Finding Tebello Malapane wasn’t easy.

To begin, Village Health Worker Manepile Mothae had to walk three hours over the winding, mountainous terrain of Lesotho. She scrambled across loose rock, over boulders and through creeks. It was summer, and the sun blazed down. At the end of her journey to Monyameng Village was a pregnant woman who needed her help. Tebello was 26 years old and rendered immobile by a degenerative disease, possibly spina bifida.

Through her knowledge of the village, Mothae identified Tebello in late 2014. Mothae has 10 years of experience under her belt as a VHW, so she knew that a pregnant woman living in a rural area with a disability could face extraordinary challenges in getting the necessary care to safely deliver her baby.

Mothae works in Mohale’s Hoek District in southern Lesotho. Her district is part of an extensive national health care reform that Partners In Health/Lesotho is supporting. As part of the reform, PIH/L has provided technical assistance to the district as it enhances or adds services that patients such as Tebello need. The reform also has included training of VHWs so they, like Mothae, can identify patients in villages and accompany them as they seek health care.

After Mothae found Tebello, who lives with her mother, she determined that the young woman needed to get to the clinic to deliver her baby. Transportation by horse or donkey, perhaps not even possible for a patient like Tebello, would cost the equivalent of $20-$30 U.S. Instead, men from the village took turns carrying her over the rugged hillsides.

Tebello stayed at the maternal waiting home at Mootsinyane Health Center for a couple of days while clinicians examined her. Maternal waiting homes, where expectant mothers stay to be near a facility while their due date approaches, are a crucial part of Lesotho’s national health care reform. Clinicians then referred Tebello to the hospital; the clinic paid for her vehicle transportation.

On Nov. 24, 2014, Tebello’s son, Bolokang, was born by cesarean section. The pair stayed at the hospital for three months, where clinicians educated Tebello about caring for her child. When she was discharged, a village health worker accompanied her and Bolokang for the long trek back to Monyameng.

Mothae continues to support Tebello and Bolokang, walking the three hours to the village two or three times each week. Tebello’s mother, Masello, cares for her daughter and grandson. The 61-year-old has hiked that same three hours to the clinic twice to get the baby immunized.

Without the dedication of a veteran village health worker, Tebello’s story might have turned out differently. Mothae and her colleagues, with their understanding of and concern for the villages they serve, are essential to Lesotho’s health care system.

PIH/L has been collaborating with the Ministry of Health to improve care across Lesotho as part of a five-year, three-phase reform. In Mohale’s Hoek District, for example, PIH/L has provided technical supervision, follow up, and training of clinical staff. Efforts have included training and recruiting VHWs, food assistance for mothers, maternal waiting homes, and support for emergency referral for transportation.

The Lesotho Ministry of Health and PIH/L started working on a plan for national reform in 2013, after the ministry of health saw the success of PIH/L’s Maternal Mortality Reduction Program. A central goal of the reform is that all health clinics will be able to deliver a comparable level of care to what PIH/L has been delivering for years. Although PIH/L will continue to be involved in training staff and providing technical assistance, the health centers will remain under the purview of the Ministry of Health.

As the reform continues, the Ministry of Health and PIH/L’s hope is for more safe deliveries and healthy patients—more outcomes like that of Tebello and Bolokang.

Manoucheca Ketan lay on an exam table as her doctor spread warm goo over her expanded belly and methodically traced an ultrasound wand back and forth. Black-and-white images of different shapes and sizes appeared on a nearby screen. They looked foreign to her, but clearly meant something to the doctor.

“Pwoblem! Pwoblem! Pwoblem!” he said in Haitian Creole.

Ketan, 35, asked what was wrong. Still staring at the screen, the doctor said he saw three heads and that, from the way the babies were positioned, he thought two of the babies’ bodies were connected.

Ketan was shocked. She’d only wanted one pregnancy, but her husband, David Bernard, wanted more than one child. Apparently both their wishes would come true. Yet the challenges were daunting: How would they afford food, clothing, diapers, and schooling for three children? Where would they find space for everyone? And what if the doctor were right—what if she had conjoined twins?

Her worries only increased. As her pregnancy advanced, Ketan and her private doctor in Port-au-Prince planned for the delivery. He proposed taking the triplets by cesarean section at 6 months. Because the babies would be significantly premature, he said post-partum care would be $1,000 a day for each child. Factoring in the cost of her delivery, he estimated her bill at $100,000.

Before Ketan sank into despair, her younger brother happened to suggest she visit Mirebalais, a town in Haiti's Central Plateau. He’d heard that patients receive free care at University Hospital (HUM), a state-of-the-art facility that Partners In Health (PIH) and Zanmi Lasante (ZL)—its sister organization in Haiti—had opened there in partnership with the Haitian Ministry of Health in 2013.

Ketan was in her sixth month when she arrived at HUM last August to meet with Dr. Christophe Milien, the hospital’s director of obstetrics and gynecology and advisor to the medical director. After an hour-long ultrasound exam, Milien confirmed Ketan was carrying triplets and that two were conjoined at the abdomen.

“The guarantee I can give you,” Milien told Ketan, “is that we're going to look for help for you so that we can keep these babies alive.”

Dr. Christophe Milien, HUM's director of obstetrics and gynecology, discusses the ultrasound in which he confirmed Manoucheca Ketan was pregnant with triplets, with two infants conjoined at the abdomen. 

One in a million

Milien was true to his word, but it was no small task to which he’d committed the HUM team. Conjoined twins are a rare phenomenon, occurring once in every 200,000 live births, according to a report by the University of Maryland Medical Center. Ketan’s pregnancy was even rarer. Conjoined twins within a triplet pregnancy occur in less than one in a million deliveries, according to an article in Case Reports in Obstetrics and Gynecology.

Their outlook wasn't good. Just over a third of conjoined twins survive only one day, according to the same University of Maryland Medical Center report. And their overall survival rate is between 5 and 25 percent. But for some reason, female siblings survive more often than males. About 70 percent of all living conjoined twins are girls.

Identical twins form when a single embryo splits in half during the first few weeks following conception. Most scientists agree that conjoined twins form when the division of this single egg stops before the process is complete. The partially split egg continues to develop into a conjoined fetus.

Dozens of variations of conjoined twins exist. About 40 percent of all cases are thoracopagus twins, who are connected at the upper portion of the torso and usually share a heart. Omphalopagus twins occur a third of the time and share a liver, gastrointestinal tract, or genitals. Craniophagus twins share a head and are the rarest type, occurring only 2 percent of the time.

Ketan’s twins were omphalopagus and CT scans revealed they shared a liver, but no major vasculature—a fact that made their separation more viable.

Overall, the HUM team’s challenge seemed daunting. They had to prolong Ketan’s pregnancy as much as possible to ensure the best outcome for the triplets, monitor the twins carefully to avoid infections and ensure weight gains, and assemble a team of experts to perform the separation procedure—the first of its kind in Haiti.

A 36-week milestone

Milien didn’t know how any of this would work out in August when he promised Ketan she was in good hands. He admitted her that day to treat her anemia, then kept her on bed rest. Triplets usually deliver around 30 weeks, or 10 weeks early, so he and HUM staff expected they would be caring for premature infants.

When Ketan reached 25 weeks, Milien thought it would great if she could get to 30. When she reached 30 weeks, he aimed for 32. She was still going strong two weeks later. Finally, at 36 weeks, she felt contractions and the HUM team prepared for her C-section.

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The night before the surgery, stress got the best of Ketan as the reality of having triplets, two of them conjoined, sank in. She worried about how she would care for and get around with the babies. She worried about the twins’ eventual separation surgery. And, possibly the most difficult part for a new mother, she worried about whether she would love her conjoined twins.

“I didn’t know how I would feel,” Ketan says. “That was a very, very difficult time.”

Milien and other HUM staff reassured Ketan. Discussing what would happen from the moment the children were born up through the separation procedure, they managed to relieve a great deal of her stress.

On November 24, a crowd of HUM staff gathered outside the operating room. Milien and Chief Nursing Officer Marc Julmisse led a team that had practiced for Ketan’s C-section during hours of simulation training. Staff stood at attention, half of them wearing red, the other half in blue according to which baby’s team they belonged. An air ambulance perched on a landing strip alongside the hospital, ready to whisk the babies away to the closest facility with a functioning intensive care unit should they need specialty care.

It all followed Julmisse’s motto: “Plan for the worst; pray for the best.”

Apparently those prayers were answered. Milien delivered Tamar. Then he delicately reached in to find the twins, Michelle and Marian—in exactly the same position his most recent ultrasound indicated they would be. All three screamed their greeting into the world; there was no need for a ventilator.

Applause erupted from behind the observation windows, where HUM’s medical director Dr. Maxi Raymonville and Deputy Medical Director Dr. Pierre Marie Cherenfant stood among a crowd of other HUM cheerleaders.

Settling in to a new life

Within days, Ketan was on her feet and went to visit Tamar, but she couldn’t bring herself to Michelle and Marian’s bedside. “Initially it was really, really hard to see them,” she says. Racked by guilt and worry, she cried for the first couple of days before she was ready, at Milien’s encouragement, to visit them.

Julmisse and her staff had set the triplets up in their own room following the surgery so they could receive specialized care and privacy. Nurses kept the twins’ materials and medicine color-coded throughout their stay to avoid confusion. They taught Ketan how to feed, hold, and carry her unique twins. Slowly her bond with them grew.

Tamar—who inherited her mother’s easy, broad smile—was the first to come home, which was now a five-minute walk down the road from HUM. PIH/ZL staff had helped Ketan and her husband find an apartment nearby, making follow-up appointments at the hospital and home visits from nursing staff all the easier. Marian and Michelle—who were identical and held hands and tugged on each other’s clothing—followed several weeks later. Ketan’s mother moved in to help out.

On a late afternoon in early May, Ketan sat in her dark living room with the twins settled on her lap facing one another. They sucked each other’s hands while their mother fanned them with a piece of paper. The heat was especially brutal and wasn’t abating with the setting sun. When Julmisse—who was calling on them for a home visit—switched their hands to their own mouths, they swiftly reverted back to their preferred position. Clearly sister’s hand tasted better.

Tamar lay in a neighboring crib and underwent physical therapy with a visiting nurse. Bigger and stronger than her sisters, she was learning to sit on her own and instantly smiled when the nurse held her up to a standing position.

The twins were steadily gaining weight, going through a container of formula each day, in anticipation of their separation at the end of the month when they would be six-months-old. As with other babies who can’t lie on their backs, their heads hadn’t rounded out and looked narrower than their sister’s. Ketan did her best to ensure the twins weren’t falling far behind, despite their limited mobility.

Going outside was tricky. Ketan was reluctant to expose her twins to others’ stares. People frequently asked her how the twins “got stuck together.” She tried to explain, but often came up short and wished more people understood and accepted her daughters as she had.

More than a village

Shortly after Milien diagnosed the twins as conjoined, the HUM team began planning for their eventual separation. One of the first calls was to Dr. Henri Ford, vice president and chief of surgery at Children’s Hospital Los Angeles, who was on HUM’s advisory board and a friend of PIH Co-Founder Dr. Paul Farmer. Ford began assembling a team of experts, including Dr. James Stein, associate chief of surgery at Children’s Hospital Los Angeles, who would travel to Mirebalais for the groundbreaking procedure. Nearly every week he called the HUM team to hammer out details of the surgery, and he visited monthly to check on the twins’ progress.

“It takes more than a village," said Ford. "It takes probably a village and a city to effectively plan the separation of conjoined twins because you're thinking in two for every single thing.”

Meanwhile, Dr. Michelle Morse, deputy chief medical officer for Haiti, coordinated the complex operation from her base in Mirebalais. Dr. Romain Jean Louis, the hospital's director of pediatrics, checked on the triplets weekly. And Julmisse meticulously tracked down materials and equipment, brought her team up to speed, and recruited nurses from U.S. hospitals to help fill the ranks. Extra staff were required for the days of round-the-clock, intensive care that the twins would need following separation.

The national and international teams came together in Mirebalais on Thursday, May 21, to run through simulations. Everyone was divided into color-coded teams—red for Marian, yellow for Michelle.

“If we are satisfied that everyone is ready on May 21, then our plan is going to be to proceed with surgery the next day,” said Ford. “If not, we will take our time until everybody is fully aware and fully comfortable with their role before we do the operation.

“It's a very collaborative process; everybody has a voice,” he added. “We are all motivated by the same purpose: We want to make sure we optimize the chance for these children to go through this separation safely and have meaningful, productive lives without any complication.”

Although nerves were on edge until late in the evening, the Thursday simulation finished strong. Friday, everyone decided, would be the day.

Separate, but together, at last

Marian's surgical team wore red bandanas, while Michelle's wore yellow ones as they worked in an HUM operating room on Friday, May 22.

On the morning of Friday, May 22, Ketan tightly hugged her twins in a staging room near the operating room. Her husband floated in the background, his cell phone recording the moment. Both parents planted kisses on their daughters’ cheeks before Marie Paul, HUM’s chief nurse of surgery, wrapped a blanket around the twins’ waists—the site where they would soon be separated—and marched them to the operating room.

Four hands, arms, legs, and feet wriggled and intertwined as the twins lay on an operating table surrounded by a couple dozen doctors and nurses. With great care and coordination, the team calmed the children, prepared them, and put them under for what would be a seven-hour procedure including pre- and post-surgery care.

The first incision was made at 1:14 p.m. Just over an hour later, Michelle and Marian had been separated. There was a quick cheer before the entire team split into two groups to separately attend to the infants.

The only major complication ended up being a miracle of sorts. Michelle had a fist-sized ovarian cyst that, had it not been discovered, would have caused problems in the near future. Milien, who stood like a sentinel at the foot of the surgical table, immediately scrubbed in, drained, and biopsied the cyst. Fortunately, the benign growth had stretched the girls’ skin so much that enough remained to close their wounds. Surgeons finished the procedure by creating a new belly button for each baby.

As he had throughout the surgery, Milien visited the girls’ parents to tell them the good news. Ketan, who hadn’t eaten all day, breathed a sigh of relief—the worst was over.

By early evening, Michelle and Marian laid in separate cribs in HUM’s intensive care unit, which had recenty opened. Tubes crisscrossed their bodies, but they were stable and sleeping peacefully. Within 48 hours, they were breathing on their own. Within 72 hours, they’d already had their first bottles. And nurses noticed one curious thing: Michelle would calm down whenever they rubbed the side of her face where Marian used to be.

Ketan couldn’t stop smiling as she gazed at her twins. It felt safe now to talk about the future, her daughters’ future, apart and together. She decided she wasn’t going to be the type of mother who told her children what to do, but would help guide and direct them. “I would love to see them develop their full potentials in whatever path they choose,” she says.

(Left to right) Michelle, Marian, and Tamar Bernard rest in the same crib days after the twins' separation. Photo by Diane Sherman for Partners In Health

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When 35-year-old Thoko* was pregnant with her fourth child, she and her sister walked to Malawi’s Neno District Hospital to make sure she could deliver her baby safely. The trip took three-and-a-half hours from her home in Makupe Village.

Thoko stayed in the hospital’s new maternity ward for a week before giving birth to a son named Joseph earlier this month. The antenatal care she received prior to delivery helped ensure she and her baby are healthy and thriving.

Thoko’s previous three deliveries took place in the hospital’s old maternity ward, where there wasn’t enough space for women to stay prior to giving birth. Sadly, two of those children have since passed away.

Thoko and her husband, both subsistence farmers, are happy to welcome Joseph, and are proud and thankful for the care Partners In Health and the hospital have provided.

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*Name has been changed to protect privacy
 

FOR IMMEDIATE RELEASE

Contact: Rebecca Rollins, Interim Chief Communications Officer

rrollins@pih.org

BOSTON (May 26, 2015)--Partners In Health and Zanmi Lasante, its sister organization in Haiti, are proud to announce that 6-month-old conjoined twin sisters were successfully separated on Friday, May 22, at University Hospital (HUM) in Mirebalais and are in stable condition within the hospital’s intensive care unit.

A national and international team of surgeons, anesthesiologists, nurses, and other specialists collaborated on the twins’ case from the time they were in utero through planning, surgery, and post-operative care. Dr. Christophe Milien, HUM’s director of obstetrics and gynecology, provided prenatal care to the mother and delivered the babies, who have a healthy fraternal triplet sister, by cesarean section on November 24, 2014.

Drs. Henri Ford and James Stein, of Children’s Hospital Los Angeles, led the international team of surgeons during the separation and were joined by their colleagues and others from Bernard Mevs, Florida Hospital, Cornell Weill Hospital, Children’s Hospital Oakland, Boston Children’s Hospital, PULSE, and Loma Linda Hospital.

