At school, Promise says, none of her friends know about her HIV status.

“No one talks about it,” she adds, shrugging her shoulders while sitting on the edge of a stage in a large community hall in Neno District, Malawi.  

Promise’s somber expression implies that talking about HIV is just not done at her school. That kind of silence can be found across the East African nation, where nearly 10 percent of adults are living with HIV and social stigmas run deep. 

Silence likely doesn’t come easily for Promise, who laughs and interacts enthusiastically with other teens running around the hall. The friendly, outgoing 17-year-old lives with her grandmother in a nearby village, lists math and English as her favorite subjects and hopes to work in a bank one day. Moving her hands like she’s riffling through a stack of bills, she jokes that she gets inspired when she sees tellers counting money.

She was diagnosed with HIV at age 7 and has been dedicated to antiretroviral therapy, or ART, for several years. She gives Promise as a pseudonym, in a region where discrimination is common. 

But on this Saturday afternoon, at a Teen HIV Club event near the Partners In Health-supported Ligowe Health Center, she was more than able to talk freely with peers about her condition, her treatment, her community involvement, and more.  

Because at Teen HIV Club, everyone talks about it—that’s the point. 

“As manager of the program, your health is my responsibility,” Dr. Dimitri Suffrin, HIV and TB program manager for PIH in Malawi, tells the 48 teens attending today’s event. “Any problem that you have, I am here to listen and find a way to help you.”

The teens stand in a circle as Suffrin speaks, part of introductions and songs before activities begin. Chisomo Kanyenda, an HIV program officer for PIH, translates Suffrin’s remarks into local Chichewa. PIH is known in Malawi by a Chichewa name, Abwenzi Pa Za Umoyo.  

PIH, Malawi’s Ministry of Health, and like-minded groups such as the We Care Youth Organization—whose Peer Power project is working to raise HIV education and awareness in Malawi—organize the regular Saturday events for teens living with HIV. They offer Teen Club in five locations across Neno and work with more than 200 children and young adults, most of them 10 to 19 years old. 

The program is part of a growing HIV program that is turning the tide in Neno District. PIH has nearly 8,000 people enrolled in HIV treatment in Neno. That number equates to 90 percent of all adults living with HIV in the district—a benchmark goal set by the World Health Organization. Moreover, about 86 percent of people in the HIV program have suppressed viral loads, meaning treatment is working and impacts of the virus are greatly reduced. 

But only about 50 percent of Neno teens have suppressed viral loads, creating a need for more education about the importance of adhering to treatment.  

Reaching youth through Teen Club is intended to meet that need and bring effective treatment much closer to 100 percent for youth—even in the most remote areas of Neno, where dirt roads wind over boulders and up steep mountain slopes, where electricity and water supplies can be unreliable, and where food scarcity is an epidemic in hot summer months, if not year-round. 

Teen Club also can be a respite from those challenges, and a place where kids can just be kids.

"I strongly believe that being a teenager is difficult," Suffrin noted. "With HIV, it's even worse."    

Participants find friendship, games, snacks, HIV education and, most importantly, support—from their peers and from adult mentors, clinicians and educators, some of whom are living with HIV themselves. 

One of those mentors is Ministry of Health teen coordinator Gertrude Daluni, who has been HIV-positive since 2002 and on antiretroviral therapy, or ART, since 2004. 

Daluni greets nearly every teen who walks in the door. Her booming voice, friendly laughter and boisterous demeanor would be instantly recognizable to anyone who has attended a summer camp—her smiling presence fills the spacious community hall. Kids run up to Daluni for hugs, while sunlight streams in large windows and other kids jump rope or play keep-away with a basketball, running and sliding on the cement floor before the programming starts. 

Later in the afternoon, Daluni bounced that basketball loudly while standing in the middle of the teens, again gathered in a circle. She asked questions about ART, viral loads, nutrition and more—punctuating each question with the “BAM” of a dribble—and tossed the ball to teens whom she wanted to give answers. 

Teen educator Kenneth Mangani also led the group in several games, including a call-and-response activity similar to “Simon Says.” If teens misheard quickly changing instructions and moved the wrong way, they were out, eliciting rowdy yells every time. 

Lessons are interlaced with the laughter. Mphatso Chimangeni, a teen educator with the Peer Power project, organized a short skit in which she and some of the older teens played roles to show how different treatment levels affected viral loads. Even that activity took on a light-hearted note, as Chimangeni, playing HIV, theatrically tumbled to the ground in defeat. 

“We play a lot of games and things like that, so the knowledge is instilled,” PIH teen coordinator Wedson Khoviwa said. 

One of the best ways to retain knowledge is to hear it from peers. And at today’s Teen Club, the most senior peer is 23-year-old Caroline Kapalamura. She’s been coming to the events for about five years, after an HIV-positive diagnosis at age 13. While nearly every youth at Teen Club—including Promise—contracted HIV from their parents, Caroline is an exception. She got the virus from a boyfriend who didn’t tell her about his HIV status.

Kapalamura said she struggled with weakness and fatigue for a long time, without understanding what was wrong. She thought that maybe she had malaria. She eventually visited PIH-supported Neno District Hospital, explained her symptoms and got tested. She began ART in 2015. Grace Nyambi, a senior clerk at the hospital’s integrated chronic care clinic, told her about Teen Club. 

“My health has been much better since I have been on treatment. I feel very strong,” said Kapalamura, who is studying to become a nurse. “My favorite part of Teen Club is teaching, and doing outreach.”

Outreach to find new members is one of the most invaluable aspects of the program. Nyambi, the hospital clerk, introduced Promise to Teen Club, too, in 2012. Promise has been attending events regularly since then.  

“She is very active,” Khoviwa said. “Ever since she joined Teen Club, she has been here every time.”

Promise now joins Khoviwa on outreach visits, encouraging other teens to come to events. She also advocates within Teen Club for more funding, more resources and more connections with other clubs, in Neno District and throughout Malawi. 

Turns out, Promise has a knack for it—and is a strong, outspoken voice in efforts to decrease stigma and fully support her peers with HIV.  

“Five other teens have joined because of her,” Khoviwa said.
 

Listen now for the latest conversation with Dr. Paul Farmer, PIH co-founder and chief strategist, and Leslie Friday, interim director of content, as he looks ahead to 2019 and reflects on his most formative experiences in global health. Farmer discusses PIH’s struggle to combat Ebola and efforts to holistically strengthen health systems, the climate justice movement, and how certain patients have shaped his outlook on global health.

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Kamohelo Phoofolo, 8 months old and bundled in a soft pink, hooded fleece, smiled happily as she sat on her mother’s lap at Mapheleng Health Center in Lesotho. 

Her mother, 27-year-old Marefiloe Phoofolo, matched her daughter not only in clothing color, but also in disposition. She was all smiles as she talked about the maternal health care she had received at the Partners In Health-supported Mapheleng facility.

Phoofolo lives in the village of Ha Matoeba, where homes dot hillsides surrounded by steep ridges. The terrain is so rough, and the region so remote, that doctors from Mapheleng ride horses to the most hard-to-reach communities. Phoofolo doesn’t live quite that far away—her village is within walking distance of the health center—but she stayed at Mapheleng’s maternal waiting home for five days before she gave birth to Kamohelo, to make sure she was close to care when labor began. 

While there, she received three meals a day, water for bathing and around-the-clock prenatal care. All of it was free.

Most importantly, Phoofolo had a safe, healthy childbirth at the health center, where she continues to have postnatal checkups and Kamohelo receives care as a toddler. Her birth was one of more than 30,000 facility-based deliveries—including 6,000 life-saving cesarean sections—provided at PIH-supported facilities around the world in 2017. Globally, PIH provides about two-thirds of its entire services to women and children, with the goal of reducing maternal deaths and ensuring healthy futures for the next generation. 

That effort is especially vital in Lesotho, a rural, mountainous country surrounded by South Africa. The remote location of many communities, rugged dirt roads and scarcity of resources create enormous health care challenges, including for expectant mothers. One in 61 women in Lesotho will die from pregnancy or childbirth. By comparison, women in Sierra Leone face a 1 in 17 lifetime risk of dying in pregnancy or childbirth—the worst rate in the world—while women in the U.S. face a risk of 1 in 3,800.

Lesotho’s ongoing national health reform is changing that dynamic, and has fueled transformative improvements in just four years. PIH, known locally as Bo-mphato Litsebeletsong Tsa Bophelo, is supporting the reform as the primary technical advisor to Lesotho’s Ministry of Health.  

Mapheleng is one of 72 health centers revitalized by the reform. Mapheleng serves about 6,200 people across 28 villages, and—with more nurses, maternal supplies and medicines—has provided facility-based deliveries for hundreds of women like Phoofolo.

Facility-based deliveries have increased by 30 percent since 2014 in the reform’s initial four districts. That equates to nearly 4,000 more safe deliveries in 2017 than before the reform.  

Kamohelo was one of them. On a sunny, clear February day, Phoofolo talked with two other new mothers in Mapheleng as she held her second child. All three of the women had been referred to Mapheleng by village health workers, who provide health resources and access to care in their communities. 

Phoofolo said she, too, would encourage pregnant women to use the health center for prenatal care and delivery—to help ensure more safe childbirths, and more newborn smiles, like her daughter’s. 

Parvannah Lee has a clear picture in her mind of what hunger looks like. It's of her mother walking miles through a snowstorm to the nearest grocery store.

So begins Lee’s essay about families in the Navajo Nation struggling to eat well and stay healthy. Published in Teen Vogue on November 22, the piece shares a glimpse of what it was like to grow up on the reservation—a 27,000-square-mile area that straddles Arizona, Utah, and New Mexico. It touches on the shameful history of the United States government toward the Diné people, and the forces that created one of the largest food deserts in the United States. And it celebrates a grocery program, created by PIH sister organization COPE and for which Lee used to work, that is successfully improving health on the Navajo Nation, one family at a time.  

Lee is optimistic. Next month, she will start working for the Indian Health Service in South Dakota. She greatly admires her mother's dedication to keeping her family healthy and hopes that “some of my mother’s magic has rubbed off on me.” 

Read the full piece here: https://www.teenvogue.com/story/im-from-the-navajo-nation-and-i-want-to…

Violet McDonald has an expressive, thoughtful face that belies her age of just one year.  

As several adults crowded around her in a small, noisy room at Matope Health Center in Neno District, Malawi, baby Violet sat on the floor in her onesie, quietly looked around and held a MUAC strip against her arm, as if she knew how to measure her own Mid-Upper Arm Circumference, a primary gauge of malnutrition in small children.

She actually might have. Lydia McDonald, 20, had been bringing her baby daughter to the Matope facility since late June, for regular checkups through the program known as CMAM, or Community Management of Acute Malnutrition. Violet’s weight had increased from 7 kilograms at her first visit to 7.9 kilograms at this visit, in early October. That equates to growing from about 15 pounds to 17.4 pounds.  

It was a significant gain, but there was plenty of room to grow. CMAM facilitator Jessie Chizumo carefully recorded Violet’s health information in large paper files, and checked her weight on a chart that showed a corresponding amount of RUTF—ready-to-use therapeutic food, or nutritional meal supplements known locally as chiponde—that Violet would need for the week ahead. 

For 2-year-old Stella Alfred, also in the CMAM clinic that morning, the number of needed meals was 23, or three-and-a-quarter RUTF packages per day. Chizumo explained the recommendation—one package in the morning, one for lunch, a snack, and one for dinner—to Stella’s mother, 27-year-old Jennifer Andrea. 

