Dr. Paul Farmer Discusses Ebola Outbreak with PRI’s The World

Partners In Health Co-founder Dr. Paul Farmer appeared on PRI’s The World Thursday to discuss the Ebola outbreak in West Africa. Nearly 2,000 cases of Ebola have been detected across Guinea, Liberia, Nigeria, and Sierra Leone, and the outbreak has been linked to more than 1,000 deaths, according to the World Health Organization.

Farmer shared an anecdote about returning to Kigali, Rwanda, last month after attending a surgical conference in Sierra Leone. At the airport in Kigali, Farmer had his temperature taken soon after getting off the plane, a positive sign that systems for disease surveillance are functioning well in the region.

He pointed out that the current Ebola outbreak is a stark reminder that we need to focus on strengthening entire health systems, from supporting community health workers who accompany patients and conduct active case-finding to bolstering the capacity of Ministries of Health so that they are well-staffed and well-supplied to respond when such outbreaks occur.

“Building those systems takes significant investment, and of course, many of us have long argued that not building them is far more costly,” Farmer told The World. "I work with airborne diseases like drug-resistant tuberculosis, or tuberculosis, and there's ample reason to be cautious, but the good news is there are always people willing to confront deadly epidemics like this. Community health workers, who almost never get remembered, could and should be the front line against epidemics like this, but they need the support that all of us need if we're going to be health care providers, and that support, again, requires tools for diagnosis, for care, and for self-protection. If we are willing to invest in these systems, we'll always find people willing to take risks to help serve the rest of humanity."

PIH is diligently monitoring the situation in West Africa, but we are not actively involved in delivering care in that region. We stand in solidarity with the patients and families, and health care providers affected by the outbreak, and we encourage international donors to support organizations that are well-coordinated with local governments so that they can provide local aid to relieve the emergency needs of the population. If you would like to support such efforts, please consider learning about the work of Last Mile Health in Liberia and Wellbody Alliance in Sierra Leone.

The full interview with Dr. Paul Farmer is available here:

Working in Global Health: Archie Ayeh

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

Each month we ask a seasoned colleague to share advice for those interested in forging a career in global health. This month we asked Archie Ayeh, program manager for Partners In Health/Lesotho, to share his perspective.

I’m not a doctor or clinician. I’m originally from Ghana and was working for an audit firm as an accountant when I first met the PIH/Lesotho team at the end of 2006. PIH was just getting started in Lesotho back then, working at one mountain clinic in a village called Nohana. The idea was to scale up to several other locations in the mountains, where the most vulnerable patients live.

On my first visit, I remember seeing a man who was so sick and thin that I thought he’d be dead within a few weeks. I didn’t know much about PIH—they were enthusiastic, but to be honest, I thought they were dreamers. At the time, the HIV epidemic in Lesotho was out of control and many people were dying every day. A lot of people were losing hope, including myself. I thought HIV was going to exterminate the population.

So I began working part-time to design accounting systems that would be effective in tracking financial records but not bureaucratic and burdensome. The primary goal was to help the organization remain nimble and make sure that nothing distracted from the clinical work.

A few months after I began working, I was out at the site and I saw the same man who I saw on my first visit—the man who was thin and sick and who I thought would be dead in a few weeks. Many months had passed, and now he was strong and healthy looking, carrying food packages for other patients. I was amazed.

It’s not just clinical care—it is comprehensive support for disadvantaged people.

Still, I was skeptical about whether PIH would be able to do all that it wanted. The challenges were huge, but I didn’t know the scale of PIH’s determination. Many nongovernmental organizations (NGOs) do what is convenient. PIH does what’s necessary to save lives. It’s not just clinical care—it is comprehensive support for disadvantaged people. The staff provides treatment, but they also provide food and work in the community to empower people. It is very refreshing to see how their approach transforms lives.

So I became the full-time program manager in 2007. PIH/Lesotho was gaining momentum and we needed to design a full administrative support structure, including human resources, finance, procurement and supply chain, and maintenance. We also needed to continue building relationships with other NGOs, government ministries, and, of course, more communities. PIH/Lesotho was growing, and we were scaling up to more and more clinics in the mountains.

What I’ve learned about working in global health over the years is that you do not need to be a doctor to make a big difference. To be effective, organizations need accountants and human resource managers and all the other types of support that companies have. I don’t try to be a doctor—I make sure that the doctors have the resources they need to do their jobs well and serve our patients.

You won’t have all the answers, but you can listen and console.

When you work in global health, you need to consider social norms, customs, and practices in the country where you’re working. You may be tempted to go the one-size-fits-all approach, but you will get terrible results. You need to work in the community and listen to the people you are serving. I wasn’t always a good listener, but this job has taught me to listen. You don’t need a magic bullet, you need to listen and sympathize. You won’t have all the answers, but you can listen and console. It’s also important to think holistically about the development of the community. When you hit the right note, health care becomes a vehicle for economic development, for stronger education systems, and for social development.

Do I miss working for the big audit firms and the world of finance? No. I never want to go back. Working for the people is amazing. Poverty is a symptom of powerlessness. PIH empowers people. It gives them a voice.

A sustained commitment

PIH has long been committed to working with the residents of Nyamicucu. In 2011, we helped construct dozens of sturdy homes for families in the region—previously they lived in grass-thatched structures that were poorly ventilated and couldn’t stand up to the strong rains, a recipe for illnesses such as pneumonia.

That same year PIH worked with the government to enroll more than 100 children from the village in primary school—they were the first in their families to attend school. Not long after, we launched a program that supplies families with livestock to improve nutrition and create new opportunities to generate income. We continue to support all of these programs today.

The Nyamicucu Health Post is our latest contribution to this long-overlooked community, and it’s one we’re especially proud of. Tucked at the bottom of a hillside, the health post is a bright and airy facility surrounded by beautiful gardens designed by a local resident.

“Nyamicucu Health Post is another step toward a true preferential option for the poor in health care. It is another milestone in the long-term journey and commitment of PIH/IMB to restore hope and ensure holistic wellbeing in the Nyamicucu community, especially among children and mothers,” said Gilbert Rwigema, PIH/IMB Burera District project director.

Celebrating partnership

To celebrate this milestone, the governor and mayor of Burera District—where Nyamicucu sits—formally inaugurated the building on July 17. The ribbon cutting was followed by singing, dancing, and speeches from both government officials and local residents.

Governor Aimee Bosenibamwe extended his heartfelt gratitude to PIH and its supporters, then expressed future ambitions for the village. “We will make sure that this health post gets a maternity ward, so that pregnant women won’t need to walk to a health center far away,” he said, after urging residents to use the newly available health services. He then discussed plans to construct a better road and bring steady electricity to this area.

PIH will continue standing with the residents of Nyamicucu to forge new partnerships and implement programs that strike at the root causes of poverty.

“Expanding access to education for children, improving agriculture and providing livestock, and making sure people have adequate shelter—they are all part of creating a preferential option for the community,” PIH/IMB’s Rwigema added. “This health post will have a huge impact—it will help reduce risky at-home deliveries and improve access to antenatal care. For thousands of people, this health post will lift the burden of having to walk hours to manage something like a respiratory infection. Nyamicucu Health Post—amazing.”

New Maternity Ward Expands Quality Care for Mothers in Eastern Rwanda

Josephine Uwamahoro, 30, was overwhelmed with joy. Not only had she just given birth to her third child, but she had done so in a new state-of-the-art maternity ward at the Kirehe Health Center in eastern Rwanda.

“This is the first time I have given birth in such a comfortable and beautiful maternity ward. The beds in the old maternity were bad … and so many people were in such a little space. I am excited to be among the pioneers in this ward,” she said.

The new maternity ward officially opened July 4, the same day Rwanda celebrated its 20th Liberation Day, when Rwandans gather to remember the end of the 1994 Genocide, which claimed more than 1 million lives. Liberation Day marks the end of the annual genocide commemoration period, the somber 100 days during which memorials and events take place throughout the country.

The Kirehe Health Center, a Ministry of Health facility receiving support from Partners In Health, is one of 16 health centers in the district that serve the primary health care needs of thousands of patients. The tiny facility is run by a small but dedicated nursing staff, and every day a seemingly endless number of patients can be found sitting in the shaded waiting areas that surround the health center.

We help around seven women deliver every day, and sometimes we get over 200 women in a month.

Most health centers in Rwanda have only two or three beds dedicated to deliveries, and they are often in a small, crowded ward. In Kirehe, the new maternity ward boosts the number of beds for expectant mothers from five to 16, says Dr. Evrard Nahimana, the PIH clinical director in Kirehe District. The larger ward also affords patients more privacy and allows staff to implement better measures for infection control. Additionally, it features multiple delivery rooms and has designated spaces for family planning consultations, postnatal care, and additional services.

“We help around seven women deliver every day, and sometimes we get over 200 women in a month. Now, we can accommodate more pregnant women, and get midwives to provide the best health care to women giving birth,” said Grace Dusabe, head nurse of the maternity ward.

Protais Murayire, mayor of Kirehe, who officially opened the new maternity wing, lauded the efforts of PIH’s Rwandan sister organization for setting up a top-notch facility and implored community members to take advantage of the expanded services.

PIH Rwanda’s Deputy Executive Director Antoinette Habinshuti added, “We can’t say we are liberated if we still have women who don’t have a safe and good facility to deliver babies in. Having the new modern maternity ward is an example of liberation.”

A Doctor in Training Returns Home

Fred Rwabukumba has come a long way over the past 24 years, from son of subsistence farmers to a medical doctor in training. He grew up in Rwinkwavu, Rwanda, a rural area two hours east of the capital city Kigali. Most of Rwinkwavu’s residents are subsistence farmers—you’re far more likely to pass a cow than a car on the road—and electricity and running water are luxuries many cannot afford.

Rwabukumba attended Kadiridimba Primary School. When he was a student, it was a bare bones facility that didn’t have chairs for students; classes often took place under the shade of trees, students lining the dusty ground. Despite the scarcity of resources, Rwabukumba knew from a young age that he wanted to improve his community and his country. Over the years, he forged an interest in science and medicine and worked to excel in his academics.

It paid off. Today, Rwabukumba is one year away from finishing his medical training at the National University of Rwanda.

This April, Rwabukumba returned home to Rwinkwavu as part of a community medicine rotation. The rotation, led by Partners In Health/Inshuti Mu Buzima physicians, is part of all Rwandan medical students’ studies at the University of Rwanda. One of the goals is to immerse students in the community so they can better understand the social determinants of health.

During his time in Rwinkwavu, Rwabukumba had the chance to return to Kadiridimba Primary School and speak to the students and to the teachers, some of whom had been there when he was a student more than a decade ago.

“I used to wake up at 6 a.m. and fetch water from the well while reciting whatever I had learned the day before,” he told a room full of students. “It was hard to study at home, as we didn’t have electricity.” After asking who of the students wanted to become a doctor, almost all of the children raised their hands very happily.

As the day moved on, Rwabukumba and colleagues distributed several boxes of books they had collected through Books for Africa. One of Rwabukumba’s fellow residents led a seminar on nutrition and the importance of eating well.
Before the day ended, the team distributed fresh fruit to the students and encouraged them to study diligently so that they, too, can achieve their dreams.

Knocking on Doors: An Interview with PIH’s Director in Peru

Dr. Leonid Lecca, 38, has worked for Socios En Salud, Partners In Health’s sister organization in Peru, since 2006. Last year, he was named executive director. We caught up with him by phone to talk about SES’s work on their 18^th anniversary, which they’re celebrating this week.

Where are you from?

I am Peruvian, from Lima. My family is from the north of the country, but my parents married and moved to Lima, where my dad found work. I studied medicine at Cayetano Heredia University here in Lima. In addition, I have two master’s degrees—one in health management and another in clinical epidemiology. Since I was a medical student, I’ve been very interested in public health and research, above all tuberculosis. It’s a disease that’s very common in our hospitals and clinics. I had the opportunity to get involved in research at the university and later at the Peruvian National Institute of Health.

How did you get involved with Socios En Salud?

I was first exposed to SES in the early 2000s, when they were getting off the ground with the project to expand access to treatment for multidrug-resistant TB (MDR-TB), funded by the Gates Foundation. I met the team from Harvard, PIH, and SES when I was the human protection administrator at the Peruvian National Institute of Health.

The approach was to knock on the doors of these people who—despite all their limitations—wanted to be cured.

When I saw the work of SES, I was impressed by the way staff tackled cases and how they approached people who were suffering from tuberculosis. SES works in the places no one else goes; they help in the farthest hillsides. The model of finding people in their communities impressed me, and I realized that patients aren’t only in hospitals or health centers. The approach was to knock on the doors of these people who—despite all their limitations—wanted to be cured.

I helped in the TB lab at the NIH in Lima, and through that work I was able to present reports to the World Congress on TB that was in Montreal in 2002. We submitted six abstracts, and all were accepted. Thanks to this, SES invited me and a group from the lab to participate in this congress. That’s when I entered the world that PIH occupied. I met more PIH colleagues, and I saw the work they were doing. It was a really strong group. In 2006, SES contacted me to see if I was available to work with them on the EPI project, a massive research study to understand how TB and MDR-TB spread from one person to another, which we’re just completing this year.

That’s where my story with SES begins.

How did you feel about all this revolutionary MDR-TB work unfolding?

The MDR-TB epidemic in Peru was, and continues to be, a difficult situation. What SES built with the state was really impressive. They managed to save many lives, and I think it was an opportunity for the same health professionals to see that it was possible to implement a program despite the limitations that existed.

As a doctor, I feel fulfilled because every day we are doing projects that save lives, the lives of the most vulnerable people. If SES hadn’t been there, those patients probably would have never received medical attention. It was always the poorest, the most forgotten, the most vulnerable. To this day, when I go to a health center and I see the work of SES, the patients we’ve supported, or how the team knows the whole life story of a patient—it impresses me.

The opportunity we have to help support the Ministry of Health is invaluable. There are more problems than we as an institution can address because we have limited resources, so it’s also important that we support the state to help ensure their resources are used in the best possible way.

So we should strengthen our alliances: that’s why we call ourselves 'partners in health.'

As a Peruvian, it’s a privilege to be part of the TB program we have in this country, which is one of the strongest in the region. We’ve struggled to define health as something more than what pertains to the Ministry of Health—it’s also about education, jobs, and better living conditions. Little by little we’ve understood—and we’ve continued to help others understand— that control of TB is not only a matter of taking pills.

What challenges do you face as the executive director?

It’s a huge responsibility to assume the leadership of a great organization that’s widely recognized for its work in Peru. While it’s true there are a lot of public health problems, the strength and commitment of SES is to work on these issues of tuberculosis, HIV, and community health. We still have a lot to do with these issues, but we’re committed to the community and the Ministry of Health, which is why we support local, national, and international efforts, public or private, of people or institutions that want to be part of finding solutions. So we should strengthen our alliances: that’s why we call ourselves “partners in health.” Our principal partners are the communities and the Peruvian government.

You’ve been executive director of SES for about a year now. What are your major initiatives at this point?

In the last year a lot has happened, and I’ve come a long way in understanding our position and in managing SES. We’re trying to focus on accompanying the public sector with greater emphasis on the most pressing problems. In the past, for example, we’ve provided treatment for MDR-TB, and we’ve accomplished a lot. Now the Peruvian Ministry of Health provides this care, and we’re working in a different role.

Now we provide social support to MDR-TB patients with the most limitations—those, for example, who have defaulted from treatment, are alcoholics, drug addicts, or very poor. We’re also focused on providing support for patients with extensively drug-resistant tuberculosis, which is often their last chance for getting better and surviving this disease. Other vulnerable populations we’re serving are MDR-TB patients in prison and children with tuberculosis, for whom diagnosis and treatment is more difficult.

Besides TB, what other programs are you working on?

Dr. Lecca walks with Nancy Rumaldo, child development program coordinator, between home visits in the community of Fray Martin. (Photo by Socios En Salud)

After this year, we’ll be focusing on several initiatives, just one of which is TB. The second is HIV. We want to continue applying our community-based model to people living with HIV who are poor, improving the management of co-infection of TB/HIV, and caring for children with HIV. We’re focusing on vulnerable populations with HIV—children and adolescents, sex workers, transsexuals, and poor and marginalized people. We want to show that to reach such marginalized groups, you have to go looking for the patients in the communities where they live, in the hillsides. They’re not the people you have in your registers at the health clinics. It’s an issue of access—not necessarily because of socioeconomic problems, but other barriers such as stigma.