The babies shared a liver but no major vasculature, and represented one of the least complex variations of conjoined twins. Surgeons separated the pair during a seven-hour procedure without any major complications. Their recovery has been rapid; both are breathing on their own and have taken their first bottles.

Read the full story here.

In March 2015, Partners In Health Co-founder Dr. Paul Farmer delivered the 2015 Gruber Distinguished Lecture in Global Justice at Yale Law School. 

Gruber Distinguished Lectures are public addresses featuring path breakers in the fields of global justice and women’s rights. Past lecturers include Justice Ruth Bader Ginsburg and Nobel Laureate Dr. Shirin Ebadi.

In his lecture "No Health, No Justice: Recent Lessons From West Africa" Dr. Farmer shared insights from his current work, including battling ebola and growing inequality. Approximate video length: 1 hr 19 minutes.

"endTB" is an innovative project using new tuberculosis (TB) drugs implemented by the international organizations Partners In Health (PIH) Medecins Sans Frontieres (MSF), Interactive Research and Development (IRD), and funded by UNITAID with a four-year, 60.4 million USD grant. This project aims to produce concrete results in the form of more effective and better-tolerated regimens for MDR-TB that will in turn lead to greater access.

For the first time in over 40 years, two new anti-TB drugs (bedaquiline and delamanid) have been developed. While the WHO has produced interim policy recommendations on their clinical use, very few patients have received these new drugs as part of national TB treatment programs. The endTB Project will provide these two new drugs in a closely monitored multi-country cohort of 2,600 patients in 15 countries. The endTB Project will also implement a clinical trial among 600 additional patients to identify novel treatment regimens that are shorter and less toxic than current MDR-TB treatment regimens. Through these activities, the end TB project will:

1) Generate evidence of safety and efficacy of new TB drugs.

2) Accelerate uptake of new TB drugs and novel MDR-TB regimens.

3) Facilitate change in evidence-based WHO recommendations.

All endTB patients will benefit from a strong pharmacovigilance system and will be actively monitored for potential adverse events through a regular schedule of clinical evaluations and laboratory monitoring tests that is consistent with WHO recommendations.

Related links:

Learn about Partners In Health's tuberculosis work

Peru: Study Aims to Reveal How TB Spreads

Marie Myrka Amazan, 66, is the cross-site coordinator of continuing education for all nurses in the health clinics and hospitals supported by Zanmi Lasante, Partners In Health’s sister organization, in the Central Plateau and lower Artibonite regions of Haiti. She has worked with ZL since 2000, contributing to the growth of services across central Haiti.

I’ve been a nurse for 35 years, so my career is a long story. I started in 1971 as a school teacher in Les Cayes, a seaside town on Haiti’s southern peninsula. In 1977, after six years of teaching, I left that job and started nursing school.

What made me decide to become a nurse was a nursing school graduation I attended. What really touched me was a song that a choir of nurses was singing. I knew I wanted to sing in that choir. I loved the words and what they were singing about. I immediately joined, and it was while I was in the choir singing that I realized I wanted to be a nurse. To this day, this music has stayed with me. Every time I sing these words, I cry. The song says that the compassionate Virgin Mary is here, as nurses are, to help assuage suffering.

I got my nursing diploma in 1980, and I became a teacher in the same nursing school. After that, I moved to Port-au-Prince and worked in a private hospital as an on-call overnight nurse. That same year, I went to work in an orphanage, where I was in charge of the health of the children as well as staffing, supplies—everything. I also worked for an organization that did mobile clinics, including family planning and vaccinations. In 1983, I became a professor at the National School of Auxiliary Nurses. Later, I worked for the National School of Nursing, which collapsed in the earthquake in 2010. I worked for 11 years in that nursing school.

At the same time I was working as a professor, I worked as a night supervisor in a public clinic in Cité Soleil, an impoverished area of Port-au-Prince. I spent 11 years there. During that time, Jean-Claude Duvalier left the country, and there were three years of intense instability until Jean-Bertrand Aristide was elected. He was ousted by his generals in 1991 and came back to power in 1994. It was very difficult. There were always problems within Cité Soleil, and it was hard to even get to the clinic. There were thefts and confrontations between different groups, and bystanders often suffered from these. I didn’t wear my uniform on my way to work because I didn’t want to draw attention to where I was going and what I was doing.

I worked in Cité Soleil not because it was challenging, but because I wanted to improve my skills as a nurse through experience in a hospital. I got a ton of experience there, because I had to supervise all the clinical services, including pediatrics, maternity, surgery, internal medicine, and emergency. I had to work wherever there was a need. It was a wonderful experience for me for 11 years. I believe in professional development for nurses. Nurses who have good experience and training can save lives and help people. If they don’t, they can’t provide services that people need. I always tell the nurses I train to enrich themselves with experience and practice.

In 2000, I joined Zanmi Lasante, working for four years as the chief nursing officer in Cange. Cange was much smaller then, with just one building as the whole hospital. Cange has just grown and evolved so much. In that time, as our program to treat HIV was expanding, we received a lot of visitors and foreigners on volunteer trips. The hospital wasn’t big, but there was a lot of activities, a lot of visitors, and a lot of excitement about the hospital—both in Haiti and internationally. During this time, I organized a training for a group of auxiliary nurses who worked in Cange, to train them and then equip them to train others.

After that, ZL decided that we needed to open a training center. It was in this period that we were thinking about training and how important it was. The critical piece of the training center was that it was integrated from the beginning with the Haitian Ministry of Health. Before, Cange had been always its own private facility, not integrated with the public system. At that time, we were getting a lot of money for HIV treatment from the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the President’s Emergency Plan for AIDS Relief. We were thinking about expanding to other sites and being asked by the Ministry to expand. We also wanted to expand our training platform through the Ministry of Health. So we rented a site across from the Catholic Church in Hinche, and I led a team along with all the doctors who are now the executive leaders of Zanmi Lasante. So I coordinated all of the training both in Cange and in Hinche.

When we started, the training was all about HIV. Health care professionals—lab techs, pharmacists, nurses, and doctors—were coming from all over the country to learn to treat HIV, because across Haiti there was a push to treat HIV with funding from the Global Fund and PEPFAR. We also did a training on infection control for people who were hospitalized in the Hinche hospital. Eventually, I took on the role of coordinating all continuing education for nurses.

We provide training on anything that the nurses need. We identify the needs through visits to all the clinics and hospitals and meeting with the nurses there. Then I plan the trainings to meet their needs. Since I’ve worked here, I’ve emphasized to the nurses I train that they should advocate for patients and design a plan of care. It’s empowering for the nurses to feel like they could create a plan of care, follow it, and provide a better quality of care because they’re advocating for patients. Nurses advocate for them when they’re facing a long wait and encourage them to ask questions. Patients might not tell the doctors everything that’s wrong with them, and that’s why it’s important for nurses to be there, so they can advocate. I tell the nurses this, because it matters to patients’ health.

The patient sees the doctor as someone who gives the treatment and sees the nurse as someone who is much closer, like a friend or a family member to whom patients can really describe how they feel. There’s a lot more distance between doctors and patients. Nurses can always figure out more of what’s wrong with the patients because the patients talk to them.

As you can see, I’m getting older, and eventually I’ll have to leave. So I would hope that I could serve as an example or a model for younger people. As for Zanmi Lasante, I hope that it’s never extinguished.

It can be intimidating to start a career in global health. It’s a diverse field that evolves quickly and demands collaboration across disciplines, from finance to supply chain and logistics, to computer programming.

In this series, we ask a seasoned colleague to share professional experiences with those interested in forging a career in global health. For this edition we asked Nataliya Zemlyanaya, the program manager of our office in Tomsk, Russia. Russia Program Coordinator Evgenia Markvardt translated.

It was the spring of 2008, and I was a tuberculosis specialist in the Tomsk Tuberculosis Hospital. I had just defended my thesis on multidrug-resistant tuberculosis and was teaching phthisiology (the science of TB) to students of Tomsk Medical School. In the evenings, I took classes toward a health care management degree. It focused on economics and the management of medical institutions, which was very different to my work as a hands-on clinician. I was not sure how I would use the degree. I had always liked working with patients, but I felt powerless to change the systematic problems of the TB field.

One morning, I saw on the hospital door an advertisement for a rural programs coordinator for Partners In Health. I read the requirements and it was as if lightning pierced me. I thought, "This is my place!" It was like a sign from above.

Thus began my new life. I say this without exaggeration because working for PIH changed my outlook on life. In my head, the “health universe” reversed: The patient became more important than the proud, inflated doctor. The people on our team were like-minded. They were all enthusiastic, creative, talented, and dedicated to helping patients.

At first, I was skeptical about their ethos—why must doctors run after patients and solve their life problems? If patients didn’t want treatment, it was their problem, I thought. With PIH, my mindset changed. I came to understand that if a patient did not want to undergo treatment, it was society’s problem—our problem. I learned to investigate not only patients’ medical conditions, but also their personal issues that could influence their recovery.

Certainly, public health is not all colorful fireworks. It requires meticulously performing daily tasks, which is different from the emotional and personal work of treating patients. Planning, budgeting, analyzing, writing program plans, holding meetings, running trainings, negotiating with the administration of local health authorities, following up on activities, and more—I had to learn it all.

At first, I did not see the impact of my work, and my time and efforts seemed wasted. But results did emerge! In rural areas where our program focused, we started identifying more people with early-stage TB, which is most easily cured. Before, I could only help individual patients as their doctor. Now I had the opportunity to improve the quality of TB care throughout the region. One of the characteristics of working in public health, in my opinion, is the magnitude of its impact.

Of course, failures can occur along the way. A certain program is not feasible in the end or does not produce the desired result. However, real failure is not doing anything. A negative result creates an opportunity to reflect and guides future actions.

The main thing is we are a good team. In Russian there is a saying: “Alone you cannot battle the mountain; you will just break your forehead.” I am fortunate to work with people who are dedicated, creative, and thoughtful, and who have a strong sense of humility—all qualities that are very important for working with patients. I love my work. I am a happy person.

To learn more about PIH's TB work, read "The Sputnik Initiative: Patient-Centered Accompaniment for Tuberculosis in Russia"

May 6-12, 2015

Partners In Health Nurses Deliver

#NursesWeek
#NursesDeliver

At Partners In Health, we’re not only grateful for nurses—we depend on them. 

Nurses deliver the vast majority of care at our sites, from the clinics of Lesotho to the maternity ward of University Hospital in Haiti.  Learn more about how Partners In Health is elevating the role of nursing around the world.

Related stories:

Haitian Nurse Looks Back on Storied Career

Nursing in Navajo Nation

Why I Nurse: Gedeon Ngoga

News of the earthquake that struck Nepal at noon April 25 has left us deeply saddened. Some of us have worked there. Others have enjoyed traveling there. All of us at Partners In Health know how an earthquake can exacerbate poverty. One moment, it is weak buildings, under-equipped hospitals, not enough rice in the bowl; the next, it is a humanitarian crisis. Our hearts go out to the people of Nepal.

Thankfully, many organizations are providing relief.

Our colleagues at PossibleHealth.org, a Nepal-based PIH partner organization, recommend donating money to the America Nepal Medical Foundation. The nonprofit has been helping Nepalis improve their health care infrastructure since 1997 and is moving fast in some of the worst-hit areas.

International Medical Corps and Doctors Without Borders, veteran disaster-response organizations, are also providing much-needed aid.

We encourage you to support them, and to stand with us in solidarity with the Nepalese.

Never mind that he knew nothing about ranching, PIH clinician Devin Platt was obsessed with becoming a rancher. After college he saved what feed money he could from seasonal jobs as a raft guide and ski patroller. During long drives around the West, he kept his eyes open for the ideal small town. He enrolled in nursing school, in part because it was a natural extension of his backcountry emergency-medicine skills, and in part because an RN promised the free time to learn something about cows. Mostly he cold-called ranchers, some three-dozen between 2004 and 2014.

“I’m a fairly strapping lad,” he’d say. “I can do whatever you want me to do.” 

Sorry, son, came the replies.

In the winter of 2014, he seemed to have a sightline to the future. He had secured a nursing job in Enterprise, a picturesque hamlet in the mountains and pastureland of northeast Oregon, and an invite to work the steers and heifers on a historic ranch. But then Platt, 34, made a tiny choice that proved a big decision. With the nonchalance of a man amused by frothing whitewater and steep avalanche paths, he tossed off an application to fight the Ebola epidemic in West Africa with Partners In Health. He received an offer to work in Sierra Leone for roughly six weeks starting in February, and accepted it.

Last week, he returned to Sierra Leone with PIH for a second time, with plans to work for at least a year. The cowboying and small-town nursing are on hold indefinitely.

“I’m super pumped,” he says.

What's he thinking? Nothing special, it turns out. Platt is part of an impressive group of former short-term, Ebola-focused employees who have opted to return to West Africa with PIH. They reside everywhere from Alabama to California, Washington to Florida. Some have extensive experience abroad, growing up off the coast of Madagascar, for example, or working in war zones and amid humanitarian crises. Others have stayed closer to home in North America. Some are single, others married with children and Harley Davidsons. They are nurses, doctors, psychologists, logisticians, ranging in age from mid-20s to mid-70s. They say goodbye to remunerative jobs, loving families, amazing cattle. In Liberia or Sierra Leone, they do maternal care and supply chain management and everything between. Unlike their first six-week-long stints with PIH, they go for the duration, up to a year. At last count, some 30 of PIH’s 190 short-term employees had doubled down with PIH in West Africa.

Their reasons for doing so are as varied as their backgrounds.

Emergency medicine doctor Luanne Freer, who emailed from the temporary clinic she is running at Mount Everest basecamp, in Nepal, might have the most personal reason for wanting to return to West Africa with PIH this summer. She wrote:

“I fell in love with a 4-year-old boy who was rendered blind by Ebola. I'm working with a group of Danish nurses and PIH to get him corneal transplant surgery.”

Longtime obstetrician Dr. Michael Grady is in Sierra Leone a third time partly for the opportunity to work with colleagues like Freer.

“The people this work attracts—they’re probably the most interesting collection I’ve ever come across,” he says.

His house in Oxford, Ga., burned down while he was completing his first tour, but he returned to Sierra Leone with PIH just weeks after the embers cooled.

Nurse Jennifer Breiman also returned to Sierra Leone in January, unable to feel settled in Atlanta while the Ebola epidemic continued. These days she is starting fires.

“I’m fortunate enough to be part of the decommissioning of our Ebola Treatment Unit in Port Loko. We have to clean and burn everything,” she says. “I’m walking through rooms where Ebola devastated so many families, and I’m reliving all the experiences I had with the patients. Throwing mattresses into the fire feels like banishing Ebola, like freeing the ghosts."

The reason Dr. Charles Callahan wants to return to West Africa with PIH this summer is a bit more abstract. A professor of pediatrics and a Christian, he sees the work echoing the gospel of Matthew 25:35.

“That gospel became real to me in a way I’d never experienced it,” he says, before quoting a bit. “’For I was hungry and you fed me, I was thirsty and you gave me something to drink….’”

Callahan will have good company. Linda Callahan—a passionate fan of Mountains Beyond Mountains, a book about PIH’s founding, a therapist, and Chuck’s wife—is tired of seeing him off. “I want this to be a part of our future,” she told him.

Cheedy Jaja, a professor of nursing who was born in Sierra Leone, feels a patriotic duty to return with PIH.

“The country has experienced massive brain drain,” he says. “If things are going to change in that country, it has to be helped by the diaspora.”

Diana Garde, a nurse practitioner and midwife, plans to go back to Sierra Leone for a third time partly thanks to the culture of the Sierra Leoneans who haven’t emigrated.

“The patients we have are completely appreciative,” she says. “Even in the saddest of times and after the most devastating of outcomes, you still have people that say, ‘Thank you,’ which is amazing.”

Of course there are other reasons short-term employees go back for the long-term—like the inspiring dedication of Sierra Leonean doctors and nurses and midwives and community outreach coordinators and drivers. Most PIHers re-up for a blend of reasons.

But if the answers have one thing in common, it is the underlying belief that the work in West Africa is far from done. Hospitals and clinics need supplies. Local health workers need training. Ebola survivors need support. Liberia and Sierra Leone’s 10 million people need modern, world-class health care systems. Now is a beginning.

For Platt, nursing in West Africa with PIH is an amazing opportunity. Back in Enterprise last winter, he was happily ensconced in a cabin on the banks of a glacial lake, working with wonderful colleagues at the hospital, and soon helping out on two ranches. But giving that up to work in West Africa isn’t a trade-off, according to him. As a nurse manager at Government Hospital in Port Loko, Sierra Leone, he’ll schedule nursing shifts and care for mothers and babies with ailments such as malaria—a disease that has proven fatal all-too-often in Sierra Leone but can be easily treated by expert, well-equipped clinicians like Platt.