Stella’s weight—at a full year older than Violet—was just 8.4 kilograms, or about 18.5 pounds. She cried throughout her checkup, as Andrea rocked her gently. 

Violet and Stella are two of the 11 children enrolled in the CMAM clinic at Matope Health Center, which serves 11 nearby villages and is supported by Partners In Health. On this particular morning, an integrated chronic care clinic also was underway, with lines of people waiting for screenings, talking with staff or resting in the shade of a huge baobab tree. The malnutrition clinic was toward the rear of the health center, away from much of the bustle. 

Known in Malawi as Abwenzi Pa Za Umoyo, PIH supports malnutrition care for more than 2,400 children younger than 5, across Neno District. 

This was the hardest time of year for them and their families. 

September and October are Malawi’s hottest months, known colloquially as “hunger season.” Riverbeds are dry, fields are dustbowls, the harvest is weeks in the past and new rains have not yet arrived. Dry heat turns bent, picked-bare cornstalks into crinkly brown matchsticks. For Neno District’s population of about 170,000, it’s a time of food scarcity and corresponding high prices for corn and other staples—especially this year, when many people around Neno cited a weak harvest.

Robert Jackson, supervisor for Matope’s community health workers, said the 115 CHWs based at the health center do all they can to screen every child for malnutrition, and refer children and parents to the CMAM clinic. It’s a busy job. Just nearby Tchenga Village, where McDonald lives with Violet, has more than 600 households. 

But the need is vital.

“By screening all children at the household level through visits by community health workers, our goal is to catch malnutrition earlier and refer children quickly to treatment, to avoid hospitalization or significant illness,” said Emilia Connolly, chief medical officer for PIH in Malawi. “This will improve the health of children and families overall, thanks to the invaluable work by the community health workers—our foot soldiers.”

Communities, clinics, hospitals, ministries of health, and global thought leadership. This year, PIH has had an impact in all of these spaces, from providing high-quality health care in impoverished communities, to pushing the world closer toward universal health coverage.

Our 2018 Annual Report serves as a record of these accomplishments—and as a thank you to all of our invaluable partners who make this lifesaving work possible.

Inside, you'll find details about where we work, a note from Chief Executive Officer Dr. Gary Gottlieb, patient and staff stories, and data showing last year's impact in cancer care, HIV treatment, maternal health, and more.

Read through the report here.

We know you’re with us in the fight to provide health care for all. This Giving Tuesday is your opportunity to make a lasting impact. We’re challenging our supporters to launch 50 Facebook Fundraisers between now and Giving Tuesday to encourage friends and family to join the cause. Help us spread the word and encourage others to join the fight to provide health care for all.

To make your contributions go even further, we’re pledging to match all donations that come in via Facebook Fundraisers on Giving Tuesday, November 27, up to a grand total of $5,000!

Together, we can provide more lifesaving health care to those in need. Will you join us?

Here’s how:

Start your fundraiser

• Go to https://fb.com/fund/partnersinhealth/, where you will be prompted to start your fundraiser.

• Name your fundraiser, set a goal, and choose an end date. Be sure to include "Giving Tuesday" in your fundraiser title, and make sure your fundraiser runs for at least one week. 

Customize your fundraiser

• Choose a goal: Commit to raising $200 or more to support health care around the world. If you meet your goal, increase it!

• Share your story: In the description of your fundraiser, tell your friends why you support Partners In Health.

• Choose a cover photo: You'll be prompted to choose between several PIH photos by clicking the "Edit" button. Pick whichever you like!

Promote your fundraiser!

• On the morning of Giving Tuesday, November 27, share your fundraiser link with your Facebook friends and ask them to give.

• Facebook Fundraisers don’t have to be just on Facebook! Tweet a link to your fundraiser, call your mom, send an email letting your friends know you’re participating in this challenge, or share any other way you know how.

• And remember, the fundraisers don’t stop when Giving Tuesday ends! Be sure to keep encouraging friends to donate until the fundraiser ends.

Feel free to direct message Partners In Health on Facebook with any questions. Thank you for thinking of us this giving season!

And don’t forget: Any gifts that are made to Partners In Health via Facebook Fundraisers on Giving Tuesday, November 27, will be matched, up to a total of $5,000!

When 18-year-old Fanta Karoma found out she was pregnant, she was scared. It was her second pregnancy—her first child had been stillborn, after a complicated birth—and it was also bad timing. She was training to become a seamstress in Kono, eastern Sierra Leone, and enjoyed stitching patterns from lapa fabric, learning to design stylish outfits for customers.

Before long, Karoma’s boss noticed her growing baby bump. Annoyed, he pressured her to have an abortion. Karoma contacted a backstreet abortion provider, someone who lived in her village. 

Because her neighbors, who had heard horror stories, told her it could be unsafe, Karoma decided to go through with the pregnancy. Her dad, with whom she lived, was angry. She briefly moved in with the baby’s father, but “he kicked me out shortly after, and didn’t want to take responsibility” for her and the new baby.

Like many women in Sierra Leone, Karoma thought she was out of safe options. Sierra Leone has one of the highest maternal mortality rates in the world, at 1,000 per 100,000, and about half of all women give birth at home, far from skilled clinicians should emergencies arise.

After Karoma told her story to a clinician at her local health facility, she was referred to Wellbody Clinic, a Partners In Health-managed facility in Kono. There, a midwife met with her, reviewed her files, and, she says, “invited me to stay at the birth waiting home.” Karoma realized that it wasn’t the first time she had heard the idea. “I had already been told about it by another pregnant woman in my village. She had visited me at my house to tell me about the birth waiting home when she heard I was pregnant again.”

The birth waiting home—a whitewashed house on a hill—provides a tranquil environment where at-risk expectant mothers, including those who live far from clinics, receive three meals a day and regular checkups. There are shaded porches to rest out of the hot midday sun, and everything, including food and accommodation, is free.

“The great thing about the birth waiting home is that it’s built specially for the pregnant women,” says Zainab Kalokeh, a midwife who cared for Karoma. “The rooms are convenient, with bed nets and everything, as well as a water supply. The place is comfortable and nice.”

Even better, the home is a short distance from the maternity ward at Wellbody Clinic, where despite the national statistics, there hasn’t been a maternal death in two years. That’s half the amount of time that PIH has been working in Sierra Leone, initially responding to the Ebola outbreak in 2014, then staying to focus on Kono district in the country’s far east, and partnering with the Ministry of Health and Wellbody Alliance to strengthen the health system.

Reducing Sierra Leone’s sky-high maternal mortality rate is a priority, and the birth waiting homes are a cornerstone of PIH’s approach.

Karoma moved in. “I felt gladi,” she says, in Sierra Leonean Krio. “I knew I would get the best possible medicine and care at the birth waiting home. When I was there it felt like my family. I made friends with the other women and I wouldn’t worry about being hungry.”

At the birth home, Karoma had help drawing up a birth plan. Because her first pregnancy had resulted in a frightening, prolonged labor that lasted for three days, the team recommended a planned cesarean section for this pregnancy.

Night was falling when Karoma felt the first pains of labor. Kalokeh accompanied Karoma in the ambulance to Koidu Government Hospital.

“I was scared and in a lot of pain, but everybody was helping me,” Karoma says. “I had confidence that it would be alright this time.”

“We managed to talk to her, calm her down,” Kalokeh says. “We gave her confidence that when she will go to the hospital, she will have a baby. And she was so eager to have that baby.”

Her baby, John David Karoma, was born by c-section soon after.   

Kalokeh says that Karoma’s case is not uncommon, and that she sees many women with complicated and at-risk pregnancies. “While some of those admitted to the birth waiting home come because they live far from a health facility, others have conditions like pre-eclampsia. Our aim is to make sure they have safe deliveries, and to save lives.”

Karoma has now returned to her home village with John. “If I hadn’t heard of Wellbody or gone there, I think I would have died this time,” she says. “I know many women who have died trying to give birth at home this way. I’m looking around now, wherever I can, for pregnant women, to tell them to go to Wellbody Clinic.”

Best of all, she is still excited about continuing to train as a seamstress. Once John learns to crawl, she hopes to get back to work. “I want to learn to be a seamstress so I can support him,” she says. Her chosen career will have an added bonus: new clothes for the little one.

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Flora and Thomas Tigone said they knew something wasn’t right when their 7-month-old son, Chisomo, suddenly became much less playful than usual. 

Their worries increased when Chisomo grew feverish, and began vomiting and breathing heavily. It was a Monday in late September, in Luwani Village of Neno District, Malawi. Chisomo is the youngest of the parents’ six children. Just a month before, their second-youngest, a 7-year-old, had contracted and recovered from malaria.

Malaria is a mosquito-borne illness that can cause fevers, chills, muscle aches and fatigue. If left untreated, symptoms can escalate to nausea, vomiting, kidney failure, seizures, coma and death.

If malaria was the case again—and this time, with an infant—Flora and Thomas knew treatment would have to start quickly, to prevent complications. They brought Chisomo to Lisungwi Community Hospital at 5 a.m. the next morning. 

Lisungwi is one of two hospitals that Partners In Health supports in Neno District. PIH, known locally as Abwenzi Pa Za Umoyo, has worked in Neno since 2007 and also supports 12 health centers there. The rural district borders Mozambique and is home to about 170,000 people. 

Malaria is one of the most consistent, severe diseases afflicting the population, and Neno health workers are concerned about the peak season, now just weeks away. During the dry season, from May to September, PIH and Ministry of Health staff conduct about 17,500 malaria tests a month across Neno’s 14 PIH-supported health facilities. 

But that number rises to about 30,000 tests a month—equating to nearly one-fifth of Neno’s entire population—in the rainy months from January to April, breeding time for mosquitos. 

About 55 percent of malaria tests across Neno District show a positive result—meaning, positive for malaria, not for the patient. Subsequent treatment and care can place a heavy load on PIH and Ministry of Health staff in hospitals, health centers, and communities. 

“To cope with the uptick in demand mostly requires more health care workers—medical assistants, nurses, clinical officers, and physicians—to diagnose and treat patients effectively,” said Emilia Connolly, chief medical officer for PIH in Malawi. “But the need also is great for rapid malaria tests, reagents for lab testing, blood transfusions, medications for malaria and its complications, and other hospital supplies.” 

Lisungwi Community Hospital, and the Tigones’ home in Luwani, sit on parched flatlands that formed broad, paintbrush swaths of brown and yellow in late September. Grassfires seemed likely. Even the cooler, breezier mountainsides were dotted with smoke plumes, as farmers used controlled burns to clear land ahead of the coming rainy season.  

But the rains had not yet arrived, and dry heat remained dominant. Thirsty, malaria-bearing mosquitos were seeking bites everywhere they could.  

“Each and every day,” said Audings Winga, a Ministry of Health nurse at Lisungwi, describing the frequency of malaria-related visits at the hospital. 

Fifty to 70 a day, to be more specific. That’s the daily amount of malaria tests cited by Allan Chimpeni, a Ministry of Health lab scientist at Lisungwi who works down the hall from the ward where Winga cared for little Chisomo, as Flora and Thomas stood by. 

Chimpeni did Chisomo’s malaria test that morning. Malaria tests take about five minutes, he said, and require a blood sample placed on a small test strip. 

The entire lab team at Lisungwi consists of Chimpeni and three technicians: Davie Chabwera, Yohane Ngwira, and Cidreck Murameya. In addition to malaria tests, their work includes blood counts, urine analysis, parasitology, tuberculosis screening, and more. 

“The workload is very high here,” Chimpeni said. 

It will soon get even higher. When the rainy season arrives in December, he expects the number of daily malaria tests to double. 