Another area of focus will be on maternal and child health. We’re applying the community-based model to improving early childhood development among poor children. We have initiatives in Lima and in the south of the country to increase the capacity of the public sector by improving training and infrastructure, including community work, to provide comprehensive care. We’re thinking about how we could help alleviate maternal mortality, too. Teen pregnancy is a particular challenge here, often affecting poor, vulnerable people. We have trained health workers in maternal care to go into communities and refer pregnant women to health clinics.

We’re also putting together a complete package of primary care in Lima. We want to make sure that programs for key health problems, such as HIV, TB, maternal health, and child health, work well in Carabayllo, the marginalized district to the north of Lima where we’ve always worked. This includes work we’re just starting on noncommunicable diseases, such as diabetes and hypertension.

I have a lot more gray hairs now than I did a year ago, but that’s part of the job.

And last, we’ve just started working to establish mental health services as part of the primary care delivered through public facilities. Right now, if someone has a mental health problem they have to go to the hospital, and there are very few who actually go. We have to equip the local health workers and community health workers to treat it and help manage cases. This is something we’re excited to start. We think it’s going to work very well.

A big part of your work also involves research. What’s happening in that arena?

We’re working right now in two areas: one, improving infrastructure and the capacity to establish ourselves as a center of global health research with our colleagues at Harvard University and other institutions. The other is to develop a critical mass of professionals interested in conducting research on local health issues in Peru. For example, we just issued a call for young professionals who are interested in research. We will recruit and train them so they join our group and can help us do our research, but also so they can learn and form more of a workforce of researchers with the capacity to do research that helps us resolve local problems. I’m talking with various local educational institutes, such as universities, to see how we can help them improve or generate better capacity for research.

That’s a lot to figure out.

It’s a puzzle, but it’s a good thing. We’re trying to prioritize which issues to work on, all with the aim of elevating the health of Peruvians. Some things could change, because we’re always attentive to the feedback of the Ministry of Health and the needs of our patients.

Did you ever imagine you would lead this organization?

I feel very fortunate. Destiny has given me this opportunity much earlier in my career than I anticipated, and I’m very motivated to succeed. I have a lot more gray hairs now than I did a year ago, but that’s part of the job. There’s still a lot to do, and our work will continue focusing on improving the health of the people who are most in need and most vulnerable.

The Life of a Medical Resident at Haiti’s New Teaching Hospital

Dr. Jean-Louis Willy Fils is a medical resident in every sense of the word.

He’s training at University Hospital in Mirebalais to become a surgeon, living in a residence hall on the hospital campus and working about 80 hours every week.

Fils is one of 14 residents—University’s Hospital’s first class—who began their specialty training in surgery, pediatrics, or internal medicine last fall. In the United States, the federal government funds medical residencies through Medicare. In Haiti, such public sector funds are slim, and PIH/ZL pay for the cost of training residents through donations raised each year.

For most of the population in Haiti, a major obstacle to better health is the lack of qualified health professionals. As a national teaching hospital, University Hospital serves to train the next generation of physicians, nurses, and other health professionals in providing high-quality health care to the poor and disadvantaged. Zanmi Lasante, PIH’s sister organization in Haiti, is dedicated to the idea that the newly trained Haitian doctors and nurses will go on to serve as leaders and change agents in Haiti's health system, ranging from treating patients in rural clinics to creating national policy at the Ministry of Health.

Fils says he doesn’t mind the long hours. This is what he dreamed of doing—becoming a surgeon of the highest caliber and serving patients.

“We’re so excited that we don’t really get tired,” Fils said. “Even on the weekend, even if we’re not on call, we’re there.”

Growing up in Cap-Haïtien

Fils grew up with his mother and older sister in Cap-Haïtien, a small city on the northern coast of Haiti. His father wasn’t involved, but Fils says he didn’t mind—he has only happy memories from his childhood.

Ever since I can remember I wanted to do medicine.

His mother worked in commerce, buying fashion jewelry in bulk from Santo Domingo, Dominican Republic, or Panama, and re-selling it in Cap-Haïtien. Eventually, she built her business to the point where she became the wholesale supplier, selling out of her home to other businesswomen.

With his mother’s support, Fils attended the best school in Cap-Haïtien. Still, he found the pedagogy wanting—as in many developing countries, it emphasized memorization. The influential Brazilian educator Paulo Freire described it as the “banking” model of education, where teachers deposit information into the otherwise empty minds of the students, without engaging their own knowledge and capacity for critical thinking.

Fils dreamed of going to medical school in Port-au-Prince, and imagined it would be different.

“Ever since I can remember I wanted to do medicine,” Fils said, then paused. “I don't know whether my mom or I wanted it the most. Because as far I can remember, she always told me to do so.”

Moving to the capital

A consummate good student, Fils was accepted into the competitive state medical school in Port-au-Prince. In Haiti, high school students go straight into medical training, rather than completing an undergraduate degree first.

The professors were some of the best doctors in the country, and the students were bright. Fils was motivated to work hard, but he was disappointed that the instructional style was the familiar rote learning. And there weren’t a lot of resources available for students—the school’s labs, for example, weren’t equipped to conduct chemistry experiments.

The professors he liked the most were in surgery. During rotations at the state hospital in Port-au-Prince, he became surer that he wanted to be a surgeon. He thought it was one of the most challenging and rewarding things that a doctor can do—oftentimes making a big, immediate impact on the life of a patient.

To become a surgeon, he would need to complete a residency. In the United States, all practicing doctors must complete residencies, the hands-on portion of their training, supervised by seasoned medical professionals. But in Haiti, there are more graduating doctors than residency programs, so many go without this training. It’s a need University Hospital is helping to meet.

But first, Fils had to do a year of social service.

A difficult year of service

A year of service in a public health center is required for new doctors as a way to repay the cost of their government-subsidized education.

Fils decided to work in Ouanaminthe, a market town on the border with the Dominican Republic, with another doctor friend. What he saw at the community hospital discouraged him.

The doctors would come in late, around 11 a.m., because the medical records staff they depended on usually showed up late. But patients tended to come early in the day, so they had time to make the long journey home and still have work hours in the day. So they had to wait for hours to see the doctors.

Fils and his friend proposed to the medical leadership that the staff come in earlier. They also wanted to start a support group for patients with chronic diseases. But the leadership didn’t support their ideas for improvements.

“It made me skeptical. I don’t know if I will be able to change things,” Fils said. “What I really dream of is to improve access to and the quality of surgical care, especially in my hometown, where there is a real lack of good surgeons. But it’s not clear that I’ll be able to, because everything is so difficult to change.”

Life as a resident

At University Hospital, Fils has experienced a different teaching style. During rounds, he presents his patients’ cases to attending physicians—Haitian and foreign surgeons with decades of experience. They quiz him on the intricacies of the case, testing his knowledge, critical thinking, and communication with the patient. It’s just one of the stressful parts of being a surgeon.

“I’m always nervous,” Fils said.

My mom is so proud of me doing surgery in one of the biggest hospitals in Haiti.

His mentors encourage him to build relationships with patients and communicate well with them, for their understanding and his.

“Doing the surgery is only a part of the treatment,” Fils said. “It’s important to obtain the collaboration of the patient. You can’t do that without talking to them.”

He’s seen some cases that have affirmed his decision to become a surgeon. For example, he saw a 23-year-old man who came into the emergency department with gangrene, which would spread without surgery. In a fully equipped operating room with proper sterilization, working with experienced colleagues, Fils operated on the man to remove the dead tissue and replace it with healthy skin from another part of his body. It likely saved his life.

Fils will finish his first year of training this fall; he has four more years to go. He’s interested in pursuing further specialty training, to become one of Haiti’s few neurosurgeons, but for now he’s busy enough being a resident. When he can get away, he goes home to Cap-Haïtien to visit his mother.

“She’s really proud of me. She loves me so much. It was a big sacrifice to give us everything we needed growing up,” he said. “She put us in the best school she could find. She believed a lot in education, even though she hadn’t finished high school. That’s why she is so proud of me doing surgery in one of the biggest hospitals in Haiti.”

In Lesotho, A New Level of Accompaniment

Masechaba Molefsame was well into her third trimester of pregnancy when she entered a rural health center in southwestern Lesotho, not far from the South African border, in April.

Molefsame made the trek in hopes of delivering her child in a safe and clean environment. But until that point, the Mohalinyane Health Center had never delivered a baby. Inadequate equipment and supplies, including food for patients, insufficiently trained staff, and subpar infrastructure had deterred women from delivering there.

Molefsame, however, had heard that her country’s Ministry of Health was working on a transformative national initiative to ensure that all health centers throughout the small, mountainous country are ready to deliver high-quality care to women and children—from an expectant mother’s first antenatal visit through her child’s vaccinations and beyond. As part of the reform, Partners In Health/Lesotho clinicians were working diligently to train staff and improve infrastructure at the Mohalinyane Health Center, including the on-site maternal waiting home, in the weeks before Molefsame walked in the door.

Now it was time to see if the health center was ready to deliver.

Improving outcomes by working in the community

Lesotho is struggling to address some of the most pressing health challenges in the world. In recent years, the country has lost ground on important measures of health. Between 2000 and 2010, maternal mortality nearly tripled, from 419 to 1,155 per 100,000 live births. In the same period, the child mortality rate climbed from 110 to 119 per 100,000 live births. Meanwhile, nearly one in four people in the country has HIV—the prevalence of the virus has held steady at 23.6 percent since 2004. This HIV crisis has helped fuel a nationwide tuberculosis epidemic—Lesotho is one of few sub-Saharan countries where TB incidence has climbed by more than 10 percent over the past two decades.

Between 2000 and 2010, maternal mortality nearly tripled, from 419 to 1,155 per 100,000 live births.

In 2006, the government of Lesotho invited PIH to help tackle some of these challenges, beginning by supporting the Ministry of Health in a handful of rural health centers. Following the PIH approach, the goal was to design and implement a comprehensive program that addressed the social determinants of illness, such as poverty, hunger, and poor work conditions, that prioritized equity, and expanded access to care for vulnerable patients in a small number of districts. PIH/L’s initial strategy focused on bringing the health system to the people who needed it by improving services at hard-to-reach mountain clinics. Village health workers (VHWs) were vital in this strategy, forging trusting relationships between patients and clinicians and overcoming cultural and economic barriers that impeded access to care.

As the years went on, PIH/L’s ambitions expanded. In 2009, in the village of Bobete, the organization piloted its Maternal Mortality Reduction Program (MMRP)—a truly integrated approach to maternal care that weaves comprehensive accompaniment and active case finding with antenatal care, HIV testing and counseling, family planning, and an array of other clinical services. Identifying patients as early as possible allows PIH/L to help prevent pregnancy-related complications, mother-to-child transmission of HIV, and other problems that claim the lives of mothers every day in Lesotho.

A cornerstone of the program is maternal waiting homes. Many pregnant women walk hours on treacherous mountain paths, sometimes in the snow, to reach clinics. Doing so while in labor could spell disaster—or keep women from trying to reach a facility at all. Maternal waiting homes provide a comfortable space for soon-to-be moms so that when labor begins, they are only a few feet from trained medical staff and a well-stocked health facility.

Addressing maternal mortality is a gate for us to address all aspects of women’s health.

“We improved infrastructure, we treated patients with dignity, we addressed transportation challenges and we made sure expectant mothers were accompanied to the clinics before their due date,” PIH/L Director Dr. Hind Satti said. “Focusing on these issues and properly training staff made a significant difference. Addressing maternal mortality is a gate for us to address all aspects of women’s health—empowering women, which impacts their children’s and families’ health.”

The program was a major success. The year before the program launched, only 46 women delivered at Bobete Health Center. The year after, more than 215 women delivered at the facility. PIH/L expanded the program to seven different health centers, and each health center saw noticeable jumps in the number of facility-based deliveries. The program also yielded significant improvements in the number of women being tested for HIV, child vaccination rates, TB detection efforts, and family planning.

PIH/L’s approach and successes caught the attention of the country’s leaders.

The question: How did PIH/L achieve substantial, sustainable progress toward key health indicators in some of the most rugged parts of Lesotho, while the rest of the country was losing ground on the same measures? Could Lesotho adopt the PIH/L model at a national level?

A new level of accompaniment

The first "reform baby" and her mother, at the Mohalinyane Health Center in Mohales Hoek District, Lesotho. (Photo by Likhapha Ntlamelle / Partners In Health)

In late 2013, PIH/L and the Ministry of Health began collaborating on a plan to scale up the maternal mortality program so that all health clinics would be able to deliver a comparable level of care to what PIH/L had been delivering for years. While PIH/L will be intimately involved in training staff and providing technical assistance, the health centers will remain under the purview of the Ministry of Health. The national reform will occur in three phases over five years.

The first phase, happening now, focuses on bolstering infrastructure, improving the supply chain, designing monitoring and evaluation systems, training staff, and building a system to support a cadre of VHWs who will be vital to earning the trust of communities. The first phase focuses on four districts.

The second phase will bring the reform to the country’s six remaining districts, rigorously document outcomes from phase one, and disseminate those findings so the program can be modified as needed.

The third phase, expected to occur in 2018, will focus on evaluating and analyzing the impact of the program. Thorough documentation may prove invaluable for other poor countries struggling with maternal and child mortality.

“This program will show that it is possible to deliver better services for patients and better outcomes at a lower cost when you work with, and work in, the communities,” Satti said.

In the first few months of the reform, nearly 2,000 VHWs have been trained, and a new national VHW policy has been approved. The team has conducted more than 50 baseline assessments and trained dozens of nurses.

Among those nurses is Justinah Kuotso at the Mohalinyane Health Center, one of the first health centers to undergo the reform. It was Kuotso who accompanied Masechaba Molefsame when she arrived at the clinic in late April. After a week and a half in the maternal waiting home, Molefsame went into labor. Staff worked together seamlessly to deliver a healthy baby girl—the first child delivered under the national reform.

In Lesotho, it is tradition not to name a baby until after the umbilical cord has fallen off. In the days after the delivery, staff at the health center affectionately dubbed the newborn “Reform Baby.” In the following weeks, several more babies, including a set of twins, were safely delivered at clinics throughout the four districts where the reform began.

In Lesotho, the challenges are still immense, and resources still limited. But with a generation of “Reform Babies” on the way, Lesotho has reason to hope for a bright and healthy future.

Working in Global Health: Medie Jesena

Each month we ask a seasoned colleague to share advice for those interested in forging a career in global health. This month we asked Nurse Educator Medie Jesena to discuss her path to working with PIH's Rwandan sister oganization.

Originally, I had no desire to be a nurse. My heart was set on becoming an architect, but when my family emigrated from the Philippines to the U.S., my father encouraged me to pursue nursing. It was a practical career choice and would provide a stable income. I was reluctant at first, but 17 years later, I have grown to love my career and have no regrets.

I have worked as a nurse and nurse practitioner in a variety of pediatric clinical settings in the U.S. and have taught nurses and nursing students. These experiences, those gleaned during volunteer trips overseas, my public health education, and having grown up in a developing country, have all contributed to my decision to move to Rwanda, where I now work as a nurse educator with PIH/IMB.

When health care providers are skilled, knowledgeable, and passionate about their work, our patients have better outcomes.

I LOVE learning and teaching. The most rewarding moments are when I see my Rwandan colleagues get so excited about learning new skills and concepts that they could not help but share their newfound knowledge with their peers. When health care providers are skilled, knowledgeable, and passionate about their work, our patients have better outcomes. This is what we strive for in everything we do, especially with very young patients whose clinical outcomes affect the course of their and their families’ lives.

Working in a radically different cultural and clinical setting from what I have grown accustomed to, I constantly struggle with my own impatience. But the more I learn from my Rwandan colleagues about their worldview and the challenges they face, the more I understand that my role here is not to impose my own ideas of how things should be done, but to support them in their goals and efforts to improve their practice.

For anyone interested in global health nursing, my advice is to prepare academically, professionally, and, not least of all, mentally. To start, it is important to know yourself, your capabilities and limitations, and where your rewards and happiness lie. If you are willing to open yourself up to the new and challenging experiences that come with global health, the work is pretty darn rewarding!

