Emmanuel Kamanzi has worked for Partners In Health for almost a decade in many places and roles. He's spent the last three years in PIH's Boston office and is now returning home to Rwanda to take on his biggest project yet—overseeing the building and development of the University of Global Health Equity. We asked him to reflect on his career and offer advice to aspiring global health professionals.

Standing on a hill in Burera, a rural district in northern Rwanda, I see other green and terraced hills all around. I can see the beautiful Butaro Hospital across a valley, and to the east is Mount Muhabura, which is home to the gorillas that attract so many tourists every year.

I’m at the construction site of the University of Global Health Equity, which is owned and operated by Partners In Health. Launched in 2015, the institution was founded to train the next generation of global health leaders. I just returned from the United States, where I have been for the last three years, to work as the university’s director of campus development.

Several people have come to me for advice on working in global health. They ask whether I am a doctor or a nurse. My answer is always very direct: No. I am trained in business studies, management, and leadership, and I use these skills to make life better for those who need it most. People think that to be successful in global health, you need to have a clinical background. While that can be very helpful, my experience tells me that anyone with spirit and a passion to make a positive impact on the lives of those in need can be involved in global health.

My parents were decent subsistence farmers who lived as refugees for 30 years. They raised me and my other nine siblings. They didn’t go far in their studies, but they were keenly aware of the importance of education and did their best to send all of us to school.

When I passed my high school exams with distinction and got awarded a government student loan to join the University of Rwanda, I wanted to do business studies. I wanted to help my family and those in need, and I thought making a lot of money was a wise way to go about it.

Partners In Health

When I graduated, the university hired me as a tutorial assistant—my first formal job after school. Six months later, I accepted a job with PIH as the human resources manager for a new hospital in rural Rwanda.

I remember all those years ago, my friends thought there was something wrong with me when they saw me packing my things and leaving the biggest and most prestigious university in the country to go work for PIH in Kirehe District, which was the most rural place in Rwanda at the time. It meant giving up clean running water, electricity, and good roads. And I’d be far from Janet, who is now my wife and was studying international economics at the same university.

But I was very sure of my decision. I hadn’t known about global health formally, but I carried its principles within me unknowingly. I truly believed in fighting extreme poverty and in health equity even before I learned about PIH. That was the start of my career in global health

It took time to get used to my new life. My house in Kirehe had no running water, electricity, and Internet. I had cold bucket showers every morning and felt quite frustrated sometimes. But this would fade when I arrived at the hospital and saw patients getting care not far from my office. I helped recruit dozens of doctors, nurses, social workers, and office staff to open Kirehe Hospital, which was the first in the district. I also put human resources policies in place that aligned with Rwanda's Ministry of Health, our close partner.

I also served on the hospital advisory committee, which helped patients benefit from PIH social support such as health care coverage, food packages, housing support, and school fees for children. Irrespective of my lifestyle, I felt very satisfied with the work I was doing.

Ten months later I was promoted to project director, managing all of PIH’s work in Southern Kayonza, another district. I helped build a team that worked closely with the government of Rwanda on many projects. One involved revitalizing 21 health centers in Southern Kayonza and Kirehe.

Twelve months later, I was promoted to a similar role in Burera District, where I remained for about two and a half years. A major highlight of the work I managed was the construction, outfitting, and opening of the 150-bed Butaro Hospital that serves nearly 350,000 people. About 3,500 jobs were created with this project. Like Kirehe, where I started with PIH, Butaro Hospital was the first of its kind in the district.

During this time, my business studies had been useful in my work, but I realized I needed advanced and specialized project management skills to manage bigger and more complex projects. In 2013, I enrolled in an online part-time MBA with Business School Netherlands. Students, who were from all over the world, completed projects with access to a 24/7 tutor and gathered twice for conferences. The skills I gained were invaluable for global health. You can read more about my MBA experience here.

Global health is about caring for people irrespective of where they live. I was honored to be a part of PIH’s work in those three districts. You get to live in the communities you are helping. You see the life-threatening needs of people and help them. You get to see people with smiling faces be discharged from the hospital—totally different from the looks they had when they came to seek care. You get to hear stories of families who earned an income from being employed on projects you manage and were later able to start new businesses, send their children to school, and pay their health insurance premiums. You also get to see children who had dropped out of school become the best performers in class with your support.

And last but not least, you see the power of partnership. This is a major component in global health. PIH’s work is about working with other organizations. I worked very closely with public officials and health leaders in all three districts. I also was honored to serve as president of the Joint Action Development Forum, a platform where private partners and civil society agents come together to map out district development priorities and make sure we were not duplicating efforts.

Coming to the U.S.

In mid-2013, I took on a new role with PIH in Boston, representing our Rwanda work as program officer. My motivation to take this role was to build my career in global health, work closely with PIH leaders, and get more exposure to PIH’s work in other countries. My wife moved with me. When colleagues in Rwanda heard, some congratulated me and thought that I would never return to Rwanda. This is common among young people living not only in Rwanda, but also in other developing countries. People leave their jobs and find ways to live in the United States. Some call it heaven or “Igihugu cy’isezerano,” as they commonly refer to it in Kinyarwanda, the local language.

Of course, the United States is one of the wealthiest nations in the world, but it’s not heaven. You can’t pick up money on its streets and become rich, as many young Africans think.

The last three and a half years in this role have been uplifting in many ways. One major experience was seeing how people make sacrifices and generously provide financial and in-kind resources to support our work in Rwanda and globally. I had never seen this spirit of concern and generosity before. PIH’s work is deep in the hearts of its supporters around the world. I always say thank you to these people, and I tell them about people our work is touching in rural Rwanda. I invite them to visit Rwanda to see how their support is making a huge impact and how Rwanda is developing and becoming a beacon of hope for other African countries.

Adjustment to the work and lifestyle in the U.S. was not easy. There was a lot to learn, and you need to adapt quickly. There were so many options and you end up getting confused between which to pick. Time counts a lot there. You miss one meeting and your entire day gets spoiled. The food was so different. The weather was not your normal forecast. The list goes on.

While navigating all of this, I found relief in many people I met, many of whom I’d worked with before in Rwanda. Some of them had shared a house with me and had also experienced the bucket showers in Kirehe and Burera. I also found a few Rwandans living in Boston. They all helped me integrate quickly and have become my adopted extended family.

Back home

Three years in, I became used to the U.S. lifestyle. My wife found a job she liked. I enjoyed the vegetarian food—the likes of Sweet Green and Panera bread menus. I made many friends. While not in Rwanda, I felt I was still serving the poor.

But another big change came my way. The day before the U.S. presidential election, PIH told staff of my decision to accept a job with the University of Global Health Equity, which we call UGHE. Amidst congratulatory messages, friends asked why I’d leave the United States. Again, I was driven by my career goals and my will to join hands with others to build my country. I am also moved by UGHE. It embodies the values of equity and service to the poor. So much of the world, Rwanda included, lacks health professionals. In Rwanda, there is only one doctor for every 15,000 people. UGHE will help to close this gap in Rwanda and in other countries.

The university will rise on the ground I am standing on, facing the hill where I helped build Butaro Hospital. I see construction workers and bulldozers digging along a dirt road winding to the hills. The government of Rwanda is helping to pave a 64-kilometer road connecting Butaro with Kigali, and the nearby border with Uganda. White aluminum poles cross the valley to the university, bringing electricity to the area for the first time. The government of Rwanda is extending electricity to the UGHE site. The progress Rwanda has made post-genocide is remarkable. However, there is still so much to do. Despite being in global health for nearly a decade, it is as if my work has just begun. I look forward to what the future holds.

My main advice to those who are still figuring out their careers is to start where your passions and interests lie. When your daily actions and decisions are motivated by those, you will pick a career you will enjoy. For those of you interested in global health, get your feet down on the ground and start by understanding the suffering that people living in poverty have, and build from there. You’ll learn how you can make an impact in the world.

Last week, Partners In Health Co-founder Dr. Paul Farmer addressed an audience at a convention center in Kigali, Rwanda’s capital. An architectural rendering projected above him showed the University of Global Health Equity, a collection of flat-roofed stone buildings framed by Rwanda’s mountains. Long glass windows reflected the lush hills surrounding it.

While the buildings aren’t real yet, Farmer’s audience included students who have been taking global health classes since 2015. Using classrooms in Kigali and PIH’s offices in Rwinkwavu, participants are working toward a two-year Master of Science in Global Health Delivery. The university accepted its second class of part-time students this fall, and applications will soon be ready for the third cohort of students starting in September 2017.

Taught by Rwandan and U.S. faculty from institutions including Harvard, Tufts, and Duke, the degree is designed to teach students—with backgrounds ranging from dentistry to nursing—how to deliver health care to people living in poor places.

While global health is an increasingly popular academic field at institutions in the United States and Europe, the university was founded to go a step beyond global health theory and turn knowledge into practice.

“One of the biggest challenges in global health is that we have the tools to prevent and treat disease, but we fail to deliver those tools to the people who need it most,” says the university’s executive director, Dr. Peter Drobac.

“UGHE is all about the ‘how,’” he said. “How to actually deliver effective health care to rural or impoverished settings.”

The university campus is currently 100 hectares of cleared space on a hilltop in Burera, a rural northern district and a three-hour drive from Kigali. A road and electricity poles wind up to the site. Red tape marks the foundations where buildings will rise, and in two years’ time, classrooms, laboratories, administrative offices, student accommodations, and dining halls will be in place for the university’s fourth cohort of master’s students.

Beyond offering degree programs, the university is fast becoming a training hub for people around the world interested in short global health delivery courses. Farmer’s audience included professionals from Switzerland, Lesotho, Malawi, Namibia, South Africa, and Liberia, who completed either a one-week or two-week training for health leaders.

Farmer taught their last class after students had studied a range of topics, from HIV program development to change management.

Participants of the course included on-the-ground experts and senior managers from the Global Fund to Fight AIDS, Tuberculosis and Malaria, a financing institution supporting countries facing epidemics of the three diseases.

Another group took a similar course for managers and executives at ministries of health and nongovernmental organizations.

“I’ve been to different courses and trainings, but this one just brought everything to reality,” said Tampose Mothopeng, director of The People’s Matrix Association, a LGBTI nonprofit in Lesotho focusing on HIV.

Drobac envisions thousands of students passing through the university. “We want UGHE to become a space for the best thinkers and innovators in global health delivery,” he said. “A place where people can come together to solve some of the world’s most complex health care problems and disseminate those lessons around the world.”

From left to right: Executive Director of the University of Global Health Equity Peter Drobac, Deputy Director of Inshuti Mu Buzima Antoinette Habinshuti, Minister of Education Musafiri Papias Malimba, PIH Co-founder Paul Farmer, and Director of Campus Development Emmanuel Kamanzi walk the grounds of the future campus. Photo by Aaron Levenson / Partners In Health

The next day, he and Farmer, along with Dr. Musafiri Papias Malimba, Rwanda’s minister of education, Dr. Agnes Binagwaho, a professor of the university and the former minister of health, other public officials, and PIH staff joined 300 Burera residents at the university’s construction site. They came to plant trees to mark the next phase of the university’s growth.

“The planting of trees has long been an important practice at Partners In Health,” said Drobac. “The beautiful tulip trees we plant today represent an investment in future generations.”

“This hill will become a beacon of knowledge, a beacon of equity, and a beacon of humanity,” said Malimba.

Children sang into microphones while community health workers adorned in custom kitenge cloth danced. Stormy clouds made the green hills more vibrant before rain plummeted down. Binagwaho ushered as many people who could fit under a single tent, where leaders mingled with villagers.

Rain in Rwanda, said many, is a sign of good luck, and even more so when among friends.

One month before leaving office, Secretary-General Ban Ki-moon apologized publicly for the United Nations’ role in the cholera outbreak that has killed 10,000 and sickened 800,000 in Haiti since 2010. Most important to Haitians and their allies, he also promised to right its past wrongs.

“On behalf of the United Nations, I want to say very clearly: we apologize to the Haitian people,” Ban read from a prepared statement, translated into French and Haitian Creole. “We simply did not do enough with regard to the cholera outbreak and its spread in Haiti. We are profoundly sorry for our role.”

“We have a moral responsibility to act,” he continued. “And we have a collective responsibility to deliver.”

The U.N. will deliver, Ban explained, in two primary ways: responding to and reducing the risk of cholera, and providing material assistance and support to those most severely affected.

Ban’s statement came within months of a scathing report, written by U.N. special rapporteur Philip Alston, that called the international organization’s refusal to accept responsibility a “disgrace.” It also follows widespread media coverage of a lawsuit the nonprofit Institute for Justice & Democracy in Haiti brought against the U.N. in a federal court in Manhattan.

Partners In Health*, known as Zanmi Lasante in Haiti, has battled cholera since the first days of the outbreak in October 2010. Staff have found and treated the sick, distributed water purification tablets to families, taught community members the importance of proper sanitation, vaccinated against the deadly disease, and petitioned the U.N. to respond to the humanitarian crisis it created.

PIH sat down with Dr. Louise Ivers, PIH’s senior health and policy advisor, on Wednesday, the same day the New England Journal of Medicine published her perspective, “Eliminating Cholera Transmission in Haiti.” She discussed the U.N.’s apology, its implications, and PIH’s continued efforts in fighting cholera.

What was your reaction to the Secretary-General’s apology?

An apology is one part of making amends for a problem, so I think it’s welcome.

Ban didn’t acknowledge that the U.N. brought cholera to Haiti. Why not?

I don’t know, but I presume there are some legal cautions on exactly what he says. However, the big public health issue is what PIH is focused on right now.

Haiti and the Dominican Republic developed a 10-year plan for cholera elimination. How does the U.N.’s proposal align with that plan, if at all?

Haiti and the Dominican Republic’s 10-year plan is a big-picture strategic plan, and it is accompanied in Haiti by a shorter interim plan to guide specific details of work for the next two years. The U.N.’s approach is not necessarily a new technical approach. But it aims to support this interim plan that was written by the government of Haiti and partners, including the U.N. humanitarian agencies, as well as provide material assistance to the most affected people. 

Ban Ki-moon said they are going to try to raise $400 million, of which $200 million will be for this material assistance package and $200 million will be geared toward the government’s interim plan, which they helped create to slow and stop the spread of cholera.

I noticed Mr. Ban also talked about their obligation to eliminate cholera, about long-term work as well as this $200 million. That’s an interesting new piece of the discussion, as that will cost a lot more than $400 million. 

What does the U.N. mean by material assistance?

They’re considering giving cash or other assistance to families and communities that were most affected. They have proposed a specific budget and are trying to come up with a plan within the budget that they have committed to it. But they’re not revealing the details yet.

It’s important that people who are the victims of the harm be the ones who individually or as communities participate in the process of deciding what appropriate compensation looks like to them. As a doctor for the poor, I often say what I think about the public health approach to stopping the harm, but the affected communities need to be represented in the process of considering what they need or want as reparations for the harm—that’s not an easy process.

Do we have any idea when the U.N. might act on these promises?

U.N. humanitarian agencies such as WHO and UNICEF are already working on cholera in Haiti and they have been for years, but they have been underfunded and could have done more if they had more funds. The Secretariat in New York is now fundraising more actively for the work they have promised to accomplish.

How much did public pressure play a role in forcing the U.N.’s hand?

There has been a lot of public pressure, including a lawsuit and regular commentaries by the editorial boards of The Boston Globe, The New York Times, and The Washington Post and coverage in the Miami Herald. I think these definitely played a role.  

Do you believe the U.N. is going far enough?

Two hundred million dollars is not enough to stop cholera in Haiti. I think it will take much more, and at the moment the contributions from countries to the fund is voluntary, so there is no guarantee that there will be that amount of money available. That said, it’s a start.

What’s the next step for those who want to see the cholera epidemic end and water and sanitation improve in Haiti?

What’s next is the same thing we’ve been doing since the epidemic started: Trying to make sure we can detect cases, treating the cases we can find as early as possible so we can save lives, and then trying to make progress on prevention. The fundamental part of prevention is access to clean water and sanitation and hygiene measures, but these are so poor in Haiti that it’s a long haul. So then we add vaccinations as one part of the solution while also trying to make progress on the water and sanitation piece. But there needs to be a pretty fundamental change in access to water and sanitation to make a big difference, and that change will also have much broader social and health benefits.

*PIH works with U.N. agencies in Haiti, including the Pan American Health Organization, the United Nations Children’s Fund, and the World Food Program.

“If it weren’t for this hospital, I would be dead.”

Isemelie Bazard, a 64-year-old street vendor who underwent surgery and chemotherapy at PIH’s University Hospital in Mirebalais, Haiti. The cancer center at University Hospital performed free biopsies for 1,600 patients and delivered chemotherapy to roughly 15 patients per day in 2016. The full story.

“Looking back and realizing it’s been a year makes me so happy to see them running around the house and doing well.”

Manoucheca Ketan, a mother of conjoined twins whom PIH clinicians successfully helped separate at University Hospital. The surgery was a first in Haiti. A year later, in May 2016, the family remained healthy and happy. The full story.

“Health is not a privilege. It’s not something that should be reserved for people who can pay for it or live in the cities. Health is a human right and it should be universal.”

Dr. Martha Arrieta on what she learned while working with PIH in Mexico. Four years after beginning to work in Chiapas, PIH surpassed 50,000 patient visits in 2016. The full story.
 

“I ran to the car and I cried and I held my son.”

Vanessa Colchado, whose infant son was diagnosed in Lima, Peru, with a rare and complex form of tuberculosis, XDR-TB. After months of treatment and thousands of pills, Hans fully recovered in 2016. The full story.
 

“Without a strong health system, the ability to respond effectively to epidemics is sharply limited.”

Co-founder Dr. Paul Farmer, during a public discussion with philanthropist and software magnate Bill Gates on the website Reddit. The full story.
 

“One goal we have, now more than ever, is that every woman in Haiti has access to family planning if she wants it.”

Dr. Louise Ivers, senior health and policy advisor, on PIH’s multipronged response to the Zika epidemic, which erupted in Haiti in early 2016 and was found to cause birth defects. PIH serves 32,000 pregnant women in Haiti each year. The full story.
 

“I have a lot of them around here who are even having their own children now.”

Nurse and Midwife M. Hnede A. Kondy, aka “Mommy Mary,” on the hundreds of babies she has delivered over four decades in the town of Pleebo, Liberia. Since PIH refurbished and began working in the Pleebo clinic, the number of monthly deliveries has increased three-fold, to 100. The full story.
 

“I can honestly say this is one of the worst things I have ever seen.”

Chief Medical Officer Dr. Joia Mukherjee on the destruction caused when Hurricane Matthew hit southern Haiti in October 2016. Mukherjee and other PIH staff supported a hospital that serves 1 million people. The full story.
 

“It's going to save a lot of people.”

Infrastructure Manager Steve Mtewa on Dambe Health Center, a 13-room clinic that PIH opened in 2016 to serve one of the most remote parts of Malawi. The full story.
 

“This is tragic and unthinkable, and it can be prevented.”

CEO Dr. Gary Gottlieb on the maternal mortality rate in Sierra Leone, where 1 of every 90 births proves fatal for the mother. Out of roughly 30 deliveries per month at PIH’s Wellbody Maternity Center, not a single mother or infant has died since the Center opened in April, 2015. The full story.
 

“The opportunities that this new partnership opens are amazing.”

Evelyn Espinoza, health director for the Rosebud Sioux Tribe, on the unique collaboration, forged in 2016, between her tribe and PIH’s program in the Navajo Nation. The full story.
 

“There hasn't been any real TB drug development for a very long time.”

Dr. KJ Seung on why he’s excited about bedaquiline and delaminid, the first new tuberculosis medicines in 40 years. In 2016, PIH began using the drugs, which are more effective and less toxic than the alternatives, to treat patients in six countries. The full story.
 

“When you enter the ER, it is almost like you are in Europe.”

Physician Assistant Paul Geah on PIH’s $1 million renovation of J.J. Dossen Hospital in Liberia, which includes the addition of the first x-ray machine since Geah began working at Dossen in 1981. The full story.
 

“Try as we might, PIH can only touch a tiny fraction of the world’s population. The university is a way to reach infinitely more people.”

Jarrett Collins, director of university operations, on PIH’s University of Global Health Equity, a private institution in Rwanda that teaches master’s candidates how to build health care systems. Construction on the 250-acre campus began in 2016. The full story.
 

“These are the best problems to have.”

Program Officer Emmanuel Kamanzi on increasing demand for breast cancer screening in Rwanda, where PIH clinicians and colleagues trained hundreds of women to spot signs of the disease. In response, PIH set up a clinic dedicated to breast cancer in 2016. The full story.
 

“All of them have been called to step beyond the traditional bounds of medical training.”

