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

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

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

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

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

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

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

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

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

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

“The difference is huge,” Avignon said.

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

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

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

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

In an opinion piece for Boston-based NPR station WBUR, Partners In Health Co-founder Ophelia Dahl spoke about her experience working alongside Haitian colleagues in the aftermath of the January 2010 earthquake, and of the remarkable resiliency of Haitians who daily confront disasters—both manmade and natural.

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

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

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

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

Partners In Health and collaborators are taking big steps forward in the fight against tuberculosis in Kazakhstan, where increasing use of the first new TB drugs in decades, an innovative clinical trial, and digital technologies that better connect patients to caregivers all are raising hopes for more successful treatments.

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

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

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

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

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

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

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

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

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

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

Local action

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

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

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

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

Those outcomes are changing. 

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

‘Prepared to die’

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

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

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

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

“He was prepared to die,” Sakhabutdinova said.

Regional crisis

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

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

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

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

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

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

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

‘Truly miracles’

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

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

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

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

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

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

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

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

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

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

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

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

There’s an app for that

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Eight years after nearly 300,000 people lost their lives and hundreds of thousands more were injured when a catastrophic earthquake struck Haiti, Partners In Health stands with the country in solidarity, support, and remembrance.     

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tell President Trump to support Temporary Protected Status for Haitians ▸

Clinicians at Partners In Health-supported facilities around the world provided more than 30,000 safe, facility-based childbirths in 2017, according to year-end estimates—and thanks to a growing collaboration, more and more of those safe childbirths are happening in a rural district in Malawi. 

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

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

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

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

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

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

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

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

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

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

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

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

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

The program’s impacts are extending well beyond Malawi. 

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

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

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

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

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

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

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

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

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

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

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

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

A plague descends

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

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

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

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

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

Battling a new disease

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

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

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

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

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

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

Launch day

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

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

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

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

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

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

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

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

Pa pike bebe

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Partners In Health is proud to announce that Ophelia Dahl, a co-founder and current board chair, made The New Yorker's end-of-year World Changers list for her decades-long work building health care systems in some of the poorest places around the world.

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

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

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

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

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

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

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

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

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

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

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

It was a landmark, a triumph, a watershed moment—without fanfare. On Oct. 6, two doctors stood under the awning of a yellow hospital on the western edge of Freetown, the capital of Sierra Leone, and gave instructions to the first patients to be discharged from the first tuberculosis treatment program of its kind in the country.

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

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

“Everything,” the doctor said.

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

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

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

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

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

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

The subdued mood felt oddly appropriate.

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

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

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

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

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

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

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

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

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

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

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

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

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

“Thank you,” she said.

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

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

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

Partners In Health received a heartwarming show of support Saturday from The New York Times columnist Nicholas Kristof, who promoted PIH's reproductive health and cervical cancer efforts in his annual holiday giving guide. 

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

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

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

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

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

In commemoration of World AIDS Day, Dr. Joia S. Mukherjee describes why this is no time for complacency in the long, global battle against the deadly disease:
 

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

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

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

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

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

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

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

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

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

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

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

As she spoke to nurse managers from Rwanda, Liberia and Haiti, Dr. Lynda Tyer-Viola—a longtime nurse manager in Texas—cited a daily situation that’s true for medical professionals anywhere. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

On Monday, the Trump administration ordered the end of a humanitarian program that granted temporary protected status to 59,000 Haitians living and working in the United States following the devastating 2010 earthquake in Haiti. These Haitians are asked to leave the country by July 2019.

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

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

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

At least 10,000 Haitians died and nearly one million have been sickened from cholera since October 2010. This diarrheal disease, which can kill within 24 hours, still plagues Haiti. This is largely because most people, especially those living in rural areas, lack access to clean drinking water and reliable sanitation systems.

PIH staff continue treating the sick, as well as vaccinating Haitians against cholera and offering options to improve safe water access. Last week, hundreds of staff launched a comprehensive campaign in Mirebalais, aiming to provide 100,000 people with two doses of the oral vaccine.

Meanwhile, basic vaccination rates are low nationwide. Haitians are currently battling an outbreak of diphtheria, a disease almost never seen in the United States because it is part of the vaccination regimen for all children.

Hurricanes Matthew, Irma, and Maria ravaged wide swaths of southern and northern Haiti in just over a year, destroying crops and aggravating regional food insecurity. Many Haitians are subsistence farmers who live on less than $2 a day. With no harvest, they not only lack food, but also any means to earn income. Their poverty intensifies and, quite often, this leads to poor health outcomes for them and their families.

This is “the stability and quality of life” that many Haitians currently endure. Should 59,000 Haitians living in the U.S. be forced to return, the situation will only worsen. The World Bank reports that the entire Haitian diaspora sent $2.36 billion in remittances back to Haiti last year alone. That money, which equaled one-fourth of the national income, supports entire families—and would destabilize the entire nation should it diminish or completely disappear.

We stand in solidarity with the Haitian people in asking the Trump administration to reconsider this order, and thereby continue to stand on the side of justice.

The teams wound down dirt paths, high-stepped through muddy slums, and climbed stairs cemented into lush hillsides. Never mind the lack of road signs and house numbers—they knew where they were going. They lived nearby.

“How di body?” one would ask a neighbor.

“Body fine,” the person would reply.

A team member in rubber gloves then would reach into a soft-sided cooler, tear the top off a tiny vial of milky solution, and let the person shoot it like a liqueur. Another would make notes in a log book. The third would hand over a paper record. And the fourth would mark the lintel of the front door: “OCVR217,” meaning Oral Cholera Vaccine Round 2, 2017. The large chalk letters felt portentous. Evil, in the form of cholera, should now pass over this house.

“A de go!” or “Bye!” team members would say and walk on to the next home. And the next.

Such was the scene in Freetown, Sierra Leone, in early October, when roughly 2,000 teams, 8,000 people total, fanned out to complete the largest cholera vaccination campaign since a vaccine was invented in 1885. Consultants are assembling a final report, but preliminary national data suggest strong results. Thanks in part to Partners In Health’s support, as many as 90 percent of half a million people took both doses, thus protecting themselves against the “kaka vomits,” as cholera is sometimes referred to locally.

“This was a huge success,” says Dr. Dennis Marke, program manager at the Ministry of Health and Sanitation’s Expanded Program for Immunization.

Seen alongside similar campaigns—recently carried out by UNICEF in Bangladesh, and Doctors Without Borders in Zambia—the record-setting goal of distributing 1,036,300 vials of the vaccine in Freetown not only saved thousands from severe, life-threatening diarrhea and dehydration. It also testified to the dramatic strides made by Sierra Leone’s Ministry of Health and PIH in fighting a disease that still threatens some 2 billion people worldwide.

The need for a vaccination campaign in Freetown was clear. Seen from afar, the capital is one of the most beautiful in Africa. Green mountains decline into a colorful downtown, which pushes up against white-sand beaches. But up close, the city, population 1 million, is a mess. A five-story high mountain of trash marks the center of downtown.

Superlatives tend to ring especially hollow in the summer. During August’s heavy rains, landslides broke loose up high and buried houses, primarily in the Regent and Juba neighborhoods. Down low, runoff swept through Congo Cross, Kroo Bay, and other decades-old shantytowns near White Man’s Bay. Health clinics were inundated with water up to the knees. Bridges collapsed. Houses, such as they were, washed away, wooden planks and scraps of metal flushed into the sea.  

“Within an hour, it was a flood,” said Serla Matukomaron, who was asleep on the floor of her shack by the ocean at the time. “Everyone was shouting, everyone was busy.”

“A handicapped man couldn’t walk,” recalled her neighbor, “so someone came and carried him.”

Matukomaron, a fisherman’s daughter and mother of two, felt the rising water while she slept on the elevated floor of her shack. She awoke at 3 a.m. and gathered her children.

“The water came higher than their heads,” she said. She got her children to safety by floating them through the slum’s dark, labyrinthine alleyways in a plastic washing tub.

When the rains finally abated in late August, the damage was clearly more than other rainy seasons. Reuters declared the deluge one of the deadliest recent natural disasters on the continent. The landslides and flooding displaced an estimated 6,000, killed 1,141 (including family members of PIH staff), and left the capital—never the most sanitary city—with pools of water contaminated by toppled outhouses, broken pipes, and blankets of trash.  

Marke kept his eyes on the horizon. While the military tried to figure out what to do with bodies after morgues ran out of space, he pulled together a small group of nonprofits and began formulating a plan. PIH-Sierra Leone Executive Director Jon Lascher, who helped pioneer the launching of cholera vaccination campaigns during emergencies, met with Dr. Marke each morning for a week.

PIH Deputy Policy and Partnership Director Dr. Bailor Barrie chose to defer beginning a PhD program in the U.S. to help Dr. Marke, whom he first met as a medical intern in 2003.

“We all agreed that cholera was next,” says Barrie.

Just beginning to formulate a plan was progress. Five years earlier, Marke might have simply thrown up his hands. Few residents of Freetown were likely to buy the vaccine for themselves. The vaccine’s $3 price is a week’s rent for roughly half the population. And his immunization department would have been largely powerless to get its hands on a significant amount. As recently as 2012, the World Health Organization considered a cholera vaccine too expensive to recommend.

But this wasn’t five years ago. Two big steps had been taken since.

First, PIH had helped make sure cholera vaccine was available to the world. In Haiti in 2012, PIH and the Haitian Ministry of Health refused to accept that poor people didn’t deserve a $3 vaccine, and had bought and delivered their own cholera vaccines. The program, run by two PIH physicians and Lascher, proved an overwhelming success. Ninety percent of patients received both doses. The World Health Organization promptly changed its position and stockpiled the vaccine.

Second, Marke now had the infrastructure to deliver the vaccine. With limited resources, he had built a thorough, albeit fragile, web of refrigeration throughout the country over the last few years. At the government’s central warehouse one day in October, a logistician opened the latch on a thick door, pushed aside a clear plastic curtain, and showed off the network’s centerpiece: a cavernous new walk-in refrigerator nicknamed France, for its country of origin. It could keep a full battery of vaccines between 2 and 8 degrees Celsius, whether stored on the bottom shelf near the door or near the cooling fan in the back, and whether the national power grid suffered one of its daily outages or not. From France, virtually any drugs could travel to solar-powered refrigerators, double-insulated coolers, and more throughout Sierra Leone—without spoiling.

All of which is to say, when cholera became a clear threat, and Marke asked about ordering the vaccine in late August, representatives in Geneva replied with hearty encouragement.

All they had to do was hand out the vaccines.

Marke, Barrie, Lascher, representatives from the World Health Organization, and other colleagues divided the city into areas, evaluated which were most threatened by cholera, and alerted staff at those 19 local health centers that drugs were on their way. Each health center would use its vehicle to pick up the medicine at the central warehouse. (Marke’s team can afford only one vehicle.) Then health care workers, trained on how best to distribute the vaccine, would walk the drugs to homes and schools. Along with sharing what they knew about delivering temperature-sensitive cholera vaccines to poor people in the tropics, Lascher and Barrie offered to loan out two dozen PIH case managers, one manager to ensure that the drugs were accounted for and in good condition at each facility in the city.

On Sept. 7, the first 518,150 vials of cholera vaccine arrived from Korea. The vials were packed in lipstick-sized boxes that were inside larger, cardboard boxes; surrounded by cold packs; nested inside Styrofoam boxes; and stacked inside bigger boxes.

The central warehouse soon looked like a cardboard explosion. Incinerators and refrigerators were double-checked. The drugs were distributed to the respective health centers, only to be shuffled again later, when population census info proved inaccurate. And a week later, on Sept. 15, 2,000 teams of health care workers fanned out into the city to administer the first dose.

“Seeing Dr. Marke pull all this together in a short time makes me really admire him,” said Barrie. “Even though it was a new vaccine, the acceptance rate was very high.”

Indeed. Three weeks later, a small team approached elderly sisters who did not necessarily look like they wanted to drink a mysterious liquid offered by 20-somethings in matching white vests.

The sisters sat on their patio, finishing each other’s thoughts while staring out at the bog water that had overflowed into their neighborhood weeks earlier and, as in other areas of the city, refused to drain away.

“Ten years ago, this place was bushy,” said Princess Hawa Goba, nodding toward a submerged field.

“Now the house is like an island,” said Phebean Brown-Coker.

Others had it worse, they knew. In Lumbley, dogs were rumored to be digging up body parts.

“Some people have nowhere to go,” lamented Hawa Goba.

The team stopped to chat. Had the sisters been offered two doses, they wanted to know?

Yes.

Had they been warned of the possible side effects, like abdominal discomfort?

Yes.

Had they chosen to take it?

Brown-Coker and Hawa Goba looked at each other in bafflement, turned their heads toward the pair, and expressed their astonishment in unison.

“Of course,” they said.

Brown-Coker put a finer point on her answer. “It’s a vaccine,” she said.

