just crying and praying. That was my only job. Crying and praying.” 

But with a diagnosis came a treatment plan: anti-TB drugs and broad-spectrum antibiotics, including a drug used to treat meningitis that PIH procured internationally, as it is not available in Sierra Leone. 

And with a treatment plan came reason for optimism—a feeling sorely needed by the Gbonbors, as Emma’s sickness wasn’t the only challenge they faced. 

Only a month prior, the family lived with just enough. As their primary earner, Rebecca ran a business making and selling soap and her daily profits—15,000 Leones, the equivalent of $1.50—fed her family of nine. Her husband supplemented this income as a miner in Kono’s diamond mine—a back-breaking job for which foreign companies controlling the mine, the largest in West Africa, only paid 7,000 Leones per day, the equivalent of 70 cents. 

But when Emma was admitted to the hospital, Rebecca put her business on hold to stay with her daughter, day and night—meaning that 7,000 Leones a day were all that the Gbonbors had to survive. Meanwhile, PIH provided meals to Rebecca while she remained by her daughter’s side. 

As the medications began to do their work, and clinicians saw Emma’s progress, the Gbonbors felt a deep sense of relief. 

“They were saying she would survive,” Rebecca said. “Emma would survive—she won’t die.” 

“There was hope” 

Three months later, Emma opened her eyes. 

Another trip to Freetown and more CT scans had revealed that the brain masses had disappeared. 

“We were so glad,” Nnanna said. “We were checking her every day, monitoring the results of the medications. ... So when she started gaining consciousness, everybody was happy that Emma was coming back. There was hope.” 

The first thing Emma asked for was to see her twin, Kadie, in her brand-new school uniform—a request Kadie didn’t need to be told as she made her daily visit to the hospital straight from school. 

“Emma was very, very happy with her sister that day,” Rebecca said. “And I had happiness within me. My child survived, and I was able to return with her home.” 

That return didn’t happen for another two months, as clinicians kept Emma in the hospital to continue monitoring her condition and to provide rehabilitative support. Slowly but surely, with the help of clinicians and Rebecca, Emma regained her ability to sit up, then stand, then walk. She began eating again, and her seizures became less and less frequent. 

Emma, eager to get back home, was finally allowed to do so. Aside from having to visit the hospital every two weeks for check-ups, life could return to normal. 

“A great joy” 

Emma got home and began sweeping. 

“That is my job, to sweep the compound,” she said. 

“That is her fun job,” Rebecca added, smiling. 

Old routines provided comfort, but of course, nothing was exactly the same. Most frustratingly for Emma, the transition back to school hasn’t been seamless. Having been pulled out of school midyear by her illness, she re-enrolled only to fail her exams, due to difficulty writing—a lingering result of her paralysis. 

This fall, Emma, now 15, is repeating her last school year, with high hopes of not only passing, but succeeding academically. She also has a new dream to motivate her: becoming a nurse, inspired by the pediatric nursing staff at KGH who helped care for her. 

And this time, her twin sister is following in her footsteps. 

“Kadie too said she wanted the same,” Rebecca said. “They love each other.” 

Though the obstacles are plenty, Emma’s health has been stable since being discharged from KGH in December 2019. It has been a year since her last check-up, and well over a year since her last seizure. 

“Sometimes I sit down with my husband and we ... say that we do not have anything; but we have something,” she continued.

"Our child has survived, we are now seeing her and all of us are sitting together and chatting. It is a great joy.” 

Thanks to Emma’s case, more families will get to know that same joy: Nnanna said that this summer, he and the pediatric staff at KGH successfully diagnosed and treated more than three cases of TB meningitis in children and many cases of extrapulmonary tuberculosis.  

“One was critically ill, unconscious, like Emma. And as soon as we started the anti-TB medications, she started getting well,” Nnanna said. “We often undermine TB here, but Emma’s case gave me a new approach, not to overlook or undermine anything. And it taught me a lesson in how to be committed to patients: Emma’s life matters a lot. We didn’t leave any stone unturned, and now, everything is okay. She is here.” 

*Names changed for anonymity 

In 2019, Ma-Kebbeh (pseudonym) began to show signs of schizophrenia. She talked to herself, refused to eat, and experienced hallucinations. According to her, strange things were happening.

“There was blood on the curtains and a dog entered our house,” she says. “And there was a big snake in the bathroom. My husband’s little brother killed it.”

Her family believed she was under spiritual attack and dismissed the thought of a potential mental illness. Hoping to protect her, her husband sent her 250 miles away from their home in Monrovia to her mother’s house in Harper, but this did not help. She was then sent to several churches by her mother and sister with the hope that prayers would heal her. For a year, they tried to rid her of the “demons” attacking her by using pepper, burning incense, and sprinkling her with Holy Water. Nothing worked.

Eventually, Ma-Kebbeh was taken by her mother to a church in Harper, where she was tied to a palm tree upon arrival to ensure she didn’t run away, as she had in the past due to her condition. Meanwhile, Prophet Samuel Howe called Garmai Cyrus-Biddle, PIH Liberia’s mental health coordinator, to immediately alert her of the situation.

Finally, Ma-Kebbeh’s journey took a turn for the better. PIH Liberia's mental health team had created a partnership with the church to provide care for patients such as Ma-Kebbeh, in collaboration with the Maryland County health team. Originally launched in 2018 to help those with depression, the mental health quality improvement initiative has since expanded to include patients with other mental health disorders, such as schizophrenia—which affects 20 million people worldwide. PIH mental health staff and the Maryland County health team work with traditional and religious healers to ensure continuous care for patients by training them to identify and refer people with common mental disorders from the community to health facilities for treatment. This is much needed in southeastern Liberia, where mental health services are limited, so residents often turn for relief to traditional medicine and witchcraft.