Co-founder Dr. Paul Farmer on the graduation of residents trained in internal medicine and global health at Brigham and Women's Hospital in Boston, Massachusetts. The full story.
 

“We would spend our evenings from 6 to 9 p.m. cutting tablets.”

Anatole Manzi, director of global learning and training, on the lengths needed to treat HIV-infected children in Rwanda in the mid-’90s. Few others treated pediatric HIV, and the medication was only available in adult dosages. The full story.
 

“I fell in love with TB.”

Dr. David Omotayo on working with tuberculosis-infected patients as a young trainee. He now works at a PIH-supported hospital in Lesotho. Botšabelo is the only hospital that treats advanced forms of TB in a country that has more TB per capita than any other. The full story.

“Nails work, but screws are very guaranteed.”

Woodworker Daniel Kakpo on a technique he learned in the PIH woodshop, which helps renovate PIH facilities in Liberia. In 2016, the PIH woodshop began to fund its work by selling furniture on harperwoodshop.com. The full story.

Partners In Health in Peru recently handed over control of its first safe house for women living with chronic mental illness to the Peruvian government, marking a major milestone in PIH's efforts to strengthen Peru's shift to a community-based mental health care system.

Peru's National Institute of Mental Health and the municipality of Carabayllo, where PIH is based, assumed responsibility of the home during a ceremony in September, just over a year after the home’s opening. Government officials hope to expand PIH’s model to 200 homes nationwide to support the roughly 1,400 people who desperately need the care and protection these safe houses provide.

PIH will advise the government during the expansion of this safe house, or hogar protegido, model. Meanwhile, staff members are visiting potential locations for the first Carabayllo-based safe house for men living with chronic mental illness.

“This needs to be replicated all over the country,” says Jerome Galea, deputy director of PIH in Peru, known locally as Socios En Salud.

Ministry of Health officials knew PIH’s long track record of providing mental health services to multidrug-resistant tuberculosis patients in Carabayllo. And so they approached PIH leaders and asked for help with a specific population of patients: men and women living with chronic mental illness who were medically stable but had nowhere to live, and so remained permanently institutionalized.

“Setting up the protected home was one of the first things the Ministry of Health asked about,” Galea says. “It came about with the perspective of strengthening the mental health delivery care system in Peru, which includes Carabayllo.”

The safe house is part of the ministry’s plan to completely overhaul mental health care. Less than two years ago, three Lima hospitals were the sole providers of mental health services, and they were heavily overburdened. The ministry committed to improving access to such care and turned for advice to the World Health Organization, which had published a guide in 2010 to help countries weave mental health care into the services already offered at neighborhood clinics.

In early 2015, the ministry began training Lima’s primary care physicians and nurses to identify mental disorders among patients visiting the capital’s 350 primary care clinics. That was the first step. The next will involve extending the same coverage to all of Peru’s 7,000 community clinics. Outpatient community health centers will also be established as specialized facilities for patients who need a higher level of care, but do not require hospitalization.

PIH staff accompany those suffering from acute and severe symptoms of mental illness to the community mental health clinic or the general hospital, depending on the severity of each case. If admitted to the hospital, patients will ideally return home or re-enter society by moving into a safe house like the one PIH piloted in Carabayllo.

So far, Carabayllo is the only community in all of Peru where this full suite of mental health services is available—from assessments in neighborhood clinics to this safe house for women.

One safe house resident, Valeria Ruiz,* 22, has settled in to her new environment. She has five roommates, a situation she seems to manage with good cheer. Community health workers teach her and other residents how to perform everyday tasks, such as making their beds, cleaning the bathroom, or buying groceries. They sometimes garden, go shopping, or take a walk in the park together.

Ruiz and another resident, Carla Torres,* are excelling. They started attending a nearby technical school three nights a week. They learn to make handicrafts and sweets, which they sell at PIH-sponsored events or to other technical school students.

Vanessa Montenegro, head of communications in Peru, says fellow students “don’t even realize” Ruiz and Torres have schizophrenia. For her part, Ruiz uses the profits to buy little things for her mother, who suffers from chronic mental illness herself and remains institutionalized in the same Lima hospital Ruiz left just over a year ago. It may be an unconventional reality, but it’s one Ruiz is adjusting to every day.

*Names have been changed.

Partners In Health’s community-based HIV work has proved to the world that excellent, lifesaving HIV care can be delivered to people living in the world’s poorest regions, writes Dr. Joia Mukherjee, our chief medical officer. On this World AIDS Day, read more about why she’s convinced that an AIDS-free generation is within reach.

After nearly four decades, we have reached a tipping point in the fight against HIV/AIDS. The global health community now possesses the tools and knowledge to stop this deadly epidemic.

What once seemed impossible is now in reach: an AIDS-free generation and even disease eradication. To achieve this ambitious goal there is much hard work to do. We need to build on a foundation of medical advances by building a layer of community-focused outreach that targets and treats not just the disease, but the social determinants that enable it.

According to the World Health Organization, more than 36 million people are currently living with HIV/AIDS, 70 percent of them in sub-Saharan Africa. Mortality from AIDS decreased 45 percent since its peak in 2005, due in large part to broader access to treatment.

A big reason why deaths from AIDS decreased so dramatically was the remarkable movement for HIV treatment access. The global movement, led by people living with AIDS, fought for new funding for widespread treatment access as a basic human right. That movement—creating the Global Fund to Fight AIDS, TB and Malaria and later the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)—has successfully expanded HIV treatment to 17 million people around the world.

Just 15 years ago, such numbers seemed impossible. Many were convinced HIV therapy wasn’t feasible in poor countries where systems were weak, health professionals were few, and people lived far from care. In 1998, Partners In Health and Zanmi Lasante, our local partner in Haiti, offered the HIV drug cocktail (a combination of three antiretroviral medications) to people living with HIV/AIDS in Haiti.

Our effort, called the HIV Equity Initiative, provided treatment for first just a handful of the sickest patients, later 50, then 100. PIH’s HIV Equity Initiative proved to the world that excellent, life-saving HIV care could be delivered to people living in the world’s poorest regions. Our work gave hope to the many millions of people, particularly in sub-Saharan Africa, who had no access to the lifesaving drugs. The HIV Equity Initiative became part of the story of the movement for AIDS treatment access. It was studied and costed out to provide Kofi Annan, the director-general of the United Nations, some guideposts in his call for the creation of the Global Fund in 2001.

In addition to overturning conventional wisdom, PIH employs community health workers and pays attention to social factors such as food and shelter to support patients’ adherence to lifetime therapy for HIV (as well as other diseases). This community-based model has contributed to some remarkable results. For example, a study of patients in rural Rwanda who received regular visits from community health workers found that 92 percent were still taking antiretroviral therapy (ART) two years after enrollment. That is a stunning achievement that outpaces similar efforts in far wealthier parts of the world.

Today, we work in seven countries with governments and communities now working to design and implement plans to achieve an AIDS-free generation through the United Nations’ 90-90-90 framework. The goals: 90 percent of people know their HIV status; 90 percent of those with HIV are on ART; and 90 percent of those on ART have an undetectable level of the HIV virus circulating in their blood, are living healthy lives, and are only minimally infectious.

To reach this ambitious goal, a broader application of proven community-based approaches—with a focus on testing, treatment, and prevention—is critical. We must continue to address patient-level barriers to testing to ensure that everyone living with HIV knows their status. These barriers are primarily related to poverty but also include long travel distances and stigma, among other factors.

Expanding HIV testing is absolutely essential to the continued progress in the fight against HIV/AIDS, and experience tells us that engaging trusted community health workers is the key to reaching more people. Ensuring the availability of an adequate number of tests and the timely transport of diagnostic specimens and results are also vital to this effort. Particular attention and tailored strategies should be applied to higher-risk and harder-to-reach groups, including pregnant women, HIV-exposed infants, adolescents and youth, sex workers, prisoners, and all people living in poverty and in remote areas.

We also need to apply community-based approaches to treatment and prevention. It is important to understand that HIV treatment and prevention go hand in hand. Patients who adhere to ART and have undetectable viral loads are not only able to lead healthy lives, they are far less likely to infect others. Pregnant women are among the most important to reach, as treatment can prevent mothers from passing the infection to their children. As with testing, it is crucial to address patient barriers to reaching treatment, using the community-based strategies and solidarity on which PIH has based its programs. This is the key to finding patients in need of ART and helping them initiate treatment and stay on medications.

It is more important than ever to advocate globally for cheaper and more available medications, including fixed-dose combination regimens for children and for patients needing second-line and third-line treatment. Pre-exposure prophylaxis has been proven as an effective strategy for some groups in well-resourced settings. It is vital to make these medications more available to provide the same opportunity to people living in resource-poor settings, particularly for couples with one partner who is HIV positive and one who is not and others at high risk of infection.

At the end of the day, our collective efforts to combat this epidemic must account for the underlying conditions that facilitate its deadly spread. PIH provides a voice and a model for reaching the world’s most vulnerable HIV patients based on a community-focused, rights-based, and equity-driven agenda. By applying these strategies more broadly, we are convinced that the elusive goal of a generation free of HIV/AIDS is within reach.

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

Photographs and comments by Partners In Health staff

Our photographers have the opportunity to visit with health workers, colleagues, and patients all over the world—many of them women.

“We meet far more women in terms of care and connection to the community and health centers than men,” says Rebecca Rollins, PIH’s chief communications officer.

Women usually bring sick children to clinics or receive care themselves. Teams of nurses—mainly female—are the backbone of these facilities. In communities, health workers who go door to door checking up on patients are invariably women. And at home, mothers and grandmothers care for their own and their neighbors’ families.

The world would be much sicker without women. Here are a few of their stories, told through the eyes of our photographers.

Yabom Koroma, Ebola survivor, Sierra Leone

“I listened to her tell her story about losing her father, her husband, two of her children, and her father-in-law to Ebola.”

Photo and comment by Rebecca E. Rollins, chief communications officer, Boston

“I met Yabom Koroma (in yellow) on my first trip to Sierra Leone. We drove to meet her and another Ebola survivor on the street, because we were worried that if we saw them at their homes, they would be kicked out by their community. They would be shunned because Ebola was so feared.

I listened to her story about losing her father, her husband, two of her children, and her father-in-law to Ebola. It was just heartbreaking — one of the most difficult things I’ve listened to.

Four months later, she was considerably better. She was working in an orphanage, taking care of children, which seemed crazy to me. But she said she felt like it was exactly where she needed to be.”

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Thamar Julmiste, nurse, Haiti

“I remember one nurse because she sang to the babies. She would belt out either Mariah Carey or Céline Dion.”

Photo and comment by Cecille Joan Avila, multimedia specialist, Boston

“I was walking the hospital grounds in Hinche, a place a few hours outside of Port-au-Prince, and passed a small, narrow door. I opened it and was in this neonatal intensive care unit. It’s air-conditioned, white, and pristine, and smells like a swimming pool. There were a ton of nurses in this tiny space, taking care of babies.

I remember one nurse because she sang to the babies. She would belt out either Mariah Carey or Céline Dion. Her name is Thamar Julmiste.”

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Benitha Germain, nurse-midwife, Haiti

“She sees anywhere from 25 to 35 patients every day just in that clinic, and that doesn’t count the babies she helps deliver.”

Photo and comment by Rebecca E. Rollins, chief communications officer, Boston

“Benitha Germain has been working at our PIH-supported hospital in Belladère, Haiti, since 2002. On this day, she saw patient after patient after patient — all women who were heavily pregnant. She made arrangements, asking them who was going to take them to the hospital. Basic things, but she made sure they were thinking through their birth plans.

She was also the only nurse-midwife on duty. In another part of the hospital, women were giving birth or in labor and she was constantly getting feedback from a runner who was going back and forth and telling her when she was needed. She sees anywhere from 25 to 35 patients every day just in that clinic, and that doesn’t count the babies she helps deliver.

The amount of her energy and personal care that went into every single life — it was really impressive to watch.”

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Eneless Manyamba, community health worker, Malawi

“She’s the type of participant you hope to have in a training because she asks practical questions.”

Photo and comment by Jeanel Drake, community health learning manager, Boston

“When I photographed our malnutrition training in Malawi in November 2015, one community health worker stood out. This is Eneless Manyamba. Just by watching her in the training you could tell she had a lot of great experience to draw upon.

She’s the type of participant you hope to have in a training because she asks practical questions that help everyone understand the new content and roles.

Community health workers like Eneless are valuable leaders in their communities, and among their peers, and their dedication really shows. I would want someone like her watching out for me if I got sick.”

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Marther Greain, nursing director, Liberia

“For decades, she’s managed with few staff and supplies, and yet she continues to press on.”

Photo and comment by Jonathan Lascher, chief operating officer, Sierra Leone

“I recently visited Liberia’s National Tuberculosis Annex in Monrovia, which PIH has just started supporting. I met Marther Greain, the nursing director. She has worked at the annex since the late 1980s and has been a tireless advocate for people suffering from TB. For decades, she’s managed with few staff and supplies, and yet she continues to press on. The building is crumbling with holes spotting its roof. I wouldn’t have lasted for nearly 30 years in that facility. She didn’t even look tired. She looked impatient to get her patients the care they deserve.”

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Shelove Julmiste, earthquake survivor and rehab educator, Haiti

“She worked with PIH’s rehab team and learned how to walk again. And now she works in a rehab center. She’s an advocate for people who think: 'I can’t do this.'”

Photo and comment by Cecille Joan Avila, multimedia specialist, Boston

“Shelove Julmiste got trapped in rubble after Haiti’s 2010 earthquake and lost her lower left leg. She worked with PIH’s rehab team and learned how to walk again. And now she works in a rehab center.

Shelove is an advocate for people who feel: ‘I can’t do this.’ She talks to them about how it’s possible to have a life after losing a limb. It’s amazing that she was able to overcome something so hard and bring it full circle. You wouldn’t know about her trauma. I think for someone going through an amputation or getting a prosthesis, it’s so powerful to talk to her because she’s filled with joy.”

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Kadiatu Kanu, Ebola survivor, Sierra Leone

“She was beaming as classmates applauded her progress, and opened her notebook for me to show off her work.”

Photo and comment by Jonathan Lascher, chief operating officer, Sierra Leone

“One of my favorite days in Sierra Leone was in Lunsar, a town with a long and difficult history. Just in the last two decades, it has been ravaged by civil war, an exploitative mining industry, and Ebola.

After the Ebola outbreak, PIH began adult literacy classes for survivors. Kadiatu Kanu had just returned to her desk after successfully writing her name on the blackboard. She was beaming as classmates applauded her progress, and opened her notebook for me to show off her work.

I can’t imagine the difficulty confronting her. She survived Ebola and might have to manage ensuing health complications, like uveitis, aches and pains, and mental health issues, among others. She makes money any way she can. She has to buy food and school uniforms for her family. Despite everything that stands in the way of her education, she is in that classroom learning to read and write.”

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Malulang Letima, maternal health worker, Lesotho

“Malulang was, you could tell, very connected to the woman and her baby, but in a caring and professional way.”

Photo and comment by Rebecca E. Rollins, chief communications officer, Boston

“I met Malulang in Lesotho. She goes from home to home in her community, finding women who are pregnant and making sure they get connected with care.

I followed her to the home of a 19-year-old woman who had just given birth. Malulang was, you could tell, very connected to the woman and her baby, but in a caring and professional way, helping her learn how to feed and hold the baby. She was gently instructive while we were there, but clearly extremely strong and committed. A woman of few words, but with such a powerful presence.”

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Esther Kabagwira, cancer patient, Rwanda

“She’s 37 and has early stage breast cancer. Every three weeks, she travels for two days from Burundi to Rwanda for chemo.”

Photo and comment by Cecille Joan Avila, multimedia specialist, Boston

“I met Esther Kabagwira* in Rwanda. She’s 37 and has early stage breast cancer. Every three weeks, she travels for two days from Burundi to Rwanda for chemo. She has three children. I was struck that she was by herself. In the United States, patients usually have someone with them. With her family a country away, she had no one. I asked her how she was in Kinyarwanda (the local language). ‘I don’t speak English,’ she replied in perfect English.

I followed her into the infusion center and watched her undergo treatment. I remember moving around trying to figure out the best angle to shoot her. I asked her what she looked forward to after treatment. She said she was excited to go back to her kids.”

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Matilda Ziyaya, mother, Malawi

“As they were climbing all over her she just kept smiling and I thought, ‘This mother is a pro!’”

Photo and comment by Jeanel Drake, community health learning manager, Boston

“Matilda* caught my eye when she was breastfeeding her twins while waiting for their immunization appointment. She made the work of motherhood look so easy even though she had two very active and alert toddlers demanding her attention at the same time. I loved the ways she wasn’t overwhelmed even though they were literally a handful — or a couple of armfuls. As they were climbing all over her she just kept smiling, and I thought, ‘This mother is a pro!’”

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Betty John, community health worker, Navajo Nation

“There is very little she wouldn’t do for her patients. She chops wood for them if they need it.”

Photo and comment by Cecille Joan Avila, multimedia specialist, Boston

“We drove around with Betty John all morning. She’s a community health worker on the Navajo reservation. It’s gorgeous out there. The landscape is different and stark. We went to three different houses to visit Betty’s patients. No one was home, so we just kept driving around until we found them.

Can you imagine driving around every day for hours? And she was so chipper in her giant pickup truck. When she finally saw a patient, Betty was so sweet with her and joking around. There is very little she wouldn’t do for her patients. She chops wood for them if they need it.”

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Isatta Jalloh, patient, Sierra Leone

“I saw how happy she was to see her community health worker.”

Photo and comment by Jonathan Lascher, chief operating officer, Sierra Leone

“I visited patients with our community health worker team in Yengema, a small town in Kono District. When we arrived at Isatta Jalloh’s home, I saw how happy she was to see her community health worker, and how proud he was to do his job.

Sierra Leone has some of the worst public health statistics in the world. Seeing patients linked to care through community health workers in a very poor place like Yengema is inspiring. This photo is a memento of the day. I know Isatta will always stay with me.”

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“You’re going to cry because you’re looking at the kids,” says Dr. Sara Stulac, putting her hand on Anatole Manzi’s shoulder. The two sat next to each other in Partners In Health’s office in Boston, bent over a thick pink and yellow album containing photographs of 184 Rwandan children—all patients of theirs living with HIV.

Stulac, a 42-year-old pediatrician from Boston and now PIH’s deputy chief medical officer, moved to Rwanda in 2005. There, she met Manzi, 37 at the time and head nurse of a small rural clinic in the southeast. He had joined PIH the same year hoping for a new phase in HIV care.

“I told [PIH], ‘Listen, I am tired of telling people that they have to eat well, behave, and wait for their final day,’” he said at his interview.

Rwanda was in the midst of an HIV epidemic, with about a quarter of a million people contracting the disease. But effective antiretroviral therapy, developed in the United States a decade prior and expensive for many who needed it, was rarely found in corners of Africa. The most Manzi and other clinicians could offer patients were tests and advice on not spreading the disease further.

The medicine cabinet at his new clinic, however, was fully stocked. PIH staff were on a mission to prove proper medication was essential for overcoming the epidemic.

But that’s not all they would prove. Stulac and Manzi, now PIH’s director of global learning and training, would make sure that an essential subgroup wasn’t forgotten. They asked their patients a revolutionary question: Had their children been tested?

In the battle to get treatment for adults with HIV, few in Rwanda, and globally, had considered pediatric HIV. But, as Stulac and Manzi would show, it was a serious problem that needed solutions separate from adult HIV care.

Over the next six years, they discovered a realm of challenges in treating kids—from drug availability to fear and stigma—and devised a series of programs to tackle the issues head-on. More than anything, they shone a light on the rights and needs of children, ensuring their equal access to HIV medication and care.

Treatment that fits

The first challenge was getting parents to bring in their children for testing—a request met with fearful stares.

Manzi remembers a mother who asked, “What are you going to do if you find out that my only son is HIV-positive?” Depressed and penniless, she could barely cope with her own diagnosis. Many of his patients had given up hoping for themselves, but wanted a better life for their kids. A positive HIV test would take that away.

“Rwandans’ hope is always in children,” he says.

To ease parents through the process, Manzi created counseling groups. They were different from hundreds already offered at public health facilities, where patients could get a test and advice, but nothing much more. His sessions gave parents the chance to ask questions about living with HIV and helping their kids live with it, too.

“It was about giving families time to express their thinking around HIV and giving them hope,” he says. Gradually, more patients brought their children for testing.

The next challenge was treatment itself. “On my shelf, I had all the tablets, but they were for adults,” says Manzi.

The valuable pills were each composed of three antiretroviral drugs of different classes that together suppressed the virus for long periods of time. In the mid-1990s, when the drugs were developed, they turned HIV into a manageable chronic illness. But they weren’t made for kids.