Some did refuse.

“I vomited after the first dose, I don’t want to take a second,” said a mother, while supervising her teenage son’s bagging of charcoal, which he would sell on the street.

Her doctor had purportedly advised as much, but she couldn’t remember his name. Or when she visited. Or what his rationale was. In any case, she wasn’t going to take it. “I going to sleep,” she said, rising and heading inside.

But like the sisters, the overwhelming majority were more than happy to take it.

“Everyone in Freetown knows cholera,” said Barrie.

Isha Sankoh, a 60-year-old vendor and grandmother, certainly does. After her first husband was killed in Sierra Leone’s civil war and her second husband turned out to be “too mean,” she moved with her five children to low-lying Kroo Bay, in hopes of growing her business selling charcoal, palm oil, and soda pop.

“Every year, I would lose property during the flood, leave and live with neighbors, then go back,” she said.

During the rainy season five years ago, she fell horribly ill and quickly became too weak to walk. Friends carried her to the health center in the slum, and watched over her kids and grandkids while she recuperated.

“I had cholera almost to the death,” she said.

After being discharged, she moved her family to this one-room shack on higher ground. “I plan to change my life,” she said. “I plan to move from here to a better house.”

Had she taken the vaccine?

Of course, she said.

So the team continued on.

Chimwemwe Chipenge easily remembers the date of the diagnosis that saved her daughter’s life: June 31, 2014.

That was the day Chimwemwe told clinicians with Abwenzi Pa Za Umoyo, as Partners In Health (PIH) is known in Malawi, that her young daughter, Sheila, “was getting smaller, losing loads of weight,” and experiencing dizziness, headaches and frequent urination. The clinicians diagnosed Sheila, now 14, with type 1 diabetes.

Sheila had been losing weight and not feeling well for weeks, but she had tested negative for malaria and other routine infections. While diabetes was a shock, and new to the Chipenge family, they were relieved to finally learn what had been causing Sheila’s symptoms. In the months that followed, Chimwemwe and Sheila learned that type 1 diabetes often affects young children, and that Sheila would need insulin twice a day. They also learned that, unlike malaria or other curable infections, type 1 diabetes was an ongoing, incurable condition that would require regular attention.  

In the years since, though, the Chipenge family has discovered that through steady access to care and a supportive community, Sheila is able to thrive.

Her story is an inspiration as the international community recognizes World Diabetes Day—an important moment to advocate and raise awareness for diabetes globally. Staff at PIH organizations around the world, from Malawi to Navajo Nation, are marking the occasion with many diabetes-related events, including patient education sessions in Haiti and a screening campaign in Rwanda.

The care that Sheila receives is part of PIH’s integrated chronic care clinic, a model developed in partnership with Malawi’s Ministry of Health. The model’s goal is to increase access to care for people with non-communicable diseases in rural areas.

PIH’s integrated care model began as an HIV program. Clinicians now are building on that success to offer community-level care and screening for several chronic diseases—such as HIV, type 1 diabetes, rheumatic heart disease, and cervical cancer—under one umbrella. Providing integrated care enables PIH to reach many more patients like Sheila, and to link them to health services and social support. 

That support often starts at home. Over the past three years, Chimwemwe has played a critical role in managing her daughter’s condition. She gives Sheila her insulin injections twice a day, at 6 a.m. and 6 p.m., and cooks healthy, hearty food, such as brown bread and whole-grain porridge, to support the injections.

Chimwemwe also is ready to recognize and respond when Sheila’s blood sugar drops unexpectedly.

When Sheila “gets a fever and sweats a lot, I know that she is dizzy,” Chimwemwe said. “So, I take a little sugar and give it to her.”

Although managing Sheila’s type 1 diabetes is a challenging new reality for her and her family, they continue to receive significant help from the community. Health workers from Neno District Hospital have coached Sheila on how to manage her diabetes at home. PIH helps operate the local hospital in rural southwestern Malawi, where the Chipenge family lives. A community health worker checks in regularly with Sheila and her mother, monitors Sheila’s health, and accompanies Sheila when she needs to visit the clinic.

PIH’s integrated chronic care clinic is a unique program in Malawi and an important model for the region. The clinic shows how complex, non-communicable diseases can be effectively managed in rural settings by investing in strong health systems and providing regular access to screening services, patient education, follow-up care, and life-saving medicines.

Over the next three years and beyond, PIH will continue supporting local communities and patients like Sheila while working with Malawi’s Ministry of Health to strengthen and expand services at district hospitals.  

For her part, Sheila is focused on things close to home—like being a teenager and growing up. She’s now in eighth grade and enjoys spending time with her friends after school.

Sheila said she plans to study hard, so one day she can become a nurse and “save sick people’s lives,” as the PIH team in Malawi helped save hers.

The Partners In Health truck kicked up gray dust as it rolled to a stop, just down the hill from the two-room shack where 17-month-old Lovenyou Pierre lived with seven of his relatives. Lovenyou’s mother, Jodanie Louis, emerged from the modest home, and he followed close behind.

Lovenyou tightly gripped his 25-year-old mother’s worn jeans and stared at the visitors with bright, liquid brown eyes. His short curls were a light rust color. He wore a blue T-shirt that said “Tough Guy,” and had nothing on his bottom except a fine layer of dust. He had been sick for the past several days with diarrhea—possibly the result of drinking unclean water collected from the nearby river. The closest pump was a “bon ti marche,” or good little walk, of about an hour.

Lovenyou’s tummy troubles weren’t why staff with Zanmi Lasante, as PIH is known in Haiti, were visiting. They had come to follow up on Lovenyou's visit, four months earlier, to the malnutrition clinic in Boucan Carré, where he was diagnosed with severe malnutrition. He was just past his first birthday and weighed 17 pounds—well below the normal growth curve for boys his age, according to the World Health Organization—and measured a below-average 29 ½ inches.

Roughly 1 in 5 children are starving in Haiti, and 1 in 3 are stunted because they don’t have enough to eat. In an average month in 2016, 127 patients received care and nutritional supplements at the malnutrition clinic in Boucan Carré. That’s just a fraction of the total number of starving children PIH helped last year; altogether, staff enrolled 9,000 children as new patients in the 12 clinics and hospitals PIH supports across the country.

Shortly after that first visit to the Boucan Carré clinic, Lovenyou took a turn for the worse. He spiked a fever, had diarrhea, wasn’t eating, and—scariest of all—kept losing consciousness. Panicked, Louis scrounged for the money to pay a driver to take her and Lovenyou to University Hospital in Mirebalais, a 30-minute motorcycle drive from their home.

PIH staff admitted Lovenyou immediately, hooked him up to an IV, and performed a battery of tests to ensure the toddler wasn’t suffering something in addition to starvation. (Some children’s cases become infinitely more complicated when staff discover they also test positive for HIV or tuberculosis.) Tests showed nothing alarming, but did confirm he was dehydrated and in dire need of additional nutrients.

Eight days later, Lovenyou was healthy enough to return home. Louis began taking him regularly to the clinic in Boucan Carré. When she couldn’t afford the motorcycle ride, they walked. By foot, and while carrying a sick child, it took her nearly two hours, one way. Once there, PIH nurses weighed Lovenyou and provided him with a supply of Nourimanba, the nutrient-rich peanut paste PIH produces and distributes to its malnutrition clinics.

Louis religiously fed Nourimanba to Lovenyou three times a day, and his appetite returned. She talked about the experience in a shy, quiet tone, while her son squirmed in her arms. He eventually wiggled free and shimmied to the ground to play with other children.

Lovenyou is Louis’s third child; she has two by another man, who’s no longer in the picture. Lovenyou’s father worked as a mason in the capital of Port-au-Prince and was not home often.

Louis did what she could to make a living. She took out a small loan from Fonkoze, a nonprofit with an office bordering PIH’s clinic in Boucan Carré. With 3,000 gourdes, about U.S. $50, she bought bouillon cubes, candies, cookies, spaghetti, and school supplies to sell on market days in neighboring communities. She repaid the loan, bit by bit, every 15 days. With the profits, she bought food and paid school fees.

Toward the end of the visit, Louis’s older sister, Magdala, appeared from inside their home and welcomed the visitors inside. Sunlight filtered between the wood slats of the walls and under the zinc roofing. Cups, jars, and cooking supplies covered a table across from the doorway. Clothing hung from exposed beams above. Near darkness cloaked the back room, where a single bed filled half the space. An elderly woman lay on a mat on the dirt floor. She was Magdala and Jodanie’s mother, and she clearly was not well.

She had been sick with a fever and headache for five days. Ms. Esther Mahotiere, the nutrition program coordinator, and Ms. Asmine Pierre, lead nurse of the malnutrition clinic in Boucan Carré, knelt down to speak with her. They asked about her symptoms, what medicines she had taken, if any, and encouraged her to go to the clinic.

Back outside, a heavy truck rumbled by on the dirt road below, its bed laden with bananas and hitchhikers. Lovenyou found a stick and chased neighbors through the tall grass bordering their yard. He laughed, deep dimples indenting his cheeks, and ran faster than his little legs could carry him until he wiped out on the ground nearby.

Louis, a slender woman with thick cords of hair, shook her head and smiled. It was the look of a tired mother whose child had been a bit naughty. And it carried a hint of relief.

Lovenyou still had a ways to go to recover, but in the past four months, he had gained 2 ½ pounds and half an inch in height. His condition had improved from severely to moderately malnourished, and he was now visiting the clinic every 15 days, instead of every eight.

Back in the PIH truck headed home, Mahotiere looked relieved.

When they act rascally, she said, it’s a good sign. That means they’re healthy.

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A recent Wall Street Journal interview with Partners In Health CEO Dr. Gary Gottlieb offers a candid perspective on the challenges of implementing and funding global health. Dr. Gottlieb, the former president and CEO of Partners Healthcare and a psychiatrist by training, has led PIH since 2015. Below he speaks to the organization’s “laserlike” focus on investments in maternal mortality, community-based health care delivery, and the use of hard data to drive decision-making up and down the board.

Over seven decades in Malawi’s Neno District, Rosemary Mapemba not only has witnessed transformative changes in health care and quality of life, but also has been a daughter, a mother, a grandmother, a Partners In Health patient, a much-loved PIH hospital attendant, and, now, finally, a retiree.

The last of those things is the only one that makes her sad.

“The government said I’m too old,” the 68-year-old Mapemba said with a rueful smile in October, via Skype, referring to national employment regulations. “I need to work again.”

Mapemba’s desire to continue working is all the more impressive when you consider her commute. She was a hospital attendant at Neno from 2008 through 2016, working for Abwenzi Pa Za Umoyo (APZU), as PIH is known in Malawi. She walked to and from work every day, up and down the mountains between her home—in a village named George 2—and the Neno hospital, about five miles away. The trip took her at least two hours each way. That meant she spent four hours walking every workday, for nine years. Through rugged country. Usually alone.

But it didn’t mean she showed up late.

“She was often the first one at the office, at 7:30 a.m.,” said Stephen Po-Chedley, a volunteer medical informatics advisor at Neno from 2013 to 2014. “We would shuffle around every morning to get out of Rosemary’s way, because she took great pride and was stubbornly persistent in her work, and wanted to make sure everything was cleaned every day.”

Mapemba’s work went well beyond cleaning—she made sure patients had basic needs, kept hospital offices supplied with materials, helped the information technology team handle requests, and more. Her diligence and sunny personality made Mapemba a favorite not only among Neno staff, but also within the larger communities around the hospital and George 2. Mapemba said simply, “I made a lot of friends.” But that doesn’t tell the story of someone whose retirement drew such a broad response—several current and former co-workers were eager to talk about her—and who is a living history of health care in the region.

Mapemba was born on Sept. 28, 1949, in the Nanzanga area of Neno District. She spent much of her childhood in Zambia and suffered full-body burns there, she said, in a fire that killed hundreds and hospitalized her for more than a year. Mapemba returned to Malawi and Neno District in 1964, shortly after the country’s first president, Hastings Kamuzu Banda, had come to power.

Health services for Neno District were based in a police station back then, Mapemba said, before a more formal health center was established in 1978. She recalled how people in the Neno area often would go into forested areas to find plants they used as natural medicines, such as tree roots that functioned “the same as quinine” and were used to treat malaria.

Mapemba said people who were very sick eventually were able to go to Mwanza District Hospital, about 30 miles south, but transportation remained scarce with just one ambulance.

“In those days, health care wasn’t good,” Mapemba said. “Even if you went to the hospital, the providers were not available.”

She said the availability of medicines also was hit or miss—“Sometimes you could find it, and sometimes not”—and did not improve after Malawi’s first multiparty presidential elections in 1994.

Mapemba has witnessed generations of change in health care. She gave birth to two of her four children, for example, at hospitals in Blantyre, Malawi’s second-largest city. She delivered her third child at a Red Cross building in Neno District, and her fourth at the regional health center. Two of her 15 grandchildren, though, were born in the new maternity ward at Neno District Hospital.