“I’m basically leaving the best job in the world for the best job in the world,” he says.

Thank you for being part of the #WeHeal project!

From April 10 through April 26,  we asked you to share stories of how you were healed or helped someone else heal. And you did—big time. We sparked a global conversation and received dozens of submissions from people who wrote poems, took pictures, recorded video, and shared stories about the healing process. Some entries brought smiles, other tears; but they all show how #WeHeal together. Here's a sampling of some of our favorites:

"#WeHeal through laughter!"

"'We' certainly did heal me—of bone cancer at age 24."

"As a patient advocate, I have found that often the best way to help someone heal is to listen."

"I found out I am cancer-free and do not need chemo or radiation treatments. I am abundantly grateful."

“Healing is about giving someone who is hurting a voice—speaking when they can’t answer the questions—from physicians, family, friends."

Although we're no longer requesting entries, we encourage you to read through all our submissions. The stories are sure to inspire you to pay forward the inspiration this project created.

And as part of that good will, we'll be mailing out 400 t-shirts in May to those who entered our HEAL t-shirt giveaway. It's one more way we can continue to share our stories of healing every day.

Dr. Fabrice Julcéus knew of one family medicine residency in Haiti, and it was in Cap-Haïtien, a northern city far removed from the bustle of Port-au-Prince. So when he heard the announcement on Radio Caribe that a new residency would soon launch in the less remote St. Marc, he jumped at the chance to apply.

Competition was stiff, but Julcéus earned a spot in the inaugural class alongside five other family medicine residents at Hôpital St. Nicolas, where he cared for patients under the supervision of senior physicians, conducted research, and designed quality improvement projects.

Family medicine was a natural choice for Julcéus, who liked the fact that “you don’t see only a part of the person, you see the whole person—and not only their body. You’re thinking about the psychological and social problems. I love this approach.”

When it launched in 2011, the St. Marc family medicine residency was PIH’s first formal training program for medical specialists in Haiti, made possible through a partnership with sister organization Zanmi Lasante, Haiti’s national medical school, and the Ministry of Health. The first six residents, including Julcéus, finished their three-year program in December; and five are now working part- or full-time as attending physicians or mentors for residents within the PIH/ZL network. Another 16 family medicine residents are now training at Hôpital St. Nicolas, which is operated by the Ministry of Health in partnership with PIH/ZL.

“The vision was really to make a difference in residency training in Haiti” by combining clinical experience with research and quality improvement projects, said Dr. Kerling Israel, whom PIH hired as the first director of the St. Marc family medicine residency program. “My only measure of success is whether I would feel comfortable to go to one of these residents if I am sick. This is the ultimate test.” And she feels she’s well on track to that goal. “I am proud of this first class.”

Jacks-of-all-trades

Choosing family medicine as the first PIH/ZL residency was a wise choice, considering these physicians are the jacks-of-all-trades of the medical world and could help fill the country’s huge health care gap. There are 25 doctors for every 100,000 people in Haiti, compared to the nearly 300 doctors for every 100,000 people in the U.S., according to the World Health Organization.

Family doctors are especially needed in the countryside, where a wide array of illnesses and injuries affect generations of families who live far from hospitals. The physicians are trained to provide primary and preventive care to people of all ages, over their entire lifetimes. They deliver babies and perform C-sections. They treat childhood illnesses. They stitch up wounds. They provide family planning counseling and advice on preventing the spread of HIV. They care for people with diabetes and hypertension. And they are first responders in an emergency or following a traumatic accident.

“We are the frontline doctors,” said Israel, who is now director of medical education across all PIH/ZL facilities—including the six residency programs at University Hospital in Mirebalais. Often family medicine doctors are the only physicians in town. Patients who could benefit from the attention of several specialists rely on them to address all of their ailments. “They can do a lot with less and they can be more efficient.”

By seeing their patients over a long period of time, family medicine doctors develop trusting relationships that allow them to encourage prevention as they treat disease. They also learn about patients’ social conditions—factors such as unemployment, homelessness, or food insecurity—to help them provide better, more compassionate care.

As family physicians we have a responsibility to be change agents.

It’s the type of expertise that’s appreciated in a bustling facility like Hôpital St. Nicolas. On an average day, it’s packed with patients. In a shaded open-air waiting area, women and children sit on rows of benches awaiting family medicine doctors. The labor and delivery staff sees more than 250 deliveries a month—one of the highest among PIH-supported facilities in Haiti. An emergency department can provide beds to 11 patients at once; it used to afford only two.

The residents provide a lot of care and have increased staffing dramatically at the hospital, from four full-time clinicians to 22. They also attract teachers—senior doctors like Israel and other attending physicians from Haiti and the United States—who bring a depth of experience and an extra set of hands to deal with high patient flow.

Research for change

In addition to hands-on clinical experience, residents are required to conduct research and quality improvement projects with the support of supervisors and mentors. In St. Marc, residents have worked on quality-improvement projects such as labeling the wards so that patients can find their way around. They’re also tackling the issue of infant identification. Nurses affix newborns with bracelets that identify them and their mothers, but it doesn’t happen all the time. Residents are investigating the systematic causes of this problem. Are there stock-outs? Is there no clear protocol for placing bracelets? Or is it a lack of training?

Residents also conducted research on teen pregnancy. With approval from the human research board in Port-au-Prince, they reviewed records of all births, miscarriages, and prenatal visits to see if a disproportionate number of pregnancies occurred during the festive Carnival season in the first months of 2014. Julcéus helped investigate the issue and said his group did not produce findings that were statistically significant. If they had, they would have encouraged community outreach and the distribution of condoms in future years’ celebrations.

 “As family physicians we have a responsibility to be change agents,” Julcéus said, “to see what doesn’t work and how we can improve it.”

Julcéus will have that opportunity for the foreseeable future: PIH/ZL hired him to work full-time as a research coordinator for the St. Marc and Mirebalais residency programs.

Dr. Eduardo Peters arrived in the town of Plan de la Libertad with a head full of knowledge, a good stock of medication, and a healthy helping of good will. While all were important in managing a public clinic in rural Chiapas with Compaňeros En Salud (CES), Partners In Health’s sister organization in Mexico, there was one thing he lacked: the community’s trust. That takes time to cultivate.

“Trust is definitely something you build over months,” said Peters, who recently completed his social service year and now works as CES’s public relations coordinator. He felt that trust grow with each office visit, successful treatment, and trip into the surrounding hillside when he checked on patients and shot the breeze. ”You are part of the community, you’re marginalized with them. You start getting into their homes, you take care of their kids, you cook with their wives and they laugh because you’re a guy” who cooks.

In these moments Peters was more than a doctor; he was a friend and neighbor. Yet he knew that after one year, he would be replaced by another first-year doctor—or pasante—who would have to earn trust all over again.

Since launching in 2012, CES has partnered with Mexico’s Ministry of Health to send seven generations of pasantes—25 young doctors in all—to rural, public clinics at 10 sites throughout Chiapas. Each transition requires a careful passing of the baton from one wave of doctors to the next. While CES staff facilitate this transition through introductions and regular site visits, outgoing pasantes smooth the path for their colleagues by remaining in the community for as many as four weeks to bring them up to speed on patients’ cases and help them adjust to life in a remote rural location.

A new home

Peters remembered vividly what it was like arriving in “Plan,” a bumpy three-hour ride from CES headquarters in Jaltenango through the Sierra Madre mountains. “I’m a city rat,” he said. “I’m used to seeing everything gray and concrete. You get to this beautiful green place full of mountains, and you see corn fields and coffee plantations”—the sources of most families’ income.

Everything reminded him that he was a long way from home. “I remember my first few months,” Peters said. “There were days when I would wake up on a horrible mattress, under a mosquito net, and say, ‘What am I doing here?’ But it wasn’t regret. It was just surreal sometimes to wake up in the middle of a forest, in a teeny house, with bucket showers and no internet, and a terrible phone” shared by the entire community. (The phone operator announced over a public loudspeaker whenever a call was for him.) It wasn’t so much culture shock, he said, as getting used to a new way of life.

Dr. Gabriela Chalup, a CES clinic supervisor, accompanied Peters his first weeks in the community and showed him how to fill out government paperwork, introduced him to patients, and took him around to families’ homes. “It definitely makes a huge difference,” he said. “I would have gone there myself, I’m adaptable, but Gabi helped with the transition.”

The best year of medical service

Peters found well-stocked clinics in the community’s two villages—Plan Alta and Plan Baja. And he learned he’d have help four days a week from Rosa Huet Pale, a Tzotzil-speaking nurse who translated for indigenous Mayan families coming to work in Plan’s coffee fields.

Still, Peters’s transition wasn’t easy. The pasante before him had to leave four months early, and he saw the difference that absence made in the community. All of the chronic patients were “a mess,” he said. People with hypertension or diabetes weren’t taking their pills or had decided to change their own dosage. One patient developed glaucoma and went blind. The hardest thing for him to take was hearing that a six-year-old girl had died from diarrhea while the clinics sat empty.

“In 2015, it’s unacceptable,” he said. “It’s not frequent, but it’s such a preventable death.”

Peters never lacked work. Depending on the day, he could see anywhere from 14 to 34 patients. And while he was the community's primary care physician, he often dealt with issues fit for a dermatologist, cardiologist, pediatrician, or EMT. He got most chronic patients on a regular regimen of medication. He started at least one middle-aged man on treatment for TB after he’d been misdiagnosed with pneumonia. And he connected with a dermatologist, who brokered a deal with a drug company so that an 11-year-old boy suffering from disfiguring eczema could get a steady supply of free medication.

Whenever a particularly tough case presented itself, Peters knew he could call CES Clinical Director Dr. Patrick Elliott for guidance. Elliott and other CES mentors visited regularly to check on his progress and deliver supplies. And he and other pasantes traveled monthly to Jaltenango for three days of global health and social justice courses, all part of CES’s social service year program.

“Even though there was a lot of work,” Peters said, “it was by far the best experience of my medical training.”

A smooth transition

When Dr. Rodrigo Bazúa arrived to replace him in February, Peters was prepared. He had Bazúa shadow him for two weeks as they held clinic and made home visits, all while providing him with cultural tips, a quick community history, and introductions to allies. He even prepared a 10-page document detailing regular patients’ cases so that no information was lost in the transition. And that was in addition to the electronic medical records that are kept for each CES patient.

“It’s nice to know that you’re helping out another pasante and making sure he knows all those details you know,” Peters said.

Like Peters, all pasantes have agreed to stay an extra two weeks after their year of service to help colleagues adapt to their communities.

"This is incredibly rare since most pasantes in other parts of Mexico eagerly await their last day of social service to head back home, to vacation, or to a new job," Elliott said. "But for our pasantes, the largest concern they had was to make sure that their patients received the best care possible. Without an active and personal hand-off, this simply hadn't been possible. ... I am incredibly proud of the way our clinicans have responded to this call."

For his part, Bazúa felt little culture shock when he took over the reins from Peters. “I think Eduardo did a great job in making a smooth transition, and I feel great,” he said. Two months in, he’s beginning to get a fuller picture of Plan and its people. He’s surprised by its diversity (he’d never expected to find such a mix of Catholics, Adventists, and Jehovah’s Witnesses in rural Chiapas) and is learning regional slang for body parts and ailments. He wants to get more chronic patients on treatment regimens and to better understand why so many of his patients endure bouts of asthma and allergies, which he’d thought were common only in wealthier communities.

By the end of his social service year, Bazúa hopes “to be absolutely capable of seeing any disease that is treatable in primary care and treating patients well.” And it would be nice to know, he said, that “the community is satisfied with their doctor.”

FOR IMMEDIATE RELEASE
Contact: Jeff Marvin, Media Relations Manager
jmarvin@pih.org

BOSTON (Apr. 9, 2015)—The Partners In Health clinician recovering from Ebola virus disease is now free of the virus and was discharged earlier today from the National Institutes of Health in Bethesda, Md.

“We’re heartened by the news that our colleague is heading home, free of Ebola, and making his way toward a full recovery,” said Sheila Davis, chief of Ebola response for PIH. “His commitment to strengthening the quality of health care in some of the world’s poorest communities is something we should all be proud of.”

Our colleague, whose name will not be released, was admitted to the NIH on March 13. After two consecutive tests that were negative for Ebola virus, the NIH clinical team determined our colleague is no longer contagious to the community and able to return home. The additional PIH clinicians transported to the United States for monitoring were cleared by the Centers for Disease Control and Prevention and local health authorities last week and released. None were infected with Ebola virus disease.

“We're cheering here in rural Liberia and in Sierra Leone, and are sure our co-workers in Boston and Haiti and Rwanda and Peru and elsewhere are too,” said Dr. Paul Farmer, co-founder and chief strategist for PIH.

We continue to ask the media and public to please respect our colleague’s privacy as he transitions out of care. We also underscore that Ebola survivors do not pose any public health risk and are not contagious to the community.

“Our colleague’s selflessness reminds us that the fight in West Africa is not over,” said Davis. “We must redouble our efforts not only in the immediate crisis, but also for the long-term, working alongside the ministries of health to strengthen their national health systems.”

Already, two clinicians who had returned for monitoring are heading back to Sierra Leone to rejoin PIH’s efforts supporting the Ministry of Health and Sanitation. PIH remains committed to bolstering the delivery of comprehensive health services in Liberia and Sierra Leone.

The Ebola situation is changing rapidly. In the week ending April 5, Liberia had zero new cases, Sierra Leone had nine new cases, and Guinea had 21 new cases, according to the World Health Organization. Cumulative recorded cases exceed 25,500. More than 10,500 people have died.

###

Aminata* was pregnant and in labor, but the baby wouldn’t come. Medical staff at a Sierra Leonean health care facility were afraid to treat her obstructed labor, thinking she might have Ebola, so the 24-year-old was referred to an Ebola holding center. Her blood was sent to a special lab to test for the disease so she could be rushed to the operating room for a lifesaving cesarean section if the test was negative.

But Aminata died of complications from obstructed labor while medical staff awaited her report. Hours later, the lab results came back: negative. Aminata never had the virus. She and her baby had died a senseless death.

Ebola poses an enormous risk for pregnant women. But many pregnant women likely to die because of the outbreak are like Aminata: They never had the disease to begin with, but they’re unable to get the care they need.

A critical challenge is this: Many pregnancy complications mirror symptoms of Ebola. When a pregnant woman arrives at a West African clinic with vomiting, bleeding, or pre-term labor (common complications of pregnancy), a clinician’s first thought, rightfully, is of the deadly disease. In an ideal setting, that clinician would send this woman to a specialized Ebola unit to receive care by clinicians in personal protective equipment (PPE) and wait for an Ebola test.

The Sierra Leonean government and Partners In Health clinicians are working closely together to move toward that ideal at a Freetown hospital. Together they’ve progressed from the chaotic early days of the epidemic to an ever-improving model of care.

Challenges of care

Early in the epidemic, PIH clinicians say, beds for pregnant women were scarce in Ebola treatment units—a result of clinicians’ fear of infection as well as pregnant women’s poor outcomes. So some women were simply refused care.

Because of the fear of Ebola, everybody was scared, and clinical staff were running away.

In the general maternity wards, the staff and systems were unprepared to triage patients for Ebola, and many clinicians fled. What adds to the tragedy is that the majority of women presenting with these symptoms did not have Ebola; they just needed basic maternity care. Such care is possible only if clinicians can triage for Ebola, if safe beds for pregnant women and providers in PPE are available, and if rapid Ebola testing can be performed.

In the first months of the outbreak in Sierra Leone, that care wasn’t available.

“Because of the fear of Ebola, everybody was scared, and clinical staff were running away,” said Sister Elizabeth Koroma, who was a senior nurse anesthetist at Princess Christian Maternity Hospital in Freetown. (Sister is a courtesy title for supervising nurses.)

Princess Christian Maternity Hospital (PCMH) provides critical services for pregnant women. It’s the national maternity referral and teaching hospital, so many women seek treatment there for pregnancy complications, said Dr. AP Koroma, PCMH medical superintendent. And because complications and childbirth involve a great deal of fluids—and fluids can spread Ebola to inadequately protected providers—hospital staff members became increasingly rattled as the outbreak progressed.

In July, that fear drove many to leave their jobs, said Dr. Koroma (no relation to Sr. Koroma). The hospital remained opened but understaffed. Pregnant women with Ebola weren’t always separated from those who didn’t have the virus, and the disease had the potential to spread.

At the beginning of the outbreak, many national staff came to work regardless of the risk. ... This heroism should not be forgotten, and we should recognize that this outbreak would have been significantly worse if not for their sacrifice.