“There just were no pediatric drug formulations,” says Stulac. So while she and Manzi persuaded parents to bring in their children for testing, they had to figure out how they would then treat them. Their only option was to use the drugs on the shelf.

“I made this elaborate dosing chart for each molecule and each weight range,” says Stulac. She taped it to tables in the clinic, and she and nurses would cut the pills into doses that were safe for children.

“We would spend our evenings from 6 to 9 p.m. cutting tablets,” says Manzi.

At first, nurses weren’t comfortable with this clunky system, but Stulac, who circulated among several clinics in the area, visited every week and insisted it become regular procedure. Soon it was the norm. When Stulac arrived every Friday morning, she found neat rows of small medication bags labeled and filled with carefully cut pills ready for each child.

Within a year, hundreds of kids were enrolled in the program and taking their medication every day. Manzi, Stulac, and other PIH staff made sure nothing got in the way of their treatment, even securing funding for the kids’ school uniforms and fees so their lives remained stable.

As their program grew, Manzi and Stulac considered their next step: how to stop children from getting HIV in the first place. If HIV-positive women are given therapy while pregnant and breastfeeding, the chance of them passing the virus to their babies can be lower than 1 percent. Without interventions, the risk could be as high as 45 percent.

So pregnant mothers became an essential part of their pediatric HIV program and the next group Stulac and Manzi encouraged to come to the clinic for testing. If they were HIV-positive, their newborns were given antiretrovirals for six weeks and tested for HIV until they turned 2. Manzi and Stulac made sure mothers were also on treatment and had baby formula if they couldn’t breastfeed.

About 50 women were in the program at any one time, and it was undeniably effective. In six years, says Manzi, none of the babies born to HIV-positive women contracted the virus. That’s hundreds of HIV-free children.

A decade later, the program and others like it are still running at 42 health centers where PIH works in Rwanda.

Globally, the situation is still dire. Six hundred children contract HIV every day. But there has been progress. Since 2010, the percent of children living with HIV who can access medication has increased from 20 percent to 50 percent. New pediatric formulations are available, and even better ones are being made. The sharp increase is strong reason to hope things will continue to improve.

The next challenge

Photo by Zack DeClerck / Partners In Health

Stulac and Manzi, who now live in Boston, continued to flip through the album. They know the kids in these photos have done something remarkable in the last decade: They got older.

“Suddenly, the world and we at PIH are faced with the amazing fact that the kids are staying alive,” says Stulac.

This brings new considerations and challenges. Their pediatric program won’t cut it for these healthy and motivated young adults. “Now they want to go to school. Now they want to have relationships. Now they want to have a career,” says Stulac.

So their program has to adjust. As the kids get older, they’ll be counseled to stay in school and to cope with treatment while studying or meeting new peers, girlfriends, and boyfriends at high school.

This approach is not used in HIV programs in most places globally. Once they turn 15, adolescents are excluded from pediatric programs and absorbed into adult ones. But Stulac and Manzi fear that without specialized support, teens could simply stop taking their meds. Caring for adolescents, say Stulac and Manzi, is the next pressing chapter in the fight against HIV. They are a group that is falling through the cracks in medical systems.

Fortunately, the children in the album did not fall through the cracks. Manzi held it up to show Stulac a particular photo. The kids’ smiling faces are the reason they forged a path in pediatric HIV care.

“It’s an amazing investment in the future,” says Stulac.

A note from Partners In Health CEO Gary Gottlieb to our colleagues, partners, and supporters:

Every presidential election, not least this most recent, reminds us what a great diversity of ideas makes up this world.

At PIH, we're privileged to be guided by a mission that is clear and unifying, defined by inclusiveness and community. We've worked for 30 years to heal the world's most vulnerable people—and have done so in the face of challenges that seemed insurmountable, imposed by poverty, disease, and natural disasters.

If any uncertainty lies ahead—and there is always some—then we will receive the challenge as we have every other. Our mission demands that we embrace those who need us most—with greater energy and focus, and with a relentless commitment to unify support from every quarter.

Thank you for being a member of this team, a part of this family.

With love and solidarity,

Gary

Last month a 6-year-old girl in remote Maryland County, Liberia, was climbing a tree, as many do during mango season, and fell from a high branch. Her forearm fractured and bent. Left to heal on its own, the two halves of her radius probably wouldn’t have aligned correctly and would have grown increasingly disfigured as she aged. Her concerned mother considered taking her to a good hospital in Monrovia, but travel outside of the county was impossible except by plane. Torrential rains had turned the one road north into a mud bog.

Thankfully, there was another option. Just weeks before, in mid-September, a brand new x-ray machine had arrived at PIH-supported J.J. Dossen Hospital. The family brought the girl there, and Dr. Rebecca Cook, a PIH clinical collaborator, ordered an x-ray and then, working with a Liberian medical director and an anesthetist, was able to get the bone properly set and splinted. Then she took another x-ray to make sure the bone alignment was correct and sent the girl on her merry, tree-climbing way. “Having an x-ray machine has been a huge thing,” says Cook.

The digital x-ray machine, the first x-ray machine at J.J. Dossen in 35 years, is just part of a massive revival of the 1950s-era hospital. Highlights from the last year?

New equipment—autoclave for sterilizing surgical instruments, otoscopes for diagnosing ear and nose infections, ultrasound for evaluating high-risk pregnancy and diagnosing abdominal masses, and GeneXpert to quickly and accurately diagnose tuberculosis.
Emergency room—doubled the size.
Operating room—built a changing area, a pre-op room, a scrub station.
Blood bank—created a room for it.
Maternity ward—replaced an asbestos roof and installed solar-powered lights.
Electrical system—purchased a massive generator and connected it to the hospital via wires buried in a 200-yard-long, hand-dug trench.

Operating room staff Helena Nyemah stands by the new autoclave at J.J. Dossen Hospital. Photo by Jon Lascher / Partners In Health

The renovated operation room at J.J. Dossen Hospital. Photo by Jon Lascher / Partners In Health

Residents certainly appreciate the renovation, and visits have increased. “‘If you build it, they will come.’ We’ve already seen that a lot,” says PIH Child Health Lead Dr. Sara Beste. “But what’s so unique is the excitement of the staff. Everyone is so enthusiastic and passionate.”

If there’s one upgrade that inspires the most devotion, it’s probably the x-ray machine. About the size of a small cabinet, the computer images it produces can be zoomed in or out, made darker or lighter.

Students at the county's nursing school used to travel eight hours to see the nearest x-ray machine, but now they can just pop down the street. The staff at J.J. Dossen was so enthusiastic they began using it even before the emergency department was fully remodeled.

Though the machine can aid in diagnosing pneumonia, the enlarged heart associated with cardiac failure, bowel obstructions, and of course broken bones, it is especially helpful with diagnosing tuberculosis, which is frighteningly common in the area. Those with HIV and TB don’t always have positive sputum samples, says Cook. And young children can’t cough up sputum at will. But an x-ray can often see the disease regardless. “Having an x-ray helps us screen those with the highest risk of death from TB,” says Cook.

The machine also helps with less fatal forms of TB. Cook recalls a young girl who was recently admitted, having been treated for a leg wound at another facility months earlier. “She just wasn’t improving in the way one would expect,” Cook says. An x-ray revealed an infection of the skin and bone, most likely from TB. 

Symbolically, too, it’s hard to match the power of the x-ray. J.J. Dossen Physician’s Assistant Paul Geah, 50, grew up in a small town in Maryland County and lost multiple siblings to malaria, which was so common and poorly understood back then that they just called it “fever.” When he was a teen, he pledged to change things. “If I go into medical school, I will be able to help my people,” he remembers thinking.

He made it to high school in distant Monrovia and was accepted into, and graduated from, medical school. But unfortunately when he returned home to work in J.J. Dossen in 1981, the x-ray machine had broken a year earlier. “It was a big regret that we could not give x-rays,” he remembers.

Now, some 35 years later, he’s still helping his people at J.J. Dossen. But with an x-ray machine. “When you enter the ER,” he says, “it is almost like you are in Europe.”

Her daughter’s wedding was one of the highlights of Isemelie Bazard’s life; it was also something the 64-year-old Haitian street vendor had doubted she’d live to see.

In March 2013, Bazard was diagnosed with breast cancer. Treatment options were frighteningly few, so chances were slim she would see her daughter get married later that year. When she heard about a recently opened hospital in Mirebalais, she decided to try her chances.

On May 23, 2013, Bazard became the first patient to undergo surgery at University Hospital, which is run by Zanmi Lasante, as Partners In Health is known in Haiti. It was a success. She followed a six-month regimen of chemotherapy and has since been on medication to help prevent a relapse. More than three years on, she is still cancer-free. Thanks to PIH, she is now among a small, but growing, group of breast cancer survivors in Haiti. 

“If it weren’t for this hospital,” says Bazard, a mother of four, “I would be dead.”

October is Breast Cancer Awareness Month in the United States, where the American Cancer Society estimates that 246,660 new cases of invasive breast cancer will be diagnosed in women this year alone. Yet early detection is common, and the chance that a woman will die from breast cancer is about 3 percent. Survivor stories here, and in many Western countries, are plentiful.

Compare that to poor countries such as Haiti, where a breast cancer diagnosis is rare and, usually, a death sentence. There are only three facilities that provide chemotherapy in the entire country. One is private, where the cost of care is too high for most Haitians, who live on less than $2 a day. The public Hôpital General in Port-au-Prince provides free care, but patients must pay for all medications.

University Hospital is the sole public facility where cancer care is completely free. In 2015 alone, 1,600 biopsies were performed on patients visiting the oncology department. Nearly 40 percent of these biopsies were breast-related. PIH clinicians who treat breast cancer in Haiti say it is aggressive, often strikes young women, and is well-advanced by the time of diagnosis.

Bazard was among the lucky few who detected a lump early. She asked her daughter, who was in nursing school at the time, to check the mass that had been slowly growing in her left breast. It didn’t seem normal. So she made an appointment at a public hospital in Port-au-Prince. She arrived in the pre-dawn hours and sat in a packed waiting room. It was early afternoon before she saw the doctor, who handed her a slip of paper with a list of recommended diagnostic exams. She knew she didn’t have the money to pay for each, nor transportation to get to the facilities scattered throughout Port-au-Prince.

The doctor, likely noting her look of desperation, said: “’Go to Dr. Damuse.’”

If it weren’t for this hospital, I would be dead.

Ruth Damuse, an internal medicine doctor by training, started providing oncology services on a shoestring budget at the PIH clinic in Cange in 2010. By the time Bazard landed in her exam room in late 2012, the doctor had already cared for dozens of breast cancer patients. She ordered an X-ray and sonogram of her patient’s breast, and then took a tissue sample to send to Boston for testing. (Brigham & Women’s Hospital, Dana Farber Cancer Institute, and Newton-Wellesley Hospital all provide pathology services to PIH). The sample came back malignant in March, and Damuse’s team decided that Bazard’s best chance at recovery was a mastectomy.

When Bazard heard the news, she started to cry. She was her family’s primary breadwinner, selling shoes to make ends meet, and worried about what was going to happen to her children. “I was thinking that I was going to die,” she says.

The stigma of losing a breast also wore her down. Oldine Deshommes, a PIH oncology social worker, shared a Haitian saying she often hears among patients facing a mastectomy. “Venn tete, se venn ke,” or "veins that feed the breasts are the same that feed the heart." Women express this concern because they feel that once some or all of their breast is removed, they will feel an irreplaceable void. Deshommes and fellow staff members speak with the women about these, and many other concerns, during breast cancer support groups.

Bazard took advantage of these groups and says that whenever she talked to Deshommes, it was “like death stopped to exist.” Eventually she came to terms with her diagnosis. She felt supported by PIH, loved by her family, and filled with faith that all would be OK. She was also honored to be the first patient to undergo surgery at the newly open University Hospital in Mirebalais.

Dr. Michelson Padovany, a general surgeon and Mirebalais native, performed the historic procedure on May 23, 2013, just two months after the hospital officially opened. All went according to plan. Within two months, Bazard was back to begin chemotherapy. She remembers experiencing nausea, vomiting, and bouts of diarrhea, but says—overall—“it wasn’t bad.” Her memory was likely colored by the strong bonds she built throughout the ordeal with Deshommes and Damuse, whom she calls her mother and daughter. They understood when Bazard asked for a break in her chemo so she could participate in her daughter’s wedding that December.

Bazard at University Hospital in 2013 after undergoing the hospital’s first surgery. Photo by Rebecca E. Rollins / Partners In Health

In September 2014, Bazard’s CT scan came back clear. Her tumor was gone, and there was no sign it had metastasized to other parts of her body. To make sure she remained cancer free, Damuse put her on Tamoxifen, an estrogen-blocking oral medication that has proven especially effective for Bazard’s strain of breast cancer. Her most recent scan in March was also clear.

Every two to three months, Bazard returns to University Hospital, where she has her prescription refilled and chats with Damuse, Deshommes, and the rest of the oncology team. Her second family. She says she’s been eating and sleeping well again. While she still has daily concerns, cancer is not one of them. Mostly, she worries about saving enough money to restart her small business.

For now, though, Bazard is busy as the local reference for neighbors who ask about University Hospital in Mirebalais. She sends them along, singing the praises of PIH staff.

“Here at the Mirebalais hospital,” she says, “you will always find kindness and a solution.”

Partners In Health tuberculosis experts are in the United Kingdom this week to discuss endTB, a project that is bringing delamanid and bedaquiline—the first new tuberculosis drugs developed in 50 years—to patients in 14 countries, where results so far have been revolutionary.

Tuberculosis is an airborne bacterial disease that can easily become resistant to antibiotics and kills 1.5 million people a year, surpassing HIV as the biggest infectious disease killer.

PIH is partnering with Médecins Sans Frontières, Interactive Research and Development, and UNITAID to tackle a form of TB that is resistant to standard drugs, referred to as multidrug-resistant tuberculosis. MDR-TB seems to have met its match against delamanid and bedaquiline. Each, in combination with other medications, is proving to be more effective and less toxic than current treatment.

PIH staff are presenting their findings for the first time to other clinicians, researchers, public health workers, and policymakers from over 125 countries at the annual Union World Conference on Lung Health in Liverpool.

Three of them—one based in Boston, one in Lesotho, and one in Kazakhstan—offered their thoughts on TB, the new drugs, and the significance of endTB.

Photo by Suzanne Camarata

Dr. Carole Mitnick began working in TB in 1996 when she joined PIH. She’s an associate professor at Harvard Medical School and a principal investigator of endTB’s clinical trial, which will test combinations of drugs in regimens containing delamanid or bedaquiline.

What day-to-day challenges are MDR-TB patients facing?

They are usually coping with years of illness. They've typically received multiple courses of treatment before getting treatment for MDR-TB. So they're facing tremendous social disruption from their families, partners, and employment. They're also facing huge financial challenges from having been sick for so long—either simply from not being able to work and earn a living, or because of the costs associated with TB treatment. And they're facing a desperate situation with treatment, which causes an enormous number of side effects, requires a daily painful injection that can cause abscesses, and much worse.

[Patients are] generally young, around 30 years old, who should be in productive periods of their lives with positive life events, like having children or developing long-term relationships. Instead, they’re facing two years of medications—often following several years of prior treatment.

How did endTB come together?

There's a long-standing partnership among PIH, MSF, and IRD that really goes back to working together on some global policy issues like the establishment of the Green Light Committee, which was one of the early mechanisms to make treatment for MDR-TB more available to people in resource-poor settings.

Some of that work extended to improving standards of measuring quality of treatment and making sure things often considered ancillary actually become a routine part of treatment—for example, social and economic support, addressing side effects, and additional tests that are required for MDR-TB treatment.

So with the conditional regulatory approval of the newest anti-TB drugs in 2012 to 2013, it was natural for these three groups to collaborate to expand access to the drugs in countries where they had a history of working. We agreed that the heterogeneity represented by patients and situations in these countries would provide important demonstrations for programmatic use of bedaquiline and delamanid for other countries in the world.

What do you hope to achieve at the conference?

Today we are holding an endTB symposium, which will be the first public presentation of the progress of the project. We're really excited to be able to present this. Over the last few years at this conference there has been a lot of discussion about planning for and preparing for the rollout of the new anti-TB drugs to the hundreds of thousands (maybe millions) who need them. But there's been very little reported progress other than in South Africa, which has been a lone pioneer with a high MDR-TB setting.

So we're pleased to talk about introducing the drugs in various settings—in Lesotho with a high rate of HIV co-infection; in Peru where there's been a lot of caution and uncertainty about these new drugs; and in Armenia and Georgia where there’s Hepatitis C co-infection and important prison populations.

We feel enthusiastic and privileged to be able to share this experience as a model for what a national TB program with these new drugs could look like.

Photo by Yerkebulan Algozhin / Partners In Health

Dr. Askar Yedilbayev, a lung specialist, is PIH’s program director for Russia and Kazakhstan.

PIH first began treating MDR-TB patients in Russia in the early 2000s. What has changed since then?

First of all, we changed doctors’ approach to treating patients. We realized that not only was treatment needed, but so was what we call ‘accompaniment.’ You can’t provide medicines and do nothing else. You need to provide food and psychosocial support to help patients adhere to treatment. We brought this comprehensive approach to the Ministry of Health, which resulted in a significant change in the national approach to MDR-TB, not only in Russia, but in neighboring countries, including Kazakhstan.

What are the challenges of the endTB project?

We haven't had these drugs before and realized more patients need them. It's so sad because there are people in other regions of the country where they don’t have the drugs because they’re simply not at endTB sites. It’s clear to me that in the countries of the former Soviet Union, like Russia and Kazakhstan, governments need to make these drugs available. I am happy that the endTB project serves as a catalyzer for this.

Another challenge is that because there are so many MDR-TB patients, we are treating the sickest. From a clinical standpoint, they are the hardest to cure. But we’re doing it.

What are the results so far?

We are collecting data and the first observations are very preliminary, but we already see improvements in patients. We have several who had been doing badly on regular drugs for MDR-TB and had had multiple treatments in the past, but with the new drugs they are responding to treatment very quickly. The drugs aren’t that toxic and patients aren’t suffering the same side effects they were before. For some, this is the first time in years they are responding to treatment. They were completely hopeless before. Without the endTB project, they would have died.

Photo by Rebecca E. Rollins / Partners In Health

Dr. Abera Leta is PIH’s country director in Lesotho. Before joining PIH, he managed TB control programs in Ethiopia for the World Health Organization.

PIH is treating hundreds of people with MDR-TB in Lesotho. To some, this amount may seem quite small. How significant is this prevalence rate?

When it comes to the burden of disease, some countries report a million cases per year. For example, China or India. But the ratio to the population is very small. When it comes to Lesotho, the incidence rate is 852 per 100,000 people in the population, which is one of the highest in the world.

This means we have many TB patients who are very sick and need diagnosis and medications. If we delay treatment, they may infect many more people who share the air they breathe—be it in a room, bus, wherever they are. TB is a public health problem. Every day counts.

What do you think of endTB?

This is definitely a landmark for the TB community and the world. We have been dealing with very old drugs, and we were treating MDR-TB with less effective, less safe drugs because we didn’t have alternatives. The two new drugs, bedaquiline and delamanid, are game-changing, and they’re our only options for improving management of MDR-TB.

What do you hope endTB will accomplish in Lesotho?

It is very important for us. We started MDR-TB treatment in 2007 in Lesotho, and we have enrolled thousands of patients, but we saw the outcome of standard drugs was not satisfactory. Most patients fail treatment or die. But these drugs are more effective and cause fewer side effects.

We have already enrolled about 55 patients, some of whom were failing treatment—they were on it for more than 24 months with no improvement, meaning they had no bacteriological conversion and were still infectious. But immediately after we put them on these new drugs, their sputum converted to negative. That means they are non-infectious. So you can see they are immediately improving.

What will happen once endTB is complete?

Since PIH is implementing the new drugs in collaboration with the National TB Program for Lesotho and jointly monitoring patient outcomes, we are hoping to make this part of the government’s national guidelines. Colleagues at the Program already appreciate what is going on now, including the significant improvement in outcomes of patients on these new drugs.

It’s not yet noon in Reforma, Chiapas, and the sun sizzles the empty dirt roads crisscrossing this small rural town in the Sierra Madre mountains. Those who venture outside walk slowly and stay within the shadows cast by overhanging corrugated metal rooves. Men wear wide-brimmed hats and women carry umbrellas to create personal bubbles of shade.

Eudeli Velasquez, 23, stops by the Reforma health clinic and lingers in the cool of the awning. She’s there to see Dr. Gerardo Murillo, a first-year doctor fulfilling his social service year through Compaňeros En Salud, as Partners In Health is known in Mexico. She asks for something to treat headaches, and he ducks into the pharmacy. Seconds later, he comes back with a package.