And earlier this year, one of her grandchildren received malaria treatment known as artemether-lumefantrine, at Neno.

Mapemba said the years have brought broad changes to the community, including a market and more streetlights, along with Neno District Hospital itself. PIH opened the hospital with Malawi’s Ministry of Health in 2007.

“Now, the hospital is good and the doctors treat us well,” she said.

Mapemba experienced that treatment firsthand, after she became so sick in 2006 that nobody would bring her to see doctors.

“They were all waiting for me to die,” she said.

Mapemba’s daughter eventually brought her to PIH’s health facility in Neno, where APZU’s first executive director, Dr. Keith Joseph, and his team diagnosed Mapemba with HIV. They started her on antiretroviral therapy, and suspected she was battling tuberculosis, as well. The timing was fortunate—PIH began working in Neno in 2006, the same year she fell ill.

There were no x-ray facilities in Neno yet, though, so Joseph accompanied Mapemba to Mwanza District Hospital, where she was diagnosed with TB and began treatment for that, too.

Mapemba said she also was struggling with hypertension at that time, but began recovering on all fronts in 2007. About a year later, she started her job as a hospital attendant—helping people at Neno, rather than the other way around.

Po-Chedley said Mapemba didn’t speak much about the hurdles she had faced in her life.

“I was aware of some of her health challenges and we discussed them, but she never really framed them as grand challenges. I think she was modest in that sense; you knew she worked hard because you could see it, not because Rosemary told you,” Po-Chedley said. “Rosemary had pride in working with APZU, and I hope she knows how important she was to the incredible work PIH does in Malawi.”

Po-Chedley added that Mapemba, “was a constant, positive, persistent, and hard-working source of inspiration.” She routinely called him “achimwene,” or brother. Mapemba often called long-term expatriates at Neno achimwene or “achimwale,” which means sister. Po-Chedley said that even though she speaks English, Mapemba tried to teach her foreign co-workers a little Chichewa every day.

Beth Dunbar, former director of monitoring and evaluation for APZU, said the same, noting that Mapemba would greet her every morning with, “Mwadzuka bwanji abwenzi?,” which translates to, “How did you wake, friend?”

“I’m sad that she’s retiring; she’s always a happy presence,” Dunbar said in October, sitting next to Mapemba on the Skype call.

Mapemba was reserved and spoke quietly on the Skype, belying the gregarious nature that’s evident in co-workers’ stories, and in photos of her with family and friends. But she smiled widely when Dunbar turned to her and gave a compliment that undoubtedly is felt by many.

“You took good care of us,” Dunbar said.

Orderly lines of homes and shelters stretch far down crowded, uniform roads at Mahama Refugee Camp in southeastern Rwanda, where more than 55,000 people have arrived since 2015 after fleeing political unrest and violence in Burundi.

The turmoil has displaced more than 400,000 Burundians across Rwanda, Tanzania, Uganda, and the Democratic Republic of the Congo, according to the United Nations High Commissioner for Refugees. The U.N. agency oversees Mahama, in conjunction with the government of Rwanda’s Ministry of Disaster Management and Refugee Affairs.

Dr. Agnes Binagwaho and about 20 students from the University of Global Health Equity (UGHE) visited Mahama on a hot day in mid-September. UGHE is a Partners In Health (PIH) initiative, with several sites in Rwanda. Binagwaho is the university’s co-founder and vice chancellor, senior lecturer in global health and social medicine at Harvard Medical School, and former Rwanda Minister of Health.

She said raw emotions from people’s displacement were starkly evident at the camp.

“This is a crisis of recently traumatized people, and it’s still ongoing,” Binagwaho said. “Even if we are happy that they have a house, that they have access to basic sanitation and basic care, it is row upon row of people who are suffering, and you can feel it.”

For students in UGHE’s new cohort, the visit to Mahama was a powerful introduction to global health equity, and inequity, during their first week of class. The visit was part of students’ intensive opening to the semester. The week also included a visit to a malnutrition treatment site—and homes of families with children in a malnutrition program—near PIH-supported Rwinkwavu Hospital, a few hours northwest of Mahama.

“The field visits are part of an overall active learning principle, getting students engaged in communities around them,” said Kamille Beye, teaching and learning manager at UGHE. “I think the (Mahama) visit helped expose the students to things that are going on in their own country…I think it opened their minds to a wider view.”

Mahama spans about 120 acres near the Akagera River, which borders Tanzania and is part of the upper headwaters of the Nile. A U.N. guide and camp director met the university group early on the day of the visit and brought them around Mahama 1 and Mahama 2, the camp’s two halves. The group saw sites including a clinical laboratory, a food distribution center, a water filtration area, and an entrepreneurship center for women and girls.

PIH co-founder Ophelia Dahl joined the visit. She praised the forward-looking vision of UGHE and Inshuti Mu Buzima, as PIH is known in Rwanda.

“It was good to meet with colleagues and new master’s students, to meet the people who will implement, on a grand scale, the details of global health equity,” Dahl said.

Mahama is proving to be a potential model for delivering equity in a setting with very limited resources.

All of the children at the camp have access to education, and there are two health centers, which Binagwaho said provide a level of care that’s comparable to what can be found across Rwanda. The Ministry of Health is also training displaced Burundians at Mahama to be community health workers, so displaced people can have links to care through people they know and trust.

“If you want the lives of refugees to be protected… you create social capital, you create trust, and you create safety,” Binagwaho said. “This camp is something new, because community health doesn’t exist (in refugee camps) elsewhere. This is a good practice that should be replicated.”

Class of 2019 student Dr. Charles Nkurunziza, a resident in obstetrics and gynecology at the University of Rwanda’s College of Medicine and Health Sciences, said conditions at Mahama were better than he expected.

“What I saw, it’s not what I thought it would be,” he said. “The health centers are really amazing.”

Andre Ndayambaje expressed a similar view. Ndayambaje, also a new student, lives in Kigali and has a bachelor’s degree in nursing sciences and midwifery, from the University of Rwanda. He’s worked for 11 years at Kigali’s King Faisal Hospital, as a midwifery nurse in the neonatal intensive care unit.

UGHE students continue their full-time jobs while earning graduate degrees in global health delivery. The university opened in 2015—the same year as Mahama, coincidentally—and held its first graduation last May. Seventeen students have received a master’s of science degree so far.

Ndayambaje has just begun pursuing his MGHD, as the master's in global health delivery is known. He said many of the practices at Mahama help create stable communities—by providing broad access to food, water, shelter, health services and education—and could be implemented outside the camp’s borders.

“They are not solely for refugees,” Ndayambaje said of the camp’s services and infrastructure. “They can be done even for local systems.”

Mahama also faces significant challenges, amid its successes. A September report by the U.N. refugee commission said the Burundian upheaval has created “one of the least-funded refugee crises in the world.” At Mahama, the commission added, space is nearing capacity and expansion efforts are underway, while more displaced people continue to arrive every day.

Beye said UGHE hopes “to build an ongoing relationship with the camp, and possibly other camps, as well,” to help students shape their roles as future global health delivery leaders and have ongoing impacts in the region.

One of UGHE’s first students already is doing just that.

Binagwaho said Dr. Angeline Mumararungu, a health program manager for Gardens for Health International and a member of UGHE’s first cohort, visits Mahama weekly to oversee and support several nutrition-related programs. Mumararungu has helped integrate health, gardening and nutritional education, along with related counseling for more than 400 displaced Burundian families. She trains people at Mahama to provide health and nutrition education, as well.

Binagwaho said Mumararungu’s work reflects UGHE’s vision.

“We want more of our students to go and provide services to the most vulnerable,” Binagwaho said. “The more our students are spread across the world to serve vulnerable populations, the more we will be able to change the world.”

Partners In Health (PIH), Interactive Research and Development (IRD) and the Zero TB Initiative (ZTBI) welcome the release of the interim results from the STREAM Stage 1 clinical trial. This is the first clinical trial of a new treatment regimen for multidrug-resistant tuberculosis (MDR-TB), and we congratulate the investigators for successfully conducting it. Unfortunately, we have noticed much confusion about the results of this clinical trial, both in the lay press and in the countries in which we work.

As organizations supporting MDR-TB treatment programs in multiple countries, we are carefully reviewing the results of this trial and considering how they should influence recommendations to national TB programs, clinicians and our patients.

The STREAM Stage 1 trial was designed to answer a specific research question. The answer is clear: the trial was not able to establish non-inferiority (equivalency) of the 9-month shortened regimen compared to the 20-month conventional MDR-TB regimen.

It is important to note that study participants in the conventional 20-month regimen arm were treated according to the 2011 WHO guidelines, which did not recommend the use of newer TB drugs. If later WHO guidelines had been used, there may have been an even bigger gap between the 9-month shortened regimen and the conventional 20-month regimen.

Also seen in the interim results of the STREAM trial was a similarly high rate of certain adverse events, such as ototoxicity and hepatotoxicity, among patients receiving the 9-month shorter regimen compared to the 20-month conventional regimen. National TB programs should ensure that patients receiving the 9-month shortened regimen are closely monitored for potential adverse events.

Despite the lack of evidence for non-inferiority, there may be countries that decide to implement the 9-month shorter regimen for reasons of cost or feasibility. They should make this decision carefully based on drug resistance surveillance and other epidemiological data. For this reason, we look forward to more detailed analysis of the STREAM Stage 1 data that may indicate what subsets of patients are more likely to have favorable outcomes or have less adverse events. This will help national TB programs determine which patient populations should be targeted for scale up of the 9-month shortened regimen and populations where the longer regimen will be preferred.

We commend the investigators in the successful execution of STREAM Stage 1, and believe that this rich dataset will help to inform future clinical trials of new TB regimens. Although Stage 1 was unsuccessful in showing non-inferiority of the 9-month shortened regimen, the findings of Stage 2, which is testing two novel regimens at the same trial sites, are eagerly awaited. Finally, we call on the WHO to rapidly convene an expert group to revise and clarify its current recommendations for implementation of the 9-month shortened regimen under programmatic conditions.

Lunie Lozama was the picture of a mischievous toddler. Shy yet curious, she hid behind her mother’s legs and played peek-a-boo with visitors to her home in rural Lascahobas, Haiti. Her round cheeks were dimpled, and her shiny black hair twisted into neat pony tails crowning her head. She wore a faded purple onesie with “Mom’s Beach Bum” across the front. Her mother smiled as she said that her daughter wasn’t afraid to fight her three older siblings.

Lunie wasn’t always that way. In April 2016, one month after turning 2, she arrived at the Partners In Health clinic in Lascahobas and was diagnosed as severely malnourished. She weighed 23 pounds and measured 31 inches—at least five pounds lighter and three inches shorter than what the Centers of Disease Control and Prevention recommend for average girls her age.

Lascahobas is among the busiest malnutrition clinics supported by Zanmi Lasante, as PIH is known locally. Nurses tended to an average of 250 patients per month, and started a total of 1,076 new children on malnutrition care last year. At all of its 12 facilities across the lower Artibonite and Central Plateau regions, PIH enrolled more than 9,000 new cases of starving children in its malnutrition program in 2016 alone.

Those numbers fail to paint a full picture of the tragedy in Haiti, where roughly 1 in 5 children are starving, and 1 in 3 are stunted because they don’t have enough to eat.

Last year, Lunie counted among them. Her mother, Gertha Morette, brought her to the Lascahobas clinic for the first time that April. The lethargic little girl had a fever and diarrhea, wasn’t eating, and her feet were so swollen that it was painful for her to walk. Morette, pregnant at the time with her fifth child, perched Lunie on her lap and patiently fed her a packet of therapeutic food. Staff instructed them to come back every eight days so Lunie could be weighed, and to pick up a fresh supply of Nourimanba, the nutrient-enriched peanut paste PIH manufactures for malnourished children.

Getting to the clinic was easier said than done for Morette. She and her husband live with their children in a two-room, wood-slat house that straddles the top of a cliff a good 20-minute ride by motorcycle from Lascahobas. Goats are more frequent sights than vehicles along the dirt road leading to their home.

Morette paid a neighbor to take her and Lunie by motorcycle each time they had an appointment, holding Lunie on her lap while riding behind the driver and using precious money that now couldn’t go toward other household expenses. (Nearly 60 percent of Haitians live below the national poverty line of $2.41 per day, according to the World Bank, and 24 percent live on roughly half that.) Morette’s time away meant she needed to find help caring for her other children, and that she couldn’t sell produce at the market or tend her crops.

But the sacrifice paid off. Within two months, Lunie’s condition had improved from severely to moderately malnourished. Her feet shrunk to normal size, enabling her to walk without pain. She started gaining weight and shooting up in height. And she regained her appetite, eating more of what her family grew in their garden, and not just Nourimanba three times a day. Nurses told them they could start visiting every 15 days, instead of every eight.