Mosquito-Borne Virus Sickening Thousands in Haiti

Chikungunya, a virus spread through mosquito bites, has now sickened thousands of people in Haiti, according to the Haitian government.

Historically, chikungunya has affected people in Africa, Asia, and Europe. In late 2013, the first cases of the virus appeared in the Caribbean, and this spring, health officials confirmed the virus in Haiti for the first time. The virus is rarely fatal but causes fever and severe joint pain; the symptoms can be treated with analgesics but there is no drug to stop the virus itself.

Since first detected in Haiti, the virus has spread rapidly. The Haitian Ministry of Health has reported more than 27,000 suspected cases at the end of May, and there are likely many more people who have been sick but haven’t gone to a health facility where the case could be recorded. Only lab testing can confirm a case of the virus.

People living in Port-au-Prince have been most affected, but Partners In Health clinicians have seen cases in the Central and the Artibonite departments of Haiti as well. At University Hospital in Mirebalais, for example, clinicians recorded more than 200 suspected cases, including about 20 children, during the month of May. Cate Oswald, senior program officer for PIH in Haiti, said that even as the staff cares for sick patients, they’re also falling ill.

“So many of our staff have gotten sick over the past weeks—all with the same symptoms,” Oswald said. “People are unable to come to work because of fever and severe joint pain.”

Dr. Gregory Jerome, director of Monitoring, Evaluation, and Quality Improvement for Zanmi Lasante, PIH’s sister organization in Haiti, said that most patients don’t seek care in a health facility, since there is no specific treatment. Many opt instead to take medicine such as acetaminophen and stay at home to wait out the virus.

The illness caused by the virus is most often a painful but self-limited disease with symptoms usually beginning three to seven days after being bitten by an infected mosquito, and lasting up to one week. Symptoms most often include joint and muscle pain, headache, and fever, with the occasional presence of a rash. Occasionally, joint pain and arthritis can last for weeks to months.

“The vast majority of people sick with chikungunya don't actually seek for care at any institution, which means their cases go unrecorded,” Jerome said. “By now, there are probably thousands of cases in Mirebalais, because the attack rate of this infection is very high all over the country.”

Chikungunya affects 95 percent of those who are infected with the virus. Although it is not clear what percentage of people infected with chikungunya develop severe disease, there are severe and even life-threatening complications including respiratory, cardiac, and kidney failure as well as meningitis and hepatitis.

To avoid the virus, people must protect themselves from mosquitoes that bite during the day. This is nearly impossible for most Haitians, who don't have access to mosquito repellent. The Haitian government has begun mass fumigation efforts to kill mosquitoes and advised people to eliminate standing water where mosquitoes breed.

‘Race to the Top’: Competition Aims for Quality Care in Rwanda

There’s nothing wrong with a little competition, especially if it improves access to health care in rural Rwanda. That’s the idea behind “Race to the Top,” a collaborative effort between Partners In Health’s Rwandan sister organization and the government of Rwanda that targets and improves specific health indicators where barriers persist.

PIH works in three districts in Rwanda—Burera, Southern Kayonza, and Kirehe. Each is home to a number of health centers that provide a range of outpatient services, from family planning to rapid malaria testing. These health centers are the first point of contact many patients have with the health system. Different districts face different challenges. Take Kirehe, where health centers have made enormous strides in recent years, yet malnutrition rates in children under 5 and maternal and newborn mortality rates are stubbornly high.

That’s where the “Race to the Top” comes in. It’s designed to foster healthy competition among health centers in each district and push them toward priorities identified by Rwanda’s Ministry of Health. For instance, the 16 health centers in Kirehe are working to see which can be the first to hit three specific targets: a 50 percent increase from the previous quarter in the number of women who have initiated family planning methods; the elimination of severe acute malnutrition in children under 5; and 90 percent enrollment of all patients in the health center’s catchment area in mutuelle de santé—Rwanda’s state-backed health insurance—or similar coverage. Health centers aren’t only competing for bragging rights; financial incentives are tied to progress on these indicators.

“‘Race to the Top’ encourages health center teams to work hard, concentrate their efforts toward reaching specific targets related to district priorities, and develop innovative approaches to overcoming challenges,” says Dr. Evrard Nahimana, Kirehe District’s clinical director. “For example, at Gashongora Health Center, the staff worked with local authorities to identify vulnerable families, which were then provided with land to cultivate and cows for milk production. The staff at Kabuye Health Center developed a program to provide fish for all kids under age 5. This type of combined social and clinical support is key to addressing malnutrition, maternal health, and similar challenges.”

Teams are not competing against one another, they’re competing together to achieve excellence.

One of the program’s biggest benefits, Nahimana says, is how swiftly it improves communications and information sharing among the health centers. When one team tried a new approach and it worked, the strategy was shared with other health centers. That’s the essence of positive competition; teams are not competing against one another, they’re competing together to achieve excellence.

“‘Race to the Top’ creates space for the different teams to share their experiences,” Nahimana says.

The goals of the program were set intentionally high. Nahimana notes that while no health center in Kirehe has hit all three goals in a single period, each has made steady, sustainable improvements. Some health centers provided family planning services to more than 1,000 women in the competition timeframe. Others saw significant jumps in the percentage of patients with health coverage. Strategies to improve food security will making lasting improvements for families and communities.

In the coming year, our Rwandan colleagues plan on working closely with local governments to expand this model to Burera and Southern Kayonza Districts. The program’s agile design allows us to modify the targeted health indicators to ensure we’re improving care for the most vulnerable patients in these communities.

“It is so impressive to see the innovations each health center implemented to push toward the program’s goals in Kirehe,” Nahimana says. “It’s exciting to know this program will help improve access to health care for patients facing different challenges in all of our districts.”

Food as Medicine: Chef Jody Adams’s Culinary Quest in Haiti

For more about this work, read the recipes Chef Jody Adams created for University Hospital or join her for a live video chat to benefit Partners In Health.

Sunlight gleamed off the stainless steel table as Louinique Occean kneaded a smooth, round ball of dough. On the other side of the table, Jody Adams, James Beard Award-winning chef, prepared a colorful spread of nutritious dishes.

This scene isn’t uncommon in Cambridge, Mass., where Occean is the head baker at Adams’s renowned restaurant, Rialto. But today they’re in Haiti, working in the kitchen at University Hospital in Mirebalais, operated by Partners In Health in collaboration with the Haitian Ministry of Health. Occean, who is Haitian-American, and Adams, a PIH trustee, have come at the request of the medical team to help the kitchen staff make healthier meals for patients, using locally sourced ingredients.

What I’ve learned from Partners In Health is that if we want a sustainable change, we can’t just impose something. We have to see what’s appealing to people.

In Haiti, lack of access to nourishing food is at the root of many health problems. About 22 percent of young Haitian children show signs of chronic malnutrition. Doctors and nurses often see poor nutrition exacerbating the effects of other health problems, including tuberculosis, HIV, and diabetes. Malnutrition puts women at greater risk of dying in pregnancy and childbirth.

The University Hospital staff aims to raise the quality of the hospital food as part of a comprehensive approach to good health just as they are raising the standard of Haiti’s public medical care. But changes to eating habits don’t come easily, especially when many nutritious foods are unfamiliar, unavailable, or too expensive.

And, Adams said, “What I’ve learned from Partners In Health is that if we want a sustainable change, we can’t just impose something. We have to see what’s appealing to people.”

Cooking for the poor

Adams is energetic and elegant, with short auburn hair that stands out against a white chef’s hat. She’s known for her use of New England ingredients in regional Italian food at Rialto, where she’s been chef and owner since 1994.

Adams got involved with PIH after meeting co-founders Paul Farmer and Ophelia Dahl as guests at her restaurant. “I had read Mountains Beyond Mountains and drank the Kool-Aid,” she joked. “The notion that you use the expertise of the people on the ground, through the model of community health workers and accompaniment, really resonated with me.”

I work in this restaurant where we feed people who have never, ever worried about their next meal. So in my world, it’s really important to have balance.

So, when Bravo’s "Top Chef Masters" invited her to appear on the show, she decided to highlight PIH as the charity to receive her winnings. The show aired in spring 2010, just after the earthquake in Haiti, when PIH faced unprecedented need.

In one episode, she netted $5,000 for PIH with a fig-and-walnut tart with pomegranate syrup and zabaglione, but not long after, an undercooked goat leg sent her packing. After that episode aired, she connected with a Haitian family —in Boston for post-earthquake medical care through the support of PIH—to show she could cook a goat properly, Haitian style. The Boston Globe covered the celebratory dinner as redemption for Adams.

In 2011, PIH invited Adams to join its Board of Trustees. She accepted, with the caveat that she wanted to do more than fundraise. She hoped her talents in food and hospitality could help patients. “I work in this restaurant where we feed people who have never, ever worried about their next meal. They don’t want for anything,” Adams said. “So in my world, it’s really important to have balance.”

Looking for ways to connect her professional experience with the goals of PIH, Adams invited Claudia Pierre Flerismond, the head of hospitality at University Hospital, to tour Boston-area hospital and restaurant kitchens.

Born in Mirebalais, Flerismond, 40, spent much of her childhood trailing her mother, who taught school for Zanmi Lasante, PIH’s sister organization, in Cange. “I grew up with Zanmi Lasante,” Flerismond said. Flerismond got her start in hospitality in Cange, pitching in as an ever-growing stream of visitors came to learn about and work at the small hospital there. Today, as the head of hospitality at the 300-bed University Hospital, she supervises more than 130 kitchen, laundry, and housekeeping staff.

The tour of kitchens in Boston inspired both Flerismond and Adams. It was during this visit and subsequent conversations that Adams zeroed in on the idea of improving food for patients at University Hospital. The need and the opportunity were great—the hospital had a huge demand for food and a shining new kitchen.

“Bread seemed to be an important part of the puzzle, and Occean could bring his expertise to appeal to Haitians,” Adams said. “What better way to do it?”

Louinique Occean, the Haitian-American head baker at Rialto in Cambridge, Mass., prepares a bulgur-flour dough in the kitchen of University Hospital in Mirebalais, Haiti. Photo: Stephanie Garry/Partners In Health

In search of the key ingredient

Occean and Adams flew to Port-au-Prince in March 2014 for a weeklong visit to the hospital. “Jody, I’m home,” Occean said soon after the plane touched down. The first order of business on this homecoming: find and purchase whole-wheat flour.

It’s not a common ingredient in Haiti, especially in poor, rural areas. After searching luxury grocery stores, a French bakery, and a hospitality supplier, they ended up at a food wholesaler near the airport.

“We’re in search of whole wheat, which seems to be impossible to find,” Adams said to the manager.

A quick tour of the warehouse revealed why. Much of what the company distributes is imported processed or frozen food, in cans, jars, or boxes—cheap and easy to store—and goes to supermarkets and hotels, not the rural poor.

The manager said he’d like to source and distribute fresh Haitian products, like coffee, rice, peanuts, and mangoes, but storage and a reliable supply are big barriers. In the 1980s and 1990s, the U.S. government coerced Haiti into lowering tariffs on imported food, flooding the country with subsidized American commodities such as rice, which were cheaper than home-grown products. It demolished much of the little agriculture Haiti had.

After hours of searching—coming across an abundance of soup-in-a-cup, condiments, and even foreign ice cream—Adams and Occean realized that whole-wheat flour wasn’t an option. But Occean had another idea, one rooted in Haitian cuisine and easy to acquire: cracked bulgur wheat, which is cooked as rice substitute in Haiti and commonly called blé.

The baking professor

By 7 a.m. the next day, Occean, sporting a baseball cap over his dreadlocks, was busy in University Hospital’s kitchen, surrounded by the dozen or so staff members preparing lunch for more than 150 inpatients and nearly 700 hospital staff.

Occean had taken the bulgur to a local business that grinds corn, and brought it back looking much more like flour. He mixed several doughs with different proportions of the bulgur flour to see which he liked most. His ideal dough would be airy and fine, mimicking the white bread many Haitians enjoy.

Occean is intimately familiar with Haitian food. Born in Haiti, at age 18 he moved with his family from Haiti to Boston, settling in Dorchester. At 25, Occean was working at Rialto as a dishwasher when Adams noticed him eyeing the bread and sent him to train at Clear Flour Bakery in Brookline so he could learn and refine the baker's craft. Now he's Rialto’s head baker, starting each day at 3 a.m., long before dinner guests enjoy his creations.

Over the years, his personal diet has changed. He’s shifted away from Maggi, sodium-rich bouillon cubes that are a favorite among many Haitians, including his own mother, and eats loads of vegetables.

Adams tapped Occean’s connection with Haitian food and personal experience in the quest to bring more nutritious food to patients at University Hospital. He is proud to play the role of a professor in his home country. “When Jody asked me to help, it was the first time something like that happened in my life, to have an opportunity to go to my country to help out,” Occean said. “I hoped to do that one day before I died. But I didn’t know if it would happen.”

Chef Jody Adams and Rialto head baker Louinique Occean examine the bulgur-flour bread Occean made for patients at University Hospital in Mirebalais, Haiti. Photo: Stephanie Garry/Partners In Health

Little by little

Flerismond had taken steps to improve the food for patients, and welcomed Occean’s and Adams’s help. She had managed to eliminate fried foods and Maggi from the menu but on other occasions when she experimented with new vegetable dishes, they didn’t go over so well. Some patients sent them back.

Flerismond described these challenges to Adams and asked for help in devising dishes that incorporate slight changes to typical Haitian food. Piti piti wazo fe nich li. "Little by little," the Haitian proverb goes, "the bird builds its nest."

Adams is accustomed to overcoming similar challenges. At her own restaurant, she tries to let delicious dishes lead and food ideology follow. In Haiti, she sees great potential to develop the agricultural industry and increase access to nutritious food without sacrificing people’s health or the environment, which is what she believes has happened as the U.S. food system has become more industrialized.

Her morning meal, a typical Haitian breakfast of ground corn with fish and vegetables called mais moulin, was reimagined as a baked casserole.

“Nobody is going to make a choice to eat an unhealthy food if they know what the impact is,” Adams said. “The doctors, the nurses, and Claudia all know that we don’t have to shove it down people’s throats. You can eat it because it tastes good.”

Local foods, international dishes

Back in the University Hospital kitchen, Adams poked around the warehouse and walk-in fridge. Staples common in the U.S., such as milk, butter, and yogurt, are too pricey for Flerismond’s hospital budget. But Haitian soil still yields plenty of other foods: onions, green peppers, eggplant, parsley, garlic, spicy Scotch bonnet peppers, and—one of Adams’s favorites—peanuts.

Inspired, Adams came up with several peanut-based sauces, including a spinoff of romesco, a Spanish sauce with tomato, and another featuring grated coconut. She prepared roasted peppers stuffed with tomatoes and topped with a parsley pesto, as well as a chicken soup with vegetables and pasta (the chicken had met its end just moments before). Her morning meal, a typical Haitian breakfast of ground corn with fish and vegetables called mais moulin, was reimagined as a baked casserole.

The hospital’s cooks gathered around as Adams showed them how to make each dish. On the other side of the table, Occean continued to knead and massage his doughs, optimistic that the patients would like the new, healthier take on a familiar staple.

“Today, they’re going to try it,” he said. “After a few days, they’re going to like it.”

Asking for seconds

The following day, University Hospital kitchen staff went from ward to ward in the hospital, pushing carts full of Occean’s bread, topped with peanut butter and wrapped in napkins. They handed it out to patients for breakfast.

“The patients loved it,” Flerismond said. “The following day, they were asking for it.”

A new industrial mixer will ensure that the kitchen staff can bake and serve Occean’s nutritious bread every day. Flerismond has dished out Adams’s chicken soup recipe several times to patients, who loved it. And the new peanut sauces, served over rice, have been a hit.

“People come to the hospital really sick. They’re often malnourished and close to death,” Flerismond said. “After they eat the food, they don’t want to leave the hospital, because they’re taken care of here. That makes me so happy. Jody and Occean are helping me to realize a dream, to take care of sick people.”

PIH staff member Aliesha Porcena contributed to this report.

Try Adams's recipes for University Hospital.