It was an extraordinarily difficult time for Sierra Leonean clinicians.

“There were only four beds in a small isolation unit that wasn’t well set up for infection control,” Dr. Koroma said. “It was taking three, four, and even five days for [Ebola] test results, and there was no space to house additional patients. Many were just lying on the floor in the outpatient department, Ebola and non-Ebola patients, and many died before they received care.”

Basic kindness also complicated the situation, Sr. Koroma said.

“It was hard to keep patients from mingling because patients were sympathetic to one another,” she said. “And in Sierra Leonean culture, we take care of each other.”

Sierra Leonean clinicians also wanted to take care of their patients—and many did so, despite often unsafe conditions.

“At the beginning of the outbreak, many national staff came to work regardless of the risk,” said Piero Pertile, PIH program officer at PCMH. “They put their own lives on the line long before the international aid community came to support them. This heroism should not be forgotten, and we should recognize that this outbreak would have been significantly worse if not for their sacrifice.”

But the clinicians who responded needed training in infection control, supplies to protect themselves and their patients, and systems to continue to support maternity care to save pregnant women’s lives.

PIH has collaborated with the Sierra Leonean Ministry of Health and Sanitation and other international partners to transform what was a small radiology unit at PCMH into a specialized Ebola holding unit, where pregnant women suspected of having Ebola are tested for the virus and receive care by staff in PPE while they await the results. In addition, PIH and Dr. Koroma’s team have leveraged this work to encourage the Dutch government to build an Ebola testing lab on the campus. Now, it is possible to know if a woman has Ebola in less than six hours.

The women who test positive are sent from the hospital to a separate Ebola treatment unit.

The key goal of the PCMH unit is to make sure pregnant women get the medical care they need. It’s critical that the doctors, nurses, and midwives providing that care feel comfortable and safe treating pregnant women, PIH Chief Medical Officer Dr. Joia Mukherjee said.

“They were doing the best they can in an impossible situation, and we were able to join hands and say, ‘In this facility, what’s the best thing we can do to give your staff the confidence to go back to work?’” Mukherjee said.

The new unit has helped Sierra Leonean clinicians overcome their fear, said Sr. Koroma, who was one of the lead nurses at the unit until March. Several have returned to work there since it opened, she said.

The Ministry of Health and PIH opened the unit in early December. It operates 24 hours a day and had admitted 204 women as of March 26.

Sister Elizabeth Koroma has cared for pregnant women in the midst of Ebola since the outbreak began last year in Sierra Leone. (Photo by Piero Pertile/Partners In Health)

High risk from the start

Pregnancy and childbirth were dangerous in Sierra Leone long before Ebola showed up. The country emerged from a decade-long civil war in 2002, and its health system continues to experience challenges. In 2013, 1,100 women died for every 100,000 live births, according to World Bank data. That’s the worst maternal mortality ratio in the world. By comparison, 28 women in the U.S. died for every 100,000 live births that year.

With Ebola present, those statistics could become even grimmer.

Pregnant women are not necessarily likelier to get Ebola than anyone else, according to the U.S. Centers for Disease Control and Prevention. But once they do have the virus, it is often fatal to the women and, to date, always so for their fetuses.

It is unclear why pregnant women’s lives are in particular danger after they get Ebola, said Dr. Theresa Cullen, who worked at the PCMH unit through PIH. Clinicians know that a woman’s physiology changes during pregnancy. Pregnancy weakens the immune system, Cullen said, which could increase a woman’s chances of dying from Ebola.

“Pregnant women who get Ebola have historically done very, very poorly,” said Dr. Regan Marsh, a PIH clinician who was part of the Ebola response in Sierra Leone. “Pregnant women definitely need specialized care. They need more intensive care; their babies need care.”

Of the 204 women admitted to the PCMH unit, 27 tested positive for Ebola, or 13 percent (Ebola was unconfirmed but suspected for six women). Nine Ebola-positive women died in the unit, and 18 were moved to Ebola treatment units.

Building a new model

But the main aim of the Ebola unit at PCMH is not to treat pregnant women with Ebola through the entire course of their illness. Rather, it is set up to provide interim care for pregnant women while it is determined whether they have Ebola. If a woman is found to have Ebola, she is transferred to an Ebola treatment unit as soon as a bed is available. Women who don’t have Ebola are moved to general wards for obstetric care.

“Pregnant women with suspected or confirmed Ebola can and should be given the same level of care as all other Ebola patients, if appropriate precautions are taken,” Pertile said.

Ninety-six people staff or support the small, free-standing Ebola unit at PCMH, Pertile said. That includes nurses and midwives, but it also includes Ebola-specific staff members such as chlorine sprayers.

After a woman is admitted, she is placed in a bed in either the “wet” or the “dry” area. Patients enter the wet area if they are emitting fluids, such as blood, vomit, or diarrhea. Others enter the dry area. The aim is to separate those likely to be positive and more infectious from those who may not be positive or who are less infectious.

All are then tested for Ebola. As recently as February, results took up to four days. But the new on-site lab services mean that test results can be available within four to six hours.

“Proper infection prevention and control, a dignified place to provide care as women wait for their results, and rapid lab testing are critical to the survival of pregnant and laboring women in the time of Ebola,” Mukherjee said.

While they await results, the women receive treatment such as intravenous fluid, antimalarial medication, and antibiotics: standard and essential care for women with pregnancy complications. Sometimes the babies come while women are in the unit, and clinicians in full PPE help deliver them. This is tricky, too.

“Management of labor is very difficult because you can’t touch patients in the same way that you would normally, and you can only spend so much time in PPE,” Sr. Koroma said. “Normally you have time to speak to patients and place a hand on their shoulder to reassure them, but this is not as easy with Ebola suspect pregnancies.”

And sometimes, if problems arise during this waiting period, little can be done. A woman with obstructed labor like Aminata can’t go to the operating room for a C-section, for example, until clinicians are sure she doesn’t have Ebola, said Dr. Michael Grady, an OBGYN who was PIH’s clinical lead at PCMH in January and February.

I am proud that we never gave up, even when things were very difficult. I am especially proud now that Ebola is going away.

Grady returned to Sierra Leone at the end of March to supervise maternal health care. Despite the challenges he experienced providing maternity care in the time of Ebola, he said he was proud of the health services that the Sierra Leonean and PIH clinicians provided.

He, along with Nurse Emily Havener and Cullen, praised local colleagues such as Sr. Koroma.

“They’re really the heroes of the story,” Grady said. “We go in for a month or several months at a time, but they’re there day in and day out. These are their fellow citizens, what they call their Sierra Leonean sisters.”

Sr. Koroma, who now works as a critical care nurse at Connaught Hospital, is proud, too.

“I am proud that we never gave up, even when things were very difficult,” she said. “I am especially proud now that Ebola is going away. I am proud to work with your team [PIH], who helped bring us the support that we needed to treat patients.”

Cullen worked alongside Sr. Koroma in December and January and said Koroma led the unit with authority and compassion.

“She was like a chameleon or a stealth bomber: She’d always be there. You’d be in crisis, and suddenly she was there. You’d wonder how she knew to do that.”

OBGYN Dr. Michael Grady said he believes more work lies ahead in the effort to improve care for pregnant women in Sierra Leone. (Photo by Jon Lascher/Partners In Health)

It just makes it even more tragic if somebody dies unnecessarily in labor because of the fear of Ebola. That’s the tragedy here.

Tragedy and hope

Of the 204 women admitted to the unit, 171 tested negative for Ebola: 84 percent. That statistic seems positive, but it suggests that some pregnant women whose lives could be saved by surgery or other interventions are dying instead. Placing them in an Ebola suspect unit, even briefly, could result in delays in needed obstetric care. The on-site, rapid laboratory test is expected to improve these outcomes.

Fifteen Ebola-negative women and 17 Ebola-negative babies have died in the PCMH unit.

“It just makes it even more tragic if somebody dies unnecessarily in labor because of the fear of Ebola,” Grady said. “That’s the tragedy here.”

Cullen said she saw more maternal death in her five weeks in Sierra Leone than she had in her life—she’s been practicing medicine since 1984.

Maternal death has serious consequences for families. Children are four times likelier to die if their mother dies before they reach age 10, compared with children whose mothers are alive. The risk of death after loss of a mother is even higher for infants. A mother’s death also comes with socioeconomic consequences; children whose mothers die are less likely to finish school.

“Mothers are the ones who take care of everyone,” Marsh said. “The mother is the real center of health for the families—and that’s not unique to Sierra Leone; that’s true in the U.S. The implications of maternal death are really, really high.”

Although these deaths occurred far too often, most Ebola-negative women at the PCMH unit have survived to be discharged (89 of 171) or transferred for general hospital care (65 of 171).

The unit has had increasingly hopeful moments. Cullen noted that many of the midwives there had worked in rural Sierra Leone, where they were the only providers of maternal care for miles. This resulted in a wealth of experience.

“The beauty is that we brought skills and they brought skills, and we found this common way to work together,” Cullen said.

PIH clinicians and the Sierra Leonean nurses and midwives established protocols to make sure the unit provided high-quality care, she said.

One of Havener’s top moments was helping a woman in the unit give birth to a daughter. Both were Ebola-negative.

“She had a little peanut of a girl, and we ended up starting the baby on antibiotics,” Havener said. “So when we discharged her we sent her to a special unit for babies so she could finish her antibiotics. Every day her mom would come over and say hello and smile and say thank you. … That was really special; we got to go see her baby and remember there were positive outcomes, too.”

What lies ahead

The Ebola situation is changing rapidly. According to World Health Organization figures, Liberia had zero new cases to Sierra Leone’s nine new cases in the week ending April 5. Guinea reported 21 cases that week. Cumulative recorded cases exceed 25,500, and more than 10,500 people have died.

The Ebola unit at PCMH will scale down from 11 beds to eight as the outbreak slows. But Grady believes the fight is far from over.

The success story is that people can survive from Ebola.

“We’re getting ahead of the curve on Ebola, and I think it’s important to chase it down to zero,” he said. “The aftermath is going to demonstrate that much more needs to be done to save women’s lives. The work really lies ahead more so than it has in the past. I think it will be years recovering from the effects of this on the country.”

Dr. Koroma expressed hope, saying hospital staff members who know that Ebola-positive women have been screened out can treat pregnant women without fearing for their own lives. And Sr. Koroma, after watching the epidemic unfold, also is hopeful.

“The success story is that people can survive from Ebola,” she said. “And when you develop infection control systems, you can help mothers with Ebola and mothers who do not have Ebola and provide safety and confidence to the providers. People can still survive when early treatment is given, and if the fight is put in place, the transmission chain can be broken and save others from being infected.”

*The patient’s name has been changed to protect privacy.
 

Read more about PIH's Ebola response here.

Nurse Karin Huster, a PIH clinical lead in Sierra Leone, writes on the need to ask tough questions in "All Lives Matter," published April 6, 2015, in Slate.

"I was there.

I was there when our clinician collapsed at the Port Loko Government Hospital in Sierra Leone a few weeks ago. And I was nearby when we were informed soon after that a Sierra Leonean colleague was suspected of having Ebola. As head of the medical team in Port Loko for Partners in Health, a global health nonprofit, I worked alongside these two clinicians.

When our American colleague fell ill, he was initially transferred to Kerry Town, a first-class Ebola treatment center run by the British Defense Ministry, and from there flown to the National Institutes of Health clinical center in Bethesda, Maryland. When our Sierra Leonean colleague, an employee of the Ministry of Health, fell ill, we helped secure his admission to the same British-run treatment facility—the best option available to Sierra Leonean health care workers.

In these differences in options for care, the stories of these two colleagues abruptly split, with one receiving arguably the best Ebola care in the world and the other receiving the best Ebola care available in one of the poorest countries in the world."

Read the full essay here.

FOR IMMEDIATE RELEASE
Contact: Jeff Marvin, Media Relations Manager
jmarvin@pih.org

BOSTON (Apr. 7, 2015)—The National Institutes of Health upgraded the PIH clinician infected with Ebola virus disease to good condition today.

“We’re very pleased with our colleague’s continued progress at the NIH,” said Sheila Davis, Chief of Ebola Response at Partners In Health. “Recovering from Ebola is a long process, often marked by highs and lows, and today’s news is yet another step forward in our colleague’s path to recovery.”

“We also recognize the tireless efforts of the NIH clinicians who continue to support our colleague and his family,” Davis said. “The entire PIH family is eternally grateful for their skilled care and dedication to ensuring our colleague recovers from this horrible disease.”

PIH will not release any information about our colleague's identity or specific clinical details.

###
 

Dr. Karla Sanchez stood in the middle of a rural public clinic in Chiapas, Mexico, and surveyed the mess. The rooms were dusty and disorganized. Patient files were non-existent or incomplete. And thousands of vials of medication in a nearby storage room were spoiled.

It was February and Sanchez was the first clinician Compaňeros En Salud (CES), PIH’s sister organization in Chiapas, had sent to Letrero, a mountainside community located several hours over bumpy roads from headquarters. She would be the first of hopefully many young doctors to come and provide care for the 2,100 people living in and around the village.

But her yearlong task was Herculean: she was to set up the clinic, identify patients with chronic illness, provide everything from primary to emergency care, and—most importantly—earn the trust of her new neighbors, who historically had unreliable access to a doctor.

The situation would have been daunting for the most seasoned doctor, but it was especially so for Sanchez, a recent medical school graduate who had just arrived for her social service year. During her first days in the community, CES clinic supervisor Dr. Enrique Valdespino organized a meet-and-greet with community representatives to talk about CES’s mission, introduce Sanchez, and explain what she would be doing in Letrero.

Apparently, his message piqued their interest. “Afterwards, everyone wanted to go to the clinic,” Sanchez said. Her patients told her, “’I just want you to check me. I’m fine.’” Days later, nearly 50 people from a village an hour’s walk away showed up for visits. She and Valdespino dove in, seeing one patient after the other and triaging serious cases for follow-up appointments.

The “first functional doctors”

CES partners with Mexico’s Ministry of Health to recruit and train young doctors like Sanchez, who manage public clinics throughout Chiapas during their social service year. The first-year doctors, or pasantes, have conducted more than 45,000 patient visits in eight communities throughout the southeastern state since CES began providing services there in 2012.

Each of the sites (Capitán, Honduras, Laguna del Cofre, Matazano, Plan de la Libertad, Reforma, Salvador Urbina, and Soledad) is located within a four-hour drive of the central office in Jaltenango. In February, CES expanded to two additional communities—Letrero and Monterrey—pushing its reach farther into the surrounding Sierra Madre mountains.

Chiapas is one of the poorest states in Mexico. Half of its population lives below the poverty line. In the Sierra Madre region, where CES operates, most rural people are coffee farmers whose income relies on the fickle ebb and flow of the international market. While all Mexicans receive universal health insurance, public clinics in Chiapas are often under-equipped or closed. That’s partly because there are 94 physicians per 100,000 people in Chiapas—roughly half the number found in the rest of Mexico and nearly a third of the number in the United States. Plus, the two nurses and one doctor assigned to each government clinic are not always reliable.

People die from things they shouldn’t have died from.

“The problem with this operation is that most doctors and nurses are not from rural Chiapas,” said Dr. Hugo Flores, executive director of CES. “They have to travel from far distances to get to their job posts.” While many arrive at health centers on Mondays and return home Fridays, absenteeism—or, simply not showing up for work—is not uncommon and is a challenge for health systems in rural areas around the world.

“That really does not translate into adequate care,” Flores said. “The truth is that in most of the places that we work, we are either the first doctors or the first functional doctors” based in the community.

It’s difficult to pin down a list of common health problems in Chiapas. As is true everywhere, people battle common colds and flu, struggle with asthma and indigestion, and need to guard against infection from simple wounds. But the prevalence of infectious and chronic disease is high. And serious cases have gone without treatment for years.

There are women in advanced stages of breast cancer, men who have nursed hernias for half a century, and adults with untreated psychotic conditions who—because they lack access to proper treatment or medication—have spent 10 years locked in cages alongside their family homes to protect themselves and others from harm.

“People die from things they shouldn’t have died from,” Flores said. “Because they’ve never had access [to health care], everything becomes a problem. … When we’re there, we see that change dramatically.”

Opening Letrero and Monterrey

Within her first couple weeks in Letrero, Sanchez came across cases of the flu and diarrhea, but also met people with fractures they’d had for four years.

“It’s been so horrible to hear that every single family has one child that has died,” she said. “They’ll say, ‘He died of fever when he was born.’”

I want them to see what a real doctor is like, to have them trust me.