Velasquez doesn’t need the pills; one of her patients does. As a PIH community health worker, she makes weekly visits to six residents living with chronic diseases—such as hypertension, diabetes, and depression—to ensure they take their medication and follow doctor’s orders. Most importantly, though, she’s there to listen to their concerns, answer questions, and keep them company on days that feel heavier than they should.

Popping open a yellow floral umbrella, Velasquez steps back into the sun and, a couple of turns later, stands in front of a red metal door with a grated window. Her round face is flushed from the short trek. Juana García answers Velasquez’s knock. She sells children’s clothing and other goods from her small store, which seems closed today—possibly because of the owner’s pounding headache. She suffers from hypertension, and Velasquez has been visiting her for the past six months. She briefly greets the community health worker and retreats into the dark store with the medication.

Velasquez next stops by the home of Maria Roman, a 60-year-old woman who is Reforma’s last remaining midwife. Today, like most days, Roman is sitting in a plastic chair on her shaded back porch, watching her chickens peck the bare, immaculately swept dirt yard. She has hypertension and diabetes, so her feet swell and make it painful to stand and walk. She hasn’t attended a birth in ages. Then again, demand isn’t the same as it used to be. Most women now prefer giving birth at the hospital in Jaltenango, a city 45 minutes away by car.  

Velasquez visits Maria Roman, who suffers from hypertension and diabetes, to ensure she's taking her medication.

A family member comes with a pillbox and hands it to Velasquez. She opens the square plastic lids for each day, counting pills to confirm Roman is truly taking her medication. Her patient used to get pills from a pharmacy outside Reforma and refused to take those from the local clinic, claiming they were bad for her. Velasquez told Dr. Jesus Rocha, the PIH-supported doctor working there at the time, and both made a home visit to explain that they were the same pills.

So does Roman take them now? “When the medication is gone,” Velasquez says with a smile, “she asks for more.” 

Velasquez turns onto the road where she now lives with her in-laws. Instead of stopping home, she goes to the next house down to visit another patient. She walks through the dark living room to the shaded patio, where Rosemberg Lopez, 52, swings placidly in a hammock. He flashes a childlike smile as his community health worker takes a seat beside him to review his medication.

Lopez lives with schizophrenia and, since Velasquez became his community health worker, has been stable on medication for the past two years. His mother, Erminia Borralles, is a petite, gray-haired woman who unconsciously wrings her hands as she retells the horrors they lived through during his illness.

Her son, she says, started acting strangely around the time he turned 18. He used to hit them, throw food, and hurl rocks at children. Occasionally he walked through town naked. He disappeared for days into the surrounding hillside. Then he arrived one day at the elementary school with a machete and started chopping away at desks. Teachers eventually detained him, walked him home, and had him chained to a tree.

People killed themselves and we didn't know why.

Ashamed and beside themselves with worry, his family took him to traditional healers and several doctors throughout Chiapas, eventually learning he suffered from schizophrenia. Although medication worked for a while, it was expensive and wasn’t available in the Reforma clinic. His family had to make a tough choice: buy food, or keep Lopez medicated. When his drugs ran out and he relapsed, they locked him in a windowless shack behind their home. And that’s where he lived for six years.

Velasquez remembers this. She was a schoolgirl when Lopez terrorized the community. Sometimes she would walk by his home, glance toward the shack, and make a wish: “When I’m big, I’m going to earn a lot of money to get him out of there.”

She got part of her wish, only not how she’d planned. When PIH announced it was recruiting community health workers in 2014, Velasquez was among the 40 residents who showed up for more information and was one of the nine women finally selected. She and her colleagues attended three months of training on everything from how to complete forms to how to identify symptoms of depression. Each was then assigned up to eight patients diagnosed with chronic illnesses.

Velasquez requested Rosemberg as one of her patients. PIH staff greatly credit her for his early and consistent adherence to medication. He now eats, sleeps, and hangs out with his family. The chains that used to shackle him to a tree lie rusting beside the vacant shack.

The sun’s intensity seems to magnify as Velasquez walks home. Before becoming a community health worker, she says she’d never heard of schizophrenia or depression. Certainly, she knew people who felt down. “But I didn’t know what it was,” she recalls. “People killed themselves and we didn’t know why.” She appreciates the difference a PIH-supported doctor and community health workers have made in two short years. “Already there are more people who have their chronic diseases under control.”

There’s been another slow change that’s possibly less obvious, but equally important. Velasquez remembers when she and her colleagues started making rounds in Reforma and word spread that “women shouldn’t be walking around working.” The rest of the sentence was implied: “…outside the home.” Traditionally, women cook, clean, and take care of the kids. They don’t have to, or can’t, leave the house. In-laws and neighbors ensure any violation of that norm is passed along to spouses, who may disapprove in unsettling ways.

With the launch of the community health worker program, expectations started changing. The nine women are on official business—visiting patients, reporting to the clinic, and attending PIH-sponsored trainings—and earning food for their families. The role shift is radical. Revolutionary. And sometimes envied.

Velasquez says women ask her if PIH is recruiting more community health workers and wonder if she will “put in a good word” for them. She laughs. They were too “shy” before, now they want in too.

Velasquez picks up her  6-year-old daughter, Devani Dean, from school on a day students made sock puppets.

It’s early afternoon and Velasquez pops open her umbrella once again to fetch her 6-year-old daughter, Devani, from school. The pony-tailed girl proudly shows a new sock puppet to her mother, who slings her daughter’s pink backpack over her shoulder. They return home, where Devani quickly changes out of her school uniform and skips out the door to play.

Velasquez mops the floor and tidies up her bedroom, the sole place she has to herself in her in-laws’ home. A TV perches on a table opposite her double bed and broadcasts a show she largely ignores. She can’t control which channel is on; her in-laws make that choice on the linked TV in the nearby living room.

A couple hours later, Velasquez gathers up six slips of white paper, one for each of her patients, and walks back to the clinic. On the first Monday of every month, she sits down with Murillo to review her patients’ progress. Together they troubleshoot particularly difficult cases.

The sun finally melts west toward the surrounding mountains. Velasquez leaves the clinic and turns back uphill, choosing a path in the deepening shadows cast by now-shuttered stores. 

Dr. Joia Mukherjee has seen devastation in Haiti. She was there just days after the January 2010 earthquake that reduced Port-au-Prince neighborhoods to rubble, killed 300,000 people, injured 300,000 more, and displaced 1.5 million. Still, she says, each brick removed and surgery performed felt like a step forward.

But now, seeing the destruction left by Hurricane Matthew, she struggles to find words to describe the scene along Haiti’s southern claw, the region hit hardest by the Category 4 storm.

“I can honestly say this is one of the worst things I have ever seen,” says Mukherjee, Partners In Health’s chief medical officer. 

Mukherjee visited the southern city of Les Cayes and neighboring communities between there and Jérémie with a small team from Zanmi Lasante (ZL), as PIH is known in Haiti. They went to speak with local officials, determine how best to help, and tend to patients at the Hôpital Immaculée Conception in Les Cayes, the sole standing public hospital for 1.3 million people. Since PIH is one of the oldest, strongest, and most trusted organizations in Haiti, the team was asked to visit the south by the Ministry of Public Health and Population to help them think through their response as they grapple to get a full sense of the storm’s impact.

What Mukherjee sees, she says, breaks her heart. Thousands of acres of peasant farmland destroyed, swept away by 145 mile-per-hour winds or damaged by gallons of saltwater that fell over a 24-hour period. Statuesque banana and mango trees snapped like matchsticks. Livestock disappeared. Many houses simply gone. Others stripped of their roofs. Clothes and household goods strewn about as if they’d been caught in a tornado.

And this is just the material damage. Mukherjee, her voice cracking, says she’s “waiting with a sense of dread that things actually will get much worse here.” Hundreds of people are using the same small, ill-equipped buildings, such as public schools, as emergency shelters. These places have inadequate water and sanitation and could quickly turn into fertile ground for deadly diarrheal diseases such as cholera. She thinks of the destroyed crops and empty storehouses and anticipates starvation. Water pools everywhere, creating potential breeding grounds for mosquitoes carrying diseases like malaria, Dengue, and Zika. And then there are the infections, such as tetanus, that come from untreated wounds sustained from flying debris during the hurricane.

“It’s really beyond measure,” she says.

There is so much to do, it’s hard to know where to begin. While field-based emergency care is needed, so too is a functioning hospital to refer patients who need specialized care and treating illnesses that will increase in the next days, weeks, and months. Given PIH’s expertise in infectious diseases and building health systems, those areas seemed a natural place to start.

People have no idea how bad this is. They lost everything.

So PIH leaders in Haiti, including Co-executive Directors Fernet Leandre and Loune Viaud, decided to focus on two areas over the next six months: reinforcing PIH’s 10 cholera treatment centers and supporting Hôpital Immaculée Conception in Les Cayes.

With some estimates claiming the number of displaced at 1 million people and no temporary shelter in the south, Mukherjee thinks hurricane survivors will start resettling in the north and west, toward where PIH works in the Central Plateau and Artibonite. They may bring cholera with them, adding to the burden the disease has already placed there, as flooding and fetid water are causing a spike in cases following Hurricane Matthew.

Mukherjee says the 150-bed Hôpital Immaculée Conception will receive the typical PIH “package” of services. Patients will be fed. (They currently aren’t, unless family members bring them meals.) Care and medications will be free for those who need it most. Social workers and mental health staff will be on hand to provide support for patients and health care providers. And the roof will be repaired, electricity restored, and medical supplies stocked to meet increased demand.

In the midst of this, PIH is tending to the needs of its own staff, many of whom have deep roots in the south. Last weekend, the organization helped roughly 150 staff members reach the regions of Sud, Grand Anse, and Nippes so they could check on family, friends, and homes left behind. PIH will be providing modest support to these staff as they help loved ones rebuild or relocate.

Mukherjee talked to many of them afterward and says they shared their stories through tears.

“People have no idea how bad this is,” Mukherjee says. “They lost everything.”

The World Health Organization announced Tuesday that it will send 1 million doses of cholera vaccine to Haiti, where hundreds of cases of the deadly diarrheal disease have been reported after Hurricane Matthew tore through the country one week ago.

Partners In Health applauds the news for a simple reason.

“Cholera vaccines save lives,” says Dr. Louise Ivers, PIH’s senior health and policy advisor.

The WHO will coordinate the use of vaccines with Haiti’s Ministry of Public Health and Population, which leads the cholera response in Haiti, Ivers says. Any decision on the final destination of the vaccines will greatly depend on need and the logistical capacity to distribute them.

Zanmi Lasante, as PIH is known in Haiti, has seen firsthand the power of cholera vaccination. In 2012, staff conducted a successful vaccination campaign that reached 45,417 Haitians in the regions of Grand Saline and Bocozel. Nearly 90 percent of patients received the recommended two dosages.

The campaign dramatically reduced the risk of cholera for those who got the vaccine, and likely for those who didn’t. As Ivers explains, cholera vaccines have an effect called “herd protection.” The more people who are vaccinated, the less cholera circulates—meaning even those who didn’t receive the vaccine have less risk of getting the disease.

Hundreds of cholera cases have already been reported just one week after the hurricane in the hardest-hit South, including Jérémie, Port Salut, and Les Cayes. Flood waters have mixed with sewage contaminated with cholera bacteria. Because fewer than half of Haitians have access to clean water, they draw from these sources and suffer the consequences. The infectious disease causes vomiting and diarrhea, and patients can die within 24 hours if the illness is left untreated.

PIH staff are now organizing mobile teams to help support partners in the South, including at the hospital in Les Cayes.

Cholera was introduced to Haiti in 2010. Shortly after the devastating January earthquake, the United Nations flew in a group of peacekeepers from Nepal, whose capital had recently suffered an outbreak of the disease, and set them up in a camp with poor plumbing. Contaminated sewage leaked into a tributary of the longest river in the country, the 200-mile Artibonite, which is a water source for countless Haitians. A cholera epidemic was born. In the six years since, nearly 10,000 Haitians have died and 800,000 have been sickened by the disease.

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Hurricane Matthew’s heavy rains will likely worsen Haiti’s six-year-long cholera epidemic, which has already been categorized as among the world’s worst.

Cholera is a diarrheal disease caused by drinking water or eating food contaminated with the bacterium Vibrio cholera, which is passed through human feces. Haiti’s poor or non-existent sanitation systems create conditions that are ripe for transmitting the disease.

With Hurricane Matthew dumping heavy rains of up to 40 inches in less than 24 hours, Dr. Charles-Patrick Almazor and his Partners In Health colleagues believe the ensuing flood waters will magnify the number of cholera cases they see across the 12 health centers PIH supports. There have been an alarming 26,000 reported cases of cholera this year alone.

“We expect lots of cases … hundreds per facility,” Almazor, PIH’s chief medical officer in Haiti, told The Boston Globe.

Cholera is found and spread in places where people have little or no access to sanitation and clean water. Those infected with cholera develop watery diarrhea, vomiting, and leg cramps. They can become dehydrated rapidly, go into shock, and die within 24 hours if they don’t receive care.

Almazor was among those who treated the first cholera patients when the outbreak started near St. Marc in October 2010.

“I worked all night at the hospital with a few colleagues; we were two doctors and six nurses for more than 300 patients who needed IV fluids,” he remembered. “We were overwhelmed by the immensity of this tragedy. Many of those 300 patients died that day. They came too late to the hospital and from too far away to be taken care of by too few providers.”

So far the epidemic has killed nearly 10,000 people.

“Cholera is a good illustration of the vicious cycle of poverty and disease, in which the most vulnerable people are most likely to be victims,” Almazor said. “In an ideal world, we would have a comprehensive approach for fighting cholera—preventing transmission with clean water sources, hygiene education, and latrine construction. Unfortunately, it will take many years before most Haitians have access to potable water and latrines.”

Your emergency gift will help us supply urgent health care for cholera patients—and all those who will need it most.

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Off a shrub-lined road on the outskirts of Maseru, Lesotho’s capital, a dirt path leads to Botšabelo Hospital. The single-story, 24-bed facility overlooks a plateau stretching to flat-topped mountains. A single notebook registers visitors at the entrance. White vans labeled “Ambulance” are parked outside.

Botšabelo is Lesotho’s only hospital for people with an advanced form of tuberculosis called multidrug-resistant tuberculosis, which is resistant to some, if not all, drugs for treatment. The TB incidence rate here is the highest in the world at 852 per 100,000 individuals. In other words, in the next year, one out of every 100 or so people will contract TB. A portion of these sufferers has MDR-TB.  

Partners In Health and Lesotho’s Ministry of Health opened Botšabelo in 2007. Health professionals from around Africa come here to learn proper ways to manage MDR-TB, which is notoriously difficult to treat. Medications are toxic and cause many side effects, making treatment difficult to stick to. Full recovery takes two years, at least.

Everything at the hospital caters specifically to MDR-TB. Doctors, nurses, lab technicians, and other staff are specially trained. Wards separate patients according to their level of drug-resistance. Even the building is structured around the disease; glass ceiling panels let in UV light, which kills TB bacteria, and ceiling vents refresh the air 12 to 15 times per hour to prevent the disease from spreading.

There are signs the hospital is making a difference. In the last decade, 1,500 patients have been admitted for care. In 2014, 60 percent of patients completed treatment successfully—a far cry from perfect, but greater than the global rate of 50 percent in 2012.

More compelling than the numbers, though, are the stories of people receiving care at Botšabelo and the PIH clinicians working to make this possible. Meet some of them below.

Botšabelo Hospital in Maseru, Lesotho, was founded by Partners In Health and the Ministry of Health. Source: Google Maps.

Botšabelo’s Nurse in Charge

Nurses provide most of the care at the hospital. They’re managed by Mabatloung Mofolo, who has worked at Botšabelo since 2011 and in other managerial roles with PIH since 2009. Her favorite part of her job? Caring for patients at their bedside. “You can provide help to save a life when it is needed most.”

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Dr. Omotayo

Botšabelo attracts clinicians from across the globe. Nigerian-born Dr. David Omotayo heads PIH’s TB and MDR-TB programs in Lesotho. The physician trained in Lagos and Pretoria, South Africa, and has brought more than 20 years of experience to the hospital. "I fell in love with TB," he says. When not helping Lesotho’s Ministry of Health craft TB policy, he’s at Botšabelo checking up on patients and monitoring their treatment regimens.

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The Patients’ Lounge

MDR-TB can’t be cured quickly. It can be months before patients are well enough to go home. Between morning and evening doses, they fill long hours in each other’s company. Those who are well enough take a break from their beds, walk the corridors, and watch TV in the lounge.

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Intensive Care for the Sickest

MDR-TB is debilitating, but the side effects of treatment can be worse. When 47-year-old Kubelo Manyeli was admitted to Botšabelo, he was so sick he couldn’t walk. The two-year regimen of daily injections and toxic pills can cause hearing loss, nausea, and diarrhea, and it was taking its toll. For months, he lay hooked up to an IV. Doctors carefully monitored his treatment, adjusting as necessary, and gradually he responded to medications. Now, they are confident he’ll be discharged soon.

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House-Calling Neighbors

Botšabelo is at the center of a wider national MDR-TB care network. If patients are well enough to live at home, their friends or neighbors bring them medication every day after receiving training at Botšabelo. Together, they report back to the hospital for monthly checkups. Makatleno Ntsasa is a 41-year-old “treatment supporter” who watches out for Mamohau Marumo, a 28-year-old accountant. Ntsasa visits her twice a day. Halfway through treatment, it’s hard to tell Marumo is sick. “I feel normal,” she says and shrugs.

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A Deadly Combination

People with MDR-TB are often already sick with HIV. About 78 percent of patients registered at Botšabelo are infected with both, including 61-year-old Thabo Selia-Lia. At Botšabelo, Selia-Lia tells Dr. Daniel Puga that he has pain on his left side and is still coughing. He’s no longer feverish, but he is vomiting and has diarrhea. Puga adjusts his medication for both MDR-TB and HIV to help manage his symptoms and side effects until they next meet.

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Testing for Resistance

It’s difficult to tell which drugs aren’t working for MDR-TB patients. When they arrive for appointments, they are asked to cough up mucus, which Sofonia Makhele collects for analysis. The samples are sent up the road to the National TB Reference Laboratory, where they’re tested for drug resistance. Depending on the results, clinicians at Botšabelo put patients on drugs that will be most effective for their particular strain of MDR-TB.

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The Youngest Sufferer

A sign reading “Isolation” hangs on the first of two doors leading to Naleli Maimane’s room. Nobody is sure how the 11-month-old got infected with MDR-TB, but luckily it hasn’t spread to other parts of her body—a common issue with infants whose immune systems aren’t strong enough to contain the disease to their lungs. Fortunately, Naleli is not suffering side effects and is doing well.

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A Recovered Patient Pays a Visit

Drug resistance develops when patients aren't taking the correct antibiotic for their strain of TB. This often happens in Lesotho, where many clinicians don't have the tools and training to accurately diagnose MDR-TB. Reitumetse Mahobela's drug resistance had built up for months before she enrolled at Botšabelo and made a full recovery two years later. She’s a believer in spreading the word about proper treatment: “There are so many people out there. They don’t know about TB, and I think [my story] would help them take their medication.”

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Interviews were conducted in April 2016.

It was still pitch black when Georgina Díaz’s alarm went off at 3 a.m. The 34-year-old single mother peeled herself from bed and started plugging away at the morning’s routine in Reforma, Chiapas. Roosters crowed, despite the absence of the sun, as she lit a corn husk and touched it to dry wood stacked in the outdoor stove behind her family home.

As the fire grew, Díaz filled a pot of water to boil coffee, which she had grown herself—like most of her neighbors—in fields spread across the arid mountainside. Then she poured white corn, also grown nearby, into a mill. The machine’s metallic grinding assaulted the predawn silence as it chewed the corn into a pasty pulp. She scooped the ground meal into a bucket and kneaded it into a smooth ball.

Over the smoky fire, Díaz prepared refried beans, scrambled eggs, and dozens of handmade tortillas for her three sons’ breakfast. She sat for five minutes to swallow a hunk of sweet bread and a cup of coffee. Then she was up again, hastily running a hot iron over her sons’ school clothes. She packed her bag, rattled off instructions to her mother about the boys’ lunch, and took off down the dirt road leading to the town square.

With a handful of neighbors, Díaz headed to a coffee nursery 30 minutes away by foot under a diamond-studded sky. The sun hadn’t yet peaked over the saw-toothed horizon of the surrounding Sierra Madre mountains. The shuffling of their feet and hushed conversation were the only sounds in the still sleepy village.  