They followed the new regimen as best they could. By mid-November, Lunie had gained more than three pounds and added another inch in height, and her mid-upper arm circumference—a commonly used indicator of malnutrition—had gone from 4 ½ inches to 6 inches.

Her body wasn’t the only thing changing. Lunie began acting much more like the stereotypical terrible 2-year-old. The toddler delivered a healthy helping of attitude, for example, on the November morning when Ms. Colin Alourdes, head nurse of the Lascahobas clinic, and Ms. Esther Mahotiere, PIH’s nutrition program coordinator in Haiti, visited her and her family. Lunie shelled green beans into a silver bowl, wedged in between Morette’s legs, as she warily watched her visitors. She barely roamed from her mother’s side, marking her territory.

A small cry came from inside their dirt-floored home. Morette stood up from her chair and led visitors inside, to where her 3-month-old daughter, Neleida, lay on the family’s sole bed. She scooped up the curly-headed infant and walked back outside.

In more ways than one, Morette had her hands full, yet the proud mother seemed calm and confident. She wanted to give back something to the nurses, whom she felt had saved her daughter’s life, and said she would recommend the clinic to any friends who feared their children might be malnourished.

There was another good reason for Morette to be at ease that morning. At the Lascahobas malnutrition clinic on the previous day, she had received wonderful news: Lunie no longer needed to return.

Partners In Health, the Government of Rwanda and other collaborators broke ground in September on an innovative, two-story building that will be able to house more than 70 cancer patients, loved ones and caregivers on the Butaro District Hospital campus, providing stability and community during extended treatment. 

Crews are laying foundations and framework for the Butaro Cancer Support Center, which will provide housing, a cafeteria and meeting spaces for patients and caregivers. Doctors at the adjacent Butaro Cancer Center of Excellence treat hundreds of children and adults every year. Many of those patients travel to Butaro from across Rwanda or from surrounding countries, where high-quality cancer care can be scarce or non-existent.

The support center’s design features open-air galleries and roofed, exterior walkways lined with arches, creating shared spaces where patients, attendants and clinicians can gather. Architectural firm MASS Design integrated a patients’ needs assessment and surveys of patients, attendants and clinicians into design decisions, which focus on dignity and wellness during the entirety of patients’ cancer treatment.

The support center’s Sept. 15 groundbreaking featured leaders of PIH and Inshuti Mu Buzima—as PIH is known in Rwanda—along with Rwanda government officials and representatives of several partners and local communities. The center's construction is sponsored by the Massachusetts-based law firm of Faber, Daeufer & Itrato and supported by the generous gifts of individual donors.

The Partners In Health pickup bumped along a rutted road, passing more cows than vehicles on a late morning last November. The driver parked in the shade of a lone tree, and 29-year-old Yonide Arelul and two PIH nurses stepped out of the cab and into the blinding sun.

It was the literal end of the road—for vehicles, anyway—so the women trekked carefully down a rocky slope, crossed a stream, and continued hiking the rough-hewn path through the lush hillside beyond.

One of Arelul’s children was enrolled in PIH’s malnutrition program at the clinic in Boucan Carré, Haiti, where Ms. Asmine Pierre is lead nurse, and Ms. Esther Mahotierre supervises as the nutrition program coordinator. The staff with Zanmi Lasante, as PIH is known in Haiti, wanted to check on the boy’s progress, but had no idea where the family lived. So Arelul walked to the clinic that morning, then mounted the pickup alongside the nurses for the first leg of the trip, and led them the rest of the way on foot.

Roughly 1 in 5 children are starving in Haiti.

Arelul, and many rural Haitians like her, overcome barriers like these every day to access health care. When PIH clinicians see them arrive at a clinic, they know the patients are in desperate need of help.

Roughly 1 in 5 children are starving in Haiti, and 1 in 3 are stunted because they don’t have enough to eat. Arelul’s son, Djouvensky Maxime, was one of the 127 patients, on average, who visited the malnutrition clinic in Boucan Carré every month last year to receive a food supplement and nursing care. That’s just a fraction of the total number of starving children PIH helps. Altogether, 9,000 such children were new patients at PIH-supported clinics and hospitals across the country in 2016.

Arriving home

The sun felt piercingly hot. Pierre held a manila folder above her head in self-defense as she and Mahotiere trailed behind Arelul. Papaya trees and sugar cane seemed to bow in the heat. A farmer and his horse ambled past, laden with burlap sacks of homemade charcoal. Farther up the path, a group of schoolchildren in checkered shirts and neatly tied hair ribbons chattered on their way home for lunch.

Twenty minutes in, Arelul veered off the path. She crossed her family’s compound, seeking the shade of the banana-leaf awning attached to her two-room home. Her mother was bathing Djouvensky in the dirt courtyard. He stood in a pink plastic tub, his short-cropped hair catching drops of water poured over his head with an empty container of Nourimanba, a nutrient-rich peanut paste PIH manufactures for malnourished children. Once dried and dressed, he tucked himself into his mother’s lap and soon fell asleep.

Djouvensky’s twin brother, Djouven, stood nearby like a sentinel—curious about the visitors, yet protective of his brother. The 23-month-old boys were nearly the same size and are Arelul’s babies. She has five children altogether. Her 9-year-old daughter was studying in Mirebalais, and a pair of 4-year-old twin boys played in the shade nearby.

Arelul adjusted Djouvensky so that his head rested on her shoulder. He was her “sick” child, the one who nearly died from malnutrition.

Some children graduate from the malnutrition program within several months by gaining enough weight and height to place them back on a normal growth curve. Others don’t complete the program the first time around. Last year alone, of the nearly 8,000 children enrolled in PIH’s severe malnutrition program, 50 percent dropped out. Their families live far from the nearest clinic and can’t afford transportation. Sometimes one parent is caring for multiple children at home, and can’t slip away for appointments. Other times, families have nothing to feed their children beyond Nourimanba, which is meant to supplement—not replace—a child’s normal diet.

Arelul faces these challenges, and others, in getting Djouvensky the care he needs. Her husband works in Port-au-Prince as a welder and comes home once a month. She relies on her parents for help, but they—like many of their neighbors—are subsistence farmers and spend long hours tending their crops and livestock. So most days, she alone cooks, cleans, and cares for her children, and tends her own fields.

Daily life is a blur for mothers like Arelul, who don’t have the luxury of choosing what is best for their children. They often get by on good enough.

A rough beginning

With her last pregnancy, Arelul didn’t have time for regular prenatal visits. She was nearly full-term when she went into labor. Her family ran for the local birth attendant so that she could deliver at home, like two-thirds of women in Haiti, and she gave birth to a healthy son. But something wasn’t right. Her placenta wasn’t descending, and she was still in an immense amount of pain. The birth attendant recommended she go to the nearest clinic. For that, she would need a minor miracle, and some strong backs.

A crew of men were rounded up. Together they lifted the mattress on which Arelul labored and hoofed it, double time, to Boucan Carré. Normally, the walk takes about an hour; that day, it took 30 minutes. Doctors examined the distraught mother and provided her with surprising news: there was another baby. She gave birth to her second son minutes later.

He had nearly fallen below both growth curves and needed immediate medical attention.

Djounvensky was the smaller of the two. He wasn’t growing like his brother and always seemed sick. Arelul took him to the Boucan Carré clinic, where he was referred to the malnutrition program. Nurses diagnosed him as severely malnourished and started him on treatment. But he just didn’t seem to be getting better, which made his mother wonder if the sacrifices she’d been making to get him there were worthwhile. She decided to stop attending the weekly clinic visits.

Instead, the family took Djouvensky to a cousin, a local traditional healer. They were thinking he wasn’t “doctor sick,” but possibly under the influence of darker forces. The cousin provided them with treatment, but encouraged them to return to the clinic. They did. That cycle repeated again as the boy’s parents became increasingly frustrated. The toddler still couldn’t walk or talk and was lethargic, while his twin brother ran around, chatted, and made mischief. Her husband was ready to give up on Djouvensky.

For Arelul, that was not an option. She arrived at the clinic a third time with Djouvensky last November. Just shy of 2 years old, he weighed 22 pounds and measured 31 inches. According to World Health Organization growth standards, he should have been 27 pounds and 35 inches—in other words, he had nearly fallen below both growth curves and needed immediate medical attention.

The turning point

Pierre and her team placed Djouvensky on Nourimanba and scheduled him to return to the clinic every eight days so they could replenish his stock of peanut paste and weigh him. Arelul stuck with the program this time, spoon-feeding him Nourimanba three times a day and attending all his appointments. Sometimes she took the family’s horse and rode with Djouvensky to the clinic. On market days, when her mother needed the animal to haul corn, potatoes, and rice, Arelul hired a motorcycle driver to take them. If all else failed, she carried Djouvensky on her back.

Her diligence paid off. Djouvensky began to walk. He played more with his twin. He even said his first word, “Mama.”

Pierre, who was sitting near Arelul in the shade during the home visit nearly a year ago, paged through Djouvensky’s file and confirmed that his condition had improved from severely to moderately malnourished over just a couple of weeks. It was a small adjustment in language, but a huge difference in the boy’s daily life—and future potential.

In that moment, though, Djouvensky had no idea he was the center of attention. He was just waking up from deep sleep. He stuck his thumb in his mouth, walked over to Pierre, and snuggled on her lap. Shy and quiet, he stared at visitors with saucer-like brown eyes. His skin shone. His cheeks looked full. He had many weeks left of treatment, but finally, things were turning in his favor.

Arelul stood to escort Pierre and Mahotiere back to the main path. The sun was still punishing as the nurses retraced their steps to the pickup. At the base of the last hill, they paused beside a front-loader parked by a stream. Someday, the machine would be used to carve the rest of the gravel road, connecting rural residents more quickly to health care in the town clinic.

But that was far in the future. Pierre and Mahotiere had many more home visits to make.

Matumisang Khasipe—a mother, wife, and nurse midwife for Partners In Health—says she loves her job at Nkau Health Center in Lesotho.

“I’ve been working for PIH for two years,” she said. “And there’s nothing better than patients telling you they’re happy.”

Nkau is about a two-hour drive southeast of Lesotho’s capital, Maseru. People often travel long distances through the mountainous region, on foot or horseback, to get care there. The clinic serves a population of about 15,000 and can see up to 30 childbirths in busy months, according to staff with Bo-Mphato Litsebeletsong Tsa Bophelo, as PIH is known in Lesotho.

Providing that amount of care could be a tall order in a country with one of the highest maternal mortality rates in the world.

But Khasipe and all of Nkau’s staff have set the bar high for maternal and infant health. They emphasize facility-based deliveries—which are much safer than childbirths at home—and conduct referrals to district hospitals for complicated pregnancies and emergencies, in order to prevent as many maternal deaths as possible.

Or, ideally, to reduce that number to zero.

“There shouldn’t be any maternal deaths,” said Khasipe, one of two PIH-supported midwives and three general nurses at the clinic.

Nkau is one of seven remote health centers across Lesotho that are involved in PIH’s Rural Health Initiative. The initiative began in 2006 as an effort to support HIV care in the most rugged, remote areas of the small country, which is entirely surrounded by South Africa.

The initiative has since expanded, adding services focusing on maternal health, children’s health, and tuberculosis. One example is the Maternal Mortality Reduction Program, which began in 2009. In that year, just 5 percent of the region’s childbirths took place at a health care facility. By 2015, the facility-based delivery rate averaged 90 percent across the region served by the Nkau, Bobete and Nohana health centers.

Safe childbirths are just a part of the personal care that Khasipe and her colleagues help deliver at Nkau, every day.

In addition to new sets of tiny infant clothes and onesies emblazoned with “Partners In Health, Baby!” for example, newborns get immunizations and other postnatal services, free of charge.

Clinic staff encourage new mothers to stimulate their babies by playing and talking with them, holding them and singing to them. Village health workers travel widely to visit new and expecting mothers in their homes.

“Among other duties, village health workers go door-to-door to identify pregnant women in early stages and accompany them to facilities for their first prenatal care,” said Joalane Mabathoana, PIH’s manager of maternal and child health services in Lesotho.

Health workers also advise pregnant women who live far from the clinic to come and stay in maternal waiting homes until their babies are safely born. They receive consistent prenatal care, including ultrasounds, and doctors can more easily identify medical complications as women approach their due dates.

Mabathoana said women often begin staying at a waiting home about two weeks before their due dates. If emergencies arise, Nkau staff can help transport women to facilities with more resources.

Khasipe said such transports sometimes involve help from the local community.

“People respect what happens here,” Khasipe said. “There’s a nearby businessman who lets us borrow his car to bring women in labor” to the closest hospital, if an additional vehicle is needed in an emergency.

Khasipe’s commitment to quality health care for everyone, regardless of their financial means, runs parallel with PIH’s mission—and with her personal story. When Khasipe was 18, her first baby died. She was devastated.