“Severe malaria can happen any time of the year, but we see it much more in the rainy season, with more cases overall,” Connolly said.

Children are hit especially hard. 

“I would say, on average, the number of children admitted to the hospital triples during the rainy season, mostly for malaria,” Connolly said.

On this September morning, the results of Chisomo’s test confirmed his parents’ fears. Despite the fact that they had placed a mosquito net around his bed, the 7-month-old’s diagnosis was severe malaria. 

Winga quickly put Chisomo on medication, initially through an IV. By early afternoon, about eight hours after the family had arrived at the hospital, Chisomo was quietly breastfeeding, appearing much healthier and acting happier. 

Relief was evident on the faces of Flora and Thomas, who sat next to each other on a hospital bed while holding Chisomo. Thomas, 45, is a bricklayer who has lived in Luwani all his life. The community is about a 10-minute drive from Lisungwi Community Hospital. Flora, 37, was born in Blantyre, Malawi’s commercial center and second-largest city, and sells vegetables in a local market. 

They planned to stay at the hospital overnight with Chisomo, in case any complications arose. 
Winga said Chisomo should be healthy the following morning. His free treatment would continue for four days, with a dose every 12 hours. Chisomo was just large enough to take pills orally, Winga said, so the initial IV would not be needed again. 

The Lisungwi staff that screened, diagnosed and treated him so quickly had great news to confirm the next day: Chisomo, indeed, had been discharged in good health, and his parents had brought him home. 

The rural compound where Agnes Paulo has lived since she was born sits atop a ridge that, in the dry season at this time of year, is dusty and brown. Steps away are downward slopes dotted by agricultural fields, including her family’s. The view across the valley is hazy through the heat of a late-September morning, weeks after what many people called a weak harvest. 

Dogs and goats amble through the cluster of small houses and outbuildings, beneath clotheslines that stretch from one roof to another. Several young kids play excitedly together, while older kids are off at school. There is a tangible feeling of shared community and extended family in this corner of Chinyani Village in Neno District, Malawi.

Agnes Paulo sits on a mat with her back against a wall of her home, and gazes at the view absent-mindedly. She’s holding her infant son, Ulemu, in her lap. Her expression is somber. Ulemu was born in August, and is her fifth child. The other four—two boys and two girls—are 5 to 14. 

Paulo, 35, breastfeeds Ulemu while talking about the struggles facing the entire community, and her immediate family. She’s a single mother and living with HIV. All four of her older children are HIV-negative, but Ulemu had not yet been tested, meaning his status remained unknown.

Preventing mother-to-child transmission of HIV is a vital goal for Partners In Health, which has worked in Neno District since 2007, as a partner to Malawi’s Ministry of Health. Nearly 1 in 10 adults—and more than 70,000 children—are living with HIV across Malawi, an East Africa nation facing some of the world’s most dire challenges in HIV, maternal health, malnutrition and other health areas. 

Neno’s arid flatlands and rugged mountains increase the barriers to health care for its roughly 170,000 residents. PIH is working to bridge those gaps, one home at a time, through a network of community outreach and regular, one-on-one visits, like this morning’s checkup with Paulo and Ulemu. 

Paulo is one of nearly 8,000 people in Neno who are living with HIV and enrolled in antiretroviral therapy, or ART, programs supported by PIH. Her commitment to treatment dramatically increases Ulemu’s chances of being HIV-negative. Mothers without ART have a significantly higher rate of transmitting HIV to their children—up to 45 percent—than mothers like Paulo, who are able to access and stay dedicated to ART, and have a much lower risk.

Paulo has taken a pill every evening for several years, regularly getting free refills at PIH-supported health facilities, including Neno District Hospital, more than an hour’s walk away on rugged dirt roads. 

Additionally, she has a team of PIH staff supporting her. Several members of that team are sitting with Paulo this morning, including Rose Zingwani, a senior community health worker for Abwenzi Pa Za Umoyo, as PIH is known locally. Zingwani is 35, same as Paulo, and lives just down the road. 

Zingwani decided to volunteer for the village’s health committee, and then become a community health worker, after seeing the challenges facing the remote Chinyani area. She’s worked with Paulo and her family for more than three years. Zingwani visited frequently in recent months while Paulo was pregnant with Ulemu, to provide education, support, and access to care.

Today’s visit is a regular monthly checkup for Paulo and little Ulemu. Zingwani kneels on the mat beside Paulo while talking about danger signs for infants, such as diarrhea and jaundice, and the importance of breastfeeding, ideally for six months after childbirth. It’s crucial to remain on ART and keep a low viral load during breastfeeding, Zingwani says, as mothers can transmit HIV to newborn children through  breastmilk. 

Zingwani shows Paulo educational materials she’s brought along, and records Paulo’s and Ulemu’s health information in a large binder. 

John Kaiya, a community health worker supervisor, and Benson Chabwera, a community health worker program officer, talk with Paulo about other needs, such as the upkeep of her home—because supporting someone’s right to health means supporting their right to healthy living conditions. 

Food is her greatest challenge, she says. Paulo feels that there is nothing she can do to improve her family’s food supply. She grows corn when she can on the nearby plots, but fertilizer often is too expensive. This year’s weak harvest has increased the price of corn amid short supplies, as well.

Also joining the visit is Sam Msiska, Malawi coordinator for PIH’s Program on Social and Economic Rights, or POSER. The program provides support including financial, food, home, and education assistance to patients who have needs beyond health care. 

Those needs can span a broad range in Neno, where Paulo has seen decades of changing seasons, ebbs and flows. She smiles rarely this morning—even when chatting with Zingwani, a friend and neighbor she’s known for years—indicating times have been harder lately. Chabwera promises to advocate for housing help, and Msiska discusses the potential for immediate food assistance. 

Above all, Zingwani emphasized the importance of Paulo maintaining her ART and her regular checkups at the central Neno clinic, to ensure the best possible future for Ulemu and her four older children.  

They would have to wait a little to learn Ulemu’s HIV status. Soon after that visit, Zingwani enrolled Ulemu in the Early Infant Diagnosis program at Neno District Hospital's integrated care clinic. He had his first HIV test there, but results would take a month or more to come back from Blantyre, Malawi’s second-largest city. Henry Makungwa, community health worker manager for PIH in Malawi, said the Early Infant Diagnosis program usually extends over two years, as infants are tested multiple times as they continue breastfeeding. 

With the team supporting his mother and family, Ulemu’s chances of living a healthy life are strong, whatever the results of his HIV tests. 

As the morning’s visit concluded, Paulo stood up, Ulemu still in her arms and wrapped in a bright green, patterned cloth. Zingwani embraced Paulo as good-byes were said, and then Zingwani and the PIH team departed—they were off to the next home.

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Five days a week at University Hospital in Mirebalais, Haiti, dozens of patients flow through the oncology ward for doctors’ visits, chemotherapy, and consultations with the team’s social worker or psychologist. The vast majority are women, and many—450 in 2018 alone—are in various stages of battling breast cancer.

For Breast Cancer Awareness Month, staff at Zanmi Lasante, as Partners In Health is known in Haiti, asked five survivors to share their journeys with cancer. Some of the women started receiving care in Cange; others first went to University Hospital, which opened in March 2013 and is still the only facility in Haiti that provides free cancer care and psychosocial support. Each woman comes with a different perspective and background, but all share the scars of the same disease. Here are their stories.

The lump in Laurie Dorce’s breast never hurt, so it was easier to push its existence out of her mind. But one day, she noticed the lump had become much harder, and her concern grew. In 2011, she visited a doctor in Léogâne, near her home in southern Haiti. A biopsy revealed she had breast cancer, and her doctor recommended she visit the PIH-supported hospital in Cange.

Dorce was still scared and in shock by the diagnosis when she arrived. But PIH staff and clinicians “explained everything to me, provided me with information, and eased my mind,” she says. She underwent a series of chemotherapy treatments to shrink the mass, then had her first surgery in 2014.

Despite taking tamoxifen to prevent a recurrence, Dorce found another lump and has had two more surgeries since 2016—all while under PIH’s careful watch. She continues to travel to the hospital regularly for follow-up care.

“By the grace of God,” she says, “I feel good these days.”

Suzie Del* was watching television on a Friday night in 2012 when a commercial captured her attention. An actress was explaining the importance of breast self-exams, especially for women over 40, and gave a demonstration. Del had never done such a thing. She raised her arm, draped it over her head, and felt for lumps in her breast. She found some.

The following Monday, 59-year-old Del visited a doctor at Bernard-Mevs Hospital in Port-au-Prince. Tests revealed that she indeed had a tumor, and that it was cancerous. She had surgery to remove the lumps, then took her first course of chemotherapy. She lost all her hair and reacted so strongly to the powerful medication that she required an IV.

Knowing she could no longer afford care at the private facility, Del traveled north to the PIH-supported hospital in Cange, where cancer care was free. Dr. Ruth Damuse, the oncology program director for PIH in Haiti, met with her, reviewed her files, and said she no longer needed chemotherapy. Instead, Damuse recommended a mastectomy, which Del agreed to undergo.

 “When I first learned that I had cancer, I thought I was going to die,” Del says. But after speaking with PIH clinicians and staff on the oncology team, she felt renewed hope, as do many fellow cancer patients. “They told us we shouldn’t worry and encouraged us to continue with our activities as much as possible.

“I never told anyone that I was sick,” she adds. “No one knew I was sick because everyone saw that I continued with my life as normal.”

Following her last surgery, tests revealed no further signs of cancer. Del has been on preventive medication and follow-up care ever since. She says she feels very well now, and thanks God—and PIH—she’s alive.

Cita Cherie is a single mother of seven who has seen a lot in her 49 years. When she found a lump in her breast, it was one of several worries was juggling at the time, including occasional homelessness. She visited doctor after doctor and got no relief, just more bills.

Then, one day, someone told her about University Hospital, where cancer care was free. She visited shortly after it opened and met Dr. Damuse. After a biopsy and several exams, Damuse informed Cherie that she had an advanced stage of breast cancer. The doctor didn’t recommend surgery, but advised her to start palliative chemotherapy, which could prolong her life. 

Five years later, Cherie rarely misses her chemotherapy appointments. Damuse has shifted her to different lines of palliative treatment over that time, with occasional recovery breaks in between. Inevitably, she arrives with a huge smile, and is always in good spirits. 

“If it were not for the Mirebalais hospital, I would not be alive today,” Cherie says. “I get all my medication for free, and when I come to the hospital, the doctors take really good care of me. They welcome me and they really value me.”

Adriana Jean had a similar reaction to many women when they first learn that the lump in their breast is cancer. She was terrified and prayed that she would stay alive, for her family’s sake.

“I have six children,” Jean says, adding that there are four boys and two girls. “My last one was in sixth grade, and I was worried that I would not be able to help him advance in school.”

The hospital she visited in Tabarre, not far from her home on the outskirts of Port-au-Prince, referred her to another facility for surgery. But she knew she couldn’t afford the procedure. A friend recommended she visit the PIH-supported hospital in Cange, where she could get free care.

Following her advice, Jean traveled to Cange in 2010 and got the surgery she needed. But her cancer was persistent, and tumors reemerged. In 2012, she underwent a mastectomy, recovered from surgery, and began taking tamoxifen to prevent a recurrence. She remains in follow-up care at University Hospital.

 “I used to say: ‘As long as the girls are young, I would not want to die before they get married,’” Jean, now 62, remembers. “Today they are older, and if I die now, I am relieved that I would not leave young children behind.”