Once at their roadside destination, Díaz and several dozen workers got their assignments from nursery supervisors. Each had to fill 500 squat black bags with a mixture of sand and soil, which eventually would be planted with coffee seedlings. This mass planting was in response to an invasive fungus called la roya, which has been attacking coffee plants and drastically reducing local yields for the past several years. The new coffee shoots were believed to be a resistant variety and symbolized hope for the region’s growers.

Beyond hope, the nursery represented a paying, although temporary, job. And those were hard to come by in rural Chiapas. Díaz was grateful for the work, despite the fact it lengthened her already long day.

Díaz, right, fills bags that will be planted with coffee shoots believed to be resistant to a fungus that's been devastating local plantations for years.

The luchadora

People around Reforma tend to call Díaz a luchadora, or fighter. Having left her abusive husband seven years ago, she supports herself and her sons through any means possible. She grows corn, coffee, and limes, raises livestock, sells secondhand clothes, picks up odd jobs like that at the nursery, and stretches to the maximum the little government assistance she receives.

Two years ago, Díaz took on another role—as one of Reforma’s first community health workers. Compaňeros En Salud, as Partners In Health is known in Mexico, recruited and trained her and eight other women in how to care for and accompany patients with chronic diseases, such as diabetes, hypertension, and depression. She and her colleagues are often the first, and most enduring, link residents have to the local clinic. They build trust, advocate on their patients’ behalf, and often answer questions that patients feel too uncomfortable to ask physicians. They receive packages of food for their efforts, yet many feel a greater reward from helping neighbors and strengthening their community’s health care system.

Díaz is proud to call herself a community health worker, or acompañante. Every week, she visits eight residents to ensure they take their medication and attend doctor appointments. Mostly though, her visits are opportunities for patients to talk about their illness or simply shoot the breeze.  

“You could say that these chats, they’ve really helped,” Díaz says. “Sometimes, if I don’t go to visit, they say, ‘Why weren’t you there?’ … Sometimes, they confide things to you that not even their family knows.”

Family members recognize the difference Díaz makes. She says some have approached her to say, “’Listen, my mother speaks very well of you. I want to thank you for visiting her.’”

That’s why I like this program, because you go along waking people up to how to take care of their health.

These are the feel-good moments of the job. But there are also times when Díaz realizes the obstacles she and her patients face are more than health-related. She often counsels those living with diabetes or hypertension to eat less corn and sugary foods. That’s a hard sell in a part of the world where tortillas are served for breakfast, lunch, and dinner. And where pozol, a sugary drink made from fermented corn dough, is thought to provide strength for farmers facing a long day’s work.

“’The doctor wants me to starve to death,’” Díaz’s patients tell her. She explains that they aren’t expected to completely cut corn from their diet, but aim for a greater variety of foods. Yet living in a household of nine people—including three growing boys, she is aware of the limited options available. Fruits, vegetables, meat, and dairy are hard to come by, or too expensive. “We have to eat a lot of tortillas to get full.”

Diabetic patients also can’t understand how they have azúcar—or sugar, what they commonly call diabetes—when they never drink Coca-Cola. Soda is a luxury they simply can’t afford; they might drink one a year around the holidays. So Díaz explains how sugar is inherently part of their diet, especially when they rely on foods like processed corn flour in times when corn stocks disappear. “That opens their eyes a lot,” she says. “And that’s why I like this program, because you go along waking people up to how to take care of their health.”

Díaz takes the same information she learns in PIH trainings and applies it to how she cares for her own family. She now cooks with less salt and sugar, but doesn’t skimp on healthy fats for her growing boys. Her mother has high cholesterol and her grandmother hypertension, so she keeps an eye on their health too. And she’s ever vigilant of how depression sneaks into the lives of her friends and, quite possibly, up on her.

A dark time

Although Díaz has a ready smile and a chatty demeanor, her eyes glint with steely determination. Her slender frame and veiny arms belie that she’s never been a stranger to manual labor. As a teenager, she met and fell in love with a man whom her father detested. Against her family’s wishes, they ran off and got married. They lived in Tuxtla-Gutierrez, the capital of Chiapas, where they both worked and lived in a modest, but comfortable, home.

Then the drinking and beatings began. For 11 years and through the birth of three children, Díaz says her husband drank away his salary and insulted, hit, and locked her outside their home. He destroyed every possession she owned. And then he tried to kill her.

“He was choking me one day,” Díaz remembers. “The first thing that I thought was, ‘My sons, my sons! What am I going to do?’” She summoned all her strength and fought for her life. “I tore away from him by giving him a kick in the genitals and that was what I used to defend myself.” While he was doubled over, she grabbed her sons and fled to the outdoor patio. She didn’t know what was going to happen, but she knew they were safe under her neighbors’ watchful eyes.

The first thing that I thought was, ‘My sons, my sons! What am I going to do?

For several weeks, Díaz and her sons stayed with extended family while she decided their next move. “I had some savings, but I didn’t know how I was going to survive with that little bit of money,” she says. “I had no other choice but to call my father and ask for his forgiveness. Fifteen days passed, no one answered me. Nothing. I was suffering, and then resigned myself to the fact that I was going to have to stay.

“But then one day, out of the blue, my father arrived with a three-ton truck and he said to me, ‘Come on. Let’s go. Right now,’” she recalls, her voice and composure barely wavering. “I was so happy that my father had arrived, that he had pardoned me, and that I could live in my house again.”

Her motor

Before leaving for work at the nursery, Díaz irons her sons' school shirts over a blanket on the cement floor.

For two years, Díaz worked an hour away in Jaltenango while her family took care of her sons back in Reforma. The separation was torture, but it was much more bearable than the hell she had lived in Tuxtla. In a sign of reconciliation, her father gave her one of his cows, as he had done with all his children. The thought of the gift brought tears to her eyes. That cow was her ticket to freedom, and she used it as a line of credit to buy land and build her own house down the road from where she grew up. After seven long years of hard work and sacrifice, the house will soon be move-in ready.

She thinks back to those lost and lonely years and is grateful to have survived. Most days are still hard. Her extended family makes demands she can’t always fulfill. Her boys are mischievous and entering their defiant teens. That’s one reason her community health work is a welcome diversion. “I get to be worried about other people,” she says, “and I forget about my situation for a moment.” She knows her past helps her support other women struggling in abusive relationships or difficult circumstances. After hearing her story, some have even told her, “’If you can do it, why can’t I?’”

They are my motor, they are the ones who move me.

Díaz shared this while sitting, slightly slumped, in the Reforma clinic. She had worked for more than six hours at the nursery before walking back home in the blazing noonday sun and collapsing for a nap. The sun was now finally losing its intensity as it slipped over the crest of the western mountains, bathing the town in a soft, rosy light. Dozens of women sat listening to a local official giving an update about Prospera, a government assistance program, under the clinic’s covered patio. The speaker’s voice mingled with children’s cries, filling the silence left in the wake of her story.

It was a rare moment to see Díaz sitting still. Up until now, it seemed she has been in constant motion, propelling herself and her family forward every day by sheer strength and will power. When asked what keeps her going, she didn’t hesitate.

“My sons,” Díaz says. “They are my motor, they are the ones who move me. Every action I do, that’s why I do it. Even though many people tell me, ‘Don’t work so much!’” They tell her to get herself a husband who will take care of her. Her sons, they say, will only grow up, get married, and leave her without a word of thanks.

Díaz doesn’t pay attention. Especially on days like this, when she was bone-tired from work and her youngest, Giovanni, ran up to her when she walked into the house. She smiled now, remembering his words: “’Oh, Mommy, you’re home. Did you work hard today, Mommy?’ Then he gives me a kiss. Those are the moments when I say to myself, ‘This is my son.’ And I feel happy.”

Partners In Health laid the first stone yesterday for the Center for Global Health Delivery, a three-story facility on the northern outskirts of Lima, Peru, that will be a hub for treating patients with multidrug- and extensively drug-resistant tuberculosis (or MDR- and XDR-TB). The center, which may be complete by the end of 2017, will also serve as a training site for health professionals interested in learning the nuances of TB care, as well as a research base for infectious disease experts.

The first floor will house exam rooms and a state-of-the-art laboratory, and the second will house rooms for patients who require hospitalization. The third floor is dedicated to administrative space and may eventually include a suite of operating rooms to handle extreme cases.

“The idea is to make this great complex where we can provide the best standard of care using all of our combined experience,” says Dr. Leonid Lecca, a renowned tuberculosis expert and executive director of Socios En Salud, as PIH is known in Peru. “We can then say to the world, ‘Here, all TB patients are cured. Here no patient abandons treatment.’”

The center’s construction couldn’t come at a better time. In 2014, TB outpaced HIV as the most deadly infectious disease worldwide—that despite the fact it is completely curable.

PIH staff in Peru know this, and have been battling the disease for years with impressive success. Since the mid-1990s, in collaboration with the Ministry of Health, they have treated more than 10,500 patients for MDR-TB with cure rates of greater than 75 percent—well above the global benchmark. Meanwhile, researchers have conducted dozens of rigorous studies and expanded the body of knowledge surrounding TB diagnosis, treatment, and prevention. All of this has been accomplished on a shoestring budget out of a small office in Carabayllo, with support from colleagues at Harvard Medical School and Brigham and Women’s Hospital in Boston.

Yet Lecca knows that much more needs to be done and has been talking with PIH leaders for years about building such a center in Peru. There are simply not enough hospital beds to meet demand among the sickest of the sick, those with XDR-TB. “Patients wait for weeks to begin treatment,” he says.

There are more cases and more need all the time.

Three years ago, Lecca spoke with colleagues at the Ministry of Health and they agreed to have PIH begin treating XDR-TB patients in their homes, the same way PIH staff revolutionized care for MDR-TB patients in the 1990s. Community nurses began making daily visits to XDR-TB patients to ensure they took their medication and had all other needs met. While this freed up hospital beds and put more patients on lifesaving treatment, it also gave PIH staff a glimpse of the epidemic’s severity.

“Ultimately, it wasn’t enough,” Lecca says. “There are more cases and more need all the time.” And so he started dreaming of a center where PIH could offer hospitalization to XDR-TB patients just beginning treatment.

Exam rooms and hospitalization services are key for another reason. As Lecca explains, Peru’s public health care system has begun to refer patients to private third party clinics for specialized care of anything from diabetes to heart disease. Because of stigma surrounding TB and clinicians’ fear of contagion, no private clinic has emerged with a focus in the disease. With no other alternative, patients visit public clinics where there are long waits or limitations in providing care.

“There are many patients now who are not receiving the best treatment,” Lecca says.  

PIH can offer that alternative while partnering with the Ministry of Health. Peru staff know what it means to deliver TB care in the community, collect samples and arrive at accurate diagnoses, select and follow rigorous treatment regimens, and provide all the supporting care patients need. They have achieved all this while caring for the most complex cases, such as drug-resistant TB in children, in HIV-positive adults, and in patients who live on the margins of society.

Thanks to an anonymous donor, Dr. Courtney Yuen (far left), a Harvard and Brigham and Women's Hospital-based epidemiologist, cuts the ribbon to lay the first stone of the Center for Global Health Delivery, while PIH CEO Dr. Gary Gottlieb (from left), PIH Co-founder Ophelia Dahl, Lecca, Carabayllo Mayor Rafael Álvarez, and the Ministry of Health's Dr. Martín Clendenes take part in the ceremony.

If he can manage it, Lecca would like to add surgery to the slate of services available to truly sick patients visiting the center. Roughly 10 to 15 percent of MDR- and XDR-TB patients need to have part of their lungs removed if they have hope for a cure. But for the past two years, not a single patient in Peru has been allowed under the knife. Health workers refused to perform TB-related pulmonary surgery after public hospital staff became infected while operating on a positive patient. The operating room’s negative pressure system, which is supposed to maintain a constant supply of fresh air, was broken and the deadly bacteria easily spread.

Following the incident, hospital staff insisted that proper ventilation systems be installed in all public operating rooms before any further surgeries are performed on positive TB patients. It’s a good idea. But that would require at least $1 million, a sum that simply doesn’t exist in government coffers.

And so many patients are stuck on a waiting list, Lecca says. A third, he fears, have already missed the window of opportunity for a lifesaving procedure.

“It’s not because there aren’t surgeons, because there are,” says Lecca. “The problem is this question of air circulation and infection control that isn’t being resolved.”

And so Lecca dreams of a surgical ward in the new center. “There are a lot of people who need it,” he says. “We can have the key to the operating room and no one can tell me that we can’t operate, because it will be ours.” That same space, he says, can also be used to train the next generation of thoracic surgeons.  

We would have the opportunity to save many more lives.

Beyond serving as a home for TB care and training, the center would also further PIH’s research agenda in Peru. Harvard investigators and Lima-based staff have partnered for years on studies that expanded the medical community’s knowledge of TB prevention, transmission, and treatment in low-resource communities like Carabayllo.

EPI was the biggest such example, having followed 18,500 patients over three years to determine whether MDR-TB is as easily transmitted as drug-sensitive TB. And the latest example is endTB, a project PIH is leading in collaboration with Médecins Sans Frontières, Interactive Research & Development, and financial partner UNITAID in 15 countries with a high TB burden. Patients who have battled drug-resistant TB for years are taking new drugs—the first developed in 50 years—with astounding results. PIH in Peru has already invited 50 patients into the project, with a goal of 420 over the next three years.

Lecca and his colleagues would like to continue conducting cutting-edge TB research in Peru, including testing vaccines and studying transmission. They see the new center as a perfect base of operations for local and international investigators.

Clearly, Lecca is not short on dreams for the new center, and he readily admits it. But who could blame him for dreaming when the stakes are so high?

“We would have the opportunity,” he says, “to save many more lives.”

Throughout the month of September, Partners In Health is celebrating the birthday of beloved children's author Roald Dahl, who would have turned 100 on Sept. 13. His daughter, Ophelia Dahl, is one of PIH's co-founders. She spoke with us live on Facebook last week about what it was like to grow up with her father, and how he had an impact on the path she chose.

“When you grow up with someone who has that kind of an expansive imagination, it feels like the normal thing," she said. "It sets you up to be able to imagine better things for other people."

Ophelia Dahl helped to found Partners In Health after traveling to Haiti to volunteer in 1983, with encouragement from her father. He became one of PIH's earliest supporters.

“He believed very, very strongly that everyone deserves access to modern medicine," Dahl said of her father.

Roald Dahl is the author of James and the Giant Peach, Matilda, Charlie and the Chocolate Factory, and many other books.

Watch the full interview here.

To celebrate what would be Roald Dahl’s 100th birthday, bakeries and ice cream shops across the United States have created “Dahlicious Delights,” inspired by characters in Dahl’s many books. Throughout the month of September, a portion of the proceeds from the sale of these treats will benefit Partners In Health.  Learn more about all the #RoaldDahl100 celebrations happening throughout the United States here.

Find a participating Dahlicious Delights vendor in your area:

Ample Hills Creamery, New York City, NY: Apple cider ice cream inspired by Fantastic Mr. Fox
Baked, New York City: Lavender and Miss Honey’s Cupcake
Baked Ideas, New York City: Cookies inspired by The BFG, Boy, Matilda, and The Twits
Coolhaus, Los Angeles, Dallas, New York City:  Bruce Bogtrotter chocolate ice cream
Craftsman and Wolves, San Francisco: Miss Trunchbull’s Chocolate Cake
Doughnut Plant, New York City: Mini Giant Peach cake doughnuts with magic green crystals
Flour Bakery and Café, Boston: Hornets stewed in tar, inspired by James and the Giant Peach
Four and Twenty Blackbirds, New York City: James and the Giant Peach Pie
JP Licks, Boston, MA: Frobscottle ice cream inspired by The BFG
Knuckle and Claw, Los Angeles: Mrs. Twit's knuckle roll
Milk Jar Cookies, Los Angeles: James and the Giant Peach cookie
The Pie Hole, Los Angeles: Miss Honey Pie and The Witches Poisoned Pie
Union Square Donuts, Boston: Apple and bacon fritter doughnut inspired by Fantastic Mr. Fox
Voodoo Doughnuts, Portland, Eugene, Denver, Austin: Assorted doughnuts

An insistent beep, beep, beep filled the neonatal intensive care unit at University Hospital in Mirebalais, Haiti. It came from an alarm on a CPAP machine regulating the breathing of a premature infant in one of the ward’s incubators. A nurse approached the machine and checked the settings, but the beeping persisted.

Lauria Cadet, the hospital’s 29-year-old nurse educator for pediatrics and neonatology, appeared at the nurse’s side. She noticed that the infant’s temperature had plummeted and that the machine’s oxygen level wasn’t right, triggering the incessant alarm. In a few quick motions, she showed the nurse how to fix the situation. Soon, the tiny patient’s temperature rose, silencing the machine.

Last year, Cadet had learned how to respond to situations like this during a neonatal and pediatric intensive care training sponsored by Zanmi Lasante, as Partners In Health is known in Haiti. Over the course of 24 weeks, she was among 25 nurses who acquired the skills necessary to take care of the tiniest, most fragile infants at University Hospital.

Cadet then passed along that knowledge. From January through July, she helped mentor and teach PIH’s second class of NICU/PICU nurses recruited from hospitals across Haiti. These 26 men and women, hand-picked by the Haitian Ministry of Public Health and Population, graduated in late July and received a government-sponsored certification in recognition of their efforts. They have since returned home to hone and share their newfound skills.

To nurse leaders like Cadet, the training is invaluable: “It will benefit not only the patient, but also the nurse and institution.

Watching her work with patients and staff, it’s hard to imagine Cadet as anything but a nurse. Yet the profession was not her first choice. A lover of math, physics, and chemistry, the Cayes native dreamed of becoming a civil engineer in her community along the southern coast. Her mother had other ideas. Tuition for nursing was much more affordable, so she pushed her daughter to pursue the career against her wishes.

Cadet was in her second year at the National Nursing School of Cayes when her father mysteriously fell ill. He started driving four hours, one way, to Port-au-Prince to visit doctors in search of answers, and his daughter often accompanied him.

“We went to five different hospitals hoping for a diagnosis, but were never given one,” Cadet said. The young nurse thought her father might be suffering from tuberculosis or pneumonia. She talked to him about his illness, bolstered his hope, and encouraged him to keep taking his medication. Finally, at the capital’s TB sanatorium, they learned he had lung cancer.

“My dad died in May of 2010,” Cadet said. “It was too late for the doctors to do anything for him.”

I needed to continue this work, because people needed my help.

Caring for her father made Cadet appreciate the value of her new profession, and small encounters during her clinical rotations reinforced her sense of purpose. One patient from her early years of nursing school stands out in her mind. The woman was in a “horrible state,” Cadet remembered. Her catheter hadn’t been changed. She hadn’t been bathed in four days. And her hair and teeth hadn’t been brushed for likely as long. The young nurse carefully washed her, brushed her teeth and hair, and changed her clothes and bed sheets.

“It was then when I realized I needed to continue this work, because people needed my help,” Cadet said. “I learned the importance of nursing; it’s not about me, it’s about my patients.”

After graduation, Cadet worked as a mentor and teacher at her alma mater. She then moved to various hospitals across Haiti to do the same or to provide care for mothers and newborns. In March 2014, she began working at the PIH-supported University Hospital as a nurse educator and quickly became an invaluable member of the team.

Cadet changes the IV on an infant who was born the day before with hypoglycemia.

Cadet appreciates the opportunity PIH provides her to grow and excel. She picked up a number of skills through last year’s NICU/PICU training, from how to resuscitate children and work the CPAP machine to how to properly use an IV pump and care for newborn sepsis patients. She started incorporating simple tasks into her daily routine, like pressing babies’ diapers to ensure the infants were hydrated and urinating regularly. And she learned the importance of including parents in patient care. When babies are hypothermic, she encourages parents to snuggle them close and use their own bodies as a source of heat. This “kangaroo care” method helps the child’s temperature return to normal.

“We are trying to practice these new methods regularly so it is not only standard, but second nature and systematic,” said Cadet, referring to neonatal and pediatric nursing staff at University Hospital.

Cadet was among a select group of national and international staff who organized and led this year’s NICU/PICU training. She helped facilitate sessions, translated for English-speaking instructors who weren’t well-versed in Krèyol, and supervised nurses as they practiced what they had learned in University Hospital wards.

She takes pride in seeing the nurses master new techniques: “I love working with other people; I like to help them become better and more skilled in what they do.”

In a report from NPR, PIH senior health and policy advisor Dr. Louise Ivers voiced her concern that Zika may be spreading across Haiti—and going undetected because of the country’s limited health care infrastructure.

"We don't have a good idea of what's going on. Now that we've seen three babies born [with microcephaly] in the span of three weeks in our own facility, we are very concerned that it's being under-reported in other parts of the country," she says.