Dr. Paul Farmer Calls for Action on Climate Change

Dr. Paul Farmer writes that climate change is a threat to human rights and calls on governments to fulfill their responsibility to address it in a new editorial in the Health and Human Rights Journal (pdf).

The editorial, titled “The Great Procrastination,” is written by journal editors Farmer, Dr. Jay Lemery of the University of Colorado, and Carmel Williams, Ph.D, of Harvard University.

“We wonder, given the evidence underlying the mounting climate crisis, if future generations will regard ours—amongst the epochs of history—as 'The Great Procrastination.' Squandering time, dithering on action, and engaging in half-measures woefully incapable of addressing a threat that our best science warns will be more catastrophic and less reversible each year.

The health effects of anthropogenic climate change are increasingly apparent and accelerating at an ominous pace. Global warming will now continue under all future scenarios, and immediate action can only slow, not reverse, the rate of warming. Our risk assessment has yet to translate into meaningful mitigation and, even with this knowledge, major industrial nations are continuing to invest significantly in new carbon-based energy technologies.”

Read the editorial and the full issue of the Journal, which explores the threats to health from climate change as human rights issues.

Recipes by Chef Jody Adams for Patients at University Hospital in Haiti

Chef Jody Adams, of Rialto and Trade restaurants in Boston, created these recipes from local Haitian foods for patients at PIH-supported University Hospital in Mirebalais, Haiti. Rialto head baker Louinique Occean created the bread recipe. Read more about their work with PIH.

Roasted Potatoes

Ingredients

10 pounds potatoes
Salt
1 ¼ cups vegetable oil
Black pepper

Directions

Peel the potatoes and cut into 1 ½ inch chunks. Soak in water for five minutes.
Drain the potatoes and put into a pot. Cover with cold water and season with salt. Bring to a boil, reduce the heat to low, and simmer until tender, about 10 minutes. Drain and toss around a bit to rough up the surface of the potatoes. This will help make them crispy.
Preheat the oven to 425 F. Put the oil in a large roasting pan and heat in the oven for five minutes. Add the potatoes, and using a spatula, carefully toss to coat the potatoes with oil. Do not salt at this point. Wait until they are roasted. Turn on the convection if you have it. Roast 30 minutes, flip over, then roast another 30 minutes. They should be toasty and crunchy.
Toss with salt and pepper.

Roasted Stuffed Peppers

Ingredients

½ cup vegetable oil
6 cloves garlic, thinly sliced
8 scallions, thinly sliced
2 hot peppers, chopped
2 teaspoons fresh thyme leaves
Salt and pepper
8 red or green bell peppers
16 small red tomatoes
1 cup grated cheese

Directions

Cook the garlic, scallions and hot peppers with the oil in a small sauce pan on medium heat for five minutes, or until tender. Add the thyme leaves.
Cut the peppers in half, remove the seeds and membranes, and season the inside with salt and pepper. Put the garlic mix in the peppers.
Cut the tomatoes in half and put two halves cut-side up in each pepper half. Season with salt and pepper.
Bake at 350 F until tender, about 40 minutes. Top with the cheese and bake another five minutes.

Roasted Beet Salad with Orange and Thyme

Ingredients

16 beets
Salt and pepper
2 tablespoons vegetable oil
6 oranges, remove and save the skin from 2 oranges
12 shallots, peeled and finely chopped
¼ chopped parsley
2 tablespoons thyme leaves

Directions

Wash the beets.
Toss in a pan with the oil. Season with salt and pepper. Add the orange skins and cover with foil.
Bake at 350 F until tender, about one hour.
Let the beets cool, then remove the skins. Cut the beets into wedges.
Remove seeds from the oranges and cut between the membranes to separate the fruit segments. Squeeze out any juice from the membrane onto the beets.
Toss the beets with the orange segments, shallots, parsley, and thyme.

Rialto baker Louinique Occean sifts ground bulgur, known in Haiti as blé, for the bread he created for University Hospital patients. Photo: Stephanie Garry/Partners In Health

Occean's Whole Wheat Bread

Ingredients

8 cups water
4 tablespoons granulated yeast
3 tablespoons salt
13 cups Haitian white flour
3 cups blé flour*

Directions

Put the water in a large bowl. Sprinkle the yeast over the water. When it swells up, stir to combine. Stir in the salt. Stir in the blé flour. Stir in the white flour until it is too difficult to stir.
Dump the dough onto the counter with any remaining flour. Push the dough around on the counter until all the flour is incorporated. Then knead the dough by pushing the heel of your hand into the dough, pulling it over on itself and then repeating with the other hand. You want to develop a rocking back and forth, pushing your hands from your hips like a boxer’s punch. The dough will be a little wet in the beginning, but as you knead the dough it will become less sticky. You may need to add a little more flour to keep the dough from sticking to the counter. Knead for 10 minutes. Cover and rest 15 minutes. Knead for another 10 to 15 minutes.
To check to see if it is ready, slice through the dough. The holes in the dough should be small, about ¼ inch, and even.
Put into an oiled bowl, cover with plastic, and allow to rise until doubled in bulk, about two hours.
Dump the dough onto the counter and cut into four pieces. Gently shape each piece into a rectangle. Fold the dough like a letter: fold the top third down and then the bottom third up over the top third. Fold this bundle in half and then pinch the edges together. Tuck the sides under and put the dough into a greased loaf pan. Cover with plastic and let rise 1 ½ hours, or until doubled. It should crest about ¾ inch over the top of the pan.
Preheat the convection oven to 350 F. Put a pan of water in the bottom of the oven and set the fan to low. Bake the loaves 30 minutes or until done.
Turn out onto a wire rack to cool, or turn on their ends on a counter to cool.

* Put (bulgur) blé through a grinder. Shake through a sieve.

Romesco—Pepper Nut Sauce

Ingredients

12 red or green bell peppers
8 tomatoes
2 onions, cut in quarters
½ cup vegetable oil
Salt and pepper
1 cup peanuts
6 garlic cloves, chopped
1 or 2 hot peppers, chopped (depending on how hot the peppers are)
Juice of 8 limes

Directions

Wash the peppers and tomatoes.
Cut the peppers and tomatoes in half.
Put the peppers, tomatoes, and onions in a roasting pan and toss with 2 tablespoons oil. Season with salt and pepper.
Roast at 450 F for 15 minutes or until the skins start to get black and the vegetables are tender. Let cool.
Remove the skin and the seeds from the peppers. Chop up the vegetables until fine.
Crush the peanuts in the mortar and pestle. Add the garlic and pepper and crush together.
Mix the peanuts with the vegetables. Add the lime juice. Season with salt and pepper.

Coconut Peanut Sauce

Ingredients

2 coconuts
2 large onions diced
½ cup vegetable oil
3 garlic cloves, chopped
2 cups peanuts, chopped
Juice of 8 limes
3 hot peppers, chopped
2 tablespoons sugar
Salt and pepper

Directions

Make a hole in the coconut and pour out the coconut water to save.
Peel the coconut and grate.
In a small pan, cook the onion in the oil over low heat until tender and golden brown. Add the garlic and cook one minute.
Put the peanuts in a blender with the coconut water and the lime juice. Blend to chop more. Add all the ingredients and blend to a sauce. Add water if the sauce is too thick. Season with salt and pepper.

Parsley Pesto Sauce

Ingredients

5 cups parsley leaves, washed, dried, and chopped
1 garlic clove, grated
2 teaspoons grated lime zest
2 teaspoons grated orange zest
½ cup peanuts, chopped
½ - ¾ cup vegetable oil
¼ cup water
Salt and pepper

Directions

Put everything in the blender and blend to a paste. You may have to stop and scrape the sides a few times. If it is too thick, add more water or oil.
Season with salt and pepper.

Brandade de Morue

This version of the dish was Inspired by Haitian mais moulin.

Ingredients

1 whole dried cod, about 2 pounds
¼ cup vegetable oil
2 onions, chopped
12 garlic cloves, chopped
1 onion, peeled and sliced
1 pound small potatoes, peeled
3 small cans evaporated milk
Juice of 4 limes
1 teaspoon thyme leaves
½ cup parsley, chopped
Salt and pepper

Directions

Soak the salt cod for 12 hours, changing the water three or four times. When finished, the cod should still taste a little salty.
In a small pan, cook the chopped onion and garlic in the oil over low heat until tender, about 10 minutes.
Cook the cod in water with sliced onions until tender, about 15 minutes. Remove from the water and let cool. When cool, remove the skin and bones.
Add the potatoes to the water and cook until tender. Drain and then grate the potatoes while they are still warm.
Put the cod into a bowl and beat until smooth. Add the cooked onion, the garlic, and the potatoes and beat again. Beat in the evaporated milk, lime juice, thyme and parsley. Season with salt and pepper.
Serve warm by itself; or
Spread the fish over a layer of cooked cornmeal.
Bake at 350°F until bubbling and hot, about 40 minutes.

Oliver’s Chicken Stew

Chef Jody Adams first created this dish for her son, Oliver.

Ingredients

1 Haitian chicken, scrubbed with salt and limes
Salt
6 carrots, peeled and cut into 1-inch pieces
26 small leeks, cut into 1-inch pieces
12 cloves garlic, smashed and peeled
1 small bag pasta
1 cup celery leaves
1 cup sorrel leaves, chopped
1 cup parsley leaves
Juice of 6 limes

Directions

Separate the chicken breast and legs.
Put the chicken in a pot and cover by 2 inches with salted water. Bring to a boil, reduce the heat to low, and add the vegetables. Simmer 30 minutes. Remove the chicken breast and the vegetables.
Continue simmering until the leg section is done, about 30 minutes more.
Remove the leg section.
Remove the skin from the chicken breast and leg section and take the meat off the bones.
Continue simmering the broth until it has good flavor.
When the broth has reduced, cook the pasta in the broth. When the pasta is done, add the vegetables, chicken meat, celery, sorrel, parsley, and lime juice to the broth. Season with salt and pepper. Heat through and serve.

A New Partnership to Change MDR-TB Treatment around the World

Multidrug-resistant tuberculosis (MDR-TB) is one of the most serious public health problems in the world today—and the global burden is growing. That’s why we are delighted to announce that UNITAID has awarded Partners In Health a grant that will change how MDR-TB is treated throughout the world.

Partnering with Médecins Sans Frontières and Interactive Research & Development, PIH will use the four-year, $60 million grant to bring two new drugs to 17 countries in which MDR-TB poses a significant burden. Called “endTB,” this project is designed to dramatically expand access to these new drugs globally. It will lead to the development of new treatment regimens for MDR-TB and ultimately improve the quality of life for countless patients. Here’s everything you need to know about this innovative program:

What’s UNITAID, and why is it funding endTB?
UNITAID is a global health financing system that works to expand access to drugs and diagnostics for TB, HIV, malaria, and other infectious diseases that disproportionally affect low-resource countries. About half of UNITAID funding comes from a small fee on airline tickets. The projects it funds are often aimed at sustainably reshaping markets so that new drugs and medical technologies are available to more people at a lower price, which is a major focus of endTB.

Who is PIH partnering with on this project?
The project consists of a consortium with two other partners. Our first partner is Médecins Sans Frontières, or Doctors Without Borders, which you’ve probably heard of. The group does amazing work in countries where armed conflict, epidemics, natural disasters, and other challenges limit access to health care.

Our second partner is Interactive Research & Development, or IRD, a global health delivery and research organization based in Dubai that works in 15 countries, including high-burden MDR-TB countries such as Pakistan, Indonesia, and Bangladesh. The IRD team leverages process and technology innovations to address global health delivery gaps, including the use of health market innovations such as social business models to engage private providers in lung health and diabetes care, as well as the use of performance-based incentives for community screeners and treatment supporters, patient incentives to enable treatment compliance, and the use of open-source information technology platforms to allow close monitoring of patient care and program quality.

The project will also work with many other “non-consortium” partners, such as national TB programs and local nongovernmental organizations and stakeholders in the endTB countries, as well as other international partners such as the World Health Organization (WHO) and MSF Access Campaign.

In what countries is endTB going to be implemented?
Patients from 17 different countries—most of which are designated by the WHO as high-burden MDR-TB countries—will be enrolled in the program. In some countries, only patients from the endTB partner site will be enrolled initially, to gain “in-country experience.” In other countries, patients will be enrolled countrywide from the start.

The 17 countries are: Armenia, Bangladesh, Belarus, Ethiopia, Georgia, India, Indonesia, Kazakhstan, Kenya, Kyrgyzstan, Lesotho, Myanmar, Nepal, North Korea, Pakistan, Peru, and Swaziland. Here’s a map to help you get a better understanding:

Why were these countries selected?
These are all countries where the endTB partners have active projects and established systems for treatment delivery and monitoring and evaluation. For example, PIH has been supporting large MDR-TB treatment projects in Peru, Lesotho, and Kazakhstan for years. This expertise will allow us to figure out the best ways to use these new TB drugs, and provide a model for other sites and countries.

And what’s the difference between TB and MDR-TB?
As Carole Mitnick, PIH’s longtime partner and renowned TB expert, explained, “The distinction lies in the drugs that are useful to treat this bacterial disease.” TB is usually treated with a four-drug, six-month regimen.

MDR-TB is caused by bacteria that are resistant to the two most important drugs in the standard regimen, isoniazid and rifampicin. It is highly infectious; each untreated MDR-TB patient can infect three to six people each year. Treating MDR-TB is grueling for patients. It often requires a minimum of 20 months, consisting of daily regimens containing at least five drugs, one of which is given as a daily injection for at least eight months. Some of the drugs carry the potential for severe adverse effects, including psychiatric disorders, kidney damage, liver toxicity, and hearing loss. It can be an isolating and painful process for patients, even when treatment is delivered through community-based platforms with comprehensive social support.

And still, only about half of the people who endure the full two-year treatment are cured. Eighty percent of patients who fail MDR-TB treatment die within three years.

How serious a problem is MDR-TB?
Drug-resistant TB is one of the most serious public health problems in the world today. Unfortunately, it appears that the global burden of MDR-TB is growing. The WHO estimated that there were 450,000 new cases of MDR-TB in 2012. That same year, approximately 170,000 people died from MDR-TB. Tuberculosis—drug-resistant strains and drug-susceptible strains combined—kills more than 1 million people every year. That’s equivalent to the entire population of Hawaii dying every year from a treatable disease.

What are the new drugs endTB? And why are they so important?
Bedaquiline and delamanid are the first new drugs approved for TB in 40 years. They have the potential to shorten the course of treatment, improve cure rates, and minimize side effects.

The problem is that these drugs aren’t getting to the patients who need them most. There are two principal reasons for this: 1) They are new and many countries are reluctant to use them because of limited safety profiles and they have no experience in their use; 2) They are not licensed in many places, or only have conditional approval. Often the only way to access them is through what’s called “compassionate use” programs, which can be cumbersome, slow, and are not an option in all countries. This all leads to a "chicken-and-egg" phenomenon, where countries are reluctant to administer the new drugs because they are not widely used, and we can’t improve our understanding of their safety because countries aren’t using them.

How will endTB change that?
endTB is designed to specifically spur early adoption of these drugs. By buying bedaquiline and delamanid for 3,200 patients across 17 countries, PIH will create a network of sites that can demonstrate the best way to use these drugs. The first patients to use these drugs at the endTB sites will likely be the ones with highly resistant strains of TB, such as extensively drug-resistant TB. These patients have very few treatment options and have the most to gain.

PIH and its partners will collect an enormous amount of data in this first group of patients. We want to make sure these drugs do not cause any unexpected side effects, and that they are as effective as initially thought. This data will then immediately be made available to the WHO to inform future policy recommendations. Showing that these new TB drugs are both effective and safe will go a long way in convincing more countries to use them. The rigorous monitoring of patients and careful delivery of drugs is possible in experienced MDR-TB treatment sites, such as those run by PIH and its partners.

Why is a clinical trial part of endTB?
A major goal of endTB is to simplify the treatment of MDR-TB by finding new treatment regimens. This will be done through a clinical trial that will take place at a subset of the endTB sites. Getting the new TB drugs to the patients who need them—especially those with highly resistant TB—will certainly save many lives. But the clinical trial component, which will employ an innovative design never used to evaluate TB regimens, has the potential to be a true "game-changer" by discovering shorter, safer, all- oral, and more effective regimens that could be used in all MDR-TB patients.