When Garmai got Howe’s call, she traveled to the church to meet Ma-Kebbeh, who was hesitant to receive care but eventually consented to counseling and—in turn—medication. For a month, the mental health team continued to visit and provide high-quality care for Ma-Kebbeh out of the church.

“It makes me very happy for us to work together,” says Howe, “because when the mental health patients come to me, when Garmai and her team were not here, I didn’t have any medicine to give them...So now, when I get a patient like that, I call them to come.” In time, Ma-Kebbeh was transferred to nearby Partners In Health-supported health facility, J.J. Dossen Hospital, to continue treatment. After consulting with the mental health team for a few hours, she was discharged to her family in Harper and continued to visit the mental health clinic at the hospital for regularly scheduled appointments. In addition, Ma-Kebbeh was visited at home weekly by a PIH mental health psychosocial assistant who counseled her and monitored her progress.

Since PIH began providing care, her health has significantly improved; she no longer talks to herself, she is comfortable being around others, and moved back to Monrovia to live with her husband and three children. She continues to make the trip to Harper every other month to visit a mental health clinician and refill her medication.

“I got hope,” Ma-Kebbeh says. “I am grateful to God for the delivery and grateful to PIH for the treatment.”

Following the devastating earthquake on Aug. 14,  Zanmi Lasante, as Partners In Health is known locally, sent a medical team to affected areas in southern Haiti to strengthen the support for survivors. Meanwhile, at Hôpital Universitaire de Mirebalais—about 150 miles from the epicenter of the quake—clinicians simultaneously prepared to treat patients.

Dr. Jean Jimmy Plantin, an emergency medicine physician at Hôpital Universitaire de Mirebalais and graduate of the hospital’s medical education program, was one of those clinicians. Working around the clock, Plantin helped coordinate those efforts and prepare staff for the days and weeks ahead.

“Hospital staff, especially those in the emergency department, were eager to support the survivors in the South,” says Plantin. “Many employees wanted to go to the field, but from the moment they learned of the arrival of some survivors at HUM, they were all ready to welcome them and provide them with the necessary care.”

In addition to training staff, Plantin helped reconstruct the “space”— one of the 5 S’s (staff, stuff, space, systems, and social support) in PIH’s approach to strengthening health systems. To prepare for an overwhelmed emergency department, Plantin and his colleagues added more than 20 beds to the former local infectious diseases unit. If that wasn’t enough, they also had an option to expand, depending on the influx of patients. They anticipated that patients would have social and psychological needs too, so the psychosocial team developed a plan to accommodate all survivors.

Their instincts were right.

Shortly after the 7.2-magnitude earthquake, the beds began to fill up with patients with various traumas, including pelvis and leg fractures, chest and abdominal injuries, and burns. Patients with psychological trauma and non-traumatic injuries, such as stroke, also came in for care. And four premature newborns received treatment for respiratory stress—unrelated to the earthquake.

Using a comprehensive triage process, Plantin and the emergency department staff worked together to identify and separate the most urgent cases from those that could await consultation within a reasonable time.

The team at the hospital has since seen dozens of patients for specialized care directly related to the earthquake. Plantin was particularly touched by the story of a 48-year-old man, who was caught in a landslide and injured his tibia. He was rushed to a hospital in Jeremie, but due to the large influx of patients and lack of staff, he couldn’t be seen immediately. Luckily, he was spotted by a rescue team and taken to HUM where he underwent surgery within two hours of his arrival.

“That day,” says Plantin, “I understood that for every survivor we saw, there could be another hundred that wouldn’t be lucky enough to come to a hospital to get the appropriate care that could avoid an amputation or even death.”

Prepared to react fast, help patients

With more than a decade of experience in general medicine, Plantin notes he’s well-prepared to react during emergencies. Even before graduating in the first cohort of emergency medicine physicians from Hôpital Universitaire de Mirebalais, he had first-hand experience working with Zanmi Lasante. In 2011, he did his social service at La Colline de Lascahobas Health Center, a medical facility in the Zanmi Lasante network, which exposed him to the the organization’s work in the Central Plateau region.

Upon completing his emergency medicine training in 2017, he continued to work in Haiti—as do 98% of graduates from the program. In 2018, he was selected to participate in Harvard University’s Humanitarian Response Intensive Course in Massachusetts. He credits all of his professional training opportunities as the reason why he was prepared to quickly react and help those in need following the earthquake.

“From the moment I heard the news of the earthquake, I wanted to be in the South to do what my training in emergency medicine has taught me so far: save as many lives as possible,” says Dr. Plantin.  “However, I understood that I could also help by staying at HUM. The arrival of the first survivors was an opportunity for all of us to lend our support to those people who really needed it.”

Hispanic Heritage Month, which runs from September 15 to October 15, is a time to celebrate the rich histories, cultures, and contributions of Hispanic, Latinx, and Afrolatinx communities. This time period, which includes the independence days of at least seven nations in Latin America, is a national heritage month in the United States.

As PIH celebrates this month, we recognize the outstanding work of our colleagues at Compañeros En Salud in Mexico and Socios En Salud in Peru and all of our colleagues of Latinx, Hispanic, and Afrolatinx descent, as we continue our work in the United States in communities with significant Hispanic populations such as Immokalee, Fla., Pima County, Ariz., and Chicago, Ill.

In honor of this special month, PIHers have shared their favorite books, movies, and songs related to Hispanic and Latinx culture. The recommendations below provide a snapshot into the diversity of cultures and experiences that make up Hispanic, Latinx, and Afrolatinx communities in the U.S. and worldwide—and where PIHers are finding inspiration during this month.