Read or listen to the full story.

Ambassador Samantha Power
U.S. Permanent Representative to the United Nations
The White House
1600 Pennsylvania Avenue, NW
Washington, DC 20500

Dear Ambassador Power:

The worst ongoing cholera epidemic in the world has killed nearly 10,000 people in Haiti since October 2010, and it shows no sign of stopping. Now that the United Nations has acknowledged its role in bringing cholera to Haiti, it is time for the U.N. to act.

We know how to eliminate cholera and prevent further transmission. In 2012, Partners In Health and our colleagues in Haiti developed a pragmatic plan that includes treat ing those who are ill, widespread vaccination, water and sanitation system improvements and hygiene education. We have demonstrated that these measures work on a small scale, but funding for a nationwide effort has been lacking. Meanwhile, even now, thousands more Haitians are becoming sick and dying from a preventable disease.

We respectfully request the United States Mission to the U.N. to press that body to take responsibility for the cholera epidemic by funding a comprehensive plan to eliminate this devastating scourge.

Elimination of cholera in Haiti should be a top priority for U.S. Western Hemispheric policy. Allowing the epidemic to p roceed unchecked is setting back other important U.S. humanitarian and development goals in the Caribbean Basin.

Thank you for your consideration of our views.

Sincerely,

Gary Gottlieb, MD
CEO, Partners In Health

Sign the petition to the U.N.

In a letter to The Washington Post, Partners In Health's Dr. Louise Ivers responds to last week's news that the U.N. acknowledged its role in bringing cholera to Haiti. Ivers is a PIH senior health and policy advisor who has been leading cholera treatment, prevention, and control activities in Haiti since 2010.

"The U.N. can save lives, restore goodwill and stabilize the country by financing a plan to control cholera in Haiti," Ivers writes. "Partners In Health supports an ambitious plan to interrupt and stop the spread of the disease using a combination of mass vaccination and household water treatment. If the U.N. follows words with financing, it will be taking very strong steps toward making amends to a country whose people it has harmed. We call on it to do just that."

Read the full letter.

Help Partners In Health urge the United Nations to fund this plan by signing this petition. We will deliver signatures to Ambassador Samantha Power, U.S. permanent representative to the U.N., when the U.N. General Assembly meets in New York in September. 

For more information, read this letter to Ambassador Power from Partners In Health CEO Dr. Gary Gottlieb.

Sign the petition to the U.N.

Last week, the United Nations acknowledged its role in the outbreak of cholera in Haiti, which began in October 2010. Since then, the epidemic has killed nearly 10,000 people; hundreds of thousands more have become seriously ill.

And it’s not over: There have been 26,000 reported cases of cholera in Haiti so far this year.

The U.N. plans to present its cholera response plan in two months, but people are dying now. Please help us fight this epidemic today. Your gift will help us care for cholera patients, support vaccinations, increase our water, sanitation, and hygiene (WASH) efforts, and improve infrastructure to provide safe drinking water for more people.

Want to know more about our efforts?

Sign up to receive updates by email

PIH has worked alongside Haiti’s Ministry of Health from the beginning of the outbreak. We have treated more than 145,000 people for cholera and led a successful campaign to vaccinate 45,000 people in 2012, which reduced the number of cases among those vaccinated by 65 percent. We have also carried out comprehensive prevention campaigns.

Check out these articles to learn more:

“U.N. Finally Admits Blame in Haiti Cholera Outbreak”: an interview with Dr. Louise Ivers, a PIH senior health and policy advisor who has led cholera treatment, prevention, and control activities in Haiti since 2010. 

“Cholera Vaccine Succeeds in Haiti” covers the successful oral vaccine campaign Dr. Ivers and colleagues led to slow the spread of cholera in 2012, the details of which are published in The Lancet. 

“Safe Water, Access to Sanitation, Key to Kicking Cholera” looks at some of our efforts to prevent cholera.

“A Chance to Right a Wrong in Haiti”: a Feb. 2013 New York Times op-ed by Dr. Ivers on why the U.N. has a moral obligation to solve a problem it created.

“The Cholera Outbreak, Three Years Later” is a reflection from Dr. Charles Patrick Almazor, who treated some of the first cholera patients in 2010.

Every Partners In Health patient has a story to tell. We take pride in telling the stories of our patients, doctors, community health workers and more through respectful and ethical photography. Here, PIH employees tell the stories behind photos they’ve taken at our sites around the world.

Mtemankhawa, Malawi, April 2014
“Showing the true nature of poverty through photographs is impossible; however, there are rare photographs that capture, at least as best as an image can, an authentic moment from someone’s life or community. The many fabrics drying on the grass show the richness of Malawian/Mozambican style. As an aside, I also love that this photo shows how clean this community is. The narrative that is often applied to places where PIH works (poor countries and poor communities) is that there is less emphasis on cleanliness, which is absolutely untrue.” – Jon Lascher

Mtemankhawa, Malawi, April 2014
“Showing the true nature of poverty through photographs is impossible; however, there are rare photographs that capture, at least as best as an image can, an authentic moment from someone’s life or community. The many fabrics drying on the grass show the richness of Malawian/Mozambican style. As an aside, I also love that this photo shows how clean this community is. The narrative that is often applied to places where PIH works (poor countries and poor communities) is that there is less emphasis on cleanliness, which is absolutely untrue.” – Jon Lascher

Chifunga, Malawi, July 2015
“Malawi clinical team member Sitalire Kapira was training village health workers at a quarterly family planning refresher training. These trainings help our village health workers brush up on the latest skills and health messages so they can be a link between the community and the health facility.” – Jeanel Drake

Bobete, Lesotho, June 2014
“A small aircraft was being used to transport patients out of Bobete Health Center in the mountains of Lesotho. This referral system can be life-saving in a setting where there is no other means of getting to the next level of care.” – Jeanel Drake

Bobete, Lesotho, March 2016
“This is a patient [Mahlakela Letima] who lives in a community where we work, probably one of the most remote places that Partners In Health works. He was feeling ill at one point several years ago, came to a Partners In Health clinic that was newly established in his village, and was diagnosed with HIV. He went on treatment and is doing well. He had come back on this day to thank Partners In Health for helping him build a house, where he now lives with his family and HIV-negative children.” – Rebecca E. Rollins

Bobete, Lesotho, March 2016
“This woman [Matlhokomelo Shoqo, left] lives in the mountains of Lesotho, delivered her baby safely at the clinic, and is about to walk home the day after. She’s placing a blanket over the shoulders of her birth attendant, who works for Partners In Health and is responsible for bringing all the pregnant women from her village to the clinic to make sure they get care. She attended this woman’s birth and is helping her get back to her village. Underneath that blanket is the baby. They’re about to walk several hours into the mountains the morning after the birth.” – Rebecca E. Rollins

Maseru, Lesotho, June 2014
“A data clerk, Ntseliseng Mabitle, was working in the lab at the TB clinic in Maseru, Lesotho. I was in Lesotho on a cross-site learning visit documenting and sharing best practices between Lesotho and Malawi.” – Jeanel Drake

Mirebalais, Haiti, January 2014
“This is Paul Mainardi. He was telling us stories about his mental health issues, which began as a young adult, and how he was really shunned by his community because of his increasingly disturbing behavior. He’s the tall person in the center, he’s actually walking next to and with some of our clinicians who helped him get medication. He’s stable now, runs a radio program in central Haiti, and is just a really wonderful person.” – Rebecca E. Rollins

Mirebalais, Haiti, May 2015
“This image was taken in Haiti. It’s a couple of clinicians who are actually in a larger circle, hands held in prayer, as they are about to perform surgery on a pair of conjoined twins at University Hospital in Mirebalais, which is the Partners In Health-supported hospital in central Haiti. These are surgeons; you can see the glasses that are worn to do very small work on very small patients.” – Rebecca E. Rollins

Mirebalais, Haiti, September 2015
“These are the twins (left and center) who were separated during that surgery. There were triplets born, two of the triplets were conjoined, and they were successfully separated at University Hospital in Mirebalais by a team of surgeons that came from all over the country and joined the team in Mirebalais, Haiti. This is their mom, Manoucheca [Ketan], who is trying to juggle them while I’m photographing. She just slipped and almost dropped one of the triplets. So that’s a shot between the shots.” – Rebecca E. Rollins

Lascahobas, Haiti, April 2016
“We were coming back from a home visit of a malnutrition patient and her grandmother. It sounds like a nice easy walk, but in reality was more of a vertical hike. The woman in the orange, Sabrina Joseph, is a community health nurse. Not only did she check in on the patient, but she made sure all of us were able to cross the stream safely. She was on one side and community member Lucien Jeun, the woman in black, stood on the other side making sure we didn’t fall. I was the last person to cross, and then Sabrina had to get herself over. It shows how far our staff will go to make sure they reach our patients, and how wonderful they are to make sure everyone else is OK.” – Cecille Joan Avila

Cange, Haiti, March 2011
“After playing for crowds of 100,000 people in cities around the world and winning the Grammy for album of the year, Arcade Fire flew to Haiti and played the first ever rock concert in Cange. And they were the openers. They played bathed in flood lights on a makeshift wooden stage in front of PIH’s warehouse. The crowd was a mix of patients and community members who had largely never heard their music. But by the time the band played “Power Out,” we could barely see the stage as the crowd was surrounded in a cloud of dust kicked up from all of the jumping. R.A.M., a well-known band from Port-au-Prince, followed Arcade Fire and the celebration continued for hours. It was like a mini-Coachella in Cange, which was badly needed following the earthquake and cholera outbreaks.” – Jon Lascher

Burera District, Rwanda, February 2015
“I was spending the day with the mental health MESH team. It’s always easier on the patient if you start out in the room and introduce yourself before the consultation starts and ask for permission to sit in, so you don’t intrude right in the middle. This was between patients and I was crammed in the corner of this tiny room trying not to get in the way of things. I just really liked the light coming through the door.” – Cecille Joan Avila

Rwinkwavu, Rwanda, August 2013
“I was with one community health worker who took me out to the home of a woman we’ve been working with named Constance Mukamunana. She told me a story about what seemed like a previous life time. She was living in Tanzania and was very ill, had a husband, and lost her first child to HIV. She came to Rwanda very, very sick, got on treatment, was able to get better, had more children—all healthy—has a house that Partners In Health helped her secure, and a job. She’s expressing her gratitude to a community health worker, who works with Partners In Health. We sat down and had an interview. This is just a sweet moment on our way out. A sweet, authentic moment where you can see the relationship between two people who live in the same space, had very different experiences, and now clearly have a relationship that will go on for the next several years as well.” – Rebecca E. Rollins

Bong, Liberia, October 2014
“This was one of my first trips to an Ebola Treatment Unit. Learning about things like how the boots of the clinicians, who were actually working in the units and treating patients, needed to dry because everything was sprayed with chlorine. It was a highly infectious area, and there were rubber boots drying in the sunshine between shifts of folks working in the treatment unit.” – Rebecca E. Rollins

Port Loko, Sierra Leone, January 2015
“This was an image I shot in a triage unit, which is basically the emergency room section of an Ebola Treatment Unit. On the left is one of our docs, Dr. Dana Clutter. The woman on the right came in and received her initial care and then was taken off into the unit.” – Rebecca E. Rollins

Freetown, Sierra Leone, September 2015
“Yabom [Karoma] lost two of her very young children (a 4-year-old and a 5-year-old), her husband, and her father-in-law during the Ebola crisis. And then, after caring for them and losing them to Ebola, she was transferred to an Ebola Treatment Unit in Freetown, Sierra Leone. This was taken about a year later. I was able to visit Yabom’s home and her neighborhood. Over in the edge of the image is her grandson and another child who did not get sick during the crisis. Yabom was delighted to have us at her home and to be able to celebrate her recovery and really be able to share her life as a healthy, working person back in the swing of things.” – Rebecca E. Rollins

Freetown, Sierra Leone, December 2015
“At the base of the hill below Yabom’s neighborhood along a main street, there was a tiny tin hut. I was waiting for our driver to come back and pick me up. I peered into this hut, and there was a guy there who’s a tailor and was making and repairing clothing. He’s got a measuring tape around his neck, and an old sewing machine is in the foreground. I leaned in and he nodded that I could shoot. That’s him with all of his beautiful Sierra Leonean fabric making beautiful clothing. Again just a day in the life of somebody who’s working in the Mountain Court neighborhood of Sierra Leone.” – Rebecca E. Rollins

Lunsar, Sierra Leone, December 2015
“One of my favorite days in Sierra Leone was spent in Lunsar, a town with a long history of injustice. In the last two decades, Lunsar has been ravaged by war, a mining industry, and an Ebola outbreak. As part of PIH Sierra Leone’s education initiative, adult Ebola survivors were enrolled in literacy classes. On the day I took this photo, I visited four such classes. Kadiatu Kanu (left) had just returned to her desk after successfully writing her name on the blackboard. She was beaming at the board, absorbing praise as her classmates applauded her progress. When Kadiatu returned to her seat, she opened her notebook to show off her work. This is one of my favorite photos taken in Sierra Leone. I try and fail to Imagine the difficulty confronting Kadiatu. She survived Ebola, and is managing the ensuing health complications. She makes money anyway she can. She has to buy food and school uniforms for her family. Despite all of the forces that would stand in the way of her education, she is in that classroom, learning to read and write. That kind of commitment to education is universal, and is especially pronounced in places that have been deprived of opportunities for so long.” – Jon Lascher

Chiapas, Mexico, March 2014
“This is one of the young docs who works with us. His name is Eduardo Peters. In Mexico, a lot of the folks who work with us are pasantes, young doctors who graduate from medical school and basically volunteer to go into the community for a year. Partners In Health is delighted to have them working with us in the clinics we support in some of the most remote places in Chiapas, Mexico. And that’s where Eduardo was in this shot. He was living in the community, working in the community, and quite a beloved member of the community in Chiapas.” – Rebecca E. Rollins

Navajo Nation in New Mexico, April 2012
“Marie Begay is one of the longest working community health representatives in Navajo. On this day, she invited me to come with her and drive around in her truck. She’s checking on people who have heart disease, diabetes, and hypertension, which are all big issues in Navajo. This person wasn’t home, so she’s leaving them a note saying, ‘I’ve been around, I’ll be back around again,’ and just letting folks know that she’s there supporting them. In fact, as we drove away from this home, they were coming up the road, and we were able to stop and have a conversation with them. Marie is just one of almost 14,000 community health workers Partners In Health works with around the world. We’re very proud to have them at the core of our mission.” – Rebecca E. Rollins

Navajo Nation in Arizona, May 2015
“A PIH writer and I were hanging out with a community health representative during her rounds, when we pulled up in front of a patient’s house to see if they were home. All of a sudden, these dogs came out of nowhere, which was amazing. As I tried to get out of the truck, they were just running by my feet, seeing what we were up to.” – Cecille Joan Avila

Photo information.

Marina López held her 3-year-old son, Wilmer Godínez, snug in her lap. The boy’s spiky black hair and worried eyes peered out from the gray woven cloth in which he was wrapped. It was difficult to tell who was more nervous as the mother and son sat in Dr. Martha Arrieta’s tiny, sun-splashed exam room in Monterrey, Chiapas.

Arrieta, a 25-year-old doctor dressed in jeans and a red hooded sweatshirt, sat an arm’s reach away and gently peppered the young mother with questions. Responses came back in halting Spanish, clearly not her first language. The family was among a group of Guatemalan migrant workers who traveled to Chiapas to help with the coffee harvest. They had walked at least two hours to get to this remote clinic atop the Sierra Madres.

Wilmer had been suffering from diarrhea since yesterday morning, López said. He’d gone to the bathroom six times in two days. Although he didn’t have a fever, he refused to eat or drink—a problem for any child, but especially one who was clearly small for his age.

When it came time for the exam, Wilmer clung to his mother and whined. Arrieta spoke to him in a soothing, playful tone, which made him relax long enough for her to finish the exam. She handed López two boxes of medication—one to reduce any future fever, and the other an antiprotozoan (assuming the reason the boy had diarrhea was due to contaminated drinking water)—and carefully explained how to deliver the drugs. Then she repeated her instructions, using even simpler Spanish.

“Whatever you need,” Arrieta said before the two left, “I’m here to help.”

Arrieta is among a group of 11 doctors fulfilling their social service year with Compaňeros En Salud, as Partners In Health is known in Mexico. She had only been working two months in Monterrey at the time of the mother and son’s visit. Yet it had been a wild ride so far. She had helped a teenage mother deliver her baby, patched up car accident victims, grieved the death of an elderly cancer patient, and sent two other patients down the mountain—a three-hour ride by car—to receive specialized care for a miscarriage and a severely mangled finger.

Her PIH supervisors assured her this was not typical. But what is typical in a community that hadn’t received regular, high-quality health care until recently?

Working in rural, marginalized communities was nothing new to Arrieta, who had volunteered with other social justice organizations. “I saw that each lacked a lot of things, but something they lacked was really central, and that’s good health,” she said. “If people aren’t healthy, you can’t ask them to learn or think differently, or not to drink alcohol, or that they imagine or write.” So she decided the best way to truly help would be to get a medical degree and to use it where it was most needed.

My entire medical training was in preparation for this year.

Arrieta fell in love with rural Chiapas during her first year of medical school while vacationing there with family. (Her father had grown up in Tuxtla-Gutiérrez, the southern state’s capital.) In her fifth year, she took a residency in a provincial hospital, where she knew resources and staffing would be limited, so that she could get the most hands-on experience possible.

Meanwhile, she contacted colleagues working with PIH as first-year doctors, or pasantes, to see if that was the best fit for her government-required social service year. They described the experience as culturally immersive, challenging medically, and personally enlightening. Good health, they learned, is not just about having access to clinicians and medication; it’s also intimately linked to food, housing, employment, the environment, and a myriad of other factors—all of which combine to make providing health care in poor communities a challenging endeavor.

Arrieta was sold. She applied and was one of four from her university to win a coveted spot.

“My entire medical training was in preparation for this year,” she says.

But as much as Arrieta prepared, nothing could match the reality of being a community’s sole doctor. She learned that lesson her first day on the job, when a little boy arrived to her clinic with a dislocated elbow. If she had been in a hospital, she would have sent him to orthopedics for an x-ray and to have it set. But such a call in Monterrey would have required long-distance travel. She’d need to find someone with a car to drive him and his family there. Or she’d have to ask them to walk three hours down a steep, winding dirt road to the nearest community with regular transportation, where they would then hitch a ride to a hospital in the valley.

Arrieta turned for advice to Dr. Fátima Rodriguez, her PIH predecessor who was staying for two weeks to smooth her transition to the community.

“'They can’t go down,’” Arrieta remembered Rodriguez telling her. “And I said, ‘Well, in theory, I can fix it.’"

“'So do it.’” Rodriguez had told her.

While Rodriguez held the boy steady, Arrieta grabbed his arm, said a quick prayer, and yanked. The boy’s elbow popped back into place.  

Health is a human right and it should be universal. Here, the people don’t live that.

Arrieta’s learning curve has been steep ever since. She credited Rodriguez and PIH supervisors for shepherding her through tough spots, either virtually or through regular visits. International residents— such as Dr. Elisabeth Poorman from Cambridge Health Alliance, who stayed with her for two weeks in March—have provided further mentoring. And end-of-the-month seminars in Jaltenango, PIH’s headquarters in Chiapas, are opportunities for her and other pasantes to troubleshoot particularly tough cases and discuss how medicine and social justice are intertwined.

Ultimately, she said, “you learn from practicing and applying medicine.”  

And that’s something she does 24 hours a day, seven days a week. “In the beginning, patients arrived and knocked on my door at 10 p.m. and said, ‘Ay, my fingernail hurts,’” Arrieta joked. “So you have to draw the line and say, ‘Look, if it’s an emergency, I’m never going to deny you care. But if not, then go to the clinic during visiting hours.’”

One saving grace is that Arrieta lives with the family of Doňa Anastasia López, one of two remaining traditional midwives in Monterrey. The family buffers late-night requests, and also provides a home-away-from-home filled with children, laughter, and companionship. “Isolation can weigh you down” she said. “I really miss my family. Having the children here helps me a lot.”

Many pasantes use their social service year to decide on next career steps. Arrieta doesn’t think medical specialization, the path most traveled, is for her. One thing she does know for sure, though, is that she despises how medicine is practiced in hospitals. “I don’t like to be closed up in a hospital; I don’t like to have 10 minutes for each patient.” She thinks the Mexican medical system is broken, because it focuses too often on caring for chronic patients and too little on prevention and primary care.

“Family and clinic doctors are only there to hand out medicine,” she said. “There isn’t a relationship with the communities or with the patients, because you have 50 patients to see every day.”