Is that typical for a PIH project?
A multicenter clinical trial may not be what usually comes to mind when people think of PIH. But PIH has a long history of research in the area of TB, though of course not on this scale. PIH will draw on clinical trial experts from our partners at Harvard Medical School, the Division of Global Health Equity at Brigham and Women's Hospital, and the epidemiological centers at Médecins Sans Frontières.

Furthermore, much of the work will be done by our experienced and dedicated doctors and nurses at our country sites, many of whom have years of experience caring for MDR-TB patients and who have been longing for better drugs and regimens. endTB will not receive any funding from pharmaceutical companies. This ensures complete objectivity when evaluating the safety and efficacy of the new drugs.

This sounds like a massive project. How long will it take?
It is quite large, but we plan to move swiftly so these drugs can get to patients as soon as possible. As previously mentioned, endTB is spread over four years. We expect to start enrolling patients this fall. This is a historic opportunity to tackle the escalating MDR-TB public health emergency.

Haitian Prime Minister Meets with PIH, Harvard

Top officials from Haiti’s government met with representatives from Partners In Health and Harvard Medical School Thursday to work on a plan to expand access to health and education in the country’s rural reaches.

Prime Minister Laurent Lamothe met with PIH co-founders Dr. Paul Farmer and Ophelia Dahl to discuss plans to improve health systems and access to primary education. The government’s top officials in these areas, Minister of Health Florence Guillaume and Minister of Education Nesmy Manigat, also participated in the working meetings.

Farmer, in his capacity as chair of the HMS Department of Global Health and Social Medicine, welcomed Lamothe and his colleagues in the marble lobby of Gordon Hall.

“From the Dominican border all the way to the coast, across Haiti, PIH and Harvard have been partners with the Haitian health authorities for more than 20 years,” Farmer said. “Bringing these worlds together has been the secret of any success we've had, and we have every intention of being even closer partners in the future.”

It makes every Haitian proud to have such a hospital.

The Haitian government has been working to introduce or improve community pharmacies in remote parts of Haiti, where poor people either have no access to medicines or access only to overpriced, low-quality drugs, with the goal of integrating the community pharmacies with the MOH’s vision of community-based care. The group discussed those plans as well as the government’s efforts to expand access to primary education.

“I’m very honored and proud to be here today with these friends of Haiti,” Lamothe said. “I can see we’re in good hands.”

PIH staff included experts on supply chain management, generic drug procurement, community health, and medical education who advised the government officials on how to set up systems that could support high-quality community-based health care. The group promised to continue the conversations as the government rolls out its plans.

PIH representatives also provided an update on the first year of operations of University Hospital in Mirebalais, Haiti, a public-private partnership between the Haitian government and PIH. Last year, the government of Haiti supported the hospital’s operating budget with $8 million sourced from multilateral post-earthquake relief funds.

“It makes every Haitian proud to have such a hospital,” Lamothe said. “I want to thank all of you who are putting your energy into the Haitian health system.”

In addition, PIH, HMS, and Haitian government officials discussed how Harvard medical specialists could help Haiti grow and train its health workforce through a similar program to the Human Resources for Health initiative in Rwanda. In discussions of primary education in Haiti, PIH, HMS, and government officials talked about better coordination of public and private education efforts to make a greater impact, including the idea of creating a model district in the central department of Haiti, where PIH’s sister organization, Zanmi Lasante, supports 10,000 students in attending school.

PIH and ZL have worked closely with the Haitian government to revitalize public health facilities throughout central Haiti. Today, PIH supports Ministry of Health facilities and health posts in the Central Plateau and the lower Artibonite department, bolstering staff, training, supplies, and infrastructure.

PBS Features Partners In Health as an 'Agent for Change' in Rwanda

The PBS NewsHour featured Partners In Health’s work to save lives in Rwanda in partnership with the government on its “Agents for Change” series this week.

Special correspondent Fred de Sam Lazaro visited Rwanda to cover the country’s staggering gains in health equity since the genocide 20 years ago. Life expectancy has doubled since then, and a million people have risen out of poverty.

The segment includes interviews with Dr. Agnes Binagwaho, Rwanda’s Minister of Health, as well as Dr. Peter Drobac, executive director of PIH Rwanda, and Emmanuel Kamanzi, Rwanda program officer.

The NewsHour piece highlights the role of community health workers in providing health care access to all people, especially poor Rwandans living in rural areas. It also takes viewers to PIH-supported Butaro Hospital, in rural northern Rwanda.

“While we were building (in Butaro), people couldn’t believe this was their hospital. They thought, ‘This is a resort coming up for the expats, for muzungu’ (white people),” Kamanzi said. “But we said, ‘Look, this is your hospital. This is what you deserve.’”

The PBS correspondent describes the work of the Butaro Cancer Center of Excellence, opened in 2012 by the Ministry of Health and PIH, as an example of the equity-based approach Rwanda has taken to expand access to comprehensive care for all Rwandans.

“The new life for cancer patients here might be a metaphor for post-genocide Rwanda, resurgent after a near-death experience with a long journey ahead,” de Sam Lazaro says.

Learn more about PIH’s work in Rwanda.

Coffee with Dr. Enrique Valdespino

Dr. Enrique Valdespino Serrato, 25, works for Compañeros En Salud, Partners In Health’s sister organization in Chiapas, Mexico. Last year, he worked for the Ministry of Health as a community doctor in Reforma, a remote coffee-farming village about a five-hour drive over dirt roads from Chiapas’ largest city, Tuxtla Gutiérrez.

This year, he’s supervising a new class of young Mexican doctors who are working in remote communities for their required year of social service.

We sat down with Valdespino in our Boston office last month to learn about his life and work. Of course, we talked over coffee. “What I like about coffee is the origin of it,” he said, sipping. “It reminds me of the sweat of the people of Chiapas.”

Where did you grow up?

I grew up in a small town of about 80,000 people in Michoacán. My grandmother mostly raised me, but I had an adoptive mother and a biological mother as well. My adoptive father died when I was 12 years old, and I was never close to my biological father.

Learning about PIH/CES opened my eyes, because it was the first moment I saw I wasn’t alone. There are others thinking the way I think.

At age 14, I left to continue my education. Michoacán is one of the worst states in Mexico for education, and I was looking for better opportunity. For the second part of high school, I went to Toluca, a state capital near Mexico City. At the beginning, it was hard to keep up because the education was much more rigorous, but I made it. When you have a lot of motivation to succeed, you push yourself, and there’s a lot of reward, both professionally and personally. When I realized that, I decided to continue investing in my professional development. I wanted to have a career that would be fulfilling.

At age 16, I decided to be a doctor. To apply for college, you have to decide your career path. It’s a decision that requires a lot of maturity and understanding of your goals, so young people can’t experiment as much as they do here. We have to decide early.

What was medical school like?

I went to the Technological Institute of Monterrey, one of the top medical schools in the country. The school’s overt mission is to train doctors to go abroad. It even says that on the website. It’s the only school in the entire country to offer international clinical rotations, so you can study medicine in hospitals around the world. One of my friends even went to Hong Kong. The majority of graduates go to the United States, and others to Europe.

I couldn’t afford to do a clinical rotation abroad, so I went to Mexico City to work in the specialized hospitals there.

How did you go from a medical school that exports doctors to work in one of the most under-served areas of your own country?

I had seen the different levels of care in private clinics versus public facilities. People who were born in Monterrey have access to great medical care through the hospital where we studied. It’s for the elite of the elite, and that’s where I trained. But during my clinical rotations I was also exposed to dozens of health centers and hospitals, both public and private. I realized that it’s what you have or where you were born that determines your access to services. These inequalities made me feel angry at the system. I didn’t want to be part of it; I didn’t want to feed into it.

I met Dr. Daniel Palazuelos, one of the founders of CES, at a student conference in Monterrey. For the first time, I heard about global health and CES’s work in Chiapas. It opened my eyes, because it was the first moment I saw I wasn’t alone. There are others thinking the way I think. There are others who have seen what I’ve seen, and although it seems impossible, they’re trying to do something unprecedented in the face of great need and great frustrations. In this moment I decided to do my social service year in Chiapas.

And how was it?

It was a hard year. I went in with a lot of energy, almost euphoria, but by the third month I was in tough shape. What you have to understand about the work of a CES doctor is that you have many jobs: you act as a manager, responsible for all the operations of the clinic; you act as a doctor, diagnosing and treating patients; you act as an administrator, making sure you order supplies and do all the paperwork. A lot of times you’re alone, because the nurse couldn’t come because of the long distances they have to travel. And there are always a lot of patients, because word gets out that there is a good doctor with good medicine.

People often say to me, 'Stop being idealistic, and start being realistic.'

As a general doctor who’s in charge of the health of the entire community, you are in charge of all these public health programs you’ve never heard of—tuberculosis, hypertension, malnutrition, and vaccines. They don’t teach it in school, and now you’re in charge of implementing it. And now you have two bosses, the Ministry of Health and CES. You need to be totally dedicated to do this.

How did the community react to you being there as their doctor?

The people of Chiapas call us from CES gringos. I’m as much a foreigner in Chiapas as an American would be. But after a year, I was very involved in the community. Living there was an entirely different experience for me. The community gave me a house, they gave me food, and I had a river to swim in every day. There were mountains to visit, and caves, and families invited me into their houses to eat. I found myself encountering nature for what felt like the first time.

I realized something remarkable: if you showed me the logos of 100 brands, I could name them by the image alone in a few seconds, but I couldn’t name five species of trees or five flowers. All the people there knew the names of the trees. It was difficult to adapt to the absence of pavement, of services, of infrastructure. It was a shock, the transition to a natural life, from the big elite hospitals of Mexico to the country. Now when I come to the city, it’s the opposite. Everything is artificial. Everything is made by human hands. It didn’t grow on its own.

Dr. Enrique Valdespino accompanies Adelaida Lopez, left, a community health worker, and Ophelia Dahl, right, PIH executive director, on the way to a patient's home in Chiapas, Mexico. Photo: Rebecca E. Rollins / Partners In Health

How did your friends and family respond to you making this choice?

I often receive negative feedback about what I am doing. Friends, family, colleagues, and others say, “What are you doing there? Are you trying to save the world? You are going to fail, you’ll be better off if you come back. Stop being idealistic, and start being realistic.”

I always respond to this by explaining that I am being realistic, which is why I’m participating in this huge, novel social science of global health. We’re creating a better reality based on equity and justice and constructing new ways to cure ourselves.

Nothing is unchangeable. If you think you can´t improve systems, the environment, or people, then you are living in a false realistic world. In this moment, while we’re talking, new doctors under our mentorship are converting idealism and clear-eyed optimism into a better reality.

Occasionally, I get positive feedback that’s also unrealistic. A lot of my friends and colleagues say to me, “You are so brave to go there, to a place where so few people live.” The reality is that millions of people live “there,” and yet no one is offering basic services and satisfying basic needs.

Now you’re working as a supervisor of the new doctors who are now going through this themselves. How is it?

I’m learning. I’ve been a supervisor for four months, and it’s supportive supervision. I’m invested in the emotional state of the doctors. They’re new doctors, just getting into their work. I want to make sure they feel good in their communities. Mental health is an important issue for global health staff, especially at the beginning when you face enormous difficulties for the first time. I make sure they have somewhere to live, something to eat, that they can communicate with us and their families. There is no cell phone signal in these communities, just one or two satellite phones for the entire community to share. And sometimes we use walkie-talkies.

I heard about this. You have code names, right? What’s yours?

I don’t really think many people use code names as I do, for fun. Mine is “bici-burro,” or bike-donkey, because I use a mountain bike to get around. Other people in the community go by names such as “pollero” (chicken guy), “corazón de leon” (heart of a lion), or “pequeña” (little girl).

What else do you do as supervisor?

My responsibilities also include clinical supervision. I visit the new doctors and provide accompaniment, teaching, and supervision. I help make sure they are taking care of patients well, giving them follow up for chronic illnesses, such as depression or malnutrition. I make sure they are there in the clinic, respecting the patients and managing their work so that they do their jobs and also prepare for the next day.

We have to make our own way. We’re the first brick, and we’re trying to build an edifice.

I help make sure they’re forming relationships with the community and with the Ministry of Health. I make sure that the clinic and the community are in harmony. I look after their professional development to make sure they are learning, and I also look after their well-being, to ensure they have free time to exercise, study, relax, and rest. I’m with them, working side by side. I also teach a monthly course on global health for them, which is certified by the Technological Institute of Monterrey.

Tell us about the pathogen that is affecting the coffee harvest this year. What effect will this have on the communities CES serves?

The plague is a fungus called la roya, and it’s the most damaging pest in the world for coffee. It’s not unique to Mexico; it’s all over Latin America. It affects the berries of the tree, which contain the beans. Normally in Chiapas about 10 percent of the crop is affected by la roya. As a rough estimate, the average coffee producer in this region harvests 10 sacks of coffee every year, yielding about US $1,000 to $1,400, to support a family of four or five people. This year, because of la roya, a family that produced 30 sacks will only produce five.

The main problem is going to be with the people who don’t grow corn and beans as subsistence crops. The coffee harvest is in January, so November and December will be the worst months, because their cash from the last harvest will have run out. We call them the thin months.

One of the issues CES has tried to tackle is to help families avoid catastrophic expenses on health. If you understand how much they make in a year, then you can appreciate the price of 1,500 pesos (about US $115) for a simple medical consultation. Sometimes it’s for a health problem as minor as a cold. If a kid has a cough or a fever, the family is going to take them to see the doctor, and they can easily spend a huge sum on transportation or for the doctor’s fee. We’re trying to provide as much care as possible in our primary care clinics for free so that these families don’t have to travel or pay fees that bankrupt them.

What’s next for you, after this job?

I’ll be here for at least a year more. Then I’d like to do a master’s degree in global health delivery at Harvard Medical School—the course PIH clinicians have helped develop. I want to work in Mexico to help strengthen its health systems and teach. I want to make global health a part of the Mexican medical education system.

We can demonstrate in Mexico and everywhere that global health is a science, it’s a field of study, and it should be taken seriously. We have to make our own way. We’re the first brick, and we’re trying to build an edifice.

Nurses Learn Critical Care Skills in New Training Program

It’s 3 a.m., and a vehicle arrives at the hospital. It’s carrying a patient, found on the ground outside a burning house.

What should a critical care nurse do?

This scenario, discussed by Haitian nurses in training, was part of an intensive weeklong course in critical care at University Hospital in Mirebalais, the national teaching hospital Partners In Health operates in partnership with the Haitian Ministry of Health.

We’re excited about the training because right now we have the equipment in the ICU—we just need the hands to use it.

The case was one of many that almost 30 Haitian nurses discussed during a week of intensive hands-on training, the kickoff to a yearlong program to prepare them to handle critical patients. The specialty certification will be a first for Haiti.

“We’re giving the staff the tools and the knowledge they need to receive the patients that they’re seeing,” said Marc Julmisse, chief nursing officer at University Hospital. “We don’t want nurses who are focused on tasks; we want nurses who are actively participating in patient care. Now our staff is confident that they can handle these types of patients.”

A lack of trained staff is a key reason why University Hospital has not yet opened its intensive care unit (ICU). The nurse training, which will continue for a year, is designed to make that possible.

“Critical care is a new experience for us. We will be seeing the sickest patients,” said Brutus Kettelie, a surgical nurse at University Hospital. “We’re excited about the training because right now we have the equipment in the ICU—we just need the hands to use it.”

The training was conducted in partnership with four French-speaking nurse experts from Canada, who work at the General Hospital of Montreal. Working alongside University Hospital nursing leaders, they helped tailor a curriculum and training schedule to fit the Haitian context.

Nurses learned about the conditions requiring critical care, including trauma, burns, emergent conditions such as appendicitis, and childbirth. Then they rehearsed the skills and responses they will need to care for such patients. For example, nurses learned that in trauma care, injuries can distract from the initial assessment and interventions that save trauma victims’ lives, known as the ABCs, for airway, breathing, and circulation.

“We were delighted to be invited to participate in this project,” said Sophie Dussault, an emergency nurse at the General Hospital of Montreal. “We were very impressed by the knowledge, dedication, and enthusiasm of the nurses who participated in the bootcamp. We greatly enjoyed the opportunity to share our experiences and knowledge in nursing and learn in return from nurses at University Hospital.”