Philomena Moise, 77, had a long journey to get the care she needed after discovering a mass in her breast more than eight years ago. It took a while, but she eventually got an appointment at the General Hospital in Port-au-Prince, where a clinician took a biopsy and sent the breast tissue away for testing. Months passed before she got results. When she learned she had cancer and would need surgery, she felt a pang of despair.

“I told Jesus I did not understand what was happening,” she remembers.

Again, Moise waited months for her next appointment at General Hospital, while the mass grew and formed a painful abscess that eventually burst. Desperate for help, she followed another doctor’s recommendation and turned to the PIH-supported hospital in Cange.

There she met Dr. Damuse, who wasted no time. Moise had her first appointment in February 2010, and by April, she was scheduled for surgery to remove the mass. She began chemotherapy in Cange and continued her care at University Hospital in Mirebalais. She has been in follow-up care ever since.

*Patients' and family members' names have been changed.

Tell us a little about the progression of mental health programs across PIH sites in recent years. 

Over the past seven to eight years, we’ve developed a lot of experience delivering mental health care in Haiti and Rwanda. In each of those countries we have several thousand people receiving care. And over the past five years, we’ve been working with all the other sites to support further integration of mental health care within existing primary care platforms.

A lot of that work has focused on care of severe mental disorders—psychotic disorders, schizophrenia, bipolar disorder—because those are the people who tend to present to our hospitals in crisis. But we have also wanted to address common mental disorders, such as depression, post-traumatic stress, anxiety, and somatic disorders.

Over the past year, we’ve increasingly moved a number of sites toward thinking about how to address common mental disorders with non-specialists.

Those conversations have really accelerated recently. 

What has tended to happen with our small mental health teams at the sites is that they’ve at times been so overwhelmed with the care of people living with psychotic disorders. It’s been difficult to give time and attention to common mental disorders, which are a significant burden in communities and societies globally. The challenge of providing clinical supervision for common mental disorders is also a challenge we face at our sites.

A year ago, Dr. Vikram Patel, who is a preeminent thinker in global mental health, became a new professor at Harvard, in the Department of Global Health and Social Medicine, where I also am on the faculty. He has been a leader in research on the mobilization of community health workers for care of common mental disorders. He is a founder of Sangath, which is a community-based organization in India that has both mobilized community health workers for mental health care and done significant research on that process.

As he and I put our heads together, we thought it would be great to bring together implementers and researchers on the topic of community-delivered care for common mental disorders, and the bottleneck that affect groups like PIH who are at the front line. We had a significant meeting at the Harvard Center for Global Health Delivery-Dubai to support this aim.

That led to a lot of groundbreaking ideas on best practices, supported by everyone from community health workers to academic researchers. What was one concrete result?

We are working toward an important consensus statement from that meeting, with recommendations for best practices in community-delivered care for common mental disorders. This month, we will be announcing a new initiative at PIH called the Many Voices Collaborative in Community Mental Health at PIH.

Our cross-site mental health team will provide support, including seed funding, to eight sites in deepening community health worker-delivered care of common mental disorders.

How else has academia shaped PIH’s global mental health work recently?

We have a fellowship in global mental health delivery at PIH, shared with Harvard Medical School. It’s called the Dr. Mario Pagenel Fellowship in Global Mental Health Delivery. We have fellows in Haiti and Rwanda, and we’re expanding the fellowship to West Africa, southern Africa, and Latin America. The West Africa fellowship will be shared between Sierra Leone and Liberia, southern Africa will be shared between Lesotho and Malawi, and Latin America will be shared between Mexico and Peru.

So our cross-site team is growing, and mental health care delivery is expanding. We are also increasingly engaged in advocacy for the need for greater commitments to global mental health delivery. Paul Farmer and I published a commentary on October 10, World Mental Health Day, in support of the Lancet Commission on Mental Health and Sustainable Development.

Can you share a sense of the need for mental health care in low- to middle-income countries, particularly regarding depression?

Mental disorders represent the greatest collective cause of disability today. Depression is the most common mental disorder. It affects 350 million people globally, it represents the leading cause of disability around the world—more than ischemic heart disease, road traffic accidents, cerebrovascular disease, and chronic obstructive pulmonary disease. 

Although mental disorders significantly impact people in low- and middle-income countries and 80 percent of the world’s population live in these regions, greater than 90 percent of mental health resources are spent in high-income countries.

Wow.

And furthermore, the treatment gap for people with mental disorders—that is, the gap between how many people have disorders and how many are receiving care—exceeds 50 percent in all countries worldwide, but it approaches rates as high as 90 percent in the least-resourced countries. And 75 percent of lifetime cases of mental health conditions begin by age 24, which tells us that we need to be thinking about prevention and early intervention as well as treatment.

How do community health workers begin to address these problems?

Community health workers can provide basic psychosocial and psychological interventions, both clinical and preventive. In Haiti, for example, we have developed a toolkit for community health workers that starts with basic information about the origins of mental illness and human rights; the role of culture and traditional belief systems; and basic skills in delivering psychological interventions that are helpful and effective. Also, it includes information on how to talk about mental health with people in the community. Helping people understand that mental disorders are highly treatable—and linked to human rights, as well as to stigma and potential discrimination—is really important.

Let’s talk more about the Many Voices Collaborative, what it is and what it might mean for country sites. 

The Many Voices Collaborative will provide seed funding and implementation support to the sites, to either build a basic level of management capacity and care delivery capacity that they haven’t had, with a focus on common mental disorders, or to enable sites to deepen their engagement on a range of mental health conditions in the community. 

For example, in Liberia, for two years, a small, local mental health team has been delivering care to hundreds of people. Mostly people are living with psychosis and are homeless on the streets of Harper. The team has been getting incredible results and the work has been very well-received and very important in reducing stigma in the community. For many people served, it’s been lifesaving. But the team has been limited in its ability to address common mental disorders, so we’ll be hiring additional community health workers and build this other component into the work in Liberia.

In the countries where PIH works, how often are mental health problems seen as shameful or disgraceful, and how do you address that?

Stigma can be embedded not just in communities, but also in the health system. It’s a huge barrier. What we’ve found is that possibly the most effective counteraction to stigma is delivery of care. Often it’s remarkable, the degree to which providing people with effective care dramatically improves lives, and eradicates stigma.

We’ve talked about a lot of growth in mental health programming and support: the Many Voices Collaborative, new staff, new funding. What’s helping us turn the corner?

Our mental health team is small, but what we are doing is quite innovative. We have an essential focus on building systems of care that are safe, effective, evidence-based, and culturally sound. Our work integrates research evidence from science, but at our core we provide accompaniment to local teams implementing needed services at the front line, where not many people work. We’re having success because our teams have real-world experience with the challenges of delivering care in difficult circumstances. And when you meet the people we serve, you’ll see that people’s lives are greatly improved.

Last Wednesday, the United Nations held a high-level meeting on tuberculosis. Presidents, prime ministers, and other international leaders were invited to publicly commit to ending the world’s deadliest infectious disease, one that kills 1.6 million people each year.

Was the meeting, which was the first of its kind, a cause for hope? Or was it an exasperation, a symbol of just how little has been accomplished in the decades since a cure for tuberculosis was discovered?

In an opinion piece in The Boston Globe’s health and science publication STAT, PIH Co-founder Dr. Paul Farmer and Lelio Marmora, the executive director of global health funder Unitaid, suggest the answer is “both.”

“History has shown just how indifferent the world can be to diseases that affect primarily low- and middle-income countries,” they write. “It’s also shown what a difference we can make when indifference is replaced by concern.”

Dr. Farmer echoed that sentiment in an interview on NPR’s Morning Edition.

“I have been a skeptic about the relevance of yet another meeting about a problem that really hasn't been addressed ever," he said. Then he tempered his skepticism by remembering that a similar meeting years ago led to massive investment in the fight against AIDS.

And maybe therein lies the big point. Global meetings are inspiring and enervating, but most importantly, they need to be followed by action.  

Read the STAT article here. 

Listen to the NPR Morning Edition story here. 

In September 2014, as the largest Ebola outbreak in history was devastating West Africa, Alusine Mark Dumbuya was struggling with an additional, very personal concern in a rural region of Sierra Leone. 

“I know it sounds bad to say, but I didn’t care all too much about Ebola,” Dumbuya said. “At that time, my mum was getting really sick with cervical cancer, so I just wanted her to get better more than anything else.” 

Dumbuya, 33, is now operations manager at Koidu Government Hospital, for Partners In Health. The hospital is in Sierra Leone’s Kono District, and less than 100 miles from where Dumbuya grew up. His experiences during the Ebola outbreak, trying to find cancer treatment for his mother amid the international crisis, motivated him to apply to PIH. And at the hospital, he continues to honor his mother. KGH, as it's often called, has a strong focus on maternal health, in a country where 1 in 17 women dies during pregnancy, delivery, or its aftermath—the worst rate in the world.   

Dumbuya remembered the Ebola outbreak solemnly.  

“The hospitals were so overwhelmed by Ebola patients that other illnesses kind of got ignored. At first, mum was misdiagnosed with a growth, but my family knew something was wrong because she felt more and more unwell,” he said. “Many hospitals closed their doors because the doctors had either died or were too scared to go to work. By the time a doctor figured out what was wrong with her, she desperately needed morphine to control her pain, but it wasn’t available anywhere in the country.

“I was so desperate to help that I ran around the big pharmacies in the area, pleading and begging to buy morphine from them,” Dumbuya continued. “The pharmacists all looked at me so funny.” 

Sierra Leone’s government implemented a nationwide, three-day quarantine amid the outbreak, ordering people to stay in their homes from Sept. 19-21.

“It was total shutdown,” Dumbuya said. “When we were finally allowed to leave and go back to the hospital to visit mum, her condition was much worse. She died the next day. We think her oxygen machine must have been taken away by someone else staying there, but I guess we’ll never know.”

His mother’s death changed Dumbuya’s life.  

“After months of insight into how flawed my country’s health care system was, I decided I should try to help if I could. So, I made that my focus,” he said. “I started a job as operations assistant at the Wellbody Clinic in December 2014.”  

Wellbody Clinic is a primary care facility in the small town of Koidu. PIH has supported the clinic since 2014, when it was just one building. It now has six buildings and round-the-clock electricity and water—precious commodities in Kono District. Since 2015, PIH also has supported nearby KGH. PIH collaborates with Sierra Leone’s Ministry of Health to provide support including medical training, supply chain management, community outreach programs, data system innovations, and more.

Jon Lascher, executive director for PIH in Sierra Leone, said Dumbuya "represents the best of PIH" through his work at the hospital.  

“Mark’s commitment to PIH’s mission exemplifies the type of team we have in Sierra Leone," Lascher said. "He works tirelessly, often behind the scenes, to ensure life-saving clinical work is possible at KGH. Since I met Mark, he has never mentioned a task was too small.” 

Longtime PIHer and Sierra Leone native Dr. Bailor Barrie, strategic adviser to Lascher, echoed those sentiments.

"Mark is a smart, passionate and dedicated staff member," Barrie said. "He strives to make work easy for PIH and Ministry of Health staff at KGH. He also is a great mentor."  

Dumbuya said his nickname, “Fire-jumper,” relates to his job as KGH’s operations manager, because of the daily need to tackle problems head on. 

He has been tackling problems—and overcoming extraordinary challenges—since childhood. 

Dumbuya grew up in the town of Makeni, near the Liberian border. Makeni is also near the majority of Sierra Leone’s diamond mines, making it a hotspot for rebel soldiers during the civil war.  

Conflicts escalated in 1991, when Dumbuya was 6, and continued for more than a decade. Rebel soldiers conducted much of the fighting, and looting, in small communities such as Makeni.  