Preventing such tragedies has become Sanchez’s main goal. She plans to speak with midwives to help ensure safe deliveries. She wants to identify patients who struggle with chronic illnesses, such as hypertension and diabetes, and get them on medication. And she hopes to visit neighboring communities to provide mobile clinics and to triage patients in need of more intensive care.

“I want them to see what a real doctor is like,” she said, “to have them trust me.”

Fatima Rodriguez hopes for the same in Monterrey, the new CES site she’s running during her social service year. Community members told her they hadn’t seen a nurse arrive in several months, which was consistent with the meager stock of medications and the cobwebs and dust coating every surface.

CES clinic supervisor Dr. Jimena Maza helped Rodriguez set up the site with supplies and proper medications and introduced her to the community. Residents were happy to hear she would be there for a year and asked if vaccinations would be available—a clear concern in a region where the majority of children hadn’t received their shots.

Within days, Rodriguez was seeing her first patients. Many children had diarrhea due to improper hygiene and sanitation or asthma because of poor air quality, and respiratory infections were common among women and children regularly exposed to the smoke of indoor wood stoves. She was surprised to find both men and women were interested in birth control, since her patients also spoke about their practice of Catholicism or other forms of Christianity. And she identified several patients who suffered from epileptic seizures, which can be controlled with proper medication.

Rodriguez is learning how to tackle these everyday issues, but emergency cases push her limits. A 13-year-old boy suffered an eye injury while splitting wood and needed to be transferred to a hospital immediately, but public transportation doesn’t exist. She managed to find a resident with a car who volunteered to drive the boy two-and-a-half hours along bumpy gravel roads to the nearest hospital.

The experience taught Rodriguez the importance of having an emergency plan in place. It’s something the community doesn’t have, but will by the end of her stay.

FOR IMMEDIATE RELEASE
Contact: Jeff Marvin, Media Relations Manager
jmarvin@pih.org

BOSTON (Mar. 30, 2015)—The National Institutes of Health upgraded the clinical status of the PIH clinician infected with Ebola virus disease from serious to fair condition today.

“News of our colleague's continued improvement has heartened us all—his family and his adopted PIH family in the United States and in West Africa,” said Dr. Paul Farmer. “We're deeply grateful for the superb critical care he received when he needed it and for the supportive care—supportive in every sense—he continues to receive from the wonderful team at NIH.”

“Most of all we're grateful for our colleague's progress, which is the answer to our prayers and the result of his caregivers' expert mercy,” Farmer said.

###

FOR IMMEDIATE RELEASE
Contact: Jeff Marvin, Media Relations Manager
jmarvin@pih.org

BOSTON (Mar. 26, 2015)—The National Institutes of Health changed the clinical status of the PIH clinician infected with Ebola virus disease from critical to serious condition today.

“Our colleague is doing much better. In fact, he has, in the opinion of some of the best doctors and nurses in the world, turned the corner. He is likely a long way from discharge, but is improving on all fronts,” says Dr. Paul Farmer, co-founder and chief strategist of Partners In Health.

At the request of our colleague and their family, we will not release any information about our colleague's identity or any specific clinical details. All other individuals being monitored remain asymptomatic for Ebola virus disease.

On behalf of all our colleagues, we appreciate the ongoing support and encouragement that continues to pour in from around the world. However, we ask that the public and media continue to respect their privacy at this time.

###

Andree LeRoy looked around University Hospital’s new Center of Excellence in Rehab and Education in Mirebalais, Haiti, and felt a growing sense of pride. The center—the first of its kind within the country’s public sector—is the physical manifestation of a dream she’s had since coming to work in Haiti as a physiatrist and Partners In Health/Zanmi Lasante’s director of rehabilitation services. Scheduled to open in June, the L-shaped facility will house a gym and 10 beds for patients embarking on the long, but ultimately rewarding, journey that is rehabilitation.

While LeRoy loved the new space, she and her colleagues knew something was missing. The white-washed walls lacked warmth and a sense of home.

University Hospital’s mission “is to really create a dignified space for people to recover,” LeRoy said. “We know for people who’ve acquired a disability, they’re devastated. And we know how important the marriage of art and medicine is.”

Looking around University Hospital, it’s clear the facility’s founders believe that environment is key to a successful recovery. Colorful, complex mosaics grace the hospital’s entrance, transform the hospital’s logo, decorate a wall of benches by the emergency department, and enliven the entire pediatrics ward. All were completed by Laurel True, a New Orleans-based mosaic artist and founder of True Mosaics Studio, and her team of Haitian artists, the Mirebalais Mosaic Collective (MMC).

True met Dr. Paul Farmer, a PIH co-founder and chief strategist, in the Miami International Airport on her way home from her first trip to Haiti, where she worked with children in Jacmel to create an earthquake memorial. Farmer suggested she come to University Hospital and took her business card. Within 24 hours, she was in touch with PIH staff to plan the first mosaic.

“Having a creative component and having visual art included in healing spaces is vastly important,” True said. “And PIH has really shared that value of bringing beauty, a dignified healing space, and a more holistic perspective on healing and well-being.”

LeRoy and Jonah Feldman, a physical therapist and the rehabilitation program’s clinical manager, were impressed by the way True and the MMC transformed University Hospital, so they asked the artists to help beautify the center. True “was instantly on board,” Feldman said.

The only remaining obstacle was funding. Feldman had heard about Kickstarter as a creative way to crowd-source, and had even donated once to a project based in South Africa, so he thought, “Why not Haiti?” He set up a page on the site and collaborated with LeRoy to create a short promotional video. They told potential funders their goal was to create “a space full of vibrant tile mosaic murals and a healing outdoor courtyard to provide a dignified, beautiful, and tranquil environment for our patients to aid in their recovery,” according to the site. “We are hoping to have images and scenes that represent inspiration, strength, and hope to help our patients on their journey of healing.”

Their $30,000 campaign launched in September 2014 and, with 212 supporters in 33 days, they exceeded their goal by more than $2,000.

With funding secured, Leroy, Feldman, and their Haitian coworkers and patients dove into developing concepts for the mosaics. They agreed the work should be “based on a marriage between the Haitian culture and the science” of rehabilitation, LeRoy said. Creole proverbs were the perfect vehicle to achieve that goal, and the group decided on two that directly applied to the hard work of rehabilitation: Piti piti zwazo fè nich li, or “Little by little the bird builds its nest,” and Men anpil chay pa lou, or “Many hands make the load lighter.” The first would feature a tree in whose branches nested a native bird, and the second would be of many hands lifting a basket filled with fruits and vegetables.

Two other murals would bring Haiti’s natural environment into the center—one depicted a sunset splitting a mountainscape, while the other was of Sodo waterfall, which Haitians visit because of its waters’ alleged healing powers. “The same way the waterfall is regenerating itself is the same way we want these patients to work on their regeneration,” LeRoy said.

True sketched the group’s ideas on a pad, further developed the designs, and later transferred them to the center’s walls. True, her student intern Randy Sanders, and the MMC worked for a week, and then MMC’s manager and lead production assistant, Mario Jeudi, and his team took it from there, snipping ceramic tiles into varying sizes and cementing them into radiant patterns within True’s design. They even trained patients in the art, giving the project a truly communal feel.

The team—who included Osner Jean Louis, Denis Bolivard, Cassius Smith, and Johnsky Chrispin—started on New Year’s Day and finished most of the work within three weeks. A Haitian artist then painted on the proverbs.

Feldman said the center now feels less sterile and more like a place filled with energy and vibrancy. “There’s a sense of moving forward and hope, of improving your function and your quality of life,” he said.

That used to be a foreign concept in a place like Haiti, LeRoy said. Most people who acquired a disability were considered a kokobe, a Creole derogatory term meaning a broken body or a broken mind, and treated as if their active life had ended. Because of the physical transformation patients have undergone at University Hospital and Zanmi Lasante sites nationwide, the Haitian medical community is beginning to understand the power of rehabilitation. That lesson will continue to be driven home in a colorful, vibrant new space.

The mosaics will send patients the message that “you’re not a castaway,” LeRoy said. “You are just as important in society as anyone else. The way to do that is to create a beautiful space.”

Consider that mission accomplished.

Click left and right buttons to view slideshow:

Artist Laurel True sketches designs for mosaics at University Hospital’s Center of Excellence in Rehab and Education in Mirebalais.

Artist Laurel True sketches designs for mosaics at University Hospital’s Center of Excellence in Rehab and Education in Mirebalais.

Most of the mosaic materials were locally sourced.

Members of the Mirebalais Mosaic Collective (MMC) arrange tiles for cloud designs. From left: Denis Bolivard, Osner Jean-Louis, Mario Jeudi, Cassius Smith, and Johnsky Chrispin.

The rehab center’s mission, illustrated in mosaic.

Artists sketch designs on the wall, then fill the space with tiles.

Patient Normil Overese (left), Richard Romage, a physical therapist and clinical manager of the program  (center), and Chrispin (right) arrange tiles in leaf patterns.

Patients have a view of this exterior wall when they visit the center’s courtyard.

Byen Vini Nan Sant Reyab, or “Welcome to the Rehab Center” is painted in Creole above the entrance.

The Creole proverb Piti Piti Zwazo Fè Nich, or “Little by little the bird builds its nest,” is one of the center’s mantras.

Men Anpil Chay Pa Lou, or “Many hands make the load lighter,” also applies to the center’s work.

Staff wanted patients to see depictions of Haiti’s natural beauty, such as this mountainside sunset.

Sodo Waterfall, located outside of Mirebalais, is believed to hold healing powers. A mosaic of it was a natural addition to the center.

Artist Laurel True sketches designs for mosaics at University Hospital’s Center of Excellence in Rehab and Education in Mirebalais.

Dr. Leonid Lecca was fast asleep in the darkness of a Sunday morning when his phone rang. A nurse was calling for help. In one of the Lima households she was monitoring, a little girl had fallen sick with fever and coughing. Her mom was worried that she’d been infected with tuberculosis from her uncle, and she didn’t know who else to call at 4 a.m. Would Dr. Lecca come see her?

Making house calls was not part of Lecca’s job description as the local principal investigator of the EPI study, an effort between Partners In Health in Peru and Harvard Medical School to understand how TB spreads from one person to another. But in his nearly 10 years working with Socios En Salud (SES), PIH’s sister organization, he had come to prize solidarity with people who are poor and sick. Groggy, he began the drive into the far reaches of Lima, where shantytowns climb hillsides like vines.

“I sat for an hour with them, talking about TB and how they could protect themselves. No one had explained it to them,” Lecca said. “They were very grateful, because they lived in a remote hillside, and no one else came to see them.”

For five years, nurses like the one who called Lecca that morning had been visiting TB patients and their families in their Lima homes, checking on their health and referring them for care when needed. The visits were part of an unprecedented study to understand the transmission of tuberculosis, both the type that can be treated with standard antibiotics and its more fearsome offspring, multidrug-resistant tuberculosis, which requires a much longer, more difficult treatment.

Scientists have long debated the dynamics of how tuberculosis spreads in people, including whether MDR-TB is as likely to spread as drug-sensitive TB. The epidemiologists behind the study hope that answering this question will better equip public health professionals to stop tuberculosis in all its forms. Researchers have already published some results of the study and expect more to come out this year, including the relative transmissibility of MDR-TB and drug-sensitive TB.

“When we designed this study almost 10 years ago, no one had actually measured TB transmission in people,” said Megan Murray, the Harvard epidemiologist leading the study. “We wanted to do a really systematic study where we observed what happened in people exposed in drug-resistant cases and drug sensitive-cases. We hope this will close the door on the discussion.”

Big questions about a big problem

The little girl Lecca visited that morning turned out to be okay—her uncle’s TB had not spread to her. But others in Peru and around the world are not so lucky. In 2013, TB sickened 9 million people and killed 1.5 million around the world. Its more fearsome offspring, multidrug-resistant tuberculosis, caused disease in at least 480,000 people that same year—probably more, based on recent research from the same group of Harvard epidemiologists.

The treatment for MDR-TB is much more difficult for patients: It takes two or more years of daily treatment and causes side effects such as nausea, diarrhea, and even deafness.

Despite the deadly toll of tuberculosis, scientists are still working to understand some of the factors that affect the spread of TB. They debate questions such as: What genetic strains of the bacteria are most virulent? What factors about the infected people—living conditions, smoking habits, immune systems—make them more likely to pass it to others? When the sick person comes into contact with others, what factors about those people—age, vaccinations, prior TB exposure—make them more susceptible to infection? How much does early diagnosis and treatment, which lessens the infected person’s contagiousness, help prevent the spread of the disease?

To answer these questions definitively, epidemiologists at Harvard Medical School studied tuberculosis transmission in a huge sample of people. Peru has a large TB epidemic, centered in Lima, with about 32,000 people suffering from TB nationwide—60 percent of whom live in or near Lima. Peru also has the highest rate of MDR-TB infection in Latin America.

In the end, we went to almost 4,500 households and collected data on 18,500 people.

PIH has worked with our sister organization, SES, for nearly two decades to support Peru’s Ministry of Health in fighting the epidemic. In 1996, SES pioneered a model for treating MDR-TB in the shantytowns of Lima. That model proved highly effective in curing MDR-TB, and has since been published as an international standard, known as DOTS-Plus. The community-based model places the patient at the center of a network of community agents who provide clinical, socioeconomic, and social support in addition to accompaniment and dose supervision.

The size of Peru’s TB epidemic, coupled with SES’s deep ties to affected communities, made it the ideal location to study TB transmission.

“In the end, we went to almost 4,500 households and collected data on 18,500 people,” Murray said. “We couldn’t have done that without the history of Socios working in the community, and having learned how to work in the community. The follow-up level is unprecedented in a big TB study. I’m not sure we could do it anywhere else.”

In designing this study, Murray and her Harvard colleagues wanted to settle the debate about whether MDR-TB is as transmissible as drug-susceptible TB. In 2007, they won a grant from the National Institutes of Health and two years later the team began implementing the study. Gathering the data in Peru cost about $6.5 million—a low cost relative to other epidemiological studies of this size.

The epidemiologists aimed to include 25 of Lima’s 45 districts, representing more than half of the sprawling city and the areas where TB was most common. They hoped to monitor every person diagnosed with TB in those districts and everyone they lived with for at least a year. Data collectors would gather information on participants’ HIV status, history of illness, nutritional condition, smoking habits, and, most importantly, the presence of latent tuberculosis infection and active disease. By observing which of the healthy people became sick after their exposure to the TB patients they live with, epidemiologists could identify risk factors and make it easier to prevent the disease in the future.

“There were huge operational challenges, because it is a huge study,” Murray said. “I don’t think we actually understood how big the study was until we started doing it.”

A small army

To collect data for the study, PIH/SES drew on its extensive experience working with TB patients in Lima’s poorest neighborhoods and with the Peruvian health system. In 2006, SES hired Lecca to be in charge of the implementation. Lecca is a doctor who previously worked for the Peruvian Ministry of Health, and had worked closely with SES on prior research about MDR-TB. He began recruiting and training young nurses and other health professionals to join the staff of the study.

In 2009, the study began enrolling participants. Study staff were assigned to Peruvian Ministry of Health-run clinics and health centers, totaling about 100 facilities. Every day, they showed up at the health centers along with the regular staff there. When clinicians diagnosed a patient with TB, they would introduce the patient to study staff, who would invite them to participate in the study. It wasn’t an easy ask—but critical to the study’s success.

“For these patients it was a difficult moment,” said Melissa Guevara, a nurse who has worked on the study since 2010. “They’ve just been diagnosed with an illness. We tried to approach them with sympathy and sensitivity. When they see this type of empathy, they had more trust in us.”

Guevara said that many of these conversations happened while patients were in tears, just moments after their diagnoses. Study staff were as ready as they could be to handle these situations—they were trained by PIH/SES on how to work with people in such difficult conditions, not only facing months or years of treatment, but also living in great poverty. Study staff invited them into a private room and used specially designed educational materials to explain to them why the study was being done, what they would have to do to participate, and how their participation could help fight the disease.

Some of the procedures required by the study—including taking blood samples from them and their families—put them off. Some patients were distrustful of the study altogether—they thought it was some sort of experiment being performed on sick people. But if they declined to participate at first, they were still eligible to enroll until several days later. The patients had to return to the health center every day to take their medicine under the supervision of Ministry of Health clinicians, and each day they saw the study staff, who worked alongside the health center staff they trusted, and always greeted them and asked after their health. Many times, the patients came to trust them and decided to enroll.

“At first the participants had a lot of prejudice against the word ‘investigation,’” said Jhudyd Cruz, another nurse who worked in health centers. “Slowly they realized that we weren’t there with bad intentions. We treated them like old friends, and once we had their trust, they agreed to participate.”