Learn more:

Chief Nursing Officer Raises the Bar for Nusing in Haiti

Empowering Nurses to Improve Care in Haiti

Why I Nurse: Gedeon Ngoga

Gedeon Ngoga, 34, is a noncommunicable diseases program manager at Partners In Health/Inshuti Mu Buzima.

I always wanted to become a nurse. As a child, I didn’t know the difference between nurses and doctors—all I knew is that the people in white coats had the power to help sick patients become healthy, and that is what I too wanted to do.

I finished nursing school and in 2007 I began working with PIH/IMB. Today, I am the manager for our noncommunicable diseases (NCD) program. This is an innovative project in which PIH/IMB and Rwanda’s Ministry of Health are designing and implementing care protocols for diseases such as hypertension, diabetes, and cancer in rural Rwanda.

With PIH/IMB, I am fortunate to be part of those contributing to policy formation and national planning for NCD care in Rwanda. The most rewarding part of my job is having the knowledge and ability to provide holistic care to those suffering, and especially to those suffering from NCDs.

When I’m not working on the big picture of NCD care in Rwanda, I love interacting with and listening to patients. Seeing our patients, especially the elderly and children, improve the quality of their lives gives me satisfaction. Nothing is better than seeing a patient smile after many years of critical sicknesses and hopelessness.

Nothing is better than seeing a patient smile after many years of critical sicknesses and hopelessness.

My biggest challenge as a nurse is working with limited resources. Patients living in extreme poverty are always very limited. It breaks my heart to see the devastating levels of poverty that many of our patients face, and it is difficult to provide enough comprehensive care to these vulnerable people.

At PIH/IMB, we have a program called Mentoring and Enhanced Supervision at Health Centers (MESH), which is very helpful. This new model focuses on improving the quality of nursing care and health centers through on-the-job mentorship. We aim to improve quality instead of simply inspecting quality.

Through this nurse-to-nurse mentorship, gaps in knowledge and ability are identified and filled in a sustainable way. I am involved in the MESH program for NCD nurses, which we have rolled out at both the health center and district hospital levels. With the NCD nurse mentors, we are establishing high-quality decentralized NCD care. This is a multi-faceted program and we think about all aspects of high-quality care, from data collection and quality, to protocol adherence for care providers and on-the-spot problem solving.

One of the most impactful experiences that I’ve had as a nurse is when I met a young diabetic patient—he was on the verge of dying at a very young age. He started to receive care at one of the PIH/IMB-supported hospitals, and was eventually transferred to another facility. I felt so drawn to him; I couldn’t see another patient die at a young age of a manageable disease. I decided to follow up with him closely, even when he was outside of the PIH/IMB catchment area. He eventually made a full recovery. Seeing this one life healthy and happy again was incredibly rewarding.

I love my job, and I love it most when I see people healthy and happy, knowing that I’ve played a role in their healing.

Working in Global Health: Elizabeth Barrera-Cancedda

Each month we ask a seasoned colleague to share advice for those interested in forging a career in global health. This month we asked TB Analyst Elizabeth Barrera-Cancedda to discuss her path to Partners In Health.

“The laboratory supplies are finished.” “The money is finished.” “The patient is finished.”

Statements like these reaffirm my dedication to global public health, especially work aimed at strengthening entire health systems. As a public health professional, I have worked in many under-resourced and poorly functioning health systems. A few central themes emerge in all of these environments: health care delivery challenges are numerous and nebulous; the solutions seem limited and difficult to implement, and they’re often impeded by a mentality of defeat. Though lab supplies and money may indeed become “finished,” patients should never suffer from avoidable structural deficiencies in health systems.

I speak from personal experience. Ricardo Barrera Aparicio, my father, a Mexican-born United States citizen, received a cancer diagnosis too late in order to alter his reality. He hadn’t been able to access the health care system for years because he wasn’t covered by insurance. When he did seek care, he frequently could not pay for the services; the care he received was insufficient or delayed; and important information was not properly communicated. His health was neglected for many years—not because he was apathetic, but because he didn’t have adequate access to a health system.

The doctors could not tell me the etiology of my father’s cancer, though they suspected it originated in his colon. By the time he was diagnosed, he had stage IV cancer, meaning that it had metastasized to distant tissues and organs, including his lungs. I watched him decline on a pulmonary ward, waiting on biopsy results that would only be available on Monday; it was Saturday—the lab was closed on weekends. I waited for a miracle that never manifested, and I had to make a difficult decision as his only biological child: I had to take my father off life support.

After my father’s death, sitting in an empty and silent ICU unit, crying and trying to understand what just happened, I was left with this question: If he had access to simple, routine care, would his prognosis have been different?

A few months later, I had the opportunity to work with Partners In Health in Rwanda as a research project coordinator for a mental health study among families affected by HIV/AIDS. The families encountered myriad challenges when it came to seeking and accessing care. Stigma weighed heavily on children suffering from psychosis, depression, and other mental health diseases, which affected their relationships with the community, with doctors, and even with their own families. Limited financial resources and delays in seeking care caused many children to drop out of school, which only perpetuated the cycle.

Treatment options became an accessible reality rather than a luxury.

But PIH worked closely with the community and the Rwandan Ministry of Health to overcome these challenges. Partnerships with local schools and church groups allowed for new ways to educate neighbors, siblings, and community leaders about mental health. Counseling was available, support groups for the children were formed, and treatment options became an accessible reality rather than a luxury.

After leaving Rwanda and returning to Boston to work at PIH headquarters, I continued to carry those experiences from Rwanda and the experience with my father. I promised that I would challenge insufficiencies in health care systems that limit patients from obtaining superior care. As a tuberculosis (TB) analyst, I was given my first opportunity to do just that.

Presently, my chief role is to provide technical assistance to Bangladesh’s national TB Program and lead the implementation of a novel infection control strategy at the National Institute of Diseases of the Chest and Hospital (NIDCH) in Dhaka, Bangladesh. Prior to the strategy’s implementation, many cases of TB at the hospital were unidentified, which resulted in costly and delayed care. Information about TB remained siloed within different departments at NIDCH.

The infection control strategy, however, led to a significant increase in early detection and treatment rates; the quality of care for TB-affected patients greatly improved. After successfully implementing this strategy at NIDCH, other high-burden, low-resource TB countries reached out for support of their national tuberculosis programs. To date, this strategy has been successfully implemented in eight other countries—a huge step in advocating for better practices around reducing TB transmission and treating infected patients.

Working in global health means promoting a better reality for vulnerable patients who are the victims of inadequate health care delivery.

Though I am eternally grateful that my father was finally able to access a health care system, receive a diagnosis, and initiate treatment (opportunities that aren’t an option for so many people around the world), I am continually challenged by the fact that it came too late. From Atlanta to Rwanda to Bangladesh to Boston, my experiences have taught me that inefficiencies undermining health care delivery can be overcome. I hope to continue to assist Ministries of Health in developing new policies and implementing innovative approaches to health care delivery in low-income settings. Specifically, I am determined to improve aspects of health care delivery that are generally considered “non-fundable,” mundane, and of limited interest, yet that can completely alter a patient’s reality and dramatically increase positive outcomes.

Working in global health means promoting a better reality for vulnerable patients who are the victims of inadequate health care delivery. I want to help all of those daughters (and mothers, fathers, and sons) who will face very difficult decisions at times when they are most vulnerable.

Finding a Job in Global Health: Advice from Five Experts

Working in Global Health: Advice from PIH’s Kathryn Kempton

TB CARE II is funded by USAID under Cooperative Agreement Number AID-OAA-A-10-00021. The TB CARE II project team includes prime recipient, University Research Co., LLC (URC), and sub-recipient organizations Jhpiego, Partners In Health (PIH), Project HOPE along with the Canadian Lung Association (CLA); Clinical and Laboratory Standards Institute (CLSI); Dartmouth Medical School: the Section of Infectious Disease and International Health; Euro Health Group; MASS Design Group; and The New Jersey Medical School Global Tuberculosis Institute.

Nursing in Navajo Nation

Yá’át’ééh (Hello). My name is Charlene Blindman. I am of the Hashk’aa hadzohí (Yucca-fruit-strung-out-on-a-line) clan, born for Naa ła nii (Lakota, Sioux). My maternal clan is Tódích’íi’nii (Bitterwater people) and my paternal clan is Naa ła nii (Lakota, Sioux). I was raised near Kaibeto, Arizona, on the Navajo Reservation. I have been working as a nurse for seven years. Currently, I am working as a public health manager at the Tuba City Regional Health Care Corporation in Tuba City, Arizona, and have been collaborating with the PIH-affiliated COPE Project for the past few years.

As a child, my goals were to help and influence people in a positive way. In doing so, I wanted to find a way to serve and give back to the Native American community. My decision to become a nurse was encouraged and supported by my high school teachers and family members. I was determined to pursue a higher education and return to the Navajo Reservation to help my people. Knowing this, I tailored my studies at Arizona State University and earned degrees in nursing and American Indian Studies. The opportunity to return to the Navajo Reservation and work with the Tuba City Health Care team was exciting.

Public health nursing is my passion. Working with the Tuba City Public Health Nursing Department allows me to work closely with an entire team dedicated to improving the health of individuals and the entire community. Many of our efforts are focused on raising awareness and community education.

We strive to empower the community by working directly with community members, whether through outreach events, health screenings, or similar programs. Because many of the team’s nurses have been in Tuba City for years, we have a strong connection to the people and know the pulse of the community.

The Tuba City Public Health Nursing Department has partnered with other programs in the community, including COPE, the community health center, and community health representatives. It takes a team to serve a community, and by collaborating with these programs it allows us to bridge the gap between the community and health care.

It’s this kind of teamwork that helps make up the backbone of community workers. It is exciting to know we’re raising the standard of care and improving how an entire community approaches health. I look forward to seeing the difference we will make in the community and individual lives in the years to come.

A Nurse Accompanier in Rwanda

I was not looking for a new job when the email arrived. I was happy at my present one. But I thought there may still be the possibility of more adventure, more exposure, and more ways to apply my nursing skills. Then an email from the Dana-Farber Cancer Institute’s Nursing and Patient Care Services (DFCI NPCS) arrived, which presented a new opportunity: working as a global oncology nurse fellow in Rwanda.

I was hooked. I was at the right time and place in my career, and leaped at the opportunity to give back to nursing by transferring my expertise to nurses in Rwanda. I applied with nary a second thought, was accepted, and departed on March 25, 2012.

I spent the next three months between Rwinkwavu and Butaro Hospitals, working closely with the Ministry of Health and Partners In Health. In Rwinkwavu, I was devoted to training a core group of nurses who delivered cancer care. In Butaro, I was helping train nurses who went on to staff the oncology unit, the first of its kind in Rwanda.

Thankfully, my years as a nurse prepared me well. I was comfortable working in teams and skilled in assessment, planning, problem-solving and re-assessment—the nursing process, in a nutshell. After the national baseline training, I worked with my Rwandan counterparts and a PIH nurse educator, Diane Longson, to develop didactic, hands-on learning sessions.

It was inspiring to see the program come together. Standard operating procedures, or SOPs, were written. Mixing rooms for chemotherapy drugs were identified and stocked. All nurses completed chemotherapy competencies. Language barriers were surmounted by Rwandan nurses willing to translate. Nurses covered each other so that everyone could make it to class. Many stayed after their night shift to attend early morning training sessions.

The three months blew by, and soon I was back to my shifts in Boston at DFCI. But as luck would have it, I was able to return to Rwanda about one year after my first trip. It was gratifying to go on rounds and to hear nurses addressing the needs of their patients and be able to mix, prepare, and administer chemotherapy safely. Sure, there were gaps, but patients were being treated and well-managed by an engaged group of nurses. And DFCI NPCS had been instrumental in making that happen.

Anne Elperin, RN, CS, works in clinical and professional development at Dana-Farber Cancer Institute in Boston.

Interested in learning more about PIH's nursing initatives? Join the upcoming Twitter chat with PIH Chief Nursing Officer Sheila Davis.

Chief Nursing Officer Raises the Bar for Nursing in Haiti

Marc Julmisse doesn’t take well to evasions of responsibility.

If a nurse on her staff claims that something isn’t part of the job, she has a story: A patient lost control of his bowels at University Hospital in Mirebalais, Haiti, and she was one of the few nurses on duty. So she put on her gloves and got to work.

On her team, anything a patient needs is part of the job.

Julmisse is the Haitian-American chief nursing officer at the hospital, which Partners In Health operates in partnership with the Haitian Ministry of Health. As her title suggests, she’s part of an effort at PIH to empower nurses at the hospital, motivated by research that shows better nursing consistently leads to better outcomes for patients.

“It’s not very often you get a chance to influence the health of a nation. I call this our ‘Nightingale moment,’” Julmisse says. Florence Nightingale, considered the founder of modern nursing, advocated for high-quality patient care against all odds, which is what Julmisse wants her staff to do. “This is our chance to change nursing for the better and set new standards of care.”

A citizen of the world

Julmisse didn’t set out to be in this role—or in Haiti.

She was born in Haiti, grew up living in Michigan, New York, and Florida, and then began her nursing career in Massachusetts, later moving to California. She describes herself as a “cultural mutt.” Depending on who she’s talking to, she might sound like she’s from any one of those places.

The vision of this hospital is to work with the Ministry of Health to change the practice of health care in Haiti. How could I not want to be part of something that would outlive me?

Julmisse specializes in nursing in neonatal intensive care units—caring for newborn babies whose lives are most in danger—but she has worked in many other areas of health practice. For several years, she alternated between working as a nurse in the United States and then traveling to rural communities in Ecuador, Mexico, Peru, Nepal, and Brazil, where she worked in community capacity building.

Julmisse became involved in health care in Haiti in 2008, when she conducted a hospital assessment for a facility outside the PIH network. After the country’s 2010 earthquake, the hospital’s administrators asked her to join their team to help develop a strategic plan to strengthen the facility. She signed a one-year contract, and stayed two and a half years.

She was ready to leave for the United States when a colleague recommended her for a position at University Hospital, before it opened in early 2013. Even though she planned to return home, she was intrigued by the opportunity to work for PIH. She had studied PIH’s work in Haiti in her public health classes, and the hospital was the organization’s most ambitious project to date. Then she spoke by phone with Sheila Davis, chief nursing officer at PIH in Boston and a tireless advocate for nurses.

“I always say, ‘Sheila had me at hello,’” Julmisse said. “The vision of this hospital is to work with the Ministry of Health to change the practice of health care in Haiti. How could I not want to be part of something that would outlive me?”

Chief Nursing Officer Marc Julmisse leads nursing rounds at University Hospital in Mirebalais. Rebecca E. Rollins/Partners In Health

The chief

As CNO, Julmisse is on the same level as the chief medical officer of the hospital—unusual not only in Haiti but also in the United States. Gradually, she’s spreading the idea that nurses are advocates for patients, and their voices can improve patient care.

Studies have shown that good nursing care improves patients’ outcomes. But nurses aren’t always involved in decisions about how wards are set up, how many nurses will staff them, or how to improve the quality of care in a facility. The goal of a chief nursing officer—and the Nursing Center of Excellence opening in May as a home for all of PIH/ZL’s nurse advancement efforts—is to allow nurses to take part in decisions that affect patients. To be “at the table,” as Julmisse puts it.

While these efforts require more opportunities for nurses to be in leadership positions, they also require nurses themselves to step up. Julmisse says she doesn’t want the nurses on her staff to be “task-oriented,” but rather, “patient-oriented,” to focus on the people rather than the illnesses. She believes good nurses can anticipate potential problems and what to do to help.

As she advocates for the role of nurses, she demands that her staff meet a high standard.

To help shift their thinking and practice, the hospital nursing staff has recently begun conducting nursing rounds for each department once a week. Julmisse questions the nurses on duty about patients’ diagnosis and treatment, the overall plan of care, and problems they should be anticipating—bedsores, side effects, gradual changes in a patient’s status, complications of an illness, secondary health problems that may aggravate the patient’s condition, dehydration, and nutritional needs.

Julmisse is quick to praise the nurses on her staff. She extols their efforts to go beyond the letter of their jobs in the interests of patients, staying late to help a new nurse on duty or volunteering to be on call. But she’s quick to hold them accountable to fulfill their duties. As she advocates for the role of nurses, she demands that her staff meet a high standard.