“I still remember my family arguing in the kitchen about whether to stand our ground in Makeni or flea to a nearby village,” Dumbuya said. “On the day we finally decided to leave, in December 1998, I saw a government troop’s vehicle drive past my house. It was covered in blood on one side. It was then that I couldn’t believe we were still in the house. I thought we were going to die.” 

Over the coming months, Dumbuya’s family would travel from village to village in search of somewhere safe to settle. 

“We would walk between 4 a.m. and 7 a.m., because this was when the rebels were quiet,” Dumbuya said. “These were difficult journeys because we had to walk in complete silence, and my sisters were young so they couldn’t walk very far.” 

His family found safety for a few months at a village called Foryeahun. But safety could disappear in a moment—like one day, Dumbuya recalled, when he was with a few friends. 

“We were fishing when about 15 rebels jumped out on us from nowhere,” he said. “The other boys ran off quickly, in different directions, but one of the rebels ordered me not to move or he would shoot. The group of rebels circled around me, pointing their guns at me and demanding to know where the village kept their cattle. One of the men behind me began to beat my shoulder with a sharp stick. I’m not sure what would have happened at this point if it hadn’t been for a familiar voice suddenly shouting out in recognition—one of them knew me. It was a boy I had known when I was younger. He was my age. Luckily, they let me run back to my family unharmed and left the village alone.”

Not long after, when rebels occupied much of the country, Dumbuya’s family managed to get him to Freetown, Sierra Leone’s capital and the home of his uncle. Dumbuya was able to finish secondary school there.   

“I feel lucky to have gained the qualifications that I did, because they’ve allowed me to do the work I do now,” he said. “During the years I spent studying, I would think about my family every day and whether they were still alive out there. I vividly remember the day I was reunited with them, after the rebels finally ceased fire in 2001, two years after the Peace Accord was signed on 7 July, 1999. It was truly the best day of my life.” 

Dumbuya said he still thinks about all the other people who were running from rebels in rural districts, like he was. He wonders if their outcomes were as fortunate as his own—and he knows there is more he can do to help heal his country’s wounds. 

“My history led me to PIH and, in a way, I feel I’m now helping communities like the ones I grew up in and experienced so much with,” he said. “I’ll jump over all the fires I have to, with PIH at my side, to ensure that the future’s as bright as I know it can be for us here in Sierra Leone.” 

Tholoana Mohapi said that when she was very young, she wanted to be a nurse one day. 

Instead, her career has led her to more than a decade of hiring nurses and other health professionals, as a leading member of the human resources team for Partners In Health in Lesotho.  

The 38-year-old Mohapi has worked since May 2007 for Bo-mphato Litsebeletsong tsa Bophelo, as PIH is known locally. She joined the team as PIH was beginning its operations in Lesotho, where now—just a decade later—PIH works with the Ministry of Health to reach 40 percent of the country’s 2.2 million people through a national health reform, plus 90,000 more people through a program supporting seven health clinics in remote mountain areas. Additionally, PIH provides treatment and support for people with multi-drug resistant tuberculosis, with an outreach team that reaches patients in communities across all 10 of Lesotho’s districts. 

Dr. Abera Leta, executive director of PIH in Lesotho, praised Mohapi’s dedication to helping build the tireless, passionate team that has led that growth. 

"Tholoana is one of our longest-serving staff members, and lives a life committed to PIH’s mission of helping the poor,” Leta said. “As human resources manager for PIH in Lesotho, she has invested her talent to develop staff who are providing health care services in hard-to-reach places. She is truly selfless and committed to bringing social justice to the most disadvantaged people.”

Mohapi began as PIH’s office administrator in Maseru, the capital, and became an HR coordinator a year later. She became HR manager, she said, “in 2014 or 2015”—and not immediately knowing the exact year could be a sign of just how hectic those years have been. 

“We’re busy,” Mohapi deadpanned on a recent day in the office.

About 50 employees work in Maseru, and about 250 more work in the seven remote clinics and the health reform’s initial four districts. About 125 other people are PIH-supported government employees. All in all, it’s a lot to manage for Mohapi and the two members of her team: HR coordinator Mojela Masupha and HR assistant Liako Lerotholi.

Mohapi handles it all with a steady hand, while focusing on building a strong team for PIH. 

“What I like the most is to get the most competitive employees, that are passionate about what they do and about bringing change to patients’ lives,” said Mohapi, a warm, personable colleague who’s known around the office as “Thully,” pronounced similar to “Too-Lee.” 

Mohapi knows what it means to be a patient. She’s from a small, Berea District village called Ha Phoofolo, north of Maseru, and was diagnosed with tuberculosis at age 15. She believes she got the disease from an uncle, who came home very sick after working in mines in South Africa. 

When Mohapi began having night sweats and rapidly losing weight, family members became alarmed and took her to a doctor. The quick intervention allowed Mohapi to stay stronger than later-stage TB patients and begin medication early—with motivation and encouragement close at hand.  

“Since we had a very sickly uncle in the house whom we supported and had observed him slowly recovering, I got courage to take my meds daily,” Mohapi said. “The only fear I had back then was the fact that most people who were diagnosed with TB were not recovering. Most were dying, and I think adherence to medication was a challenge.” 

Grueling side effects from TB medications can be a deterrent for many patients, who sometimes stop treatment when they start feeling better but before the disease is entirely eradicated. Mohapi said she was able to overcome those challenges because of the people around her, even as her treatment stretched from the usual six months to eight. 

“I can say a strong family support system helped me to beat the disease,” Mohapi said. Her uncle beat TB, as well, and remains healthy today.

Ultimately, TB didn’t slow Mohapi down—she went on to earn an honor’s degree in industrial and organizational psychology at the University of South Africa, and a degree in human resources development at Vaal University of Technology in South Africa.

She’s now a mother of three children, and lives in Maseru with her family. Her role at PIH is vital to the organization’s growth and success across Lesotho. 

“I may not be directly helpful in assisting patients, but I believe we are all working as a team,” Mohapi said. “I believe that’s what has kept me here—doing what is fulfilling.”
 

When Mojela Masupha was a site administrator for two rural health clinics in Lesotho, he needed a way to travel over steep mountain trails and rugged terrain. 

It wasn’t easy to meet village leaders, collect blood samples, carry medical supplies, and more, in some of the most remote areas of Lesotho, a high-altitude nation surrounded by South Africa. Cars weren’t feasible. Neither was walking the long distances between villages, or flying frequently by small plane or helicopter.  

So, Partners In Health trained Masupha to ride off-road motorcycles—and a new passion was born.

“It was my first time riding a bike on my own, and it was a dream come true,” Masupha recalled. “It has since become a lifelong habit—so much so that in my spare time, I teach people how to ride with discipline.” 

Masupha, 36, now works in the Maseru office as a human resources coordinator for Bo-mphato Litsebeletsong tsa Bophelo, as PIH is known locally. Along with his supervisor, Human Resources Manager Tholoana Mohapi, he is one of the longest-serving members of PIH’s team in Lesotho. Masupha was hired in 2008, about a year after PIH began supporting Lesotho’s Ministry of Health.  

Mohapi said Masupha’s personality makes him a natural fit for human resources.   

“He is passionate about the work we do, and once he is convinced about any new intervention or strategy, he runs with it, with strong commitment,” Mohapi said. “He’s a people person. He interacts with people with ease and is able to disseminate needful information to staff and other partners skillfully.”

Masupha began his PIH service at the mountain clinics, spending two years at Nkau and a year at Nohana before joining the Maseru staff in 2011. Getting around in Maseru, Lesotho’s capital, is a little easier than it was in the mountains. But Masupha still has a bike parked outside the office, and another one at home. 

He especially enjoys riding with his two sons, ages 5 and 12. 

“I ride my bike almost every day to work and my youngest son is thrilled by bikes,” Masupha said. “I take him on short rides. My older son has just recently shown interest, after I took him for a good rough-terrain ride.”

Mohapi has worked with Masupha since he joined PIH. She said he gained far more than motorcycle experience during his time in the mountains. 

“That was where his leadership skills were groomed,” Mohapi said. “He proved himself to be an excellent, remarkable leader.”

Masupha also honed valuable skills in handling finances, supplies, transportation, scheduling and hiring, while supporting staff and community outreach. 

And he gained some memorable stories. 

Like when PIH staff in Maseru asked Masupha to travel to a remote village, about four hours from the Nohana clinic by horseback, to get a letter from the village’s leader. When presented to government officials in Maseru, the letter would enable a sick patient from the village to get a passport and cross the border into South Africa for specialized treatment. 

Co-workers who knew the area told Masupha that no one had ever reached the village by vehicle, including motorcycles. Nonetheless, he decided to ride his Honda. 

The ride back turned out to be the problem. 

After reaching the village and getting the necessary papers for the patient, Masupha was returning to Nohana when the bike got stuck between boulders in a small stream at the bottom of a ravine, known as a “donga.” 

“I wrestled the bike with no luck, until I was sweating profusely,” Masupha recalled. “I had to climb out of the donga on foot and seek help.” 

Fortunately, some boys tending herds nearby agreed to lend a hand, and with much effort—and a few falls into the stream—they all were able to push the bike out of the ravine.  

“When I got back to the clinic, many were in awe that I made it,” Masupha said. “But in my head, I was just remembering that at PIH, we have a saying: We do ‘whatever it takes’ to see someone get the medical attention they need.”

Masupha said he thinks about that trip sometimes, when he’s riding along the paved roads of Maseru. It makes him think of how far PIH has come with supporting health care for all, over the years. 

Masupha has come far, himself. He was born in Maseru but his family is from Berea District, just to the north. He said he “grew up in a hospital setting,” as his mother was a nurse and he volunteered during high school at Queen Elizabeth II Hospital in Maseru. 

Masupha said when he saw the opportunity to join PIH, he jumped at it. 

“I thought, ‘This is what I’ve wanted to do for a long time,’” he said. “Even if I’m not a doctor, at least I could touch sick people somehow, and help them. It really satisfies me when I see a patient who is happy, who is healed, and know I had a stake in that.”

Themba Nyirenda was lying in bed at about 7 a.m. one morning this May, checking email on his laptop, when he got news he’d been hoping for since 2015. 

He immediately called his girlfriend, despite the early hour.

“You cannot believe what I’m looking at,” said Nyirenda, a 26-year-old data analyst who was living and working in Nairobi, Kenya, at the time. 

He was looking at an acceptance letter. And it was one that could be a game-changer, in terms of Nyirenda’s career, personal values, and life path.

The letter said Global Health Corps had named Nyirenda as a Fellow for its 2018-19 class. He’d join more than 130 other dynamic young professionals in the yearlong leadership development program, which focuses on providing health care for all and places fellows with partner organizations in Rwanda, Uganda, Malawi, Zambia and the U.S.

The letter meant Nyirenda would have to resign from his job, apply for a visa, travel to the U.S. in a month, and move back to his native Malawi for a year. 

He accepted right away.

Nyirenda will work with Partners In Health in Malawi’s rural Neno District, where PIH provides comprehensive care for more than 160,000 people through a network of hospitals, health centers and clinics. 

As part of the medical informatics team for Abwenzi Pa Za Umoyo, as PIH is known locally, he’ll help develop software to better track and manage patients’ medical records and data. 

Nyirenda has been working in informatics for several years. He’s from Karonga in northern Malawi, near the Tanzania border, and has a degree in business information technology from the National College of Information Technology in Lilongwe, Malawi’s capital. 

He was working for an IT service provider in Lilongwe in 2015, he said, when he became disillusioned with his professional track. Learning about Global Health Corps around that time gave him a broader view of career options.  