After a patient agreed to enroll, study staff would follow up with a visit to his or her home, where they enrolled everyone who lived in the household. They returned three months, six months, and a year later to perform tests. If a member of the household tested positive for TB or any other illness, the study staff member referred them to the health center for treatment.

In all, the study ended up enrolling about 18,500 people—including about 4,500 TB patients and 14,000 household members. And the team managed to retain more than 90 percent of participants in the study from beginning to end. At the peak of data collection, the study was employing 200 people and enrolling 1,000 new participants each month. They even adapted an open-source electronic medical record system to facilitate data collection on specialized smartphone apps. The scope of the work meant that PIH/SES was running a small army for more than three years, concluding most of the work in 2012.

“We were working 24 hours a day,” Lecca explained. “Many of the participants left home at 5 or 6 a.m. to go to work or school, so our team had to be there before then. This meant that we had to leave from the office at 3 or 4 a.m. If we needed to take a blood or sputum sample, we had to bring a cooler and other supplies. So if someone left the office at 4 a.m. to do a home visit, another staffer had to be in the office even earlier to prepare the coolers. We had shifts in our warehouse day and night.”

Once blood and sputum samples were collected, they had to undergo various kinds of testing that helped make a diagnosis of TB or MDR-TB and identify the genetic strain, so that researchers could study the virulence of the specific bacteria. PIH/SES started out using Peru’s regional laboratory, but the volume of samples quickly overwhelmed it. PIH/SES thought the country needed greater lab capacity anyway, so it built a new lab that can run tests more quickly than any other lab in the country.

The staff worked so hard, and cared for their patients so much, that many were at risk of burning out. Lecca recalled that PIH/SES tried to inspire a sense of unity and purpose in the team through all-staff meetings that included icebreaker activities. Once he even hired a clown to cheer them up.

“By working for EPI, I’ve gotten to know many districts in Lima that I never would have visited otherwise,” said Guevara. “The difference from the wealthy parts of Lima to where we were working is striking. I went where people are very poor. In these areas, people are struggling to provide for large families—struggling to find something to eat, and experiencing domestic violence and crime. To visit them, I would have to climb stairs, going up and up and up, not knowing when it would end. There are tiny houses that are very difficult to reach. And in this environment, people are trying to study and work. It helped me to see more of Lima, which was very gratifying and very difficult to witness.”

Many participants ended up feeling grateful for their involvement in the study. The home visits from study staff allowed them to ask questions they otherwise might not and identify problems earlier than if they waited to go to the health center. The case where Lecca woke up in the middle of the night was not exceptional. That morning, Lecca explained a lot about tuberculosis to the family, and with that understanding, the uncle who was sick took his medicine religiously. No one else in the family fell ill.

“One of the reasons for our success was that we didn’t only focus on the activities of the study,” Lecca said. “If we found a problem with the patient, we tried to do whatever we could to help. As a result, the study staff became very involved with the study participants—they felt like family. The participants were very grateful for the opportunities to have a visit from a medical professional. They lived in remote hillsides, and no one else came to see them.”

Results so far

Harvard researchers are analyzing the data that the SES team collected and plan to publish their major results in coming months. In the meantime, the study has generated new knowledge that can help fight TB. For example, the group has published a study showing that both the bacille Calmette-Guerin vaccine for tuberculosis and Isoniazid preventive therapy do help prevent active disease, which was previously less certain. They also published research showing that TB patients with HIV were less likely to transmit the infection to their household contacts, compared to TB patients who were not infected with HIV. Another finding was that TB patients who smoke cigarettes are more likely than non-smokers to transmit the disease.

As a result of genetic testing on the TB strains collected, the team now has an archive of information about which genetic strains are likely to be drug-resistant, which Murray hopes can be used to improve diagnosis of drug-resistance in patients. Right now, all tuberculosis patients are at risk of being under-treated for drug-resistant tuberculosis because clinicians lack information on what drugs their bacteria is resistant to.

“We see this as a huge gold mine of data on the risk factors for infection, disease, and drug resistance in this very big cohort,” Murray said.

Dr. Salmaan Keshavjee, senior TB specialist at Partners In Health and director of Harvard Medical School's Center for Global Health Delivery-Dubai, writes in a recent op-ed for NPR that countries must stop the spread of tuberculosis by investing in health care systems that can find, diagnose, and treat people exposed to and sick from TB.

As the Ebola epidemic in West Africa slows and falls from the headlines, there is a temptation among many to view this outbreak as an isolated event. In fact, the opposite is true. Ebola is the tip of a global health crisis: a crisis in our collective ability to deliver the essentials of modern medicine to those who need help the most, in the most timely and efficient manner.

Few diseases illustrate the ongoing nature of this crisis better than tuberculosis, a highly transmissible airborne infection that kills more than 1.5 million people every year. Many people think that tuberculosis—a disease often associated with 19th century Romantic-era poets or artists—has been eradicated. But this is not the case. In fact, the global burden of the disease is staggering.

Last year, 9 million people became sick with TB. That's more than the entire population of New York City falling ill with a disease that we have largely been able to cure since 1947.

Read the full op-ed.

Keshavjee's most recent book is Blind Spot: How Neoliberalism Infiltrated Global Health.

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Partners In Health's work around tuberculosis

Joe Lusaka is a clinical officer with Abwenzi Pa Za Umoyo (APZU), Partners In Health's sister organization in Malawi. He has been leading the flood response team in the Chikwawa District since the first week of February. We asked him to reflect on his time there so far.

Last month, PIH/APZU offered me the opportunity to assist flood victims living in the displacement camps in Chikwawa District. As a clinical officer with a degree in health systems management, I decided to move to Chikwawa in order to alleviate the disease burden unleashed by the floods, and to bring us closer to making real the human right to health care.

Chikwawa District is located in the southern region of Malawi, 47 kilometers (about 30 miles) from the city of Blantyre. The district covers an area of 4,755 square kilometers and is home to more than 450,000 people. The district’s health system includes a district hospital and 21 health centers, which are arranged in six zones: Nchalo, Chikwawa, East Bank, Chapananga, Ngabu, and Changoima.

Nchalo Township, where PIH/APZU is working, supports a population of 68,671. The area’s primary source of health care is a mission hospital, which charges user fees for most services. Because many people in Nchalo—especially those affected by the flooding—cannot afford even a nominal fee, PIH/APZU’s free clinic provides a vital service.

Clinical Officer Joe Lusaka (Photo: Lila Kerr/Partners In Health)

A typical day starts at 7:30 a.m., when I arrive at the clinic with our team of two nurses and a pharmacy technician. Dozens of patients will be waiting for us, with some having walked from as far as 20 kilometers away (about 12.4 miles). Others are referred to the clinic from displacement camps via PIH/APZU’s community officer, who arranges transportation for them. As we prepare for the day’s activities, a health surveillance assistant from the Ministry of Health delivers a health education talk, including cholera prevention lessons.

Patients then are triaged so those with critical conditions are seen first. The most common issues are malaria, diarrheal diseases, respiratory infections, skin diseases, anemia, musculoskeletal pain, and schistosomiasis (a disease caused by a parasite). We have also seen a number of patients that have suffered trauma because their house collapsed during the heavy rains. Very critically ill patients that require more advanced health technology are referred and transported to Chikwawa District Hospital, which is 27 kilometers (about 17 miles) from our clinic. In addition to treating these conditions, we are screening patients for diseases like tuberculosis, diabetes, HIV, malnutrition, and hypertension. By the end of the day, a nurse and I will have assisted over 200 patients.

In addition to providing clinical services, we are working with local displacement camps and communities to track infectious diseases, such as diarrheal diseases and scabies. Patients with these conditions are logged in a register where we record their basic information and their village. Despite reported cases of cholera in nearby towns and districts, we have so far been fortunate to avoid any cases in the camps and clinic where we are working, and we are continuing aggressive surveillance.

We started monitoring scabies upon hearing that there had been over 200 cases at Chikwawa District Hospital. Flood victims are at high risk for this kind of outbreak because of the high population density and poor sanitation infrastructure at the displacement camps. We started investigating the cause and found out that people in the camps were either not bathing at all or were bathing in the nearby stream. A local sugar company had constructed three bathing sites in the stream: one for men, one for women, and one for children. Unfortunately, that same sugar company uses cattle manure on its nearby fields, and the recent heavy rains caused that animal waste to wash into the streams, contaminating the water that so many flood victims bathe in every day.

We reported these findings to our leadership team, who rushed to visit the site and plan control measures. We have distributed water buckets for bathing and have constructed bathing facilities in the displacement camps.

In addition to providing clinical services, we are working with local displacement camps and communities to track infectious diseases, such as diarrheal diseases and scabies.

Providing comprehensive health care necessitates strong relationships with communities, so we have made a point of introducing our team and our services to nearby villages. During a meeting at Chikwawa District Hospital, I heard that there was an island, Mazongoza, that had not yet been reached by any of the partners working in the district. Mazongoza is the epicenter of flooding in Chikwawa and often relies on a rescue helicopter for evacuation, but some people still call the area home, and it was important that we reach out to them to make sure their health needs are met. The community officer and I decided to take that risk together. The road to the village was waterlogged, so we walked 14 kilometers (8.7 miles) to the river, where we boarded a canoe to reach the island. The area has many crocodiles, but the locals know how to scare them away, and fortunately we didn’t encounter one.

Once in Mazongoza, we learned from the village leaders that people are struggling and that they felt sidelined from the rest of the district. They are drinking untreated water from unprotected wells since they are often cut off from government services, and many of their crops were washed away in the heavy rains. They are now trying to plant rice due to the abundant water. I was touched by our conversations, and felt empathy with them. We weren’t able to promise any specific services, but simply establishing communication with them will allow us to better serve their health-related needs and to act as ambassadors for them in future meetings.

Working in Chikwawa has been challenging, as the work often extends beyond my position as a clinical officer, but I am confident in my ability to serve as a steward to the flood victims, as an advocate for this community at local meetings, and as a leader to my fellow team members. It has been my dream to directly assist the vulnerable people in my country, and I am motivated by this opportunity.
 

We make long-term commitments to the communities we serve.

“I came up from under the building,” says Shelove Julmiste, remembering her escape from the rubble of a collapsed six-story building, “and that’s when I realized my foot was crushed.”

Julmiste is among thousands of Haitians who have lost a limb or suffered serious injury— many, like her, in Haiti’s 2010 earthquake—and who desperately need treatment. While some facilites offer surgery, almost none offer rehabilitation services. People with injuries can become permanently disabled, unable to earn an income or contribute to their families.

Julmiste, who lost her leg and was fitted with a prosthetic, is not inhibited by her injury. As a Partners In Health patient, she learned to walk on her prosthetic and regained the use of her muscles. We then recruited her to serve as a coordinator for our rehabilitation program, now at University Hospital in Mirebalais. She uses her experience to help disabled patients see that they can lead normal lives through rehabilitation.

Walking freely on her prosthetic leg, laughing and chatting, she guides patients through exercises and talks with them about their fears and progress. “Every time I find a patient who has lost courage because they have lost a limb like me, I speak with them,” she says. “I comfort them, try to encourage them, and we rehabilitate together.”

Soon, PIH will open the doors of a newly constructed 10-bed rehabilitation center on the hospital grounds. Julmiste would like to see the program grow even more. She recites the Haitian proverb: “Piti piti zwazo fè nich li,” which means “little by little the bird makes its nest.”

We began our work in the town of Cange nearly 30 years ago. Now, at 12 sites across Haiti, we look toward the future and the impact we can make, continuing to open facilities such as the rehabilitation center to fulfill the health needs of the communities we serve.

Learn more about our principles:

We work closely with national governments and other partners to improve and expand health services.

Muhamed Kallon, 19, is an Ebola survivor. Last September, he was admitted to an Ebola treatment unit in Freetown, Sierra Leone, where he was closely supervised by health workers and received rehydration therapy. After 10 days, Kallon was well enough to return home.

“I am so happy and proud he survived,” says Musa Kallon, the uncle who raised Kallon after his parents died in the country’s civil war. “Really, I never believed he would survive this sickness because he was so weak.”

The Ebola death rate is high—nearly 4,000 people in Sierra Leone had died as of April 2015.

However, Ebola need not be fatal. Most people who are infected with and die from Ebola are poor and don’t have adequate health care available to them. As Kallon’s story shows us, recovery is possible with proper treatment.

The great majority of Ebola patients can survive with high-quality care, asserts Dr. Paul Farmer, co-founder of Partners In Health. He says “staff, stuff, space, and systems” are needed to combat the disease in Sierra Leone and Liberia, two of the world’s poorest countries with health systems that are barely functioning.

Since our founding, PIH has worked to raise the standard of care available to the poor and fought the notion that only so much can be done in places of poverty. As has become increasingly clear, we pay the price of accepting a lower standard of health care for the poor with crises such as Ebola and the lives of thousands of people less fortunate than Kallon. It doesn’t have to be this way.

PIH has trained and deployed more than 250 U.S.-based doctors, nurses, and other professionals, and hired more than 600 Ebola survivors as full-time support staff, community health workers, and orphan caregivers. Kallon also is now among our staff. He and our many partners are helping to address the crisis and develop a long-term plan to equip each country’s health system with “staff, stuff, space, and systems.” That means training local health professionals and ensuring facilities have proper tools and equipment to care for Ebola patients, as well as other people needing care.

Over time, we aim to expand our work by continuing to collaborate with the ministries of health of each country to strengthen more clinics, train more people, and build strong health systems to meet the ongoing health needs of the population.

Learn more about our principles:

We visit patients in their homes to deliver medication and guide them through treatment.

"I’m just doing my job. This is what it takes.” Rebecca Tsosie drives down the dusty roads of Crystal, New Mexico, to see her first patient of the day. An ID card—her photo under the official seal of the Navajo Nation government—swings from the rearview mirror of her truck.

Tsosie, a senior community health representative and a lifelong resident of Crystal, will visit five or six patients today to check on their health and deliver medicine, as she does every day. “I do a lot of stuff on my own,” she says. “If they need something from Walmart, I’ll try to work it into my schedule.”

Through the Community Outreach and Patient Empowerment program, a partnership among Partners In Health, the Navajo Nation, and Brigham and Women’s Hospital, PIH helps train community health representatives on the management of chronic illnesses. These diseases commonly afflict American Indian communities but could be prevented with medication and early guidance on healthy behavior.

But high-quality health care is hard to come by in the Navajo Nation. The region is one of the poorest in North America, and basic health care is underfunded. Residents live in remote areas with few clinics or trained health professionals. People are forced to travel long distances to obtain medical care and often can’t afford treatment.

Home visits from community health workers like Tsosie are critical. “Diabetes and old age—it’s really hard,” says 79-year-old Betty McCurtain, as Tsosie checks her vital signs. “I used to be strong, but not anymore.” Tsosie’s patients rely on her for the consistent care she provides.

Tsosie and her fellow community health representatives are members of the communities they serve, and their patients know and trust them. They embody the PIH ethos of accompanying patients through their illnesses, treating them like family, and doing whatever it takes to help them get well.

“I just call her my daughter,” McCurtain says, pointing to Tsosie.

Tsosie’s patients are among the nearly 8,000 Navajo that PIH is helping to receive high-quality care in their homes. Tsosie is proud of her role. The best part? “Meeting people. Helping them. Seeing what I can do to help them.”

Learn more about our principles:

We travel to remote places where health care options are limited or barely exist.

Beyond Russia’s Ural Mountains, in the dense forests of southwestern Siberia, Tomsk has historically been a destination for exiles. Even now, many people still live on the fringes of society.

Many people suffer from tuberculosis. The region has some of the world’s highest confirmed rates of tuberculosis and multidrug-resistant tuberculosis. Patients are poor, living in shacks or cold apartments, and lack access to proper medical care. Tomsk’s harsh climate, landscape, and roads also make it difficult for them to receive care.

Partners In Health has worked in Tomsk since 1998. Every day our nurses visit TB patients, delivering medication and food packages, and monitoring those who are most likely to struggle to complete treatment. The initiative is named “Sputnik,” a Russian word for “life partner” or “special friend.” It reflects our aim to put patients at the center of our treatment efforts, traveling to where they live and need care.

Our patient-centered approach is seeing results. This year, we released a report highlighting Sputnik’s success in the treatment of drug-resistant TB. Seventy-one percent of our patients have remained on medication since the program’s launch in 2006—a remarkable achievement for patients who otherwise would probably not have finished treatment.

Our approach is the same in all the work we do, worldwide. All of our sites are difficult to reach. In the hills of Haiti, Malawi, and Rwanda; the mountains of Lesotho and Mexico; the remote towns of the Navajo Nation; the slums of Lima, Peru; and—this year—remote areas of Liberia and Sierra Leone, PIH goes to where people lack access to high-quality health care and works to ensure they get the care they need.