Julmisse believes she has a key leadership role to play in modeling patient advocacy, interdisciplinary communication, and nursing leadership. She hopes the example she sets will help bring the nursing voice to the table, to inspire nurses to be active participants in identifying issues and work on solutions that impact hospital functions and patient care. Her goal is to work herself out of a job.

“I want to be replaceable, because my job is to train the next team coming forward,” Julmisse says.

Global Nursing: Catch Up on Our Twitter Chat

During International Nurses Week last year, Partners In Health Chief Nursing Officer Sheila Davis wrote an article for The Huffington Post about “Why Nurses are the Unsung Heroes of Global Health.” She highlighted examples of what organizations such as PIH and others are doing to honor nurses and celebrate their leadership, noting that “grassroots initiatives are shaping the new face of nursing in global health.”

This year, she continued the conversation by taking questions on Twitter.

To learn more:

Follow @PIH and @Sheila_DavisDNP (if you haven’t already) for future chats and updates on PIH’s work.
Twitter chats are a great networking tool, so follow users who made interesting points or asked thoughtful questions. By following them you can continue the conversation beyond the chat and make new connections.

Empowering Nurses to Improve Care in Haiti

A circle of nurses pauses at one bed and then the next, discussing the progress of each patient inside a clean, spacious ward of University Hospital in Mirebalais, Haiti.

They approach the bed of a woman with end-stage AIDS. She is emaciated, awake but hardly responsive. Looking at her file, the nurses see she’s not taking her medicines or eating. The doctor suspects depression and has ordered an evaluation from the hospital’s mental health specialists.

The nurses take a closer look. One gently says, “cheri, can you take a drink for me?” They watch her, and then ask why she hasn’t been taking her medicines. The reason: she’s having trouble swallowing, and is afraid she’ll choke on the pills she’s been prescribed. With this insight, they arrange for her medicines to be given through an IV drip and her food to be liquid, greatly improving her care.

This sort of “aha” moment is what Partners In Health nurse leaders want to happen many times a day in PIH-supported hospitals and clinics. Research from the United States and Europe shows that good nursing care improves patients’ health—no surprise to those who understand nurses as the care providers in most intimate contact with patients. So PIH and our Haitian sister organization, Zanmi Lasante, are this month opening a Nursing Center of Excellence at University Hospital—a hub for nurse mentorship, leadership, and specialization to raise the standard of nursing in Haiti.

“I want our nurses to think critically, to go beyond the task of doling out medicine,” said Marc Julmisse, chief nursing officer at University Hospital, who led nursing rounds on the day the nurses intervened for the woman suffering from AIDS. “By thinking holistically about the patient, nurses can make a huge difference.”

Haiti has a long way to go before this vision is reality. The country has many nursing schools, but of those, only a handful are public, and only 32 are recognized by the Haitian Ministry of Health. The country is just beginning to implement a standardized curriculum and to introduce specialties to help nurses advance in providing complex care. Nurses in Haiti are rarely trained as specialists, making it difficult to deliver complex services such as cancer care and intensive care.

All this was the case even before the country’s 2010 earthquake destroyed the public nursing school in Port-au-Prince, killing an entire class of students and many faculty.

The Nursing Center of Excellence offers standardized, specialized training programs, mentorship, and supervision based on a successful PIH pilot in Rwanda, and opportunities for nurses to become educators. So far, PIH/ZL has promoted eight nurses from within the system to serve in leadership roles as educators or mentors. PIH/ZL nursing leaders have also appointed nurses to serve as disease-specific specialists in each PIH-supported facility—connecting efforts to fight malnutrition and HIV and tuberculosis, for example, and serving as advocates for quality care in the institution and in the community.

With all these efforts, PIH/ZL nurse leaders hope to build on nurses’ roles as patient advocates, both on the level of the health system and in the treatment of individual patients.

“Raising the status of nurses is part of the PIH approach of empowering the people closest to the problem,” said Sheila Davis, chief nursing officer at PIH. “It is the nurses by far who are closest to patients, who can see what needs to happen to improve their care.”

Nursing rounds are a new approach in Haiti that PIH/ZL nurse leaders designed to challenge nurses to think critically about patients and how they can help meet their needs. Julmisse and the hospital’s nurse administrator, Naomi Marcelin, go into rounds prepared to test the knowledge of the nurses on the floor about each patient’s diagnosis, treatment plan, and risks—including side effects and hazards such as falls or bedsores. Julmisse wants the nurses to think about all the ways they as nurses can help the patient—including advocating for changes to their care when necessary.

For example, a man with a broken neck has to lay on his back without moving his head. When the nurses visit the patient during rounds, Julmisse asks what the implications of this might be. If he has to lay on his back, he might have trouble swallowing. He may become dehydrated because he can’t drink. Nurses can help by making sure he always has a straw or by providing IV fluids. They should also think about his mental health. All these responses are rooted in medical science, and require critical thinking about the patient’s condition to prioritize needs and interventions.

“On nursing rounds, our staff starts thinking about what they can do for this patient rather than just focusing on the task of giving a pill,” Julmisse said. “These are things that nurses can do that require them to advocate for the patient.”

The Nursing Center of Excellence has a space in University Hospital in Mirebalais, but it represents efforts to improve nursing care across the 12 facilities PIH/ZL supports in central Haiti. Nurse mentors and educators are located at five community clinics and hospitals around central Haiti, and nurses from across the PIH/ZL network attend trainings at University Hospital.

While the mentor and educator teams are small, they provide essential training to hundreds of nurses and nurse assistants. Their role is to train in two ways—first, through formal education, and second, through on-the-job coaching.

From neonatal resuscitation to infectious disease management, educators teach lifesaving skills and concepts based on the latest clinical science and suited for the setting. And mentors reinforce those skills in clinics and hospitals—the key function of translating book learning into practice.

Some of the improvements to the nursing system are simple, yet powerful. For example, the nursing team now has its own vehicle, which is critical for the nurse leaders to be able to visit various health facilities, see how nurses are doing, and help solve problems. It also makes a statement about nursing, because vehicles signal importance in a place where few people have personal cars. Another simple improvement is that PIH/ZL Chief Nursing Officer Beatrice Romela advocated for a nursing office in the PIH/ZL office in Port-au-Prince. Before, she worked at a drop-in desk.

These investments add up, signaling that nursing leaders are essential to good health care and not peripheral actors in health care delivery.

“My vision is for ZL nursing to be a model for all nursing in the country, with excellence in education and patient care,” Romela said.

And the investment in nurses is already showing results. During one site visit in Verrettes, a community clinic supported by PIH/ZL, Romela met a Ministry of Health nurse who was working in the malnutrition program without a regular supply of therapeutic ready-to-eat food, Nourimanba, which PIH/ZL produces from Haitian peanuts to treat malnourished children. Nor did she have an experienced leader to help her learn the proper assessment and follow-up skills to ensure quality care.

“People stop asking for things because they think they’re never going to get it,” said Sheila Davis, PIH’s chief nursing officer. “We’re building more of a system so people feel they’re not out on their own.”

Romela connected the Ministry of Health nurse to the PIH/ZL appointed nurse leader on malnutrition across central Haiti, Marie Landy Zamor, who could support her in the future with medical and programmatic advice, training, and supplies.

When Romela returned in April, the program had improved substantially, as evidenced by data showing that more children were receiving adequate follow-up at the clinic and through community health worker visits. The nurse proudly opened the once-bare cabinet to reveal jar after jar of Nourimanba.

In Lesotho, Nurse-Midwife Mary Lesesa Delivers more than Quality Care

This month we're honoring the work of Partners In Health nurses with a series of articles about their efforts to care for patients and lead others in strengthening health systems around the world.

Mary Lesesa is busy. As a nurse-midwife at Tlhanyaku Health Center in Lesotho, she plays a critical role in making sure expectant mothers, newborns, and families have consistent access to high-quality health care. On any given day she could go from delivering a baby to discussing family planning options to coordinating HIV education programs for the community.

Tlhanyaku Health Center is located in the mountains of northern Lesotho, a three-hour car ride from the nearest referral hospital. “Our country is so mountainous. Doing outreach and home visits to some areas is difficult as the cars cannot reach those areas, hence we travel by horses or on foot,” the 37-year-old nurse says.

This rugged geography is a major barrier to health care. Lesotho has one of the highest maternal mortality rates in the world; one in 62 women will die during pregnancy or childbirth. That’s why PIH/Lesotho has constructed maternal waiting homes at each of its mountain clinics and accompanies mothers from their villages to the health center before they’re due.

HIV also poses an enormous burden in the tiny country. As noted in a recent PIH Report, Lesotho has an adult HIV prevalence of 24 percent, and nearly 60 percent of maternal deaths are estimated to be HIV-related.

Tlhanyaku is one of seven hard-to-reach areas in which PIH/Lesotho collaborates with the Ministry of Health to operate a health center. At all of these sites, nurses are the lead on-site clinicians. As such, they juggle a multitude of medical tasks while simultaneously providing administrative and logistical support to the organization.

“Nurses at PIH/Lesotho are highly trained clinicians who provide complex health care services,” PIH/Lesotho Country Director Dr. Hind Satti says. “They’re also skilled managers who oversee the operations of the health centers.”

In recent years, PIH/Lesotho’s comprehensive Maternal Mortality Reduction Program (MMRP) has made enormous strides in increasing the number of women who deliver their children in safe environments with trained medical staff at the ready. The program extends far beyond safe deliveries, however, and is designed to significantly reduce the risk of mother-to-child HIV transmission.

“Our efforts to stop HIV transmission are well coordinated,” says Lesesa, who has worked for PIH/L since 2010. She notes that from the moment a woman is pregnant through the child’s first 18 months of life, PIH/L provides robust clinical and social support, and regular testing to ensure the child does not have HIV.

“From a mother’s first antenatal care visit at which she’s tested for HIV, we accompany families. We provide education and support, and we continue to follow up with them,” she says.

Lesesa and her colleagues at PIH strive for an HIV-free generation in Lesotho. Thanks to dedicated nurses like her, we’re heading in the right direction.

Inside University Hospital’s 24-hour Emergency Department

Of all the lifesaving technology in University Hospital’s emergency room—the portable X-ray machine, the digital medical records, the wall-mounted oxygen—the most important may be a process that dates to 1792 on the battlefields of Napoleon’s army.

“Here we have a triage system so we can care for the sickest patients first,” said Dr. Mirrielle Bien-Aime, a Haitian doctor training to be certified in emergency medicine at the hospital. “At other places I’ve worked in Haiti, we didn’t. We saw all the patients at the same time.”

A working triage system allows experienced clinicians to sort patients according to acuity, rather than just their complaint, and it saves lives. It’s just one of the ways University Hospital is raising the standard of care in emergency medicine.

Emergency medicine demands a swift response to a huge array of injuries and illnesses—clinicians must be prepared for anything at any time.

PIH and our Haitian sister organization, Zanmi Lasante, are working to make University Hospital’s 15-bed emergency department a fertile training ground for doctors and nurses, who will take their learning to hospitals around Haiti, pass on their skills, and inspire a higher standard of care wherever they land. In March of this year, PIH/ZL launched a new emergency medicine certification for Haitian physicians, the first in the country, in collaboration with the Haitian Ministry of Health.

Emergency medicine is by no means new to Haiti. Most hospitals have an area they call “Ijans” after the French “urgence.” But caring for the sickest—or the most injured—requires much more than just a dedicated space open 24 hours a day.

Emergency medicine demands a swift response to a huge array of injuries and illnesses—clinicians must be prepared for anything at any time.

“Emergency physicians, at the end of the day, are the best generalists with a broad knowledge across all the areas of medicine,” said Dr. Regan Marsh, co-director of the emergency department at University Hospital and attending physician at Brigham and Women’s Hospital. She is training Haitian physicians in her specialty.

The curriculum for the certificate program reads like a list of terrible things that could happen to you, masked in dry clinical terms: Blunt trauma (falls or car crashes); penetrating trauma (gunshots or stabbings); cardiac arrest (heart attack), dyspnea (shortness of breath); environmental emergencies (lightning; electric shock, and near drowning); mass casualty events (war or natural disasters).

And in Haiti, poverty puts people at greater risk of needing emergency medicine. Because people don’t always have regular access to primary care, chronic conditions can become acute—for example, high blood pressure that goes untreated can lead to stroke. Traffic crashes can be even more life-threatening than in wealthy countries, because roads and vehicles are less safe—including overloaded, poorly maintained buses, and motorcycles, a cheap way of getting to remote places unreachable by road. And many people still depend on subsistence agriculture for food, causing injuries in farming accidents and falls from fruit trees.

A visit to University Hospital’s emergency department proves this notion. Inside the swinging double doors, the space is clean but hot and crowded at 8 p.m. The doctors are beginning their rounds, reviewing treatment plans for each patient and the hand-off from the day shift to the night shift, which allows for continuous quality care.

A 24-year-old woman who had a baby four months ago is in septic shock from an untreated infection. A man with psychosis is agitated by the critically ill patients around him. A 15-year-old boy suffers from intermittent fever, cough, and diarrhea. They test him for HIV and tuberculosis, and order a chest X-ray. Another young man is missing part of a finger.

To be ready for whatever comes in the door, University Hospital’s emergency department depends on highly trained staff—and enough of them to staff the department 24 hours a day, seven days a week.

To give high-quality emergency care, we work as a team with people across the hospital, and across the entire health system of central Haiti.

In the United States, highly trained emergency doctors and nurses care for patients. For physicians, this means at least three years of hands-on specialty training beyond medical school. PIH/ZL’s certificate program offers a formal teaching program for emergency medicine, which will be expanded through a three-year residency to begin later this year. This will be Haiti’s first emergency medicine residency. The residency will begin the process of training highly skilled emergency medicine physicians and leaders in their field who can help develop the specialty across the country and raise the standard of care. Meanwhile, Zanmi Lasante nurses are training to be specialists in critical care.

These clinicians can’t use their skills to save lives without high-tech medical equipment to make diagnoses and provide therapy. They also rely on other services in the hospital to treat patients. Many trauma patients will require surgery. People with infections need inpatient care with internal medicine doctors and specialized nurses. The emergency department even helps diagnose severe mental illness, and relies on the mental health team to provide psychotherapy and medication.

University Hospital provides the system the emergency department needs to save patients’ lives.

"To give high-quality emergency care, we work as a team with people across the hospital, and across the entire health system of central Haiti,” Marsh said. “Collaboration across the hospital is essential—the lab, the blood bank, and other specialists like pediatricians and surgeons and critical care nurses."

Dr. Mirrielle Bien-Aime, 30, is training in Partners In Health’s emergency medicine certificate program, the first in Haiti. Photo: Rebecca E. Rollins/Partners In Health

Dr. Bien-Aime is one of the physicians training in the new certificate program. She had worked for the Haitian Ministry of Health in southern Haiti before starting at University Hospital about a year ago.

“Mirrielle is going to be an amazing emergency physician,” Marsh said. “She is smart, thoughtful, compassionate, and able to care for many critical patients at the same time—keeping her eye to the whole system. I could not be happier that she’s on our team and will be leading the specialty of emergency medicine in Haiti.”

“Before I worked here, I didn’t know anything about emergency medicine,” Bien-Aime said. “Since May, I’ve learned a lot. In Haiti, we don’t have emergency medicine specialists. I want to help train ER doctors.”

Bien-Aime said one of her most moving experiences at University Hospital was helping a 2-year-old boy receive surgery. He was born with a congenital defect of the colon, and needed a two-part surgery to correct it. He underwent the first part at another hospital in Haiti, which created a hole in his abdomen and connected his colon to a bag for excrement. But his family couldn’t pay the $1,500 that hospital asked for the second part of the surgery, which would allow him to go to the bathroom normally. The colostomy brought stigma to him and his family, and eventually began to cause health problems.

“University hospital is very, very important for us in Haiti,” Bien-Aime said. “We provide free, high-quality care—that’s why we receive so many patients from all over Haiti in Mirebalais.”

Samson Njolomole: The Spirit of Togetherness

I am Samson Njolomole, community program and external relations manager for Abwenzi Pa Za Umoyo, Partners In Health’s Malawian sister organization. I'm responsible for activities surrounding prevention and health education, community mobilization, sensitization, and awareness, and I help represent the organization to stakeholders.