There has to be another way, Arrieta said, and she wants to help find it. A master’s degree in community development and health seems to her like a logical next step. What she has seen so far confirms her belief that “health is not a privilege,” she said. “It’s not something that should be reserved for people who can pay for it or live in the cities. Health is a human right and it should be universal. Here, the people don’t live that.”

Now that’s changing, with Arrieta and PIH.

Dr. Martha Arrieta listens to the heart of Rolando Morales, who lost sight in his left eye 10 years ago.

Her last patient of the day walked into her exam room. He wore dusty sneakers, was missing a front tooth, and had pulled a black cap over the left side of his face.

Rolando Morales, 36, slumped in the chair next to Arrieta, who asked him how she could help.

“I came so that you could bring me back my sight,” Morales said, pulling off his cap to reveal a milky blue cloud where his left iris used to be.

Ten years ago, he explained, someone sliced his eye in an accident on el otro lado, or “the other side.” (That’s what he and other migrant workers call the United States.) He went to a local emergency room, but all they gave him were eye drops and told him he’d completely lost vision in his left eye.

Arrieta had him sit on the exam table and shone a light directly into the damaged eye. “Negro” was all he saw, but she noted that his retina still looked intact. He knew it was highly unlikely he’d see again, but was hoping to get a prosthesis. Ashamed of his appearance, he always wore a cap to mask his eye.

“Whenever I walk down the street, people think that I’m a bad person,” Morales said. “I don’t want to be this way.”

Arrieta explained that, with her PIH colleagues’ help, she could get him an appointment with an ophthalmologist in Tuxtla. He would have to gather proper documentation to apply for seguro popular, government-provided health insurance. Once he did that, it still might take some time, since there was only one ophthalmologist in Chiapas. And surely there would be a long waiting list. But would he like to try?

Morales’ shoulders relaxed and he flashed a crooked smile. “A lot of time has already passed,” he said. A few months was nothing compared to 10 years of partial blindness and social isolation.

Arrieta nodded knowingly: “We’ll see what we can do.”

A year ago this month, Partners In Health was settling into its work in Liberia, helping to rebuild health care in the far southeast. Ebola was over. Staff and patients’ lives were looking brighter. Everything was falling into place. Except for the smallest little detail. The Formica-topped desks that PIH’s infrastructure team bought in the capital city of Monrovia were delaminating.

“It was just horrible,” says architect Christine Lara, director of infrastructure at PIH/Liberia. “We went to see about a refund and the shop owner assured us that the desks were ‘really good quality.’” In other words, there would be no refunds.

She and Operations Project Manager Sulaiman Nazier scrambled to find replacements. They visited more stores and a dozen woodworking shops and looked into wholesale imports from the United Arab Emirates. But nothing affordable would stand up to the onslaught of equatorial heat and humidity.

With the clock ticking, they decided PIH would make its own furniture. Near the facilities that needed it. And the stuff would rock. “We want things that are going to last at least as long as Partners In Health is in Liberia,” Lara remembers thinking. “We don’t want to do this again.”

They won’t have to. Fast forward a year. At the base of J.J. Dossen, an 83-bed hospital in the southeast, is a low-slung tin-roofed building with bay doors. Gospel or Senegalese hip-hop plays from a small boom box. Off-duty nurses and maintenance guys hang around shooting the breeze. And three craftsmen covered in sawdust—Ebeneser W. Sieh, Amowzeu K. Vanentin, and Daniel Kakpo—crank out custom-made furniture with noisy jig saws and disc sanders, to standards not seen elsewhere in West Africa, and at lower prices.

Their joined, stained, bespoke desks—built by Liberians from sustainably harvested Liberian wood—cost just $200 each. The flimsy, mass-produced desks bought in Monrovia had cost $300.

“Infrastructure has a maintenance team, an electrical team, a water collecting team, and a biomedical technician,” says Lara. “The woodshop is the coolest.”

How the five of them were able to pull this off has much to do with verve. Last August, a few days of legwork turned up no wood that wasn’t ethically suspect, no boards that could be guaranteed not to come from some poor guy hacking down an ancient Bubinga tree. So after some challenging moral calculus, Lara and Nazier settled on kiln-dried lumber from multinational Firestone Natural Rubber Company, which had recently begun harvesting, milling, and replanting rubber trees after the taps ran dry (rather than burning and replanting the trees).

Then they had to hire master craftsmen. Not surprisingly, many of the men wielding hammers and hand-planers on the side of the road focused on offering good value in a low-price market, not legacy-level quality. Lara and Nazier asked around. Word spread. In the middle of the month, they invited six carpenters to show off their skills by making a box. 

It was obvious who had “the hands for the craft,” says Nazier. Sieh, 28, a single guy who had worked in his father’s wood shop since he was a teen; Vanentin, 32, a part-time carpenter with a sharp eye for details; and Kakpo, 35, a churchly father who owned his own woodshop, were clear standouts.

Vanentin accepted Nazier’s offer without hesitation. “I’m so proud that PIH is here to help,” he says. Enticing Sieh and Kakpo proved more difficult. “I took the job because even if it’s not too much money, I can improve my skills,” says Kakpo.

In less than a week, they built out the woodshop and got busy learning new techniques. “I trained them every day for a month,” says Nazier. “It was quite strenuous.” Two of them had never used power tools and all of them needed to learn the basics of precision woodworking, he says. 

PIH woodworkers Ebeneser Sieh, Amowzeu Vanentin, and foreman Daniel Kakpo pose in the woodshop below J.J. Dossen Memorial Hospital on April 18, 2016. Photo by Eric Hansen / Partners In Health

The guys remember it differently. Nazier simply taught them some European designs and gave them better materials. “The way I used to finish a table was with an overhang, but Sulaiman taught us a new model with no overhang,” says Kakpo. “Also, now we use screws. Nails work, but screws are very guaranteed.”

In September, the three of them switched on the table saws, and working six days a week, their short assembly line quickly produced mountains of stuff—desks, tables, chairs, benches, cupboards, drawers, shelves, trusses, footlockers, molding, frames—all joined, sanded, and stained. The southeast headquarters was fully furnished in two months. A health center not only got the seating it needed, but solid-wood doors and interior trim.

And just up the hill, J.J. Dossen is getting a smattering of typical items, such as wall cabinets and tables, as well as custom pieces to help with a massive renovation that’s under way. The guys are building reception areas, marble-top counters, and benches for the expanding emergency rooms and operating rooms.

Nazier stops by mostly just to say, “Hi.” “They’re incredible,” says Lara. “They’re totally self-sufficient.”

Recently, the Danish Refugee Council, a development organization from the country synonymous with modern furniture, asked if they could place orders, and Lara and Nazier began looking in to selling the furniture in Europe.
“We hope that, through these kinds of sources and other income-generating activities, the infrastructure team could fund itself,” she says.

The guys aren’t waiting around. On their days off, they each work on their own projects, such as Vanentin’s bed, which is made with screws and baseboard overhangs. “I love my cousins,” says Sieh, referring to Vanentin and Kapko. “Thanks god to Christine and Sulaiman.”

Recently, Nazier asked them to make ceiling-mounted channeling to hide lightweight wires in J.J. Dossen. The guys not only did it in record time, they connected the channel’s sides and bottom with indestructible tongue-and-groove joints.

“It’s a little overkill,” says Nazier, clearly proud.

As Partners In Health Co-founder Dr. Paul Farmer reminds us in "The Danger of Ignoring Tuberculosis," a recent article in The Atlantic, we can’t let the Zika virus or other emerging diseases distract us from working to eradicate deadly diseases such as tuberculosis.

In addition to the need for newer drugs and a faster way to diagnose tuberculosis, particularly drug-resistant TB, Farmer stresses the need for the kind of community-based care that PIH builds and sustains around the world -- where community health workers, nurses, and others visit patients regularly to help them stay on course with their TB treatment, which can last up to two years.

“Without community-based care, I don’t see how it can work,” Farmer says. “There’s not a lot of evidence that anything else works. It costs a lot more to give bad care in a facility than to give good care with community health workers.”

Why is it so important that we continue to do the work we do in global communities? Farmer’s last point answers that question best:

“…[T]he history of tuberculosis control is really one of forgetting. This is a transnational disease. So is Zika. So is Ebola. Without investments in the health system, the dream of rounding those last cases up? It’s really not a good dream. It’s more like a nightmare.”

Read the full article here.

Hategekimana Bashar first began suffering from hallucinations and paranoid delusions when he was 26 years old. Dismayed, his family watched his behavior change until he was unable to care for himself, let alone his farm or cherished livestock. They tried to help—they even consulted a variety of traditional healers—but nothing seemed to work. At a certain point, desperate, they had no option but to tie him up at home to keep him from what they felt would be even greater harm.

Relief eventually came in the form of Sifa Dorcas. A year ago, community health workers told Dorcas—the mental health social and community support coordinator at Inshuti Mu Buzima, as PIH is known in Rwanda—about Bashar’s predicament. Dorcas visited Bashar’s family and raised the possibility that Bashar was suffering from a serious mental illness, and that treatment would be able to help him function in the community again. Dorcas accompanied Bashar and his family to Kinyababa Health Center, where Bashar was diagnosed with schizophrenia.

At the time, Dorcas was working with government health center nurses who IMB has trained and supported in delivering mental health care to people living in rural areas. This health center-based model of mental health care is new for the country, started in 2012.

About 1 in 100 people globally suffers from schizophrenia, a biological illness. Per PIH’s model, Bashar and his family received education about his illness, as well as caregiver support, social assistance, and medication support by a public primary care nurse supervised by a psychiatric nurse (both Rwandan Ministry of Health staff) who travels to the health center from Butaro District Hospital, a hospital built by the government in collaboration with PIH.

The improvement was as immediate as it was marked. Within a month, Bashar’s hallucinations stopped and he was able to farm and participate in community activities again.

Such are the transformations that PIH’s mental health team strives for, and sees, daily. While much of the world still, somehow, debates the idea that quality mental health care can be effectively provided to people in poor countries, PIH’s mental health leaders are working with governments to push ahead in treating neuropsychiatric disorders such as depression, schizophrenia, bipolar disorder, and epilepsy.

With the “radical” idea that people have a moral obligation to eliminate suffering when they can, PIH Mental Health Director Dr. Giuseppe Raviola and colleagues are advising dedicated mental health teams at PIH’s 10 partner country sites to develop safe, culturally sound, evidence-based, and dignified programs that focus on integrating mental health care into the organization’s public health systems-strengthening efforts.

That’s no small challenge. “Mental disorders impose an enormous burden on society,” states the overview to “Out of the Shadows: Making Mental Health a Development Priority,” a two-day conference hosted in April by the World Bank, headlined by researchers from institutions such as Harvard University, the World Health Organization, and the United Nations, and featuring PIH’s work in Rwanda, Haiti, and Peru. Roughly three-quarters of people who experience a mental disorder come from poor countries—precisely the kinds of places with the fewest resources available for mental health care. Indeed, in low-income countries, upwards of 90 percent of people receive no care for a treatable illness such as Bashar’s.

It was the high burden of mental disorders coupled with the dearth of psychiatrists and other specialized mental health professionals that caused PIH to begin applying its expertise to mental health care. 

Bashar and Dorcas confer near his family home. A year ago, Dorcas helped Bashar, a farmer who was suffering from hallucinations and paranoid delusions, get his illness diagnosed and treated.

In Rwanda, PIH’s efforts began in 2009 with the establishment of IMB’s first mental health team to support the Ministry of Health’s goal to integrate mental health care at district hospitals. Over the past seven years, the program has grown from a small community education program to a robust team supporting quality mental health care at district hospitals and health centers, with support provided by community health workers.

Each player in this comprehensive system has a key role in helping people such as Bashar to feel better, and in supporting their families. Primary care nurses provide support, medications, and education. Government-employed supervisors travel to the sites to mentor frontline nurses. Community health workers support family caregivers and help people access care.

The IMB mental health team, comprised of Dr. Christian Rusangwa, Hildegarde Mukasakindi, Beatha Nyirandagijimana, Dorcas, and others, has worked closely over the past five years with PIH’s cross-site mental health team and Dr. Stephanie Smith to track the clinical and economic progress of 150 patients in Burera district. Findings suggest marked improvements, with both symptoms reduced and functioning improved by over 50 percent in the vast majority of patients. The program works, and it now serves more than 1,200 people via 15 decentralized health centers in Burera district. It is increasingly held up as a model for possible scale-up across the country.

The program may also fuel the world’s increasing appreciation of the burden of mental disorders. In September 2015, the U.N. included “promote mental health and well-being” in the Sustainable Development Goals, 17 goals that world leaders agreed to try to meet before 2030. And in April 2016, dozens of foreign ministers gathered in Washington, D.C., to hear experts from the World Bank, WHO, and the field argue the case for increased spending on mental health, citing new evidence that the return on investment for mental health care is up four-fold.

Bashar and his family’s experience show firsthand how small investments in mental health care pay off. Bashar no longer suffers from debilitating hallucinations and paranoia, and his illness is treated. He does the washing and collects water from the well. He walks to the clinic independently to receive care. He cooks for his busy sisters and mother.

“I am very happy,” says his mother. “Now I agree that everything is possible and will usually praise God.”

Kairat Birbekov,* a surgeon from Astana, Kazakhstan, has had tuberculosis seven times. At age 24, he caught a cold that turned out to be TB. Twenty years of recurring bouts of the disease followed. Now, the 43-year-old’s left lung is completely destroyed. He’s being treated in the country’s National Tuberculosis Center, a 400-bed hospital embedded in the mountain-surrounded city of Almaty. A ventilation tube protrudes from his throat—preparation for next week’s surgery to remove the lung.

In the same Center, 24-year-old Aigerim Yekeubayeva has nightmares that her friends are also in the hospital with TB. In 2011, she was diagnosed with the disease for the second time and had to forgo applying to university. Long, empty hours in a sanatorium replaced the Japanese-language study groups she used to lead.

When she was 26, Zhanna Ushbayeva owned a beauty salon that offered makeup, haircuts, and products. The business dwindled after she was diagnosed with TB in 2007. She’s tried everything in search of a cure, including moving to China to buy alternative medications. Then she ended up at the center. “I’m afraid of thinking about the future,” she says.

Their stories are common in the TB world. Birbekov, Yekeubayeva, and Ushbayeva have had the disease on and off for years. It’s unclear where they contracted it, but TB is rife in Central Asia where state-funded health programs came to an abrupt halt after the collapse of the Soviet Union. Treatment isn’t working for them; they have become resistant to almost all TB medications and their options are running out.

But this year a hopeful new chapter will begin for each of them. The three are enrolled in a Partners In Health-led project called endTB, which will bring new drugs to 15 countries with some of the highest rates of multidrug-resistant tuberculosis (MDR-TB) in the world. PIH, Médecins Sans Frontières, global health organization Interactive Research and Development, and financial partner UNITAID are leading a massive effort to enroll 2,600 people on new treatment regimens through 2017.

The key ingredients are Delamanid and Bedaquiline, new drugs that were developed by Otsuka Novel Products GmbH and Janssen Pharmaceutica, respectively. They were approved for the first time by the European Medicines Agency in 2014 for TB sufferers who do not respond to treatment.

Project Coordinator Nataliya Morozova (left) and Aigerim Yekeubayeva discuss the many years she's had tuberculosis and how she's responding to a new drug regimen that includes Bedaquiline, in Almaty, Kazakhstan. Photo by Askar Yedilbayev / Partners In Health

Like Birbekov, Yekeubayeva, and Ushbayeva, people usually contract regular TB before the disease progressively overcomes tiers of drugs and becomes resistant to them. Multidrug-resistant tuberculosis then must be treated for at least two years with a handful of toxic antibiotics taken up to three times daily. The drugs will likely make the patient feel worse and there’s no guarantee they will work. The patient has probably been very sick for a number of years. They’ve lost a lot of weight, and their lungs are infested with bacteria.

Sticking with treatment is hard—very hard. Side effects can be worse than symptoms. The drugs can cause nausea, vomiting, diarrhea, and hearing loss. When patients perceive little or no improvement, they often stop taking the drugs and opt for the occasional fever and fatigue instead—although it’s almost certain they will just get worse.

Askar Yedilbayev, PIH’s program director for Russia and Kazakhstan, has watched many of his patients struggle with treatment. “It can get to the point that when they see a nurse come into the room with their drugs, they start vomiting,” he says. Yedilbayev estimates that at least 70 percent of his patients will have an adverse reaction to the drugs. “The drugs can damage the liver, kidneys, and nervous system. It’s a lot.”

Program Director Dr. Askar Yedilbayev reviews the lung x-rays of a patient enrolled in the endTB program in Astana, Kazakhstan. Photo by Yerkebulan Algozhin / Partners In Health

The difficulty of completing treatment is one of the reasons MDR-TB is on the rise and why the disease continues to spread—to an unprecedented global level. In 2014, 1.5 million people died of all forms of TB, making it the leading infectious disease killer, surpassing HIV for the first time. Of those with MDR-TB, only 50 percent—a quarter of a million people— are expected to recover.

The answer is to get better drugs out there. But TB sufferers are not an attractive group for big pharma; they are often poor people who have no money for treatment, live in cramped homes, and are likely to get ill with something else first, such as HIV, before TB takes advantage of their struggling immune systems. For 50 years, barely any research and development has been devoted to TB. 

Which is why the endTB project could be revolutionary. Delamanid and Bedaquiline are not yet part of mainstream TB treatment in most countries, but PIH, MSF, and IRD aim to prove they should be. When combined with other TB drugs, these two new drugs are believed to be less toxic than current medications. They could be a godsend for TB clinicians and patients alike.

While it’s too early to formally declare success, there are already signs in Kazakhstan that the new drugs are working.

Since Birbekov was enrolled in endTB in February, things are looking up. He’s tested smear negative, meaning his TB is no longer contagious. His only side effect is dry skin. “Like an old man,” he laughs. He still has surgery to get through, but the test is the first good news he’s had in a while.

As for Yekeubayeva, she’s a believer in having a positive attitude. Now resistant to nearly every antibiotic available, she has to be. But with Bedaquiline, she’s hardly had side effects apart from high blood pressure. 

“We’ve had a really great response,” says Yedilbayev, regarding Yekeubayeva’s progress. He thinks this was her final chance. “Otherwise she would have died.”

Eager to catch up on the six years she’s missed since she was diagnosed, Yekeubayeva is planning to take online courses toward a degree. Her brother has an entertainment business. No more hospital beds for her; she says she’ll be his event organizer.

For Ushbayeva, treatment is still hard. The pills sit uncomfortably in her stomach, preventing digestion. She doesn’t have much energy except for the occasional walk, although she’s more active than before. It’s a waiting game to see if her culture tests—which detect any remaining bacteria—turn negative. For now, she’s back at home and taking treatment every day. 

Yedilbayev says the project is not only giving patients hope, but could transform MDR-TB treatment across Kazakhstan. “We’re bringing evidence to authorities to open markets to these new drugs and incorporate them into national protocol, so that more people receive treatment,” he says.

More than 120 patients have joined Birbekov, Yekeubayeva, and Ushbayeva in the project. Roughly 600 people will be enrolled in total.

Yedilbayev is sure more success stories will come. “I’m really proud that Kazakhstan is part of endTB.”

*All patient names have been changed.

In an op-ed published in The Hill, Partners In Health CEO Dr. Gary Gottlieb writes about the recently released USAID report, "Acting on the Call," and how better health for poor women and children strengthens global security.

"At Partners In Health, we applaud USAID’s focus on the very poorest populations and on women and children. As we know too well, social injustice and care disparities cause the greatest suffering and misery; the opportunity for breathtaking improvements is at our fingertips. Every day for more than 30 years, we have seen the importance and the benefit of that focus. We see people dying unnecessarily from preventable conditions—and poor women and children are the most vulnerable. Nearly 800 women die every day in childbirth, and 99 percent of those deaths occur in developing countries.

"In 2014, during the height of the Ebola epidemic, Partners In Health began providing health services in Sierra Leone. According to the World Health Organization, in that West African country, a woman dies in about one in every 90 births. That’s more than 50 times higher than in the United States. This is tragic and unthinkable, and it can be prevented."

Read the full editorial.

Today at 12:30 p.m. EDT, Dr. Louise Ivers will discuss Zika on Facebook Live. 

The video will be streamed here.

We’ll be taking questions before and during the interview. Submit them here!

Ivers, a senior health and policy advisor at Partners In Health, will discuss symptoms of and treatment for Zika, how PIH is addressing the virus in Haiti, and how Zika may have an impact on the Summer Olympics in Brazil—the site of an ongoing outbreak.