Learn more about our principles:

A loud bang on the hospital door leading to the ambulance bay announced the first trauma case the morning of October 10. A patient had just arrived at University Hospital’s emergency department in Mirebalais, Haiti. The victim was one among nearly 50 people injured when an overloaded passenger truck flipped on a hairpin curve along Route Nationale. Within minutes, dozens more victims flowed into the facility, transported by private vehicles that had happened upon the scene. Hospital staff quickly triaged patients and settled them into emergency department beds. When those filled, they found space on the floor and in the neighboring hallway.

The scene was “controlled chaos,” said Alan Simmons, the medical informatics implementation manager who lent a hand that morning. Chief Nursing Officer Marc Julmisse stood atop the nurse’s station with a bullhorn shouting instructions to medical personnel. Regan Marsh, a co-director of emergency services, dashed from one victim to the next, giving advice to staff in Creole, French, and English. Administrative personnel from across the hospital rushed in to help, fetching equipment and supplies as needed. Facilities staff brought in fans to keep the beehive cool. And security officers blocked curious onlookers while keeping the entrances clear. Inside an hour, all the patients had been sent to surgery suites or accommodated into various wards.

Marsh and Shada Rouhani, co-director of the emergency department, reflected on the success in an email sent that afternoon to hospital staff. “While a tragic event like this shakes everyone involved, it has also revealed the power of the hospital community,” they wrote. “Thank you all for your assistance and support. It is a privilege to work with you each day.”

Had University Hospital not existed, patients would have had to travel several hours over treacherous roads to the towns of St. Marc or Hinche to receive care. Some surely would have died en route. The horrific accident was a test that proved the hospital’s mettle and signaled how far medical and administrative staff have come since the day the hospital’s doors opened in March 2013—two years ago this week.

The 205,000-square foot, 300-bed facility was a boon for the region and the country following the January 12, 2010, earthquake, which devastated Haiti’s largest public teaching hospital, l’Université d’Etat d’Haïti, nursing school, l’Ecole Nationale des Infirmières, and other critical medical infrastructure in Port-au-Prince. Partners In Health and its sister organization, Zanmi Lasante, had been planning to build a small community hospital at the site, but up-scaled those plans following the natural disaster at the request of Haiti’s Ministry of Health.

Thanks to generous donations, the hospital was designed, built, and fully outfitted within a $17 million budget. It’s now the nation’s largest public sector hospital, which provides care to 725 patients on an average weekday.

Meeting growing demand

Since 2013, University Hospital has steadily expanded its services and now offers primary and dental care, mental health services, pediatrics, maternal and women’s health, emergency medicine, oncology, surgery, and HIV care. Patients are taking advantage of their options.

Hospital visits grew exponentially from 232 in the first month of operation to 15,822 in January 2015, according to PIH’s Monitoring, Evaluation and Quality (MEQ) team. The vast majority of patients schedule general consultations, but a large proportion come for specialty care in the women’s health, pediatrics, maternal, and surgical departments.

Maxi Raymonville, the hospital’s medical director, says one of the biggest rewards for him is “bringing access to the most vulnerable” patients in Haiti, such as women who die needlessly during pregnancy or childbirth. “I’m really proud as an OB-GYN to see the big differences in Haiti in cutting maternal mortality.”

The steady stream of patients at University Hospital relieves some of the pressure placed on public hospitals in Port-au-Prince an hour away. Roughly 40 percent of patients come from communities immediately surrounding Mirebalais, yet a surprising number travel longer distances to access the hospital’s free care. About 30 percent come from St. Marc, Port-au-Prince, and its surrounding suburbs.

Teaching the next generation

In Haiti, there are currently 25 doctors for every 100,000 people, compared to the U.S. where there are nearly 300 doctors for every 100,000 people, according to the World Health Organization. A major part of University Hospital’s mission is to help train the next generation of Haiti’s health professionals to improve that ratio, especially when it comes to medical specialization.

Hospital staff, in collaboration with l’Université d’Etat d’Haïti, l’Ecole Nationale des Infirmières, and other international partners, developed academic programs to train future nurses, doctors, and hospital support staff. So far, at least 420 medical professionals—including doctors, residents, and nurses—have received more than 10,600 hours of training.

Dr. Kerling Israel, director of medical education for PIH/ZL, has been the one leading that charge. She helped launch the first round of residencies two years ago in internal medicine, surgery, and pediatrics, and created three more last year in obstetrics/gynecology, anesthesiology for nurses, and emergency medicine—the first such residency in the country. These 48 residents have completed more than 2,800 hours of training in their respective specialties over the past two years.

The application process is highly competitive, Israel says, adding that 260 recent medical graduates applied for the 34 spots in last year’s class alone. The high number indicates that opportunities to specialize are still scarce in Haiti.

“We have a lot of Haitians, both teachers and students, who’ve gone to the U.S., Canada, or the Dominican Republic because they couldn’t find a place to get proper training,” says Pierre Paul, PIH’s program director of talent management and leadership development. “In my class in medical school in Haiti, more than 80 percent is now working in the U.S. or Canada. … That’s still true after the earthquake. That increased the magnitude and speed with which people are leaving.”

University Hospital’s residency program, Paul says, “has been a game-changer,” especially for young physicians contemplating whether they can find work in Haiti and practice with a standard of excellence.

Ideally, University Hospital residents will not only transform the health care system, but “stay in Haiti in the public sector, and staff and run the teaching hospitals opening across the country,” says Michelle Morse, PIH’s deputy medical director for Haiti.

Nurse training is an equal and important need in the health care system. Julmisse has seen her staff grow from 40 registered nurses two years ago to just under 300 nurses, nursing aids, midwives, sterilization technicians, and nurse anesthetists. Through a combination of bedside training, nursing rounds, and courses toward specialty certification, she has seen employees grow in confidence and competence. They talk to her about the types of specialties they would someday like to develop. And many have assumed leadership roles within their respective teams.

“Compared to questions asked before, what they ask today is deeper,” Julmisse says. “They’re faster, they’re doing a lot more critical thinking. They’re not afraid to advocate. It makes me proud.”

More than a medical mission

University Hospital has undoubtedly improved access to quality health care in the suburban and rural regions surrounding Mirebalais. And its impact reaches beyond the medical. For every $1 invested in the hospital annually, $1.82 is pushed out into the larger Haitian economy, according to MEQ, which arrived at the figure in partnership with Haitian and U.S. researchers.

Although measuring this impact is complex, the idea is simple. Hospital employees use their salaries to pay for housing, education, transportation, and food for themselves and their loved ones. They buy goods at local markets from farmers and shopkeepers, who in turn use those additional funds to invest in their businesses or improve their family’s standard of living.

Success comes in many forms at University Hospital. More patients receive preventive or life-saving care; more doctors and nurses obtain advanced training; and more money flows into a community with few economic options. And there’s something else that may be harder to measure: trust. It surfaces in the choices community members make when they pick Mirebalais as the place to go in an emergency, just as they did that day back in October.

FOR IMMEDIATE RELEASE
Contact: Jeff Marvin, Media Relations Manager
jmarvin@pih.org

BOSTON (Mar. 18, 2015)—At the request of the Centers for Disease Control and Prevention, four clinicians working with Partners In Health in Sierra Leone were transported to the United States on Tuesday for active monitoring. These individuals may have been exposed to the Ebola virus in the course of helping a Sierra Leonean colleague, also a clinician, who later tested positive for the disease. These individuals were transferred as a precautionary measure. None has shown symptoms of Ebola.

The Sierra Leonean clinician diagnosed with Ebola is currently receiving care at a specialized treatment facility for health workers run by the British military.

On March 13, a Partners In Health clinician was admitted for care at the National Institutes of Health after testing positive for Ebola in Sierra Leone. Ten PIH clinicians who cared for their ailing colleague have also since returned to the United States for monitoring. None has tested positive for Ebola.

Partners In Health remains committed to working alongside public health authorities in Liberia and Sierra Leone to raise the standard of care for Ebola treatment, and also to improving the quality of care for all by training health workers and bolstering primary health systems.

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On March 10, which seems like years ago to many of us, we learned that one of our employees working in Sierra Leone had fallen ill with Ebola Virus Disease (EVD). This has been a hard few days for many of us, but most of all for our colleague and family.

Cases of EVD among health care workers result from the transfer of the virus from patient to provider during care. Partners In Health is collaborating with the Centers for Disease Control’s superb local team, along with the World Health Organization and Sierra Leonean authorities, to thoroughly investigate protocols, policies, procedures, and safety around the incident leading to the positive Ebola diagnosis of our PIH colleague, and the potential exposures of subsequent caregiving contacts. Since we are working in more than 23 facilities, all of them public, across two nations, you can imagine the tens of thousands of patient-provider contact hours we have logged over the past few months.

After the 2010 earthquake in Haiti, which took the lives of so many of our colleagues and friends and family, but which led to a redoubling of our efforts with Zanmi Lasante and the Haitian Ministry of Health, many of us were given to saying, “Partners In Health is not a disaster relief organization.” But, in truth, the everyday health conditions faced by the poor across much of West Africa are nothing if not a disaster. Redoubling our efforts in Sierra Leone and Liberia, while supporting the Guinean effort as we are able, should be the next step for PIH and its partners. That will require a great deal of humility—How might we have moved faster? How might we provide better clinical care so that our case fatality rates are lower? How might we do so more safely, so that there are no more occupational exposures, for either expatriates or national staff? How can we learn from our mistakes? How can we make sure that the end result of our efforts is to strengthen local and national institutions so that they can do their work more effectively, and with the staff, stuff, space, and systems they need?—as well as determination and persistence.

Our greatest concern right now is our colleague who is sick. We know that this first responder is receiving the highest standard of care in the world, and from close friends and supporters of PIH. We also know from the patients who’ve been treated elsewhere in the United States and Europe—again, the places where EVD has truly collided with modern medicine—that this is not an acute disease but a stormy one usually lasting a month or more, and with many ups and downs along the way. So I am in close contact with our clinician’s family (who request confidentiality, but are grateful for moral support and prayers; we can pass on messages from colleagues and supporters) and with the physicians leading a large team of expert caregivers. We also stand in solidarity with our Sierra Leonean colleagues and patients, and will continue to do so. We pray for the continued wellbeing of those counted as “contacts” but who are not sick. I’m sure you can imagine the anxiety associated with the long wait, in unfamiliar places, and hope you will join us in supporting them and in protecting their confidentiality.

I know I speak on behalf of the leadership of Partners In Health and staff across the world in arguing that the best way to honor their service, and that of the many others who have gone before them, is to redouble our efforts to build enduring institutions within Liberia and Sierra Leone and with our national partners there. We have to do more, not less, and better, and remind ourselves that freedom from want includes freedom from the catastrophic impact that serious illness has for so many people in the world, as it sometimes does for those who reach out to strangers to offer help.

Dr. Paul Farmer is a co-founder and chief strategist of Partners In Health.

Dr. Gary L. Gottlieb is the CEO of Partners In Health.

From 2010 until February of 2015, he served as president and CEO of Partners HealthCare, the parent of the Brigham and Women’s and Massachusetts General Hospitals, operating the largest health care delivery organization in New England and among the nation’s largest nonprofit biomedical research and training enterprises. Dr. Gottlieb is a professor of psychiatry at Harvard Medical School and a member of the National Academy of Medicine. He served as president of Brigham and Women’s Hospital, as president of North Shore Medical Center, and as chairman of Partners Psychiatry.

Prior to coming to Boston, Dr. Gottlieb spent 15 years in positions of increasing leadership in health care in Philadelphia. As a Robert Wood Johnson Foundation Clinical Scholar at the University of Pennsylvania, he earned an M.B.A with distinction in health care administration from the Wharton Graduate School of Business Administration.

Dr. Gottlieb established the University of Pennsylvania Medical Center’s first program in geriatric psychiatry and developed it into a nationally recognized research, training, and clinical program. He served as executive vice-chair of psychiatry and associate dean for managed care at the University of Pennsylvania Medical Center, and as director and CEO of Friends Hospital in Philadelphia.

Dr. Gottlieb received his M.D. from the Albany Medical College of Union University in a six-year accelerated biomedical program. He completed his internship and residency and served as chief resident at New York University/Bellevue Medical Center.

As a leader in the greater Boston community, Dr. Gottlieb served as a member of the Board of Directors of the Federal Reserve Bank of Boston from 2012-16, and as its chair from 2016-18. 

FOR IMMEDIATE RELEASE
Contact: Jeff Marvin, Media Relations Manager
jmarvin@pih.org

BOSTON (Mar. 14, 2015)—On Wednesday, March 11, a clinician working with Partners In Health’s Ebola response in Sierra Leone tested positive for the Ebola virus disease. The clinician was evacuated from West Africa and is currently receiving treatment at the National Institutes of Health Special Clinical Studies Unit in Bethesda, Maryland.

Ten clinicians who came to the aid of their ailing colleague were subsequently identified as contacts of the evacuated clinician. These individuals remain asymptomatic for Ebola virus disease. Out of an abundance of caution, and in collaboration with the U.S. Centers For Disease Control and Prevention, these clinicians are being transported to the United States via non-commercial aircraft. They will remain in isolation near designated U.S. Ebola treatment facilities to ensure access to rapid testing and treatment in the unlikely instance that any become symptomatic. The clinicians have agreed to be monitored, and will voluntarily self-isolate during the remainder of the 21-day incubation period, in accordance with CDC guidelines.

Meanwhile, PIH is working with the CDC, the WHO, and the Ministry of Health and Sanitation of Sierra Leone to conduct a thorough assessment of safety and clinical protocols to ensure that we continue providing the best possible care for our patients, and safe workplaces for our staff.

PIH remains fully committed to the Ebola response in West Africa and, in the months and years to follow, working shoulder-to-shoulder with the governments of Sierra Leone and Liberia toward rebuilding the health systems in both countries.

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FOR IMMEDIATE RELEASE
Contact: Jeff Marvin, Media Relations Manager
jmarvin@pih.org

BOSTON (Mar. 12, 2015)— A Partners In Health clinician working in Sierra Leone has tested positive for the Ebola virus. Our colleague remains in good spirits and has been transferred to the United States for treatment.

Out of respect for the privacy of our colleague and their family, we cannot release additional information at this time. PIH is providing full accompaniment to our colleague’s family. We ask that the media and public respect the family’s privacy.

This is the first clinician deployed with PIH to be diagnosed with Ebola as a result of a confirmed occupational exposure since PIH began treating patients in Liberia and Sierra Leone in November 2014.

PIH is following its established protocols to ensure the safety of our staff and patients, and all clinical staff are formally trained in infection control following CDC guidelines. However, we are reminded every day that Ebola has been, from the very beginning, a disease of caregivers.

We are proud of all of our clinicians at sites across the world—especially those who have fallen ill in the line of duty—and will seek to ensure that we do our very best to protect them and our patients.

PIH is making every effort to provide the best possible support for all of our Ebola response colleagues as our work in West Africa continues. PIH has 2,000 employees working in West Africa, including 600 Ebola survivors and 100 expat clinicians currently deployed to the region.

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Inserting IVs into tiny veins, persuading sick children to eat, discerning the presence of other diseases, comforting children who are separated from their parents—the challenges of treating the youngest Ebola patients have proved medically difficult and emotionally brutal for Partners In Health clinicians and their colleagues in West Africa.

Although precise figures are hard to come by, reports suggest that children under 5 have dismal chances of surviving the virus.

Dr. Chuck Callahan, a pediatrician with more than three decades of experience, worked in Sierra Leone as part of PIH’s Ebola Response.

“These were the sickest children I have ever seen,” Callahan said. “In a bad year in my intensive care unit in the States, we’d have six or eight kids die out of hundreds of admissions. In the two months I was there, I think there were 23 deaths.”

Callahan is a pediatrics professor and retired U.S. Army colonel, and former director of Fort Belvoir Community Hospital in northern Virginia. He believes what makes young children vulnerable to dying from Ebola are the lack of round-the-clock nursing, malnutrition, and other underlying diseases. He and other PIH team members have created protocols to care for children with Ebola, which they hope to make available through publication in a medical journal.

The challenges begin with poverty-related health issues. The probability of survival for Sierra Leonean children was among the lowest in the world even before Ebola. According to World Bank figures, the likelihood that a child in the country would die before age 5 was 161 per 1,000 in 2013. By contrast, probability of death before age 5 in the United States was 7 per 1,000.

“The common causes of death for children in Sierra Leone are treatable conditions such as malaria, pneumonia, and diarrhea—all of which are significantly more dangerous when a child has malnutrition,” said Dr. Joia Mukherjee, PIH’s chief medical officer and a pediatrician. “These underlying conditions have made mortality very high among young children with Ebola.”