“I just came to realize that there should be more to my skills than just going to work and making profits for someone else,” Nyirenda said. “I didn’t really believe in it. I decided that I was never going to work for a private company again.” 

He decided to leave his job and go to the University of Malawi, for a master’s degree in informatics. He started the degree in late 2015 and expects to complete it by the end of this year.  

Nyirenda also applied for Global Health Corps in 2015. He wasn’t accepted—competition is steep; the nonprofit had more than 5,500 applicants for this year’s group of 134—so Nyirenda said he worked on his studies and continued to look for fulfilling professional opportunities.

He moved to Nairobi to check out the IT industry, in the bustling tech hub that’s been known for a decade as “Silicon Savannah.” An internship at an information technology company turned into a full-time job, mining social media data to help clients raise their brands’ profiles online. 

“Data is what I’m passionate about—to see the way everything comes together,” he said. 

But, of course, that was another private company. Nyirenda still was not satisfied with his work, and decided to reapply for Global Health Corps.

This time around—after two shortlists, three interviews and some nervous waiting—he made the cut, and got an email that May morning. 

“That’s where the journey begins,” Nyirenda said. 

Although his job in Nairobi wasn’t fulfilling, Nyirenda said, his co-workers there felt like family. That made it difficult to leave, especially so quickly. 

“The last days were not easy,” he said. 

Nonetheless, he packed up and took a bus from Kenya to Tanzania, then got a rental car. He had a tight schedule for a visa interview at the U.S. Embassy in Lilongwe, and drove hundreds of miles in two days to reach the Malawi capital. 

Some logistical hurdles arose, as can happen with international travel. But about a month after that fateful email, Nyirenda found himself in New Haven, Conn., in the U.S. for the first time, attending a three-week leadership training on the campus of Yale University. 

The training included community service work, group discussions and plenty of motivation.  

“I realized that leadership is not about the skills. It’s about the values that are in you,” Nyirenda said. “I was really inspired by the speakers that were there.”

Emily Wroe, chief medical officer for PIH in Malawi, said Nyirenda will help create positive change in Neno District. 

“He’s joining the team during a huge and key time for growth. Very exciting work is happening with informatics,” Wroe said. “I just emailed the team today on what a big difference in patient care some of the recent improvements made. Themba looks ready to go.” 

Ellen Ball, a software engineer on PIH’s medical informatics team, said she was very impressed by Nyirenda’s desire to work for social justice and determination to be part of Global Health Corps.

“He kept wanting to do more for the people of Malawi,” Ball said. “I love the persistence, and am looking forward to all we will learn from him.”

Nyirenda visited PIH’s Boston office in early July, just a few days before flying back to Malawi to begin his fellowship. 

“I feel that this is the beginning of my career in this field,” he said. “As for what comes next, I do not know. But what I hope to be doing is continuing what I do with PIH.”

The movement toward universal health care is growing—no matter the setting. 

Two new studies highlight incredible improvements in child and maternal health in Rwanda and Madagascar in recent years, showing repeated success, in very different environments, for Partners In Health’s ground-up model of building health systems and supporting universal care.  

Deaths of children younger than 5 dropped by nearly 20 percent in just two years in a poor, rural district in Madagascar—despite the island nation having the world’s lowest public health spending, per capita. Under-5 mortality in Ifanadiana District dropped from 104 deaths per 1,000 live births in 2014, to 84 per 1,000 in 2016.  

A similar transformation happened in Rwanda, which has seen a nationwide reduction in child mortality. This reduction was very notable in a region of about 400,000 people in Eastern Province, where Rwanda's government worked in collaboration with PIH. Deaths of children younger than 5 dropped 60 percent between 2005 and 2010 in the region, which includes Kirehe District and southern Kayonza District. Specifically, under-5 mortality fell from nearly 230 deaths per 1,000 live births in 2005, to about 83 per 1,000 in 2010.

Both studies also showed corresponding increases in births that occurred in public health facilities, rather than mothers’ homes; in prenatal care visits; and in postnatal care visits. All three of those gains represent lifesaving improvements for new and expectant mothers. 

The results in Rwanda and Madagascar are detailed in two papers recently published by BMJ Global Health.

While Rwanda has been boosted by strong government support and a vast infusion of international resources since its 1994 genocide, Madagascar has been politically unstable and largely forgotten by the international donor community. 

Global health nonprofits PIVOT, in Madagascar, and Inshuti Mu Buzima, as PIH is known in Rwanda, led the efforts, in partnership with each country’s Ministry of Health. 

“The positive health outcomes in both Rwanda and Madagascar document our collective progress in reinforcing universal coverage, as both a moral imperative and an achievable reality,” said Dr. Paul Farmer, PIH co-founder and chief strategist, and a co-author on the Rwanda study. “PIH and PIVOT, in partnership with the Harvard Medical School Research Core and its affiliated faculty, are charting stronger, more equitable, mechanisms for improved care delivery.” 

A leader of that affiliated faculty is Dr. Megan Murray, who also is director of research for PIH and an example of how the teams behind the studies are interconnected. 

PIVOT is a mission partner of PIH, and was founded in 2013 by Drs. Michael Rich and Matthew Bonds. Both doctors were leading PIH’s work in Rwanda between 2005 and 2010, and later applied lessons from those years when starting work in Madagascar. 

Before they began that work in 2014, through PIVOT, questions arose in global health circles about whether a community-based, long-term model for building a health system could succeed in a southern Africa nation like Madagascar, which didn’t have strong government resources like Rwanda.
 
PIH and its partners have heard those kinds of doubts before. Similar questions arose years ago, when PIH began working toward expanding its model from Haiti and Peru to African nations including Rwanda. 

Dr. Joia Mukherjee, PIH’s chief medical officer, said questions about whether Haiti and Rwanda were exceptions to the usual barriers facing public health improvements are not helpful, ultimately, for conversations about creating a real, viable model for universal care. 

“What is helpful is to say: What can we learn?” Mukherjee said. “Why has Rwanda been so successful, and what pieces of the model are portable and can be adapted to other settings?”

PIH began working in Rwanda in 2005, at the invitation of the Ministry of Health. PIH’s initial efforts were focused in southern Kayonza and Kirehe districts, which had some of the worst health outcomes in the country, including high child mortality rates. 
Actions included renovations of health facilities; recruitment and training of local health staff; development of a medical record system; increasing child vaccinations and prenatal care for pregnant women; financial support for patients; and implementation of a community health worker system to help patients with HIV, tuberculosis and other chronic conditions, through daily home visits. 

Professor Agnes Binagwaho is a senior author on the new Rwanda study, and was Rwanda’s Minister of Health from 2011 through 2016. She also is on the faculties of both Harvard and Dartmouth Medical Schools, and is the vice chancellor of the University of Global Health Equity, a Rwanda-based university and PIH initiative that trains global health professionals from across the globe. “Through Rwanda's commitment to a universal right to health, we have continued to witness transformation that has rendered our country's health system an example for not only Africa, but for the world,” she said. “We embrace the shared vision and work of our partners in Madagascar. Together, we can pave the way to inclusive health systems that advance equity and health for all people.” 

About 1,600 miles south and across the Mozambique Channel, the island nation of Madagascar has a population of about 25 million, with low rates of HIV but significant health priorities including malnutrition, maternal health and tuberculosis.  

Results in the new Madagascar study cover PIVOT’s work from 2014-16, in the rural district of Ifanadiana, and represent the organization’s first batch of data-driven outcomes. 

Dr. Alishya Mayfield, senior clinical advisor on strategy for PIH, worked with PIVOT as a consultant for two years, and frequently traveled to Ifanadiana between 2015-17. 

“The challenges that PIVOT faced when they started working in Ifanadiana District in rural Madagascar were similar to the challenges that PIH has faced in most of the countries we’ve worked in,” Mayfield said. “They had some of the worst child and maternal health outcomes in the country.”

Mayfield said PIVOT took steps similar to steps PIH has taken in several countries, such as developing human resources by training and retaining staff, improving public health facilities and infrastructure, building reliable stocks of essential medicine, and reducing financial barriers to care. PIVOT and Ministry of Health teams worked primarily with four health centers and the district’s one hospital. 

In addition to fewer deaths of young children, they also saw a reduction in wealth-related inequalities, while overall use of the health system tripled.  

PIVOT and the ministry also developed the first public ambulance network in Madagascar. 

"A lot of these health centers in Ifanadiana are very remote. It's quite hilly, it can be dense jungle, there are large rivers, they have flooding and big storms, so it's difficult to get to a health care facility, for a lot of people,” Mayfield said. “So, early on they set up an ambulance system, and they worked with health centers they weren’t supporting to have a mechanism where those facilities could contact PIVOT and say, ‘We have a woman who's going into labor and she's having some complications,’ or, ‘We have an acutely ill child we needs a higher level of care.’”

The network includes designated meeting points on local roads. Patients whom an ambulance can’t reach directly can go to a meeting point and be picked up in emergencies.

“That's part of how they had a larger, district-wide impact, even while focusing on a small number of health facilities,” Mayfield said.

She added that the majority of health staff put in place through PIVOT are Malagasy.

“I think that has profound ripple effects over time, when you build capacity of the local staff,” Mayfield said. “And once the word gets out that you’re providing better care, and that services are being offered at no charge to people who can’t afford them, then more and more people come to the facilities for care.”

The success of that model is spreading beyond PIH and PIVOT sites. 

Mukherjee said shared lessons from empowering community health workers and strengthening care are also reflected in Mali, where health nonprofit Muso used a community-based model to drop child mortality from 154 deaths per 1,000 children to seven between 2008 and 2015. Those findings also were published by BMJ Global Health, in March.

“We have many groups around the world that we support,” Mukherjee said. “This is not an isolated phenomenon.”

Rich said the collective results are realizing a fundamental PIH vision, of working to achieve universal care.
 
“I think, all along, the overall goal of PIH has been to create a movement in global health equity,” Rich said. 

PIVOT Co-CEO Tara Loyd agreed.  

“PIVOT and Partners In Health ascribe to the same, unshakable philosophy – that no one should die of preventable illness,” said Loyd, who worked for PIH in Lesotho and Malawi before helping launch PIVOT in 2013. “Partnering with communities and governments, we have seen that it is possible to transform health care in some of the most challenging environments in the world.”

Rich added that while, globally, child mortality has fallen by half over about 25 years, Rwanda’s corresponding drop took just five years, in the catchment areas identified by the new study. 

“We actually can make a difference in the world and solve these problems,” he said.

Mukherjee described PIH as, “uniquely positioned to support countries in the delivery of care, to progressively achieve universal health coverage,” which is one of the United Nation’s Sustainable Development Goals. 

“A lot of people are talking about financing of universal health coverage. Many fewer people are talking about the delivery of care,” Mukherjee added. “We feel like we have something really important to add about delivery of care.”

Bonds said the studies reflect the broad scale and impact of PIH’s global work to improve health care for all. That work is poised for future collaboration between PIH, PIVOT and other partners. 

"This is equally about the culture of the global health movement and the practical tactics for impact,” Bonds said. "We will continue to build systems of care that work for everyone and prove that it’s possible and effective to provide care at the last mile. These papers have shone a light on the cumulative scale of what we have already accomplished, and the promising work we have yet to do.” 

 

It was a story no doctor wants to tell. 

But at Botšabelo Hospital in Maseru, Lesotho, during a recent training on mental health care, a doctor related the story of a man who had successfully completed two grueling years of treatment for multidrug-resistant tuberculosis, or MDR-TB—only to succumb to a different, devastating illness, that far too often goes unseen.   