The sudden emergence of Zika in dozens of countries over the past year has attracted worldwide attention. And justly so. While some people infected with the virus experience fever, headache, joint and muscle pain, or red eyes, others suffer more alarming consequences. Research has linked an expectant mother’s infection with Zika during pregnancy with microcephaly, a condition in which babies are born with small heads and underlying lack of brain developoment. There are also reports of patients infected with Zika later developing Guillain-Barré syndrome, a life-threatening neurological disorder that requires intensive care.

Cases of Zika infection have already been reported in Haiti, where PIH has thousands of staff and serves thousands of patients every day. Working with the Ministry of Public Health and Population and several international organizations, we are training community health workers to spread the word about Zika, explain the risk to pregnant women and helping them to protect themselves by distributing mosquito repellant, as well as increasing access to family planning. We also care for the sick and are working urgently to protect staff by ensuring clinic and hospital windows have screens—among other efforts.

Ivers’ Bio

Ivers is helping to guide PIH’s response. An infectious disease expert, Ivers served as PIH’s clinical director in Haiti for almost 10 years. She is an associate professor of medicine at Harvard Medical School and an associate physician within the Division of Global Health Equity at Brigham and Women’s Hospital. She has published dozens of articles on HIV and food security, cholera, and human rights in journals such as The Lancet Global Health, The American Journal of Tropical Medicine and Hygiene, and The Journal of Infectious Diseases.

More information on the Zika virus is available here.

Earlier this month, Partners In Health began construction on a 250-acre campus for the University of Global Health Equity. When complete in 2018, classrooms, administrative buildings, a library, and dorms will drape a picturesque hill in the Burera District of northern Rwanda. The structures, the first of two UGHE campuses planned in the region, will house thousands of students and medical professionals from around the world, teaching them not just how to treat patients, but how to build health care systems.

“Try as we might, PIH can only touch a tiny fraction of the world’s population,” says Director of University Operations Jarrett Collins. “The university is a way to reach infinitely more people.” 

The need is clear, especially in Africa. Despite consistent improvements in health care over the last decade, far too many children still die of easily preventable ailments such as malaria. Mothers struggle to find trained professionals to attend their births. HIV and tuberculosis afflict thousands who can’t get treatments. The average life expectancy in developing countries in sub-Saharan Africa remains a mere 58 years.

UGHE began confronting these disparities last September. In borrowed classrooms, Collins and others launched the university's cornerstone program: a two-year, part-time Master of Science in Global Health Delivery, the study of how to create excellent national health care in developing countries. Lecturers from Rwanda's Ministry of Health, Harvard Medical School, Tufts University, and elsewhere taught students, mostly from Rwanda, everything from epidemiology to budget management.

This year, a throng of applicants have already applied for the second class, starting in September. Nearly 250 professionals from as far away as Mexico have applied for 27 spots. Degrees in other subjects, including nursing, are soon to follow.

“As a regional hub for research and innovation, the Burera District campus will not only give students the tools, but the space, to investigate complex health care delivery challenges,” says Project Director Rogers Muragije.

The location 80 miles north of the capital of Kigali is no accident. Being in the safe, stable, ever-healthier nation of Rwanda serves as a constant reminder of what’s possible. (In the last six years, for example, the number of women dying from complications due to pregnancy or childbirth has decreased by half, to roughly 1 in every 475 births.) And sitting across a valley from Butaro Hospital, a 150-bed facility built by PIH and operated by the Government of Rwanda, offers students the chance to gain practical, first-hand experience.

Boston-based architecture firm Shepley Bulfinch designed the campus to be on par with the best. Solar panels on the roofs will provide electricity. Windows and hot-air “chimneys” will allow a light breeze to blow through, connecting the indoors with the outdoors and reducing the need for air-conditioning. In classrooms, desks, chairs, and tall whiteboards will easily move to suit lectures or discussions, team brainstorms or individual work. Boston-based MASS Design Group is in Rwanda overseeing the construction and using local materials, craftsmen, and laborers.

“A year ago, UGHE was an ambitious idea,” says Executive Director Dr. Peter Drobac. “In 10 years, it will yield some of the world’s leading minds in global health delivery.”

The thing about triplet toddlers is that they never sit still. Twenty-month-old Tamar, Michelle, and Marian Bernard walk, run, squirm in their seats, dance, and generally create chaos for their parents, Manoucheca Ketan and David Bernard. But instead of being a headache, their movement is a source of constant relief and joy.

Just over one year ago, Michelle and Marian were conjoined at the abdomen. Clinicians from Zanmi Lasante, as Partners In Health is known in Haiti, delivered them and their triplet sister by cesarean section on November 2014 at University Hospital in Mirebalais, Haiti. At 6 months, they returned to the hospital and were separated during a procedure in which PIH doctors and nurses collaborated with a team of international experts.

The procedure was historic—the first of its kind successfully performed in Haiti and a watershed moment for PIH, which started 30 years ago as a scrappy nonprofit based out of a remote clinic in Cange. Most importantly, though, it was life-transforming for the girls and their parents.

“Looking back and realizing it’s been a year makes me so happy to see them running around the house and doing well,” Ketan says. “Sometimes I cry thinking about how happy they are.

“I think about how it could have been if they didn’t have the surgery and were still conjoined,” she adds. “The health system here is difficult for people with very common health conditions, so to have conjoined twins and think about how I was going to be able to raise them was hard. I am so blessed.”

Bernard remembers wondering whether they should go through with the surgery as “what ifs” flooded his mind. But doctors at University Hospital reassured him and Ketan and answered all their questions. On the morning of May 22, 2015, the couple gave Marian and Michelle a final hug and handed them to awaiting nurses.

Within seven hours, Marian and Michelle were separated. Within 48 hours, the girls were breathing on their own. Within 72 hours, they’d had their first bottles. And within two weeks, they had left the neonatal unit to return home to their parents and sister, Tamar.

Although they had undergone a major procedure, neither girl suffered debilitating side effects. Each girl’s head had become twisted to one side since birth as they adjusted to life together. Now that they were apart, they required physical therapy to relax and retrain their neck muscles. PIH physical therapists and visiting specialists led the infants through various exercises and taught Bernard and Ketan how to continue the work at home. Months into therapy, both developed full range of motion in their necks.

“After the separation, parts of their bodies were crooked,” Ketan says. “But after physical therapy, both at home and at the hospital, they started to get better.”

Michelle and Marian Bernard, 20 months, share a step near their home in Mirebalais, Haiti.

Ketan lovingly calls her daughters dezod, Krèyol for rambunctious, and watches them tear around the family’s apartment in Mirebalais, just blocks from University Hospital. The three toddle around, pulling out chairs and climbing on top of everything. They dance whenever they hear music. And they walk around “talking” on their toy phones all day, even though their vocabulary doesn’t extend much beyond mom and dad.

The girls’ personalities have emerged over time too, Ketan says. Michelle is practical and gets into everything, while Marian keeps to herself. Tamar is the social one and acts like an older sister charged with protecting her siblings. Michelle prefers playing with Tamar and ever since she started biting, her sole target is her formerly conjoined twin. Their mother admits she sometimes gets confused and calls them all by the wrong names.

“It’s magical watching them,” Ketan says with a smile. “Sometimes they do things that surprise me, like when they fight over the same toy when they have so many other toys they could play with.”

“Every day there is something different about them,” Bernard says. “The way they eat, laugh, play.” 

The past year has given Ketan and Bernard time to reflect on what they’ve been through and how they want to share their experience. She teaches community members seeking prenatal care and has started working with nurses and translators in University Hospital’s neonatal and pediatric intensive care unit. And the couple has written a memoir, to be released next May on the second anniversary of their daughters’ surgery. The book was a way for them to share their story, emphasize the importance of prenatal care, and educate others—especially expecting couples—about the medical possibilities for conjoined twins.

“It’s important for people to know that this separation happened in Haiti, to know it’s possible,” Ketan says. “We want our story to be an example for others.”

Partners In Health co-founder Dr. Jim Yong Kim, who currently serves as president of the World Bank Group, made clear in The Washington Post last week (“A plan to deal with the next pandemic,” July 1, 2016) that pandemics know no borders:

“The growing concern over the Zika virus highlights a frightening reality: The world remains ill-prepared for a fast-moving virus. … U.S.-led efforts are critically important. But as with Zika, Ebola, avian flu, swine flu and other pandemics that have affected the United States over the past decade, it’s likely that the next big one will start in a developing country. In those countries, weaker health systems and a lack of investment in preparedness leave all of us, no matter where we live, vulnerable to the spread of a deadly pandemic. Pandemics are a global security threat, and they demand a truly global response.”

Dr. Kim went on to discuss how the newly created Pandemic Emergency Financing Facility will more quickly and efficiently direct global dollars to where emerging diseases most likely start.

At Partners In Health, we know that building and sustaining public health systems in poor communities around the world is the most effective way to spend these dollars. Strong health systems must be on the frontlines of combating emerging diseases such as the Ebola and Zika viruses. Our experience has shown us that containing or mitigating emerging diseases where they start is the most effective way to handle global public health threats. The robust health systems we build and sustain not only transform poor communities, they will help safeguard the world.

Read Dr. Kim’s opinion piece in The Washington Post here.

Since 2012, a Partners In Health-supported public hospital in northern Rwanda has treated thousands of patients for breast cancer, lymphomas, and more. But even Butaro Hospital has struggled to treat late-stage cancers and other conditions needing radiation therapy. Like many developing countries, Rwanda lacks a $4 million radiation therapy machine.

So clinicians at the hospital refer patients to Mulago Hospital in Kampala, Uganda, and accompany them on the 300-mile bus trip there. Or rather, they used to. In April, Mulago’s 20-year-old, second-hand radiation therapy machine broke. Experts soon declared it unfixable, and tens of thousands of cancer patients from Uganda, Burundi, South Sudan, and Rwanda were suddenly left without treatment.

Partly in response to this, the government of Rwanda pledged to open a radiation therapy service. Uganda has also said it will. But neither facility is likely to be ready within a year and a half, let alone immediately, which is of course what patients need.

Clinicians at Butaro were not content to wait. They went looking for options available now. Of the handful of radiation therapy machines within a 1,500-mile radius of Butaro, they settled on referring patients to one in Nairobi, Kenya. The private hospital is topnotch, and relatively close, just 500 miles away.

In the letter below, Dr. Alex Coutinho, the executive director of PIH’s program in Rwanda, describes visiting Nairobi and meeting the first radiation therapy patients, and he explains why spending $6,000 per patient is a terrific deal.

Dear colleagues,

This letter is from Nairobi, Kenya, where I am to finalize arrangements for radiation therapy service for our cancer patients for the next two years. Some of my management team members—Neil Gupta, Paul Park, Cyprian Shyirambere, and Antoinette Habinshuti—had done a great job identifying the right provider and negotiating the right discounted price for PIH. My time here has been used to evaluate the services provided and finalize the wording of the legal document that will guide our relationship with The Nairobi Hospital, as well as meet the Rwanda embassy in Nairobi to ensure that they are aware we have referred patients and that they can provide support if needed.

Most important, though, was to meet the very first five beneficiaries of the new radiation therapy service. The five exemplify the characteristics of the people we serve in Rwanda—mainly women, almost all from rural areas, and probably from the poorest of the poor categories. I could sense that The Nairobi Hospital had no experience dealing with an organization like PIH, one that prioritizes the poor and offers them sophisticated medical services usually far beyond the reach of even the middle class in Rwanda.

I found the five women huddled in a group outside, sitting on the grass and basking in the sun on a chilly morning. Three of the women are Catholic, another is Pentecostal, and the fifth is a Muslim, which highlights the diversity in Rwanda and the fact that all religions co-exist very well there. (I had to find out the religions to arrange a pastoral service for them if they needed it). I had a long conversation with them through an interpreter and their main concerns were about the unfamiliar food, about the exact nature of the treatment they were receiving, and of course about whether they would be cured. Yet overall they were upbeat and excited. They had flown in an airplane to come to Nairobi and much preferred it to the arduous journey they had had on a bus to and from Uganda when their first radiation therapy quest went awry. I asked them if there was anything else they wished for. And I was so surprised that they requested a tour of Nairobi city. They wanted to have “stories to tell their relatives when they get home.” In keeping with the ethos of the Make-a-Wish Foundation, arranging a tour of Nairobi city and Nairobi safari park is now my task. The five live in a hostel just across the road from the hospital and are in clean, comfortable accommodations with plenty of food and drinks. However they are not used to city traffic so crossing the busy road requires an escort.

Our oncology program in Rwanda has helped nearly 5,000 people since it started in 2012 but one can only understand its impact when one speaks to an individual beneficiary, hearing their thoughts, their anxieties, their aspirations, and their hope for a “second life.”

The program in Nairobi is not cheap. The radiation therapy program alone costs $6,000. If  one adds the chemotherapy, pathology, biopsy, etc. that we perform in Butaro, then the unit cost of caring for one patient who receives radiation therapy is closer to $10,000. I can recall when this was the unit cost for Anti-Retroviral Therapy in the U.S. and very very few Africans could access it. And I recall the frustration I felt then, as my patients, my friends, and even my relatives perished of AIDS. Today the unit cost of ART in Rwanda is about $450 per year, and if the normal life expectancy of that HIV+ individual is increased by 30 years, then the lifetime ART cost will be $13,500. Therefore if we can achieve an oncology cure for these five women with $10,000 and gain 20 additional years of life for them then the costs would have some equivalence.

And yet this is not primarily about cost. This is about not giving up when faced with the “conventional wisdom”—that ART will not work in Africa because we don’t have watches  or that oncology is not scalable because of complexity and cost. Well, in The Nairobi Hospital, I had a tour and saw a state of the art radiation therapy unit with two linear accelerators, a brachytherapy unit, an MRI and CAT scan dedicated for staging and planning therapy, and a team of Kenyans managing this complex. This is what Rwanda aspires to have in the coming years and what we want in Butaro or Kigali, to be able to provide universal health coverage, including oncology patients.

So PIH referring patients to Nairobi at great cost is a call to action, a demonstration that no obstacle is permanent, and it’s a rally cry for the global health community to respond to the cancer crisis that is looming in the developing world. But in the end, it is about women and men and children like these five, about their lives, and the lives of their families and children and loved ones.

My last letter highlighted the continuing challenges PIH will face, in partnership with the Rwandan Ministry of Health, in trying to meet the need and demand at all of our sites, and the need for oncology services at all out sites. We know that for now we cannot meet all the need, but we can attempt to respond compassionately, and we can attempt to help those that somehow, against all odds, find their way to our facilities. I am truly uplifted to be part of PIH as we take on this oncology challenge. I am also thankful to the generous supporters around the world. As the proverb goes, “People who say it cannot be done should not interrupt those who are doing it.”

Have a great week,

Alex

From a long reading list that’s circulating around PIH this summer, we’ve handpicked 12 books that we think our supporters would also enjoy, with comments from staff on why. For scholars and wonks, there are a few spectacularly researched books on the big questions in global health. For fiction fanatics, we’ve included a couple of novels based in places where PIH works. For everyone in-between, the list is mainly nonfiction, ranging from the indispensable Mountains Beyond Mountains to a story about a doctor bringing peace in a war zone. Below, our recommendations. Enjoy!

On June 29, 2016, Dr. Michelle Morse, deputy chief medical officer at Partners In Health, discussed social medicine and how she and others are working to make it part of health education around the world.

If you missed it, watch the video here.

Social medicine is at the core of PIH’s mission. Our doctors, nurses, pharmacists, and community health workers focus on the social factors that make their patients sick. Simple examples illustrate why. Someone with HIV will not get better if they can’t afford to travel to a clinic for medication. Telling a diabetic to eat healthy foods is of no use if that person does not live near stores that stock fruit and vegetables.

Morse goes beyond medical examinations and prescriptions. She works to solve a broad array of problems that make her patients sick, and cares just as much about their incomes, education, and access to food and shelter as she does about their symptoms and medical history. She argues these issues are just as important for health practitioners to study as biology, chemistry, and physics—the so-called “hard” sciences that make up the majority of nursing and medical studies.

Morse’s bio

Morse’s role at PIH spans positions at Harvard Medical School, where she is an instructor in medicine, and Brigham and Women’s Hospital, where she practices as a hospitalist and serves as assistant program director for its internal medicine residency. She spends the rest of her time with PIH in Haiti, Rwanda, and Liberia, working to strengthen medical education systems and supporting clinical programs. She also co-directs EqualHealth, a nonprofit dedicated to ensuring high-quality medical and nursing education in Haiti.

Morse is a leader of the Social Medicine Consortium, which, in partnership with the nonprofit SocMed, held a conference for 700 social medicine enthusiasts in Minneapolis in April 2016.

“The end goal of the social medicine movement is to achieve health equity. We can't achieve that without very clear and explicit education tools and experiences so that health professionals feel equipped to address the health needs of very poor and very vulnerable populations all around the world,” she says.

Morse demonstrates how to use a portable ultrasound at a PIH-supported hospital in Haiti. Photo by Jon Lascher / Partners In Health.

Want to learn more about social medicine? Check out these resources:

Videos: PIH Co-founder Paul Farmer and PIH Chief Medical Officer Joia Mukherjee address more than 700 people at the Social Medicine Consortium in April.

Article: Westerhaus M, Finnegan A, Haidar M, Kleinman A, Mukherjee J, Farmer P. The Necessity of Social Medicine in Medical Education. Academic Medicine. 2015; 565:568.

Article: Frenk J, Chen L, Bhutta Z, Cohen J, Crisp N, Evans T, Fineberg H, Garcia P, Ke Y, Kelley P, Kistnasamy B, Meleis A, Naylor D, Pablos-Mendez A, Reddy S, Scrimshaw S, Sepulveda J, Serwadda D, Zurayk H. Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World. Lancet. 2010; 376; 1923-1958.

“We started losing friends our own age,” remembers Dr. Paul Farmer, a co-founder of Partners In Health.

In a grey vest bearing PIH’s logo, he leans on a wooden podium in Boston’s Brigham and Women’s Hospital and describes working in Haiti in 1983, where he watched a friend die from undiagnosed cerebral malaria. A ruptured spleen killed another with typhoid.

“Stupid deaths,” Farmer often calls them. Deaths that modern medicine can prevent but that readily afflict people living without proper health care.

Farmer’s audience includes four young physicians who are graduating this day from a Brigham and Women’s Hospital residency program—the Doris and Howard Hiatt Residency in Global Health Equity and Internal Medicine—in which they’ve seen firsthand how poverty affects the health of people and their communities.

The graduates’ practicing ground has been the clinics and hospitals where PIH staff work. Since 2011, they have traveled between the U.S. and poor countries, qualifying as specialists and gaining skills to practice in impoverished places. Whether on a remote mountain or the slums of a city, they’ve learned to provide care where there are few resources.

“The surgeons at the Brigham—we don't ask them to build their own operating rooms,” Farmer tells the group. “We don't ask them to buy generators and fuel for those operating rooms. We don't ask them to figure out how to get the staff, the stuff, the space, and the systems they need to do surgery. But global health equity residents often do get drawn into that part of the work.”

As he speaks, photographs of the graduates are projected behind him. In them, Ryan Schwarz, a father, pediatrician, and internist, lights a candle with colleagues at a patient’s bedside in Nepal. Daniel O’Neil, 32, an internist, leans over paperwork in a crowded waiting room in Haiti.

Morgan Espérance, a mother of two, a pediatrician and internist, sits with a Haitian patient, talking intently, her stethoscope dangling from her knee. And Omar Amir, 35, smiles and waves from a truck in Liberia. The internist worked with Last Mile Health in the eastern district of Konobo during the height of the Ebola crisis. Another photograph shows a note pasted on his door, “Dr. Omar Amir. Welcome to Konobo, the land of the brave.”

“All of them have been called to step beyond the traditional bounds of medical training,” says Farmer.

The residency honors Howard Hiatt, 91, a pioneering microbiologist and leading figure in Boston’s preeminent medical institutions. The program aims to increase the number of physicians who dedicate their careers to improving the health of impoverished people in the U.S. and around the world. Previous residents have strengthened health services in rural Malawi; built a graduate medical education program in Haiti; and developed treatment protocols for Ebola treatment units. Many continue to work at PIH sites around the world.

The vast majority of the program’s 41 graduates—soon to be 44—still work in global health. This was the dream of Farmer and others. When Farmer started his residency in the same hospital, working abroad wasn’t an option—at first.

Another photograph flickering on the wall, taken in the early 1990s, shows him and Jim Yong Kim, another co-founder of PIH who is now president of the World Bank, with Marshall Wolf, then director of medical residency training at the Brigham.

Wolf allowed the aspiring global health physicians to do something different. He agreed to their request to be part-time practitioners at the hospital, while spending the rest of their time with their fledgling nonprofit in Haiti.

That nonprofit was Partners In Health.