Some children who came to the unit had diseases such as malaria or pneumonia—sometimes instead of Ebola, sometimes in addition to it—and these were difficult to diagnose. The latter typically would be evaluated by listening to the lungs. But clinicians can’t use a stethoscope while wearing full-body personal protective equipment (PPE). In these cases, pediatric nurse practitioner Tracy Kelly said, they did their best to treat children based on visible symptoms and history from caregivers.

Challenges of care

Callahan worked at the 108-bed Maforki Ebola Treatment Unit in Port Loko in December and January. Port Loko is about 2.5 hours northeast of Freetown, the capital, in an area with a large number of Ebola cases. The ETU has admitted 788 patients—84 younger than 5.

As with adults, care for children begins with fluids. People who have Ebola lose liter upon liter of liquid through vomiting and diarrhea, making fluid replacement crucial. During Callahan’s stint, responders started putting IVs in children more regularly to resuscitate and rehydrate them. In some cases, they used intraosseous lines (inserted into the bone) if insertion into a vein wasn’t possible. 

“The more aggressive use of hydration has certainly dropped mortality rates,” Mukherjee said.

Many more children younger than 5 with Ebola died at the Maforki ETU, compared with older children.

This might be related to differences in their immune systems, Callahan said. Younger children’s immune systems haven’t yet matured, and an attack from Ebola might be too much to handle. Younger children also are less likely to be able to eat and drink on their own, and they require more hands-on care.

Dr. Regan Marsh and Dr. Guy Giordano place an intravenous line in a 3-year-old boy the night of Jan. 9, 2015, at the Maforki Ebola Treatment Unit in Port Loko, Sierra Leone. IVs have become standard for all patients at the ETU. Clinicians later found that this boy had malaria and not Ebola, and he was transferred out of the ETU for care. (Photo: Rebecca E. Rollins/Partners In Health)

Malnutrition and breastfeeding

The high death rate among young children also might be related to malnutrition, Kelly said. Before heading to Port Loko, Kelly worked in Rwanda, Cambodia, and Indonesia, where she developed a keen interest in the issue.

According to Sierra Leone’s 2013 Demographic and Health Survey, 38 percent of children younger than 5 were stunted (having low height for their age)—18 percent severely. Stunting suggests chronic malnutrition. Children who are short for their age probably have received inadequate nutrition for quite some time. In the same year, 9 percent of children under 5 were categorized as wasted (having low weight for height). Wasting reveals acute malnutrition. Sixteen percent of Sierra Leonean children younger than 5 were underweight for their age, which can indicate both acute and chronic malnutrition.

Malnutrition is related to a number of factors. Most obvious is poverty: buying and even growing food requires resources. In addition, people living in poor countries often don’t have access to micronutrients such as zinc, vitamin A, vitamin D, and iron, Kelly said. Foods aren’t fortified with those elements as they often are in rich countries. And families do their best to feed their children, but diets often contain mostly staples, such as cassava and maize, and limited fresh fruits and vegetables.

Clinicians working with PIH have started to measure mid-upper arm circumference to determine whether children who arrive at the ETU are malnourished, Kelly said.

“We believe that very aggressive treatment of severe malnutrition has to be given at the same time as treatment for Ebola,” Mukherjee said. “PIH has experience in treating children with malnutrition in many countries, and what we see is that unless adequate calories are given every two to three hours, children will die. The timing and ‘dosing’ of food—whether therapeutic milk or nutrition-fortified peanut butter (ready-to-use therapeutic food, RUTF)—is critical to ensuring survival.”

Another major challenge is breastfeeding. Breastfeeding mothers often enter the ETU clutching their babies, and clinicians ask them to stop breastfeeding until results of Ebola tests for both are available. Close contact puts people at risk of becoming infected, and breast milk can contain Ebola virus.

“A 3-month-old child comes in with their mother … who’s also very sick, and we say right away ‘stop breastfeeding, no breastfeeding’—the infant doesn’t know how to feed by bottle or cup or spoon, and the mother is too sick to prepare the formula,” Kelly said. “If you’ve ever had an exclusively breastfed child and you’re introducing a new tool, it’s very difficult.”

Further problems arise when a child and mother come in and one is Ebola-positive and the other negative. Clinicians must separate the pair. If a mother is positive and a child is not, the child is taken to an observation center for 21 days, Ebola’s maximum incubation period. If the reverse is true, the child must be separated from his or her family and placed in the unit for treatment.

“Very often I had a sense that a child who was malnourished was not going to make it,” Kelly said. “And we know virtually all the children under 1 year of age were not going to make it, and all those children were breastfeeding.”

Dr. Regan Marsh cares for 9-year-old Mariatu while an adult Ebola survivor helps to feed and encourage the little girl Jan. 9, 2015, at Government Hospital in Port Loko, Sierra Leone. Mariatu, who suffers from extreme malnutrition, had been so close to death that PIH clinicians were preparing to call the burial team. Her condition was improving by the time this photo was taken. (Photo: Rebecca E. Rollins/Partners In Health)

Realities of the treatment unit

A child alone in an Ebola unit is extremely difficult to feed, Kelly said. Clinicians in PPE have to tend to as many patients as possible in about two hours, the maximum length of time it is safe to stay suited up. There is little time to sit and help a toddler eat. Adult patients or older children frequently help care for the small ones.

Kelly described a 9-month-old child she was treating. Clinicians put in an intraosseous line and placed the child carefully on a mattress on the floor with a makeshift railing, as there were no cribs or beds with railings. An older girl was receiving treatment in the next bed.

“Invariably, every time I came in, the 12-year-old girl was lying on the mattress cuddling the child, trying to provide a safe, secure environment,” Kelly said. “And those two were not related in any way. You can just imagine if that 9-month-old had died, what’s the impact on the 12-year-old girl? … There’s a whole psychological effect of what went on in the Ebola unit that I don’t think we’ve tapped into all that much.”

The 9-month-old and the 12-year-old survived.

Building protocols

Past outbreaks have been far smaller than the current epidemic, sickening a few dozen or a few hundred people rather than more than 23,000. Children typically account for only 20 percent of cases. This may help explain why there has not historically been a special focus on children in Ebola outbreaks, even though they are among the most vulnerable. If another epidemic occurs, Callahan said, responders should be prepared to take their specialized needs into consideration. That’s where published protocols come in.

The protocols Callahan and other clinicians have crafted call for antibiotics, vitamins, antimalarial drugs, fluids, and nutritious foods. They also include systematic screening for malnutrition and treatment when needed. The protocols offer adjusted treatment courses depending on symptoms and severity.

Continuous nursing care also might improve survival, he said. Callahan believes there’s a need for child-only Ebola treatment units with nurses tending to them 24 hours a day. This type of care is difficult because of staffing numbers and PPE-related limitations.

“Children with Ebola are very often critically ill, and effective critical care involves three components: critical care monitoring, critical care nursing, and critical care treatment,” he said. “Those are the three things that we have to plan on, and those are the three things that have not been consistently available to care for these children, in my assessment.”

Three-year-old Ibrahim survived Ebola but lost his sight as the virus ran its course. Ibrahim, who lost both parents to Ebola, is receiving treatment for malnutrition at Government Hospital in Port Loko, Sierra Leone. (Photo: Rebecca E. Rollins/Partners In Health)

Emotional toll

Medical needs aside, caring for children with Ebola is gut-wrenching, Kelly and Callahan said. Clinicians have to avoid unnecessary physical contact with all patients, to protect themselves from the disease. Sick children often have other ideas.

“You really want to try to keep your physical distance if you can so you don’t risk contamination,” Kelly said. “Think of any 3-year-old child you know. They’re going to come up to you; they want to hug you.”

After watching a child suffer from Ebola, clinicians are heartened to see little ones overcome the disease. When survivors leave the Maforki ETU in Port Loko, they tie a ribbon to a survivors’ tree. The clinicians, still in protective gear, help send off the children.

But many children survive only to return to situations where malnutrition, uncertainty, and disease pose a constant threat. Although the efforts of West African clinicians, the Ministries of Health, the local people, and international teams have helped slow Ebola, primary health care concerns must be addressed to give the children and families that survive Ebola the opportunity to thrive.

“Many of them are going back to a community they don’t know well or they’re going to an orphanage, or maybe their mother or father died or brother and sister died,” Kelly said. “This very joyful celebration is very bittersweet … to realize that they still have a lot of difficulty in their next years of life, and though it is joyful that they have been discharged and they’re survivors, the journey is only just beginning.”

Related Links:

See more photos of PIH's response to Ebola.

Read reflections from clinicians who have been to West Africa to fight Ebola here and here.
 

Nurse Cheedy Jaja returned to the U.S. in late January.

Nurse Cheedy: Why I serve from Partners In Health on Vimeo.

As rainy season continues across Malawi, the already-historic flooding has reached a new peak, leaving a path of destruction in its wake. Abwenzi Pa Za Umoyo, PIH’s Malawian sister organization, immediately responded with a weekly mobile clinic in its home, Neno District. In February, PIH/APZU expanded its flood relief efforts to the nearby district of Chikwawa, marking the first time the organization has provided care outside of Neno.

Chikwawa sits in southern Malawi, in floodplains of the Shire River, and is among Malawi’s poorest and most food-insecure districts. Chikwawa was one of the 15 districts declared to be a disaster zone after heavy rains in January, and a new storm system last week has exacerbated the situation. There are about 20 displacement camps in the district.

PIH/APZU’s efforts are based in the town of Nchalo, where there are three camps for displaced families: Sekeni 1, Sekeni 2, and Jombo. At the peak of the flooding, the three camps together housed about 9,600 people, with some families coming from villages as far as 14 kilometers (about 8.5 miles) away—a two-hour walk. Nearly 69,000 people live in Nchalo. In the past few weeks, families had started going home, but many have returned to the camps amid the resurgent flooding. In one nearby village, the chief estimated that 80 percent of homes had been destroyed.

At the core of PIH/APZU’s efforts is a clinic established with consultation from the Ministry of Health and operated by PIH/APZU staff. A clinical officer, two nurses, and a pharmacist staff the clinic. They see about 250 people from both the camps and the town each day, with most patients presenting with malaria, diarrhea, skin and eye conditions, and respiratory infections. Clinicians are also screening for HIV and tuberculosis, and are providing pregnancy tests and antenatal care.

PIH/APZU is also addressing hygiene and sanitation concerns, as flooding is especially detrimental to environmental health systems. The camps have access to clean drinking water, but for weeks people were bathing in a nearby canal that had been polluted with sewage. PIH/APZU responded by building bathing facilities and educating residents on ways to prevent the spread of diarrheal diseases. In that same vein, the team is monitoring infectious diseases such as cholera and typhoid by visiting and mapping surrounding villages. If a community suspects a case, they know to call PIH/APZU so the patient can be treated and transmission can be prevented.

The devastation in these communities will far outlast the rains.

As with all of PIH/APZU’s programs, community outreach is integrated at every step. The response team includes a community liaison who visits the camps each day to survey emerging needs and coordinate programming with local leaders and other nongovernmental organizations. This approach builds trust between PIH/APZU and the camp leaders, who know they can count on the response team for assistance. One night, camp leaders called at 1 a.m. to request care for a severely ill elderly woman; she had malaria and diarrhea and was very dehydrated. The team visited the patient right away to administer intravenous fluids, malaria treatment, and antibiotics.

PIH/APZU has committed to providing emergency relief in Chikwawa for the next six months. The team is making headway, but the challenges are many. The 20 displacement camps in the district are spread out, and there simply isn’t enough staff or transportation to provide relief to them all.

The most significant challenges, however, will be in the long term.

“The devastation in these communities will far outlast the rains,” said Dr. Emily Wroe, PIH/APZU’s director of clinical services.

Even once the floodwaters recede, many families will be left without housing, without latrines, without many of their possessions, and without their recently planted crops. Because the floods hit a population that was already so vulnerable, replacing these resources and rebuilding infrastructure will require significant investment.

Go here to support PIH/APZU's work in Malawi.

Zamanta Huarcaya Tamani was not a typical toddler. Unlike other one-year-olds born without a developmental disability, she didn’t babble or wander haphazardly around the house, leaving little disasters in her wake. She simply sat statue-like on her mother’s knee, her round face staring up at the stranger who came to visit her family in the remote hillside community of Miraflores in the impoverished Carabayllo district north of Lima, Peru.

The visitor, Inela Espinoza Cadenas, immediately noticed how calm and quiet Zamanta was. Cadenas is one of six community health workers employed by Socios En Salud, Partners In Health’s sister organization based in Lima, and was visiting Zamanta’s family as part of Project CASITA, a program that identifies Carabayllo children ages 6 months to 24 months at risk of developmental delays and trains caretakers in activities that encourage age-appropriate behavior. Since launching the program in November 2013, community health workers have enrolled 138 children and mothers, whom they visit at least a dozen times and provide access to social services.

Project CASITA is supported by a $250,000 Canadian (roughly U.S. $199,000) grant through Grand Challenges Canada, and is administered in partnership with Peru’s Ministry of Health and local government and health centers. Community health workers undergo a comprehensive training and certification process before they begin rounds in Carabayllo.

Cadenas began visiting Zamanta last June and found a humble family lacking basic needs. Eight people lived in a 130-square-foot house divided by a curtain into a kitchen and bedroom, where the entire family shared two beds. The tight quarters were particularly worrisome, considering Zamanta’s aunt and cousin—who were living with them at the time—had both been diagnosed with tuberculosis, a disease that spreads through coughs and sneezes.

Although she always planned her visits close to lunch time, Cadenas never saw the family preparing a meal or heard any of the four children begging for a snack. She later learned that food was scarce, and that the family’s sole breadwinner was Zamanta’s 15-year-old sister, Milagros, who sang in a cumbia band on weekends. Her earnings helped the family skate by each week. Zamanta’s father was recovering from a botched surgery and hadn’t worked in months. Health insurance or basic medicines like aspirin were luxuries the family simply couldn’t afford.

Cadenas took this all in while working with Zamanta’s mother, Karina Tamani Manihuari, teaching her activities that would encourage Zamanta’s mobility and language development. Meanwhile, she connected the family with food vouchers, federally-subsidized health insurance, and contractors who could remodel their cramped living quarters.

”Everything they learn with the girl they should try to apply to their other children,” Cadenas remembered telling Zamanta’s parents. “In CASITA, we really look for interaction between mothers and children, that the mother makes a special connection with the child, that she looks into her baby’s eyes, that she responds also to what the child does, that she gives her all her love and care, that she shares games with her daughter, and also includes the whole family [in these activities]. This will give her child more confidence and security.”

Zamanta’s Transformation

Manihuari said she typically carried Zamanta everywhere she went. She knew her daughter should have been babbling by seven months, sitting on her own, and preparing to walk (although the prospect possibly made her nervous considering the house perches at the edge of a steep hill). Still, she had her doubts about Project CASITA.

“The first time that Mrs. Inela came and did the activities with us, I thought that my daughter wasn’t going to do them,” Manihuari said.

Her husband, Carlos River Huarcaya Java, was equally skeptical. He’d had a bad experience with another nongovernmental organization, which offered his family help that never materialized. Even so, he witnessed his daughter’s gradual improvement following each session with Cadenas and slowly gained faith in the program. Soon he was sitting in on Zamanta’s sessions and participating in her daily exercises.

To advance Zamanta’s language development, Cadenas had the girl’s parents create toys she could blow through to exercise her tongue and a picture album of animals they could use as a vocabulary tool. She also coached the parents to speak to their daughter often and have her repeat their words.

Following Cadenas’ advice, Manihuari made a rolling pin-like device from recycled materials over which she rocked Zamanta and often stood her child on her lap to strengthen the girl’s abdominal and leg muscles in preparation for walking. She collected small objects like bottle tops and had her daughter pick them up and place them into containers to build her fine motor skills. And she and her daughter played peek-a-boo with a bed sheet, a game that encourages cognitive development by reassuring children that objects exist even when they can’t be seen.

Cadenas demonstrated each new activity to Manihuari and left her with “homework” to practice with her daughter throughout the week. “At first, I thought the activities were difficult,” Manihuari said, “but they became easier by the third week.”

By the end of 12 sessions, Zamanta was talking and taking her first steps around the house, much to her parents’ surprise. “I even saw changes in Zamanta’s mother’s attitude,” Cadenas said. “Karina herself confessed at the last session that she initially hadn’t put much importance in the intervention, but as the weeks passed she saw changes in Zamanta. She realized how important it was to do the activities with her daughter.”

“Mrs. Inela told me that everything I do, my daughter will repeat,” Manihuari said. “Now she seems like such a big girl. I was very happy and my husband was as well. He says Mrs. Inela has a real knack with children.”