That illness was mental, rather than physical, and likely involved severe depression. After beating MDR-TB by taking thousands of pills and enduring frequent, painful injections along with side effects including nausea, the patient was discharged by doctors at Botšabelo and returned to his home. 

It was only there that, unemployed and lacking a support system of family and friends, he took his own life. 

One-fifth of Lesotho’s 2.2 million people suffer from mental illness, according to a 2016 study led by Dr. Daniel Vigo of the Harvard School of Public Health, in work supported by PIH. That’s the highest rate of mental illness of any country in which Partners In Health works—but mental health is a need that crosses every border.  

Lesotho also has one of the highest HIV rates in the world, affecting one in four people. Infectious diseases such as HIV and TB, and their treatments, are significantly affected by mental health, and mental illness. 

“Mental health is the biggest total burden of disease, globally,” said Dr. Bepi Raviola, PIH’s director of mental health. “And diseases such as HIV and TB cannot be treated most effectively without considering mental health.”

That’s why PIH is ramping up its mental health programs in Lesotho and at PIH sites around the world, by training more providers to incorporate mental health into primary care and improving diagnosis and treatment for illnesses including depression, schizophrenia, epilepsy, and more.

Dr. Melino Ndayizigiye is clinical director for Bo-mphato Litsebeletsong tsa Bophelo, as PIH is known in Lesotho. He said the integration of care is vital in a country where the only mental health professionals are psychiatric nurses—usually just one or two for every 200,000 people, he added—and where many communities are in remote areas far from the nearest health facility. 

“We cannot separate treatment of mind and body,” Ndayizigiye said. 

The May mental health training in Lesotho, during which a doctor shared the tragic story of a patient’s suicide, was one part of an ongoing effort to bridge that gap, and followed a previous training there in August 2017. Dr. Stephanie Smith, associate director of mental health for PIH, led the first training session, while Dr. Todd Holzman, a Boston-based psychiatrist, led the second. Doctors and nurses participated at Botšabelo Hospital in Maseru, Lesotho’s capital, and at a regional hospital in the district of Mohale’s Hoek, south of Maseru. 

The trainings’ goals included raising clinicians’ awareness of mental illness among  patients and improving their diagnostic skills. They learned to screen patients and monitor progress, identify symptoms of depression during pregnancy, and recognize common mental health concerns among different age groups. 

Holzman said that, ultimately, much of the work is rooted in listening to patients, asking them how they’re feeling, and understanding the social and familial scenarios that can affect their health. Some people might show signs of depression that actually stem from medical conditions. 

“Be sure you eliminate that possibility before you initiate treatment,” Holzman said. “A depressed mood can be caused by a number of medical conditions, such as hypothyroidism, early pancreatic cancer, or Parkinson’s disease—to name just a few.” 

Dr. Lawrence Oyewusi, MDR-TB program manager at Botšabelo, said his staff appreciated the sessions.  

“It was an intensive training but interactive, where people were able to discuss, share their experiences and ask questions,” Oyewusi said. 

Staff at Botšabelo said some MDR-TB patients can exhibit severe depression or even psychotic behavior as a side effect of the powerful drugs, and depression also can affect patients’ families. Several doctors emphasized the need to strengthen mental health training and extend care not only to patients, but also to family members and caregivers. 

“Given that patients suffering with MDR-TB and HIV/AIDS are desperate, often depressed, and already taking more than a dozen medications daily, it is essential that we raise the capacity of health care providers at all levels to screen for psychiatric disorders, especially depression,” Ndayizigiye said.

Oyewusi’s team has a plan in place to screen all patients for mental health. He said that, anecdotally, depression is the most prevalent mental health disorder at Botšabelo, where patients struggle with two years of treatment coupled with high co-infection rates for HIV, diabetes, renal failure and more. 

He said the screening process will provide stronger data for rates of depression and other mental health disorders. 

More successful treatments and broader awareness about mental illnesses also could go a long way toward changing societal perceptions.

Smith told Botšabelo staff that stigma and discrimination against people with mental illness can create significant barriers to treatment.  

“Stigma can lead to neglect, physical abuse, denial of access to help and a violation of an individual’s human right to quality health care,” she said. “It’s important that we address stigma on all levels. Getting people the treatment they need, including successful reintegration into the community, demonstrates that mental disorders are treatable. That is one of the most important stigma-busting activities that we can support.” 

PIH is spreading that message on an increasingly large scale. 

PIH’s largest mental health programs are in Haiti and Rwanda, which each have more than 3,000 patients. Socios En Salud, as PIH is known in Peru, has expanded its program significantly in recent years and is piloting a safe house program, for example, that the government has adopted and is scaling nationally, to 350 locations. Compañeros En Salud, as PIH is known in Mexico, has incorporated mental health care since 2011, when it began operating in the mountainous region of Chiapas, and also has expanded its program in recent years. 

PIH also is supporting growing mental health programs in Liberia, Sierra Leone, and Malawi. 

Often, that growth is from the ground up. Raviola said in most countries where PIH is supporting the development of mental health care, the field is not taught in medical or nursing schools. Nearly all patients have few, if any, options for treatment.  

“In the countries where we work, we’re often starting from scratch, but, in collaboration with local Ministry of Health teams, we’re making rapid progress in piloting effective, community-based mental health care delivery systems,” Raviola said. 

Additionally, in collaboration with a new Harvard University initiative called GlobalMentalHealth@Harvard, PIH is bringing together front-line organizations who are proving that mental health treatment can be delivered in low-resource settings. In June, Raviola and Professor Vikram Patel of Harvard Medical School— supported by the Harvard Medical School Center for Global Health Delivery-Dubai—led a meeting focused on increasing the role of community health workers in mental health care. Representatives from all PIH sites participated, along with leading researchers and members of nongovernmental organizations in India, Bangladesh and Pakistan. 

Oyewusi said that in Lesotho, improving the availability and quality of mental health care comes down to a universally common need: more resources. Specifically, he said, more “staff, space, supplies and systems.” That PIH mantra applies to health care delivery across the board, whether it’s for TB, HIV, maternal health or mental health. 

And the same motivation for that care—that health is a human right—applies to mental health as much as any other condition.

“People get better,” Raviola said, “and it has a truly remarkable and transformative effect on attitudes and beliefs.” 

According to local legend, a group of high school students on the edge of the Navajo Nation created the first Piccadilly in late 2017. Half a year later, the homemade snack has spread throughout the largest Indian reservation in America. Cars now queue at roadside stands selling it for $3, highschoolers with driver’s licenses deliver it throughout the rez, and regional variations of the treat continue to pop up. What is Piccadilly? Essentially, a snowcone with sugary toppings. The most popular flavor combines orange-flavor syrup, Gummi Bears, watermelon Pop Rocks, strawberry Kool-Aid powder, and a diced pickle. The Navajo Times called it “an acid trip for your mouth.”

It’s also a small example of something much larger—the unhealthy forces that Partners In Health is battling, successfully, with a wholesome eating program.

The roots of the problem run deep.

Since the United States federal government forcibly resettled the Navajo in 1868, they have lived on land that is not exactly under their control, and one of the upshots is a lack of nutritious food. Just 13 grocery stores exist on the reservation straddling Arizona, Utah, and New Mexico—a reservation the size of Vermont, New Hampshire, and Massachusetts combined. A 2014 study found that the average resident drives three hours to stock up at a grocery store. Minimart-like trading posts, with tall aisles of chips and soda, reign. Not surprisingly, one in two Navajo children are unhealthily overweight. One in five adults suffer from diabetes—the third-highest rate in the world (after Pacific islands Nauru and Mauritius). And many tastebuds have grown unimpressed by mere Monster Energy drink. Hence, the Piccadilly.

But also hence the rebellion. In April 2015, Navajo leaders helped levy a small extra charge on potato chips and more, creating the first “junk food tax” in America. (Berkeley, California, quickly followed suit.) Researchers are unknotting the political and economic tangles around everything from produce distribution to farming. And the wholesome eating program supported by Partners In Health—or COPE, as it is known locally—has begun to do nothing less than reset the Diné dinner table.

Called the Fruits and Vegetables Prescription Program, or FVRx, it relies on an odd alliance. Doctors give patients, usually mothers, “prescriptions,” or vouchers, for a month’s worth of free fruits and vegetables for their families. The mothers spend the vouchers at their local store. And PIH reimburses the stores for the cost of the produce.

The program launched in 2015 at Teec Nos Pos trading post, in the Four Corners region. Since then, the hope has been to create a virtuous cycle, in which patients drive demand, which increases supply, which ultimately leads to everyone eating leafier and living healthier.

Is it working? In the early days, some store owners bought extra produce, and ate the loss when the grapes didn’t sell, for example. But stumbles like that appear to be in the past. All told, 1,688 people have benefited from FVRx food vouchers and education. Fully 85 percent of them have met the goal of eating five servings of fruits and vegetables per day. And after six months, almost a third of children who were initially overweight met the criteria for healthy weight. Prescriptions can now be filled in 26 grocery stores and trading posts. And 15 health clinics have adopted the FVRx program, from north to south, east to west.

“I wasn’t expecting health care providers to be above-and-beyond champions,” says COPE Executive Director Sonya Shin. “But the physicians really care.”

Many regions have formal cooking classes, where pediatricians answer questions about how to prepare eggplant or quinoa or other FVRx foodstuffs. At the Tonalea farmer’s markets, about 50 miles east of the Grand Canyon, physicians recently gave food demos, showing shoppers how to create paprika-spiced “flamin’ brocs,” a broccoli-based alternative to popular Flamin’ Hot Cheetos. (“We tried to introduce some more unusual or interesting things,” explains Dr. Margaret Ray.)

Stores are also embracing the program and introducing regional variations, welcomed by design. At Basha’s Diné Market in Window Rock, Arizona, there is a wheeled flower cart with baskets of bananas and apples that are simply free for children age 10 and under. In Tuba City, Arizona, a trading post is working with a food bank to pool their produce orders and lower costs. At Naschitti Trading Post in Farmington, New Mexico, signs encourage patrons, perhaps just stopping in to gas up their trucks, to formally join the program.

Families are signing on. Naschitti clerk Brenda Tsosie enrolled herself, as did her 4 year old, who is now a fan of carrots, thanks to FVRx, she says. (Green smoothies, sweetened with bananas, appear to be the most popular with kids.)

Shanna Rose Nez, who has four young children at home in the town of Many Farms, Arizona, loves FVRx. After she and her husband began earning too much to qualify for WIC—the nutrition program commonly called food stamps—but not enough to fill a grocery cart, FVRx allowed them to buy fresh fruits and vegetables.

“I take the kids to the grocery store and have them choose one vegetable they haven’t tried and then I cook it,” she says. If dinner feels too much like a game of Iron Chef, then she’s not ashamed to fudge.

“I usually end up going online to see if there is a recipe for it,” she says. “Like kale. What is this?!”

FVRx items might not unseat the Piccadilly as the trendiest food in the Navajo Nation this summer, but the future certainly looks bright.

On a Thursday afternoon not long ago, a 20-something in Pueblo Pintado, Arizona, surveyed the scene at a senior center. While the elderly played bingo, familiar grade-schoolers wandered around the tables.

“That one girl, she really likes tomatoes and grapes. That boy likes broccoli,” she said. “FVRx really works with kids.”

Last summer in Maryland County, Liberia—the poorest corner of one of the world’s most impoverished nations—16-year-old Mable Elliot found out she was pregnant.