The experience motivated her to go to nursing school.

“I took the chance to be a nurse in search of answers to why my baby died,” she said.

At the National Health Training College in Maseru, Khasipe studied general nursing and midwifery, and got firsthand experience in providing care.

“But I was traumatized,” she said. “I thought I could save all babies, like no one had saved mine.”

Khasipe and her colleagues have saved plenty of lives since. She’s been regularly promoted for her skills and commitment to her patients. And in 2012, she got another, more personal reward: She gave birth to twins. Her husband was away at the time, working in a mine. He now helps raise and support the family by farming. He lives with the children on their land while Khasipe spends most of her time in Nkau.

“I talk to him almost every day,” she said. “It’s hard to be apart. He’s my best friend.”

Khasipe reflected on the significant changes she’s seen at Nkau over just the past two years, and said the facility is continually expanding its role in the community.

“We save many lives,” she said, “both young and old.”

After torrential rains flooded Freetown, Sierra Leone, in August, raising fears of a cholera epidemic, government employees supported by Partners In Health will fan out from health centers around the capital October 5 to deliver the second and final dose of a vaccine that will protect roughly half a million residents from the deadly diarrheal disease.

Discussions about a vaccination campaign began as soon as floods washed through coastal slums, contaminating drinking water with bacteria-infested sewage. PIH Sierra Leone Executive Director Jon Lascher, a cholera campaign expert, and PIH Deputy Policy and Partnership Director Dr. Bailor Barrie, a Sierra Leonean physician with strong relationships in the government, joined emergency coordination meetings.

Things progressed quickly. Barrie worked hand-in-hand with Dr. Dennis Marke, Sierra Leone’s Programme Manager for the Expanded Programme on Immunization, to help deliver drugs from an international stockpile of essential medicines. PIH also bolstered the government’s plan by adding three dozen supervisors for the effort, everywhere from the warehouse that received the drugs to the health centers that sent employees out into neighborhoods. As a result, nearly all of the proposed population of 518,000 received a first dose of oral vaccine—an impressive number given that campaigns elsewhere, in less urgent times, often reach a far smaller proportion of targeted patients.

Hopes are high for the final dose. By all accounts, the government’s emergency vaccination campaign, supported by Partners In Health, has been swift, smart, and thorough.

“Having the vaccine accessed and delivered so rapidly in Sierra Leone adds some much-needed relief for people often last picked to receive the benefits of modern medicine,” said Lascher.

Check out the full story, which will include PIH’s paradigm-shifting cholera vaccination work in Haiti, when it appears in early November.

Partners In Health staff reported no significant damage or injuries at the 10 rural clinics and maternal waiting home that PIH supports in Mexico, following the country’s second major earthquake in two weeks.

The 7.1-magnitude earthquake struck roughly 100 miles outside Mexico City early Tuesday afternoon, killing more than 200 people and causing dozens of buildings to collapse.

Partners In Health is known as Compañeros En Salud in Mexico. Staff reported feeling light tremors in their region of rural Chiapas, some 500 miles to the southeast of the quake’s epicenter in Puebla.

All PIH doctors and staff checked in safe and sound. No damage was reported at PIH’s 10 rural clinics or the maternal waiting home in Jaltenango, where PIH is headquartered. But many staff and clinicians have friends and family living in the affected region, including Mexico City, Morelos, and Puebla.

Dr. Hugo Flores, executive director of PIH in Mexico, and Dr. Jimena Maza, director of primary care, spent most of Tuesday afternoon and Wednesday morning contacting the offices of collaborators to check on their safety. PIH works locally with colleagues from Advent International, Johnson & Johnson, Promotora Social, the MacArthur Foundation, and the National School of Nursing and Obstetrics.

“We have tracked down all of them, and they and their families are fine,” Flores reported.

Doctors who completed their social service year through PIH in Chiapas were in touch with current staff to transmit emergency information. At least three of the clinicians plan to volunteer in medical relief efforts in and around Mexico City, including Drs. Aníbal Gutiérrez Torres, Luciano Torres Sánchez, and René Delgadillo González.

“Doctors are now seeing patients at the hospitals,” González reported by voice message, while sirens whined in the background. “The question now is the people who are outside and in need of medical attention, because the hospitals here are usually full.”

González, who has volunteered in the past for Red Cross in Mexico, said medical brigades were forming to provide emergency aid throughout the capital and encouraged anyone with time and ability to lend a hand. The arrival of earthquake victims adds pressure on the already overburdened emergency rooms dealing with normal demand, including patients arriving in labor or from car accidents, gunshot wounds, heart attacks, and falls.

“So we are covering both fronts,” he said. “We’re working in ambulances, emergency rooms, and the Red Cross Hospital.”

Tuesday’s powerful earthquake struck less than two weeks after an 8.1-magnitude quake struck off the southwest coast of Mexico, killing 90 people and destroying thousands of homes. PIH clinicians and staff and the facilities in which they work were located far enough away that all remained unharmed.

Born a Crime

Trevor Noah

In his uplifting memoir, comedian, social critic, and “The Daily Show” host Trevor Noah recounts his extraordinary experiences growing up biracial and under apartheid in South Africa. He never quite fit in, but he used his “outsider” perspective to his advantage. A speaker of English, Afrikaans, Xhosa, Zulu, Tsonga, Tswana, German, and Spanish, Noah bounced from group to group and won acceptance from all of them.

Although his story is often tragic, the comedian’s writing leaves me laughing.

—Ryan Jiha, finance grant manager, Partners In Health

The Black Jacobins

C.L.R James

“The Black Jacobins” is a history of the Haitian Revolution of 1791–1804, and of the role of Touissant L' Ouverture, a former slave who led the uprising and later became governor of Saint Domingue (before Napoleon ousted him in 1803).

James is an odd historian. He wrote the book in 1938 and his writing is anything but dispassionate, so the book comes across as not very objective or academic. But I found it refreshing that James made his political views clear, and he effectively captures the horrors of slavery and the hypocrisy of the French.

One of the most interesting and puzzling parts of the story for me is how L'Ouverture—with no military training or experience—emerged as a brilliant military strategist. We tend to think people can only do what they have been trained to do, and I feel this creates passivity that stunts creativity. While we have recently seen what can happen when someone with no preparation for leadership becomes a national leader, and I don’t want to encourage people to follow his lead, I think the idea that we need technocrats to move fields forward is an error that can be easy to make.

—Megan Murray, professor of global health and social medicine, Harvard Medical School

Harry Hole Series

Jo Nesbø

Nesbø is a Norwegian writer known for his crime novels and their main character, Harry Hole, who is kind of a mess but “gets the job done.” There tends to be grisly murders of very nice people and lots and lots (and lots) of coffee drinking (in between benders).

—Sidney Atwood, programmer and analyst, Division of Global Health Equity, Brigham and Women’s Hospital

Forty Million Dollar Slaves

William C. Rhoden

Rhoden’s book is disturbing and uncomfortable. It draws parallels between slavery and today’s black athletes playing for white-owned sports teams. He goes back to the beginning of sports in America to show the plight of black athletes, from jockeys to boxers, under white control.

It gave me a broader view of today’s athletes. I look at Colin Kaepernick, the former 49ers quarterback who protested racial injustice by refusing to stand at games during the national anthem, and it’s apparent to me that Kaepernick understands that he and his peers are not really playing for themselves.

While riveting, it was saddening and made me feel we haven’t come very far. But if nothing else, it’s a must-read for its historical background, which shows how important a role African-Americans played in starting sports in America.

—Mary Cooper, accounts payable accountant, Partners In Health

All the King’s Men

Robert Penn Warren

This summer I reread Robert Penn Warren’s “All the King’s Men,” which won the Pulitzer Prize in 1947. The novel is loosely based on the story of Huey Long, a populist politician in Louisiana in the 1930s, but it’s really a story about how people compromise or uphold their values. After 70 years, it seems incredibly current, demonstrating the power a politician can wield over people who feel they are unappreciated and not getting a fair deal. It captures how narrators can be unreliable and how seemingly hardened people can still be damaged or change completely. It’s totally captivating.

—Jennifer Goldsmith, director of administration, Division of Global Health Equity, Brigham and Women’s Hospital

Siddhartha

Hermann Hesse

If I were pleasure-reading, I would pick up my tattered copy of Siddhartha and read it for the fifth time. The novel, set in ancient India, is about a young man who journeys to discover the meaning of life. As he wanders, he tries to find enlightenment through practices ranging from spiritual idealism to materialism. It’s a highly accessible book that’s short in length but profound in impact and has always been my go-to when I have felt stuck in life or need some inspiration. It’s also rather poetic—where else have you heard of lips resembling ‘freshly cut figs?’

—Jerome Galea, research associate, Department of Global Health and Social Medicine, Harvard Medical School

Moving Kings

Joshua Cohen

L.A. Times’ critic Mark Athitakis called it brilliant. The New Yorker’s James Woods ultimately found it unsatisfying. Whatever your take on this short novel published in July, Cohen’s maximalist writing style definitely makes other contemporary fiction look timid by comparison. (E.g. One character wears “a vintage polyblend suit pullulating with pleats.”) And the story, about a young Israeli soldier attempting to start afresh in modern-day New York City, never panders to a reader’s desire for easy truths. Indeed, it made me squirm, snort with laughter, and deeply appreciate the traumas that can hide behind familiar faces.

—Eric Hansen, senior writer, Partners In Health

Buzz Aldrin, What Happened to You in All the Confusion?

Johan Harstad

For a book that I imagine no one’s read, I’d recommend a novel called Buzz Aldrin, What Happened to You in All the Confusion? by a Norwegian author named Johan Harstad. It’s about a guy who has a bit of a mental breakdown and ends up recovering in the Faroe Islands. The narrator’s voice is quirky and unique, and the descriptions of the Faroe Islands have kept me wanting to visit for years. I found it at the library accidentally, but the story has stayed with me.

—Lewis Seton, senior grants administrator, Division of Global Health Equity, Brigham and Women’s Hospital

Cash In, Cash Out

Hannes van Rensburg

This is Hannes van Rensburg’s personal story about starting a mobile banking business in South Africa in 1999. The entrepreneur poured his blood, sweat, and tears into the company, Fundamo, and is brutally honest about his struggles, doubts, failures, and lucky breaks. He describes choosing between his personal and professional goals and how his morals guided his business decisions. 

It is still too early to understand how mobile banking will change the lives of the poorest citizens, but van Rensburg offers exciting possibilities: He believes that the mobile banking economy goes hand in hand with poverty alleviation. It’s a book that challenged me to consider how banking fits with human rights and our work at PIH.

—Mike Johnson, MEQ senior analyst, Partners In Health

Inside Out and Back Again

Thanhha Lai

Lai’s story is about a 10-year-old Vietnamese refugee girl who fled Saigon with her family to resettle in Alabama. It’s based on Lai’s own experience leaving the city at the end of the Vietnam War. She writes in verse and tells the story through the young girl’s eyes. It won adult and children’s literary awards and is a New York Times bestseller. I read it as part of a mommy-daughter book club I just joined. It’s timely, considering the current political climate in the U.S. and Trump’s position toward immigration. A quick and lovely read.

—Leslie Friday, senior writer, Partners In Health

Five years after opening, the Butaro Cancer Center of Excellence is achieving extraordinary successes in rural northern Rwanda, amid daunting challenges.

Doctors at the Partners In Health-supported facility are treating about 1,700 patients every year, young and old, on the campus of the public Butaro District Hospital. The campus lies amid lush, green hills in a remote region not far from the Ugandan border. Many patients, family members, and caregivers travel to Butaro from across Rwanda or from surrounding countries such as Burundi and the Democratic Republic of Congo, where high-quality cancer care is scarce or nonexistent.

Antoinette Habinshuti is deputy executive director of Inshuti Mu Buzima, as PIH is known in Rwanda. She said the care provided at Butaro is incredible, especially given the cancer center’s location and limited resources.

“This is a place where you wouldn’t easily find a pediatric ward for cancer patients,” she said.

Some of Butaro’s greatest successes can be found in its youngest visitors—children who come to the cancer center with slim hopes buoyed by fighting spirits, often with cancer that is in late stages because of treatment delays or misdiagnoses elsewhere.

In recognition of Childhood Cancer Awareness Month, which continues through September, we spoke with Dr. Cyprien Shyirambere, Dr. Grace E. Dugan, and other current or former members of Butaro’s pediatric oncology team. With optimism and energy known only to doctors who see positive steps toward recovery happen daily, they described what it takes, and what is needed, to treat the hundreds of children who have come to the cancer center since it opened in 2012.

“A normal day in the pediatric oncology ward at Butaro would have about 15 patients to see,” said Shyirambere, associate director of the oncology program and one of the center’s two pediatricians, along with Dr. Alexis Manirakiza. “Among them are 10 who need chemotherapy and maybe four other patients who were admitted because they are sick, very sick and on oxygen.”

Shyirambere said his day usually starts around 7 a.m., making rounds through the ward to see if any children have immediate needs. If all is well, he’ll start preparing chemotherapy regimens for the day. That process can take several hours, Shyirambere said, adding that the crafting of chemo regimens is part of an ongoing collaboration with Dana-Farber Cancer Institute in Boston.

Shyirambere’s afternoons at Butaro can include administering chemo, conducting bone marrow biopsies for new patients, and, of course, just spending time with the children he’s treating.

“It’s a busy day for a doctor and a few nurses,” he said.

Patients in the pediatric ward last spring included Frank Mugisha, 6. In March, Frank completed 30 months of treatment for acute lymphoblastic leukemia, and was shown in PIH photos smiling in a doorway and spending time at Butaro with his aunt. Butaro staff will continue monitoring him for the next five years.

Dugan, who’s been a clinical officer in Butaro’s pediatric cancer ward for about a year, said relapse is a constant concern.

“It takes a long period of follow-up to be sure you’ve really cured someone,” she said.

Also in Butaro last March was Blandine Umurisa, 12, who was completing more than two years of treatment for acute lymphoblastic leukemia. Her treatment had included three rounds of chemotherapy. PIH photos of Blandine show her working on math homework a day after chemo, and walking through the ward with her arm around Shyirambere’s waist, and his arm over her shoulder. Although she had finished her cancer treatment, doctors diagnosed Blandine with pulmonary tuberculosis in November 2016. Her treatment for TB was ongoing last spring.

Dugan said Blandine was from the Democratic Republic of Congo, and living in a refugee camp in Rwanda. Blandine visited Butaro for a routine follow-up Sept. 18, Dugan added, and her cancer still was in remission.

The names of both children have been changed for privacy.

Their stories are among hundreds.

The 20 or so beds in the cancer center’s pediatric ward are nearly always full, because of rapidly rising demands for cancer care and the hospital’s already high-volume general pediatric ward.

Dugan spoke frankly about the challenges of operating the only full-service cancer care facility within hundreds of miles.

“There are times when every second bed has two kids in it,” she said.

Monitoring all of those patients around the clock requires staffing levels that the cancer center doesn’t always have.

In an August conference call from Butaro, Shyirambere quickly cited a desire for an “adequate number of nurses,” when asked his greatest need. But he also was quick to praise the nurses he has on his team.

“They work extra hours, to make sure every child with cancer receives care before they go home,” often working well into the evening, he said. “I really appreciate the hard work of our nurses.”

Habinshuti, IMB’s deputy executive director, said increasing recognition of the work at Butaro—and increasing numbers of people seeking care—can create difficult decisions for doctors.

“I think the challenge we have now is being victims of our own success,” she said. “Cancer treatment requires a lot of resources, but it’s going well so far.”

A shortage of health care workers is a global problem, and particularly severe in Africa and southeastern Asia. A 2015 report by the World Health Organization estimated a global shortage of 17.4 million health care workers, including nearly 2.6 million doctors and more than 9 million nurses and midwives. The document estimated there were 43 million active global health workers worldwide in 2015. 

Butaro’s staff often is boosted with support from Dana-Farber and PIH.

Jen Haley, for example, is a former Dana-Farber cancer nurse who worked at Butaro as an oncology nurse educator from September to December 2016, through a PIH program.

Haley said she helped nurses at Butaro learn to watch for symptoms at various treatment levels, improve the overall quality of treatment, and educate patients’ families and caregivers about cancer and related care.

Haley said she also stressed “the importance of letting them be kids,” amid the rigors of extended treatment. She and Dugan hosted Movie Fridays, for example, showing children’s movies on laptops—Haley said “Madagascar” was a favorite. Young patients at Butaro also were fans of pop music, Haley added, and liked to grab her smartphone to sing and dance along.

“I think that was where I kind of got my mental health from, just going in and playing music with the kids,” Haley said. “Kids are so resilient. One minute you’re giving them a shot and the next minute they’re running up and giving you a hug.”

Butaro’s staff has to be equally resilient, amid limited resources.

They don’t have a CAT scanner, an intensive care unit, or enough nurses. Stocks sometimes run out of needed medicines, and radiotherapy machines are a distant hope.

Dugan said working at Butaro has showed her that those things should be staples, not wished-for items.

“Cancer treatment is not a luxury. This is not an optional extra for a health system in a poor country. It’s very much at the core of what should be provided,” she said in August, days before returning to Rwanda after a visit to the U.S.

Shyirambere said he draws strength from successes. Treating children with cancer can be incredibly emotional, he said, but the reward is seeing young patients come back for positive follow-ups, return to school, and resume healthy childhoods.

“You feel like your day has been excellent,” he said.

Check out this photo gallery to see more images from Butaro's pediatric cancer ward.

One week after a monstrous 8.1-magnitude earthquake struck off the southwest coast of Mexico, Partners In Health staff said all 10 clinics they serve in rural Chiapas remained structurally sound, and that doctors, nurses, and community health workers escaped shaken, but unharmed.

Stories of individual challenges—including a woman who gave birth during the quake—poured in over the past week.

Clinicians continued providing services through the past week, while other staff assessed damage in the region of the Sierra Madre served by Compañeros En Salud, as PIH is known locally. Aftershocks rocked the region for days after the quake struck, just before midnight Sept. 7. The National Seismological Service in Mexico recorded more than 2,055 throughout the country, some registering as high as magnitude 6.1.

"The CES team and the communities where we work escaped the worst of the earthquake,” said Dr. Hugo Flores, executive director of PIH in Mexico. “And yet, while these emergencies serve as sharp reminders of the fragility of human life and that of marginalized communities, I could not emphasize enough how the impoverished people of this world live in a constant state of catastrophe.

“More than the occasional natural disaster, these communities are faced with adversity every day as they struggle to find the means to survive.”

This reality became all the more evident in recent days as PIH staff checked on colleagues, friends, and community members throughout Chiapas. Logistics coordinator Moíses Mazariegos discovered at least a dozen mudslides blocking the serpentine routes he travels regularly from Jaltenango to the various clinics. Local residents cleared most of the roads by hand, despite treacherous conditions caused by the rainy season.

In Reforma, 10 families evacuated their homes due to damage caused by the earthquake, according to Dr. Assad Daniel Saad Manzanera, a PIH doctor fulfilling his social service year there. It was unclear Friday morning how many families in other communities faced a similar situation.

Electricity is generally spotty in Laguna del Cofre, another community that PIH serves. Some residents reported that power cut off shortly before the earthquake and remained out until Wednesday. Crews have since knocked out power again to repair damage caused by the quake.

Power in Jaltenango, the base of PIH operations in Chiapas, also cut out during the quake, leaving the city’s hospital in the dark. A PIH patient from Salvador Urbina was in active labor when the lights went out in the delivery room, according to Dr. Mariana Montaño, the maternal health program coordinator. Working together, Ministry of Health clinicians and Miriam Torres, a PIH obstetrics nurse, remained by the woman’s side—risking their own safety as the building shook—and successfully delivered her baby.

“I want to congratulate our maternal clinic staff for continuing to deliver care in the middle of the crisis,” says Dr. Valeria Macías, director of secondary and tertiary care. “Without them, the life of the mother giving birth during the earthquake would have been at risk.”

Hundreds of miles away in the state capital of Tuxtla-Gutiérrez, the children’s hospital cancelled all of the week’s appointments as a cautionary measure as aftershocks continued. PIH visits this and other hospitals regularly to accompany young patients seeking specialized care. Staff scrambled in recent days to reschedule appointments for four such patients, all of whom are in stable condition.

As staff recounted the hurdles they overcame this past week, they knew the situation could have been much worse. In the neighboring state of Oaxaca, 76 people died and 11,000 homes were destroyed as a result of the powerful quake, according to The Washington Post.

The next big natural disaster in Chiapas might not be as forgiving. So PIH staff are reviewing contingency plans, evaluating ways to improve security across sites, establishing clear evacuation routes, and prepping emergency kits as precautionary measures. They don’t want to regret the disasters they could have prevented, especially when—for some of their poorest patients—every day is an unnatural disaster.

“No matter what they do, they know that something can come out of nowhere and change their present and planned future in a single instant,” said Dr. Rodrigo Bazúa, coordinator of community programs, referring to the poor communities PIH serves. “We need to acknowledge that this difference in perspectives is the product of persistent neglect throughout history. We have to start building resilient systems for everyone.”

A Partners In Health collaborator in Peru is examining why many teenagers are struggling to consistently take their HIV medication, and working with team members to improve care and support for the vulnerable, often-overlooked patient group. 

Dr. Molly Franke, a Harvard Medical School epidemiologist and longtime collaborator with Socios En Salud—as Partners In Health is known in Peru—turned her attention to adolescents living with HIV at the request of a colleague at National Children’s Hospital in Lima. About 130 adolescents receive HIV care and treatment at the facility, but many of them struggle to routinely take their medication. In the most severe cases, adolescents stay in the hospital until they show steady improvement. Franke and the SES team set out to find out why these young adults were struggling and what she and her colleagues could do about it.

There’s great potential for very positive results: The development and increasing availability of antiretroviral therapy in recent decades means HIV is no longer a death sentence. But taking daily medication is crucial for enabling patients—of any age—to live full lives. 

The teen-focused project at National Children’s Hospital is still in its early stages, but Franke and PIH are making quick progress. They’ve piloted a support group for affected teens and have submitted a paper for publication in a medical journal. They’re also applying for grants to develop and study interventions to improve teens’ health. 

We spoke with Franke about her research, the obstacles that teens living with HIV face, and the steps PIH is taking to keep them connected to care.

We don’t hear much about adolescent HIV in Peru. Why not?

HIV isn't as prevalent in Peru as it is in other countries in the world. We often hear about HIV in Africa, where the prevalence and overall numbers are much higher. But really, everyone is very far behind in addressing the needs of adolescents with HIV. It’s only relatively recently that large numbers of children who were infected with HIV at birth have survived into adolescence. 

Whether we are talking about medication adherence, HIV diagnosis disclosure, HIV education, or sexual and reproductive health, there is a dire lack of interventions that have been designed specifically for adolescents and proven to be effective. It’s alarming because we’re seeing rates of death and non-adherence rise during adolescence, and this likely reflects the gap in health services for this group.

Adolescents living with HIV are not different from other adolescents in that they often begin to explore romantic and sexual relationships. Many health providers and caregivers feel unequipped to discuss sexual and reproductive health with this group, and health providers often have competing demands for their time. The consequence of this is that these conversations never happen and the adolescents don’t have the tools they need to make informed, confident decisions that will keep themselves and their partners healthy.

How do pre-teens fare?

Our own data, from a group of about 30 adolescents in Lima, suggests that most children were doing relatively well from 10 to 12 years of age. They reported taking their medications and generally did not report experimenting with sex, drugs, or alcohol. Beginning around age 13, adherence rates started to decline, and they began to report sexual activity and experimentation with drugs and alcohol. This, of course, is exactly what you would expect to see in adolescents, regardless of HIV status, in many places in the world. The take-home message is that interventions need to be in place to address these issues well before the age at which we begin to see these behaviors.

How did your research begin?

It was really at the request of a collaborator, an extremely committed pediatrician who provides HIV care to all of the children and adolescents living with HIV who receive their care at the National Children's Hospital in Peru. She approached the SES team for support in providing an adherence intervention for adolescents she treats. She was nearly at the end of her rope because the only recourse she has for kids that are not taking their meds is to hospitalize them, until they get back on track. Of course, this is not a long-term solution.

What obstacles do the teens face?

On top of the daily struggles that go along with the adolescent life phase and confronting an HIV diagnosis, many are living in poverty and don't have strong support at home. Among adolescents receiving care at the National Children’s Hospital in Lima, 25 percent are orphans of both parents and about 20 percent live in a group home environment.

What has the PIH team in Peru done so far to help these teens?

We are very much in the early stages of addressing this problem and so our initial approach has involved talking to HIV providers, guardians or caregivers, and adolescents, to understand their needs.

We piloted a peer-support intervention for adolescents living with HIV who, according to their physician, were struggling to maintain optimal adherence to their HIV meds. We work with a fantastic psychologist who trained women living with HIV to serve as facilitators of these groups. The goal was to give the adolescents a space to speak their minds and to take advantage of their peer group to help think through some of the challenges they were encountering. Overall, the adolescents really enjoyed the groups and we would love to find a way to keep them going. The groups also helped us understand what the adolescents were thinking about, what they are worried about, and what they would like to see in a future intervention.

What have you found so far?

Our first analyses have focused on factors that facilitate or interfere with good adherence to HIV medications, considering the perspectives of caregivers, health providers, and the adolescents. We started there because this information is, of course, critical to developing and tailoring interventions to this group. We found that barriers included a lack of caregiver support and supervision, pill fatigue, side effects from antiretroviral drugs, and a lack of information or misinformation about medications. Having strong support from a caregiver facilitated good adherence.