She promptly visited J.J. Dossen Hospital, arguably the best referral hospital for the southeast region of Liberia. It serves half a million people and has been supported by Partners In Health since 2014. After that first visit, Mable returned to the “big belly clinic,” as she called the hospital’s prenatal clinic, for two more check-ups over the next couple of months. When her due date neared, she walked over ahead of time to drop off a bag of clothes and other things she’d need after delivery.

Mable was a bright, resourceful young woman, who had to quit school in the eighth grade to help her mother around their home, and was eager to resume her education.

What unfolded at the hospital while she was in labor, though, was devastatingly tragic, as Mable ultimately lost her baby. The fact that her own life was saved, however, is a testament to the strides PIH has made in remote, under-resourced Maryland County, where 4 out of 5 people live in absolute poverty.

There was something off from the moment Mable went into labor. One morning about a week before she reached full term, while Mable’s grandmother was away and her mother was at the market, Mable’s stomach felt far more tender than it should have. Her aunt, assuming she was just hungry, advised her to stop waiting in the yard and eat a big breakfast. When that failed to lessen the pain, her aunt steered Mable, now fighting back tears, to the bathroom, in case she needed to vomit. She didn’t. With Mable feeling panicked and confused, and hurting, her aunt took her on a motorbike to J.J. Dossen.

The hospital was better off, at that time, than it had been in quite a while. Médecins Sans Frontières had helped the government run it from 1997 to 1999. Merlin, a United Kingdom-based charity since absorbed by Save the Children, tried to revive it from 2004 to 2013. Both organizations had left, though, by the time PIH started working with the government’s County Health Team in late 2014. Mold and corrosion had taken a toll, and shortages of equipment, pharmaceuticals, and pay for government staff all had affected services. PIH has worked since 2014 to rebuild or refurbish almost all of the wards, train and pay staff, and collaborate with the government to get the hospital standing tall on its own two feet.

Unfortunately, when Mable arrived that warm morning, J.J. Dossen—like virtually all hospitals in Liberia—still lacked a blood bank.

Dr. Sarah Anyango, the maternal health lead for PIH Liberia, examined Mable immediately upon her arrival.

Mable was not in a good state. Her baby's heart rate was as fast and faint as a hummingbird's. For mysterious reasons that affect about 1 in 150 pregnancies, her placenta had begun tearing away from her uterus, a condition known as placental abruption. Blood was seeping out and soaking into her uterine walls, causing the bellyache. Her baby, missing the oxygen that normally would have come through the now-detached placenta, was working hard to survive.  

In most countries, Mable, despite her significant internal bleeding, would be virtually guaranteed to survive, and her infant would have decent odds of not only being born, but thriving.

In Liberia, though, maternal mortality rates are among the highest in the world.

Mable’s labor did not take place amidst a stable health system, with facilities reached on passable roads, reliable electricity, and an adequate drug supply. The odds provided by an insufficient health system were stacked against this mother and child, and the baby passed away before a cesarean section could even be considered as a viable option to securing life. The physician put Mable’s own chance of survival at 50 percent, as she wheeled the faint and pale young mother into the operating room. Mable had incurred a dangerous amount of blood loss due to her abruption, and was in desperate need of seven units in order to live.

The team scrambled. Mable lay on the table as a handful of nurses and orderlies rushed through the hospital gates and fanned out into the community. They talked with passersby, shopkeepers, motorcycle-taxi drivers—anyone who might be willing to donate a pint of blood. Four hours later, they returned with roughly a half gallon of clean O-positive.

However, in the time it took to go out into the community, Mable’s obstetrician, Dr. Sarah, needed to make a medical decision that would save Mable’s life, but alter her future. In order to stop the rate of bleeding and give Mable a chance of survival, she needed to undergo an emergency hysterectomy, closing off her ability to have children. Fortunately, a skilled Ugandan obstetrician had arrived one month prior, to serve the women of Maryland County. Her ability to perform the nine-hour procedure and her experience working in challenging environments were both necessary to keep Mable alive, as the community banded around her to acquire lifesaving blood. Otherwise, this story could have had a much more tragic ending.

Mable required all of the lifesaving blood gathered from the community to recover from the initial abruption, and for Dr. Sarah to safely complete the operation. PIH understands that such a difficult experience doesn’t end at discharge, and the team continued to provide counseling to this grieving young mother. The PIH and J.J. Dossen team also know that helping this talented young woman return to the classroom is important for Mable personally and economically. The reality is that her viability for future marriage, and economic stability through that institution, diminished with her inability to have children. Education is her best option for economic stability.

Mable’s is a story of what could have been, if only. If only poverty did not take children out of school. If only reproductive education and access to birth control were readily available. If only teen mothers and other high-risk pregnancies received more monitoring and scheduled care. If only there was 24-hour electricity, to ensure a blood bank that would allow a short window from decision to incision. If only.

Every improvement in Maryland’s health sector has been made in the face of competing priorities. J.J. Dossen’s new electricity generator meant a longer wait to raise funds to purchase the anesthesia machine. Even with the generator, there is still not a guarantee of 24-hour electricity. An irregular power supply means a blood bank is not possible at this district hospital. Difficult choices are made every day. New infant warmers meant no funding for meeting the increasing demand for tuberculosis drugs. These tradeoffs over necessities are fundamentally tied to how Mable was able to survive, while her baby didn’t.

Mable, and the many other young mothers in Liberia and other communities in which PIH serves, remains front and center in the minds of the committed PIH staff and partners as we make sure we need not say, “if only,” again. A blood bank is in the works, as are other advances that would help emergency cases like Mable’s, ranging from talks about reproductive rights to scheduled C-sections for high-risk patients. There are so many needs, and every gain is vital—something Mable knows especially well. She’d like to become a doctor, she says.

The New Yorker staff writer Ariel Levy has an intimate understanding of pregnancy and loss. On her second day of a trip to Mongolia in 2013, she went into premature labor in her hotel bathroom and delivered her 5-month-old son, who died within 24 hours.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Partners In Health Co-founder Ophelia Dahl recently wrote for WBUR’s Cognoscenti, the Boston-based public radio station’s opinion page, about the need to reduce maternal mortality in countries like Sierra Leone, where 1 in 17 women die in pregnancy and childbirth. For comparison, the rate is 1 in 3,800 in the United States.

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

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

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

Read Dahl’s entire article here.

To coincide with the class of 2018’s graduation this month, the official news outlet for the university spoke with Professor and Partners in Health Co-founder Dr. Paul Farmer. After a flattering introduction, the interviewer got right to it.

Q: Do you still love what you do?

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

Q: It’s a good question.

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

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

 

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

Laboratory Director Roger Calderon needed more space to support tuberculosis work in Lima, Peru, so he led design and construction of a new lab made from a shipping container. Four people can work in the 400-square-foot facility, which has centrifuges, freezers and a customized ventilation system that recirculates the air 27 times an hour.

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

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

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

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

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

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

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

Those necessities are not always there.  

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

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

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

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

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

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

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

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

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

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

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

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

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

Every three months or so, Atlehang Seisa saddles up.

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

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

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

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

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

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

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

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

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

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

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

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

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

Ebb and flow

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tiiti said the increased structure and communication is paying off.

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

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

The work is yielding clear results.

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

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

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

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

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

Safe deliveries

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Home by home

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

‘Success challenges’

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

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

PIH is doing everything it can to meet that demand.

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

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

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

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

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

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

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

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

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

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

‘Don’t give up’

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

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

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

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

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

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

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

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

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

The prime minister then added a joke.

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

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

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

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

“Fantastic,” Thabane replied.

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

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

Alejandra Catalina Ramirez was starting to feel big—a completely normal sentiment for a petite woman in her sixth month. This being her third pregnancy, the 29-year-old had naturally begun showing much earlier than she had with each of her two sons. But at the rate she was growing, who knew how large this baby would be after three more months?

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

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

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

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

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

Breaking barriers

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

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

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

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

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

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

An epic voyage

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Together, in Soledad

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

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

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

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

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

Magda Louis Juste is a woman on a mission. She may not be big in stature, and her voice might carry more squeak than roar, but there is no doubt that she commands attention when she enters a room.  

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

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

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

What do you like most about your job?*

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

What is the relationship like between doctors and nurses?

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

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

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

In what ways do you advocate for your patients?

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

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

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

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

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

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

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

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

*This interview has been edited and condensed.

Thabo Lerata* was born at 1 p.m. on Jan. 1, 2018, the first baby of the New Year to be delivered at Holy Cross Health Center in the highland district of Mohale’s Hoek, Lesotho.

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

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

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

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

The Leratas’ one-story home fits that description.

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

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

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

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

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

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

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

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

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

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

But not in Mohale’s Hoek.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Processing Thabo’s results would take about an hour.

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

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

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

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

Soon enough, Thabo’s results were ready.

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

HIV-negative, just like his brother and sister.

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

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

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

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

Next door, pharmacist Malefetsane Letsosa filled the prescription.

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

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

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

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

* Names have been changed.

This pregnancy was different.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"As this week’s special report shows, the goal of universal basic health care is sensible, affordable and practical, even in poor countries. Without it, the potential of modern medicine will be squandered.”

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

PIH features prominently.

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

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

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

The full series can be read here.

An introductory overview can be read here. 

Usually poor. Generally living in the slums or countryside. Busy just trying to stay alive. People who suffer tuberculosis struggle to be seen, let alone treated.

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

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

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

Read the full piece here: https://www.project-syndicate.org/commentary/neglected-tb-treatments-by…

Partners In Health community health worker Patricia Mankuah often uses a motorcycle taxi to reach her patients in Harper, a town in remote southern Liberia, and last summer, she frequently hired Paul*, a friendly, trusted 30-something with a reliable motorcycle.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

*Name has been changed for privacy.

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

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

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

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

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

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

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

An MDR-TB hotspot

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

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

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

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

A painful journey

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

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

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

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

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

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

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

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

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

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

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

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

“That’s Melquiades?”

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

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

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

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

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

Kim was shocked at the sight of his former patient.

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

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

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

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

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

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

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A severe form of tuberculosis killed Moeketsi Ts'osane’s mother in 2008, and one of his brothers in 2010. Health workers suspect the disease may also have contributed to the 2005 death of Ts'osane’s father, who had worked as a miner in South Africa.

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

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

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

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

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

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

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

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

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

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

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

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

Ts'osane is an example of why. 

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

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

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

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

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

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

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

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

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

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

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

Seated nearby, Ntlamelle smiled. 

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

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

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

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

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

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

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

So could his energy and outlook. 

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

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

Slowing the spread of multidrug-resistant tuberculosis (MDR-TB) in Lesotho means going to many more places than hospitals and clinics.

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

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

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

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

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

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

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

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

“The core of our program,” Mofolo said.

That program has seen significant growth over its first decade. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

On a sunny morning in February, near the end of a hot, dry summer in the southern Africa nation of Lesotho, Mafelleng September held her month-old infant on her lap while two young children played on the floor in front of her.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

When asked how many tuberculosis (TB) patients she’s treated over the past 20 years in Kazakhstan, Dr. Zhenisgul Daugarina smiled before giving numbers for just the past three.

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

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

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

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

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

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

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

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

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

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

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

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

—Yekaterina Sakhabutdinova, PIH endTB Observational Study Manager in Kazakhstan

Martha Cassemond curled her petite shoulders forward and shrank into her chair. The 25-year-old patient was shy and reserved. Her hands fidgeted whenever she spoke. Clearly, she was nervous, a normal reaction for someone not used to talking about her battle with cancer.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

That, many parents would agree, is never nothing.

It all started with a pain in her left breast. She thought the tenderness was just another annoyance of that time of the month, a passing thing really. But then it didn’t go away. And if the discomfort were a symptom of her period, wouldn’t it have been in both breasts?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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