What interventions are being put in place to help these teens?

The two things we are aiming for right now include an accompaniment intervention to support adolescents with suboptimal adherence and an accompaniment intervention to help adolescents bridge the transition to adult care. For the adherence support intervention, we’d like to evaluate the traditional in-person accompaniment model as well as alternatives, such as accompaniment via mobile messaging, which might be more appealing to teens. For the transition intervention, the idea would be to provide accompaniment support through the precarious period during which they switch from the warm, nurturing environment of the pediatric clinic to adult health facilities and adult providers. The idea would be to match them to a peer-supporter who can accompany them to their initial clinic visits, help them enroll in health insurance, etc.

How did you start working in HIV?

In college, I began working at a summer camp in New York for children who were infected with or affected by HIV. This was 1998, so not long after the more potent and lifesaving combination antiretroviral regimens became standard in the United States.

I grew up in a small town that was not very diverse, and I had no idea of the extent to which HIV was disproportionately affecting the African-American community. It was a jolt to my admittedly naïve view of the world to find that nearly all the campers were either African-American or Latino. My first summer I worked with the oldest girls, who were 13, so not that far from my own age. After a week of spending 24 hours a day with the kids, the injustice felt personal, and I knew that I needed to find a way to contribute to fight against HIV and health inequality. For a while, I thought this would be through social work, but when I saw the ways in which researchers at Partners In Health were using data to move the needle on multidrug-resistant tuberculosis and access to antiretroviral treatment, I became convinced of epidemiology as my weapon of choice. 

The good news is that, 20 years later, most of my former campers are healthy and have families of their own. Many adolescents’ concerns in Peru mirror those of adolescents living with HIV in the U.S. They want answers to questions like, What does my future look like? Can I have a romantic partner? Can I have children? Is everything going to be OK? Many have a hard time envisioning their future. I would love for them to know that their future doesn't have to be any different than the future of their peers.

A magnitude 8.1 earthquake struck off the southern coast of Mexico late Thursday night, with tremors felt hundreds of miles away in the capital Mexico City and into neighboring Guatemala. The epicenter was closest to the state of Chiapas, where Partners In Health collaborates with the Mexican government to provide health care in 10 rural clinics throughout the Sierra Madre.

PIH leaders in Chiapas surveyed communities early Friday to check on clinicians and staff. Doctors at all 10 clinics had been contacted by Friday afternoon, and all responses were positive. Some clinicians heard reports of minor damage to residents’ homes or roofs, but no one had come to PIH clinics for emergency care as of late Friday.

One clinician in Soledad said the powerful quake created a crack along an interior wall in the clinic there. Another doctor, in the remote community of Monterrey, reported a mudslide on a nearby mountain, but hadn’t heard of any resulting injuries. Other staff based in Jaltenango saw piles of rubble dotting the streets.

Aftershocks continue to rock the region, and PIH staff worried that the situation could take a turn for the worse.

“We are concerned for those living in very poor, inaccessible mountainous regions, where landslides have historically wiped out entire communities,” wrote staff with Compaňeros En Salud, as PIH is known in Mexico. “We are in the rainy season, and another strong earthquake may cause major disasters in the area. Because most people live more than two hours away from the nearest hospital and the unpaved roads often become impassable, a huge effort to open channels of transportation and communication would be required to provide adequate medical care.”

The PIH team continues to collaborate with the local government by providing medical supplies and helping prepare a contingency plan if evacuation is necessary from the hospital in Jaltenango or nearby clinics.

It was unclear late Friday how many people had been injured or killed in Chiapas or other states closest to the quake’s epicenter, nor how much damage it had caused to roads and buildings.

The New York Times reported Friday afternoon that dozens had been killed in what is being called Mexico’s biggest quake in decades.

As Hurricane Irma churns through the Caribbean north of Hispaniola, Partners In Health staff in Haiti watch the skies preparing for the worst, while hoping for the best.

Rain has been falling over the Central Plateau since the predawn hours, according to Dr. Paul Farmer, a Partners In Health co-founder and chief strategist, who’s weathering the storm there. Farmer spoke at noon today with PIH leadership in Haiti, whom he said sounded confident about staff preparations and optimistic that the country might escape a direct blow from the Category 5 storm.

Irma’s path through the Caribbean has been erratic so far, having leveled much of the island of St. Martin and largely spared Puerto Rico, for example.

Farmer said the biggest concern for Zanmi Lasante, as PIH is known locally, is how aging infrastructure will weather the potential 180 mile-per-hour winds and torrential rains. Clinics and hospitals in Hinche, Belladère, and St. Marc are at least 80 years old, he said, and not built to withstand such fierce tropical storms. St. Marc, which lies at sea level on the west coast, is expected to see storm surges over the course of the day.

PIH hospital staff are primarily concerned about a spike in cholera cases, trauma from road accidents, and tetanus caused by cuts from flying debris. University Hospital in Mirebalais will serve as a reference for all severe cases throughout the country and is currently staffed to handle mass casualties of up to 40 people at once.

Staff morale is good, Farmer said. For better or worse, they have gained valuable experience after enduring numerous hurricanes, earthquakes, and other disasters in Haiti over the past decade.

“I don’t think it’s an exaggeration to say that Zanmi Lasante is the strongest institution, medical or otherwise, in Central and Artibonite, Haiti,” Farmer said. “We have the biggest staff, the most resources, and the most allies in the United States and elsewhere.

The next 12 hours will test the team’s strength as it continues to prepare for Hurricane Irma’s worst.

Nearly a year after Hurricane Matthew battered Haiti’s southern coast, the Caribbean nation is preparing for another blow, this time from Hurricane Irma. The Category 5 storm could make landfall across a northern swath of Hispaniola, hitting the Dominican Republic and Haiti as early as Thursday morning, according to the National Hurricane Center. Meteorologists predict winds of up to 180 miles per hour and torrential rains.

Several public hospitals and clinics supported by Zanmi Lasante, as Partners In Health is known in Haiti, lie in the storm’s predicted path. At sea level on the west coast, Hôpital St. Nicolas in St. Marc is expected to receive the worst blow from heavy rainfall and flooding.

Other facilities near the Artibonite River, such as those in Belladère, Cerca-La-Source, and Boucan Carré, could suffer from flashfloods and mudslides, said Sheila Davis, PIH’s chief clinical officer. University Hospital staff in Mirebalais spent most of Tuesday covering exposed walls with plastic, filling sandbags, fueling vehicles, and storing extra water in preparation.

“The team there is taking preparedness very seriously,” said Dr. Paul Farmer, a PIH co-founder and senior strategist, who spoke today from Haiti.

“City officials and the community of Mirebalais are looking toward that hospital as the primary site for not just a clinical response, but helping to organize a broader response.”

University Hospital is the largest physical structure in the region and could serve as a shelter during and after the storm. “The hospital itself is secure and built to withstand a major earthquake,” he added.

Irma follows less than two weeks after Category 4 Hurricane Harvey slammed into Houston, Texas, dropping a record 52 inches of rain, and less than a year after Category 4 Hurricane Matthew killed 1,000 people and left 1.4 million in need of urgent aid in Haiti.

Experts have labeled Irma a Category 5 hurricane, the most severe form, and expect it to be extremely violent and deadly. Most rural Haitians live in houses built from mud, stones, sticks, and corrugated metal. Many are subsistence farmers who rely on their crops, livestock, and fruit trees for food and extra income.

“A Category 5 storm, if close enough to Haiti, will take off roofs … and wash people away if they’re anywhere near someplace that might flood,” said Farmer, who has weathered numerous severe storms in Haiti and will again this week.

“People learned the hard way through previous storms to get on top of their buildings if they’re made of cement,” he said. “But that’s not possible if there’s heavy wind.”

Farmer added that despite the fears of a potentially devastating storm, the strong preparation he has seen in central Haiti reflects decades of work in the country to improve health systems and resources—and the resilience of people who have endured significant disasters in recent years.

“There’s not only the fact that there’s more national preparedness, and there are more places like University Hospital that are built for this…but there’s also the indomitable spirit of the Haitians, and I don’t think it’s corny to say it,” said Farmer. “We have motivated, well-trained, and decently supplied staff who reach from the Dominican border to the coast of St. Marc, and that just wasn’t here 30 years ago.”

After a decade of working for Partners In Health in Haiti, in early 2015 Dr. Patrick Ulysse moved to Maryland County, Liberia to help his colleagues and the national government fight the growing Ebola epidemic. The regional director then stayed on to strengthen the health care system in the remote southeastern region, where a ferry brings supplies roughly once a month and one university, PIH-supported Tubman University, trains nurses. “I remember when I first started in Haiti in 2006, I said, ‘I’ll go to PIH for one or two years, then I’ll go for my master’s in public health and continue on,’” he recalls. “But I just fell in love with the mission, the values, of PIH.”

Earlier this week, we chatted with him about his love for those values, the transition between continents, and his thoughts for the future of Maryland County.

Q: How would you describe Liberia, and Maryland County specifically?

You can look at Liberia two ways. On the one hand, it is still a poor country, still has a lot of challenges around its health indicators. To make it simple: About 1 in 28 women die of maternal causes.

At the same time, you have a generation of young people who want to learn, want to know. And when you work with them, you can see hope. They are open to learn, they are ready to make a change.

Maryland County is a beautiful place. When I say a beautiful place, I mean a beautiful place. The beach. The palm trees. The forest. I’m from the Caribbean, but I would pay for a vacation in Maryland County.

Q: How are the challenges in Haiti different from those in Liberia?  

One of the big difference is HR. In Haiti, we have a lot of human resources available—training, schools, all those things—which are not available in Liberia.

But I’ve been working for PIH for so long, being in Liberia is sort of like déjà vu. I see the challenges and know that if we do what we need to do, we’ll be where we need to be.

Q: What are the central challenges in Maryland County?

Supply chain at the county level is challenging (especially regarding road transportation and management), however, we are working together with the county health team to improve the situation. So is the lack of human resources available in the country and county. But maternal death is still on the top of the list. We still have a lot to do, but we are making progress. And even small improvements have a big impact.

For example, if I train all the midwives in Maryland County, if I give them all a refresher, this has a big impact on the quality of care they can provide for pregnant women (they call them “big belly” women). And how much does it cost to do a training? It’s small compared to the impact.

Q: What’s the team like?

The team is great. We have a lot of folks who worked for PIH before as part of the leadership, so it’s easy to make decisions and move forward with the same vision. We also have newer staff that have came on board in Liberia, so PIH's values are only proliferating. After that, the partnership we are building with the Ministry of Health—it’s great.

We have a director of policy and partnerships working inside the Ministry of Health and we share all our outcomes weekly. That’s why more than 20 percent of our funding is from partnerships established directly in Liberia.

We are accompanying the Ministry to run the new ward for patients with drug-resistant tuberculosis, which will open in Maryland County soon and will be the first such ward outside of the capital. And that was the decision of the Minister of Health, who said, given PIH’s years of experience working on MDR-TB, we were in the best position to partner with them. Since February, we've supported the county health team in opening a new HIV clinic in Pleebo Health Center, which has enrolled 65 newly diagnosed patients. (Approximately four patients test positive every week.) And after eight months of the community health program, the rate of tuberculosis patients who default has dropped from 77 percent to 12 percent.

Q: You’ve worked at, or in concert with, other development, emergency aid, and health organizations. What sets PIH apart?

PIH is different because we don’t accept ‘no.’ We always try to figure out a way to save a patient’s life. The drugs aren’t available? We try to get them. A service isn’t available? The patient is transferred.

PIH is also exceptional because, thinking of Haiti, we built a generation of physicians—physicians who, when they see a patient, they don’t just see a disease or pain, but the patient’s living situation, the patient’s social challenges, the patient’s emotional health. PIH trains you to see the patient in his entirety, and to value that entirety.

Partners In Health’s top official in Sierra Leone described “staggering” losses Tuesday among PIH family and friends in Freetown, where rescue work was ongoing after devastating floods and mudslides killed hundreds a day earlier.

Just before dawn Monday, while most of the city slept or prepared for work, uncommonly heavy rainfall caused hillsides to give way in southern neighborhoods of Freetown, the nation’s capital. Mud roared down unstable slopes, killed at least 300 people, and left at least 1,000 homeless. Rescuers were continuing to search through debris into Tuesday evening.

Numerous family members of PIH staff are among the dead.

“There have been staggering losses among some of our staff members,” said Jon Lascher, executive director at PIH Sierra Leone.

One PIH employee lost eight members of his family, Lascher said. Another lost five. A third lost his sister.

“And the list goes on,” Lascher said in a Skype conversation Tuesday.

His comments reflect the massive tragedy in Freetown, where many residents lost entire families and homes. Reuters called the mudslides one of the deadliest natural disasters in Africa in recent years.

Sierra Leone’s Ministry of Health, army, and more were leading the response from a downtown command center, using logistics and communications systems originally set up for the Ebola epidemic. Lascher and Sierra Leone native Dr. Bailor Barrie, medical director at PIH’s Wellbody Clinic, were involved and assessing how PIH could help.

They said the response’s first priority was managing the overwhelming number of bodies arriving at morgues. Finding shelter for people who lost their homes also was a high priority. Lascher said many of the displaced were camped at National Stadium, a roofless soccer stadium.

PIH has also been focused on taking care of its staff.

“We spent much of yesterday trying to provide support to those we know who lost family members and homes,” Lascher said. “Early today, I went to visit one of our staff members whose house was destroyed and what I noticed in the mud were pots and pans and clothes and stuffed animals—everything that people owned, washed away.”

While the larger response takes shape, PIH also is helping arrange funerals and counselling.

“I think the next few days, as more people are recovered, is going to be a difficult time,” Lascher said. “You hear sirens from ambulances passing much more frequently than normal, and you know those ambulances are unlikely to be carrying the sick.”

One Stone’s response wasn’t exactly a surprise. In up-country Sierra Leone, in the central chiefdoms of Kono District, the man with the rapper-inspired nickname was a known member of a young gang that tried, a bit too aggressively, to wash cars on the red-dirt avenues outside the gaping diamond mines. “He was a rude guy,” recalls Fodei Daboh.

Still, no one expected One Stone* to explode quite like he did. After being diagnosed with HIV, One Stone left the clinic, threw away the free anti-retroviral medicine, and gathered up his posse. They surrounded the house of a local health worker and shouted obscenities at her loud and long, as if she was somehow responsible for his illness.

Daboh, Partners In Health’s community health worker manager in Sierra Leone, took over. Since 2010, he has worked with PIH and its precursor in Kono, Wellbody Alliance. He currently manages a large staff, including 101 community health workers who support and advise patients during treatment and accompany them to the facility when they need care. One of those community health workers was the woman One Stone had yelled at.

“He’s just such a boss,” says Mara Kardas-Nelson, director of community based programs at PIH Sierra Leone. “You walk through the back streets of Koidu on a Saturday morning and everyone greets him. He stops to say ‘What’s up,’ ask how a person’s health is, ask about their goats, make little business deals. He knows everyone, is an integral part of the community.” And by all accounts, he goes the extra mile to make sure patients get what they need. He wasn’t a fan of One Stone’s bad behavior, but he also wasn’t about to let the man kill himself.

After asking around a bit, Daboh found the car washers and sat down with One Stone. “They were having beers, so I went to the bar and bought two bottles of beer and came back and gave him one,” Daboh recalls.

It seemed to ease tensions, and provided an entré into the clique. Every few days for more than a month, he hung out with One Stone, often buying him a beer but never bringing up his HIV diagnosis.

“Then, one day, I spent the whole day with him,” says Daboh. “And I realized, he has really, really accepted me.”

Daboh finally entreated One Stone to get help: “I said, ‘One Stone, you are my brother. Before you die young, before it’s too late, I want to take you to a hospital.’” It worked. The slow accumulation of trust allowed them to take the first steps toward treatment together. Today, a year later, One Stone is not only healthy, but a friend to PIH and Daboh.

Only some of the 800 HIV and tuberculosis patients that Daboh’s team of community health workers support are as demanding, but the anecdote is illustrative nonetheless. Every health worker strives to meet the unique needs of each patient. And Daboh—personally, expertly—has invested similar time, energy, and sympathy toward hundreds of patients, from a baby abandoned at the clinic to a grandmother who needs help going to the bathroom.

“Daboh understands how to communicate with his community,” says Storm Portner, who co-managed the program with Daboh and is now a medical student. “He understands what people are going through better than I ever could.”

That empathy wasn’t easily won. Daboh was born in Sierra Leone’s Bo District in 1972 and dreamed of being a lawyer. Beginning in 1990, he moved from school to school to stay ahead of the spreading civil war, ultimately fleeing Freetown when the violence finally caught up to him there. In neighboring Monrovia, Liberia, his sister, gainfully employed, paid his university tuition fees until that country’s civil war engulfed them, and he went from budding law student to homeless man in a bullet-riddled city. “It was not easy,” he says.

Allen Peal, the son of the Liberian ambassador to America, who had seen Daboh around and liked him, gave him a chance to manage a one-truck shipping enterprise. Daboh quickly proved his worth and was invited to work as a clerk on a rubber plantation, where he again excelled. Some four years later, he supervised 1,000 rubber harvesters.

With an aging mother in need of care, he returned to Kono, Sierra Leone, in 2004, and used his savings to set up a small mining operation. It wasn’t a bad bet. Kono was then one of the most valuable and productive diamond mining regions in the world. Alas, his 10 employees found no diamonds, and he ran out of money. He looked for work for two years, without success.

“I became a street guy again,” says Daboh. “People started pointing fingers. ‘A rich man can become a painter,’ that is the saying.”

In 2007, things started to look up when a former headmaster offered him a job as a teacher, but the sunny forecast didn’t last. “I started getting sick—continuous, continuous, on and off, on and off,” he says. Weight loss. Fatigue. A chronic headache. He persisted as a teacher, but with hospitals and clinics in the area offering few, shoddy, or no advanced tests for illnesses like HIV or TB, Daboh treated himself with whatever medicine seemed right. He was 37 years old. He had been rich and homeless, safe and caught in crossfire, and healthy and perilously sick. And he had yet to give up. 

He also proved a natural leader. Convinced his symptoms spelled HIV, he joined a nationwide support group called NETHIPS, the Network of HIV Positives in Sierra Leone. He learned about the disease, became a district coordinator, and supported the organization’s expansion, helping them win a grant from a partnership with the World Health Organization.

When Wellbody Alliance, which is now a part of PIH, began the community health worker program in Kono in 2010, it immediately hired him as a community health worker. And that’s when he secured for himself yet another chance at a stable, long life. “On the day of the TB training,” recalls Daboh, “the guy knew how to teach so well, after he had explained the signs and symptoms, I stood up and said, 'I know my problem.'” With help, he managed to finally get a TB test, which confirmed that yes, he had had TB all along.

Daboh is cured now, and his community health worker program is seen as a model for the nation, with government officials, including the Minister of Health, visiting the district. The program supports patients across Kono, which has a population of just over half a million people, and sports impressive results: patients attached to a community health worker are 50 percent more likely to stay in care and demonstrate higher CD4 rates, a measure of immune response.

“At the beginning, maybe a person says things just to get the job of community health worker,” says Daboh. “But as time goes—one month, two month—you see that person’s attitude starts improving and every day you see their commitment increasing. Because the more a person comes across patients, the more they will get committed.”

Of course the increasing commitment might not have to do with patients. It could be that people become more and more committed to helping the sick and vulnerable the more time they spend with Daboh.

*Name has been changed.

Life in a house with three children under 5 is, to say the least, chaotic. Analy Cipriano spends most days cooking, cleaning, doing laundry, and keeping a watchful eye on her babies in the cramped slums of Carabayllo, north of Lima, Peru. Money is tight, and spare time practically non-existent.

Yet when staff from Socios En Salud, as Partners In Health is known locally, came by with formula for her infant daughter, Ashley Minaya, and mentioned a free child development group, Cipriano was interested. Although nearly 6 months old, her baby still couldn’t sit up without support and seemed lethargic. The young mother decided to give it a try.

Every Wednesday for three months, Cipriano brought Ashley to the nearby health post in Punchauca, where PIH staff led early childhood education sessions for her and seven other mothers and their children. They sang songs, played games, read books, and practiced activities that encouraged age-appropriate language and motor skills. Each week, they were given tasks to practice at home and report on later in class.

Our children are able to learn more than we know.

Cipriano saw Ashley excel with the extra attention. Her baby learned to sit and started crawling. She was more animated and began saying little words here and there. She understood and followed instructions around the house. And she played by herself with toys they’d learn to make from recycled materials.

“I didn’t see my other kids do the same,” Cipriano said, crediting the PIH sessions for the difference. “Our children are able to learn more than we know.”

Cipriano’s experience wasn’t unique. Among the 180 families enrolled from 2013 to 2016 in PIH’s pilot program, called Proyecto CASITA, 85 percent of children at risk for developmental delays showed marked improvement, said Maribel Muňoz, leader of Proyecto CASITA. This was true regardless of whether families participated in individual, home-based interventions or group sessions like the one Cipriano and her daughter attended.

The results proved so strong, in fact, that PIH earned a grant from Grand Challenges Canada to vastly expand the program to reach 3,000 children between the ages of 6 months to 24 months in and around Carabayllo. The work will be accomplished over a three-year span, which started in May 2016, with the help of partners in the municipality of Carabayllo, the Ministry of Health, and the Korean International Cooperation Agency.

To meet the expansion’s ambitious goals for recruiting more families, PIH trained an additional 30 community health workers. The workers have diligently knocked on doors throughout the district to identify young children at risk of developmental delays.

Sadly, they don’t have trouble finding candidates.

Carabayllo’s extreme poverty means families often face tough choices and live under constant stress. Malnutrition, domestic violence, teen pregnancy, and chronic illness are among their many daily challenges. PIH found, for example, that at least 70 percent of women enrolled in the CASITA pilot suffered some form of depression or stress, often related to spousal abuse. Such environments are toxic for children who, like sponges, soak up and internalize household tension.

Those families who qualify for CASITA are invited to attend three months of group sessions, hosted in community centers or any one of nine health posts or clinics throughout the district. Community health workers run the sessions and divvy up activities so that caregivers practice skills related to their children’s specific developmental delays.

Activities are both fun and focused. To hone fine motor skills, families make a game of picking up lentils from the floor. To strengthen tiny abs and backs, they sit supported while grabbing for toys just out of reach. And to practice speech, they read books and repeat words together.

Beyond group sessions, PIH provides support to families through food baskets, mental health services, and assistance in applying for national identification cards, which give them access to a range of services—including subsidized health care—provided by the government.

Muňoz is encouraged by the progress these select Carabayllo children have made over a short span of time. “They are breaking down paradigms in our country,” she said, by growing up well-fed, well-educated, and in healthy home environments. “These children can be reference points for future kids. We are betting that what we do today isn’t for today. You have to see it as an investment in the future.”

One of the first patients Dr. Emily Wroe met in Malawi, the slender nation bordered by Tanzania to the north and Mozambique to the south, was a pregnant mother with severe rheumatic heart disease. “Normally a patient in her condition can’t climb a flight of stairs,” says the Partners In Health clinical director for the country. “This woman, Nimiya, she walked seven hours to the clinic.”

Soon Wroe and fellow PIH staff will be able to help more women fiercely determined to get better. With donors’ support, PIH and the Ministry of Health will break ground on an outpatient clinic at Neno District Hospital this fall. The new single-story building will sit next to the main facility and will include smartly designed check-in areas, consultation spaces, and exam and treatment rooms. Thousands of sick people, who now sometimes face long queues, will be diagnosed and started on treatment for a variety of illnesses—in a single visit. “It’s so exciting to be able to match health service and infrastructure design, and meet such a tremendous community need,” says Wroe. “It makes care much more accessible.”

The new clinic adds to services that Ministry of Health clinician Grant Gonani already calls “awesome.” In 2007, the government of Malawi invited Partners In Health to work in Neno, a rugged district of hills, maize and potato fields, and weak health care. Most pressingly, local farmers, earning less than $1 per day, were suffering some of the worst rates of HIV on the continent. Roughly 1 in 7 adults in the district were infected.

PIH dove in head-first. Staff constructed health centers; hired and trained hundreds of people in the community as health workers; and built Neno District Hospital as the centerpiece of a revitalized health system. HIV survival rates in the district skyrocketed, becoming the highest in the country, with 90 percent of patients alive one year after starting treatment. The hospital grew busy, despite the fact that for many, the easiest route to it still involves a long walk and fording a river.

The outpatient clinic is a logical next step. People with more routine health needs, and those needing emergency care, will be treated at the facility. They will check in, have their medical records pulled, get tested for common conditions such as HIV and hypertension, be offered family planning, and be treated for everything that’s troubling them—be it HIV or epilepsy, hypertension or diabetes—as they would in the United States, for example.

Astoundingly, the clinic will also be seen as pioneering. Research suggests that Neno District is one of those rare places where patients can have most of their chronic health conditions taken care of in a single visit. In most health care facilities in sub-Saharan Africa, if you come for HIV treatment, for example, you must return later for a diabetes exam.

To doctors who treat women who’ve walked for hours to make an appointment, that, of course, doesn’t sit well. “We’re doing ‘innovative’ stuff,” says Wroe, of the new outpatient clinic, “but actually, most of it is bloody obvious.”