I came home to Neno, Malawi, in 2007 because I was sick. At the time, I was in a different part of the country working, but the manager told me that I had to leave because they could not afford to keep someone who was sick. I had no option but to come back home.

I was very sick. My mother thought I had died and that someone else was responding to her calls. So I had to go home to show her I was alive, to make her happy. When I returned home, my father saw how much I had wasted away. I was so skinny, and I remember when I arrived home how my mother was really sorry to see me in this condition. My father told me that I had to go to the hospital for an HIV test. I didn’t want to do that because I was thinking of all the problems and issues associated with HIV: the infection, the stigma, how people are marginalized.

It took a couple of weeks before I could make my decision. My father came to see me every night to remind me that I had to think about going to hospital for HIV testing. There was an organization [PIH] providing basic care to people who were sick. At times, I would get angry because mentioning HIV to me was like telling me all the bad things in the world. But he would say, “Son, I’ve been advising you to take care of your life. This is a bold decision that you have to make. I love you and I want you to take action, because otherwise you are going to die and I don’t want you to die.” He was so passionate about what he believed and about what he had seen in PIH.

I remember one night I fell so sick and I just gave up on my life. I thought that it was the end. So my father took me to the hospital, I was admitted, and they told me the next morning to go for an HIV test. The results came back positive. It was in July 2007 that I learned I was HIV positive.

I was really nervous. I was totally down. So many people had already died in my community. I had lost at least three of my sisters to the same infection.

This was not what I expected. Before my test I was thinking: How do people get HIV? Are these people not smart enough to avoid it? Can’t they prevent it? Is there any way these people can stay in this world with HIV?

If I don’t speak about it, then people in my community are going to die.

After my test came back positive, the clinicians referred me to an antiretroviral clinic through PIH’s HIV program, where I met Dr. Jon Crocker. The way he talked to me and told me the story about PIH, about how they would help provide medical care and social services and nutrition, gave me encouragement. If I take my medications properly, I can make it again. It was like my second chance to live.

I went home and started taking my drugs every day; barely two months later I found myself strong and healthy. That is when I started on this mission to tell other people about my experience. If I don’t speak about it, then people in my community are going to die.

It wasn’t easy to speak about it at first because a lot of people knew me in the community. When I came home and I was wasted away, there were people literally pointing fingers at me: “Look at Samson, he has HIV, he is going to die,” they’d say.

It is never easy to think about how to disclose your status to your neighbors and your friends and family.

In October 2007 [three months after being diagnosed with HIV], Dr. Jon Crocker and the team said that they could give me a job as a translator. I wasn’t doing anything at the time. I told them I would love to work for PIH based on what I saw and how they cared for the very poor people.

I so believed in the mission: whatever it takes to provide a preferential option for the poor. It’s a very definitive statement. It’s a mission that propels us to do more, that goes beyond the blame so many place on poor people.

So they employed me in October 2007 as a translator. I was working in the HIV program. Every morning I was working; I would stand up and tell people about HIV. I would give myself as an example: “When I came here, you saw me and you saw how I looked. Now look at me! We can do the same thing for our brothers, our sisters, our relatives. And we can reduce a lot of deaths that are happening due to HIV.”

I grew up with the organization. I was promoted to a supervisor in the clinic, preparing all the paperwork for the patients and for the doctors. We were seeing 600, 700 patients a day, from 6 in the morning to 10 at night. It was really a tough time.

They then promoted me to be HIV program coordinator. I was collaborating with the Ministry of Health at the district hospital, working with the clinics to make sure everything we were doing was supported, and making sure everything was dignified for patients. I worked with PIH doctors to think outside the box, to say “what else can we do?” If we can scale ART (antiretroviral) services to other clinics, then the burden would be reduced. A lot of people died because they could not find transport money to ferry them to those places.

There has been a significant change in Neno since 2007, when I came. Back then, there were just five patients who were taking ART. We have now seen that number climb to over 6,000. This tells you that we are actually reaching out to the people, and more people are joining us.

I’m here to help you, we can walk together to the hospital. That is the spirit of togetherness.

You can have a beautiful hospital, but if you don’t have doctors in there, if you don’t have the drugs, the people you are actually sharing that beautiful hospital with will die. If they go there and can’t get treatment, they go back home and die. But if you stock the hospital, if you provide clinicians and other human resources, the people know they will get the help they need.

PIH goes beyond just giving the treatment; we have programs that complement what traditional authorities are doing and what the government is doing. People from the community accompany the patients and say, “You need to take your medications. I’m here to help you, we can walk together to the hospital.” That is the spirit of togetherness.

Partners In Health Welcomes FACE AIDS Students

We’re delighted to announce that FACE AIDS, a nationwide student organization whose mission is to mobilize students in the fight to end AIDS, will soon join the Partners In Health team. Starting this fall, the organization’s college and high school chapters will become the new student arm of PIH | Engage.

A PIH partner since 2005, FACE AIDS has mobilized high school and college students across the country to raise money—$3 million to date—and awareness about our work to provide HIV care in Rwanda.

PIH has supported the organization from its beginning, recognizing the power of students to further the movement for health equity.

"FACE AIDS has profoundly altered the landscape of movements for health equity in the U.S.," said PIH co-founder Paul Farmer. "Students have a crucial role to play in the fight for social justice, as FACE AIDS’ pragmatic solidarity with the patients and communities we serve has demonstrated. We are grateful for their partnership, over many years—and proud, now, to formally welcome FACE AIDS as part of Partners In Health.”

The union of FACE AIDS and PIH | Engage will strengthen students’ connection to the impact of their fundraising for PIH. In turn, PIH will be better positioned to foster future global health leaders, influence global health education, and engage in grassroots advocacy for the right to health.

In the fall, FACE AIDS chapters can choose to continue their work with the support of PIH | Engage leaders, including attending a fall training institute in Boston. Last year, participants heard from Paul Farmer, Ophelia Dahl, and Joia Mukherjee.

“We are overjoyed by this opportunity to be incorporated into the work of Partners In Health, and we are excited to watch the student chapters thrive in this new setting,” said FACE AIDS Executive Director Margo Watson.

When FACE AIDS was founded, PIH had just begun working with Rwanda’s Ministry of Health to scale up access to treatment for HIV. At that time, only about 150 rural Rwandans with HIV were receiving treatment with antiretroviral therapy. Today, Rwanda has achieved the United Nations standard for universal coverage of HIV treatment, and PIH supports three hospitals and 41 health centers, serving a population of about 800,000 people.

“FACE AIDS has been a crucial partner in helping PIH fight HIV in Rwanda,” said Jon Shaffer, PIH’s community engagement coordinator. “Now we have an opportunity to build on this success. I believe we can build a massive movement of young leaders dedicated to realizing the right to health.”

Dr. Paul Farmer on Medicine and the Boston Marathon Bombing

Dr. Paul Farmer, co-founder of Partners In Health, delivered this address at the Celebration of Partnership event on April 28, 2013, at Hôpital Universitaire de Mirebalais (HUM) in Haiti. We’re publishing it for the first time, in gratitude to all who helped make possible University Hospital’s first year of services, and in remembrance of the victims of the Boston marathon bombing one year ago.

Many of you here today are from—or are somehow connected to—Boston, where Partners In Health is headquartered. But all of you, whether from Mirebalais or Cange or Washington or Miami or Chicago, have been thinking about the aching city of Boston, of those lost or injured at the home stretch of its annual marathon. A tranquil day, at least for such a massive sporting event, until suddenly there were hundreds of injuries, many severe.

And they all happened at once, as is ever the case with bomb blasts and most disasters, natural and unnatural.

Not a single patient who made it to a hospital died.

You have imagined or contemplated the scene. Now imagine it as a patient or a doctor or other provider of medical care. George Packer described the bombing’s aftermath in this week’s New Yorker:

In the minutes, hours, and days after the blast, everything seemed to work. People knelt on the pavement and used belts or scraps of clothing to tie off tourniquets and prevent the maimed from bleeding to death. A pediatric resident who had almost finished the race jumped over the barricades and evaded the police to tend to victims. Volunteers instantly transformed the medical tent behind the finish line into a triage station. A man who had just lost his own son in the Iraq War rushed a young man whose lower legs had been blown off to the tent, and so kept another father from losing his son. . . . Ambulances made their way through the chaotic streets in minutes. Staff at Boston’s hospitals quickly and methodically prepared to receive mass casualties and began operating on the injured within half an hour of the blasts, preventing any more deaths after the first, tragic three.

Boston law enforcement functioned well, too, but my point today is that our teaching hospitals did a splendid job that day and in the days that followed. Not a single patient who made it to a hospital died. “Since we live in a period when many things in America don’t work,” Packer continues, “it’s almost strange to find so many institutions and individuals meeting our highest standards.”

In other words, there was, in addition to heroism and compassion, a system in place in Boston hospitals. It worked. A few days ago, I was consulting with George Dyer, a Brigham orthopedist, about a patient with a possible bone infection due to an injury unrelated to the bombings. But I asked him how he and his team were doing in their wake. I knew they’d been working long hours, from April 15th on, to respond to the spike in demand for trauma care, and was grateful for the attention he turned to every case, including the patient we were discussing. I’d come to expect such attention, at the Brigham as here in Haiti, where Dr. Dyer has often volunteered since the earthquake.

“We had the largest number of serious injuries, as it turned out,” he responded. “I was proud of how well the Brigham managed the patients and most are doing well, at least physically.” Knowing I was headed back to central Haiti, Dr. Dyer added the following: “This was a small disaster, in the scheme of things. It made me think again how important it is to have clear plans in place for Haiti’s next big disaster and the role HUM will play in it.”

The H stands for hospital and the M stands for Mirebalais, the town in which we gather and the one where Father Lafontant and Ophelia and I and several others here today met over 30 years ago. More on the U in a second.

I love practicing medicine at the Brigham. And I want Haiti to have something like it, too.

The need for a better system of care was evident from the start of our collective efforts here, humble as they were; it’s why we founded Partners In Health. In our first few years of a health survey in Cange, we lost three of our close friends and co-workers. That was almost half our team. All of them were more or less my age and as enthusiastic about introducing health services to this region. Not one lived to see 30. I sometimes get the order of their deaths confused, not because it was such a long time ago but rather because they’re still so painful to think about. Acephie died of cerebral malaria, misdiagnosed as a psychotic break. She died sitting in a psychiatrist’s waiting room. Another, Michelet, was felled by typhoid fever, complicated by an ileal perforation: microbes ate through his small intestine.

He was taken too late to the operating room, and died in a busy referral hospital, writhing in pain and fear, well-founded fear, while waiting for surgery. The first to go was named Marie-Therese but everyone called her “Ti Tap.” She died of puerperal sepsis days after delivering a baby boy, who is here with us today. The disease has been rare in places like Boston since doctors and midwives learned to wash their hands properly before and after each delivery, and almost never registered in such settings after the advent of modern infection control and antibiotics. In every sense, these were three pre-modern premature deaths.

Each of these young people, our friends, lived in the town of Mirebalais, which did not figure, until today, on the map of modernity. As you can see, HUM is the acronym for Mirebalais University Hospital. There’s not really a university in this town. Not yet. But University Hospital was built to be a teaching hospital because the hypothesis, here, is that the quality of medical care will be improved whenever training and research—the “feedback loops” that allow us to learn—occur in tandem with compassionate care.

I love working at a great Boston teaching hospital, as do Dr. Dyer and several of the physicians who lead them, here today. I love being able to train the next generation of physicians and nurses. I love that the Brigham has large teams able to respond to complex emergencies, which in many parts of the world are unattended and result in death, up to half of them that would have been averted with proper medical care. I love the collegiality between and within teams of caregivers who know, even when they protest to the contrary, that they have adequate time and resources for the sickest patients, the toughest cases. I love not having power-outages or stock-outs or strikes or anything that might interrupt patient care. I love that there are back-ups and redundant and hidden systems that work and even the ability, when overwhelmed, to bring in more resources—which is difficult to imagine when one sees how well-staffed and supplied the Brigham is.

I love practicing medicine at the Brigham. And I want Haiti to have something like it, too.

In recent decades, such aspirations have sometimes been derided in public health, especially by those tasked, by self or other, with serving the poor. Teaching hospitals are not “cost-effective,” nor “sustainable,” nor a wise use of “scarce resources.” They’re a “black hole,” doomed to fail in settings of poverty and privation.

So why are we standing here today at University Hospital, now up and running? Because those gathered here, like all those who’ve joined Partners In Health, have rejected low-ball aspirations. You have rejected cynicism, defeat, paralyzing anxiety, and a host of other common, indeed universally felt emotions. You’ve interrogated analyses that place risk to ourselves and our home institutions far above risk to unknown others. We stand inside this monument to expert mercy and human solidarity because you have accepted responsibility for the well-being of your fellow man, woman, and child—and not because you know them, as I did Acephie and Michelet and Ti Tap, but although you do not. You’ve all said, in other words, We can do this right here because it is the right thing to do.

And so you have. Today we celebrate what is already done and the partnerships that gave flesh to our dreams, that we may provide expert care for those known and unknown. We give thanks for all “staff and stuff,” of course, but in our division of labor, I’ve been accorded the chance to thank those who helped to build University Hospital by donating time and skills in the building trades to erect here a hospital worthy of the Haitian people. Most of all I’d like to thank the hundreds who’ve sweated on this campus from the time it was mostly a swampy rice field to now, so I’ll add a word in Creole. Mwen ta remen di mesi, chapo ba, pou tout moun ki te kraze ko yo, anba gwo soley, pou leve lopital sa a. Se nou ki bati kokenshenn lopital sa a.

But today we’re giving thanks for the transnational accompaniment that after the earthquake brought new skills, in design and engineering and construction, to central Haiti. People like my college classmate Ann Clark, who kept a 20-year-old promise by laboring over the plans, revising them more than a dozen times when, after the earthquake, we kept saying, No, bigger. People like Mark and Teresa Richey who helped provide the lovingly finished mill work. The members of the electricians’ union, IBEW 103, the carpenters’ union, and the painters’ union, who made apprentices, then skilled tradesmen and tradeswomen, out of the young Haitians on the job. We thank folks like John Cannistraro, who designed the medical gas and mechanical systems that constitute the hidden guts of the hospital, and Maria Concha Hein who spent months writing up the equally invisible contracts for companies, and Andy Leonard, who led the site work and shaped the very earth you’re standing on, and Beth Floor who connected us to GE. We thank Bill Horan who helped build the potable water system. We thank Laurel True and her band of newly minted mosaic artists, who made the pediatrics ward a place of beauty rather than a site of suffering and fear.

Most of all I’d like to thank two people even though they know as well as anyone that it takes a legion to build a medical center. You know who they are, and what they did to build HUM. Jim Ansara, more than 30 years after joining a carpenters’ union, as most Amherst College drop-outs do, years after slowly growing a successful construction company in his hometown by investing in the best skilled labor, did something else that not every builder-turned-CEO does. He kept and maintained his friendships with all those who build hospitals like the ones that functioned so well in Boston over the past two weeks. Jim’s web of connections gave us builders who came here from across the United States, the Dominican Republic, Mexico, Ireland and South Africa and sweated side by side with the Haitians. Together they built this, the hospital we needed here during the long years we lost too many Acephies and Michelets and Ti Taps because of poor infrastructure, a lack of emergency and intensive and surgical care, and because, frankly, of an impoverishment of aspirations.

These professionals—engineers and carpenters and electricians and people from all the building trades—came to Haiti not just to build this facility but also to train their Haitian co-workers and apprentices how to build better. They also came to learn. So you see, thanks to Jim and the spirit of this web, HUM became a teaching hospital long before the first patient entered its doors. The highest praise I can give you, Jim, is that you remind me of Tom White.

We have a long way to go just to make this one institution function, as the Boston hospitals functioned after the bombings.

Last but not least, I thank Dr. David Walton. He’s shed blood, tears, and sweat since his first year at Harvard Medical School, when he, also at 23 years of age, came to Haiti: no one sweats more than David. Like most physicians in training, David was always interested in making broken things work again. Unlike most medical students, David was always interested in design and building, in infection control and how patients flowed, or did not, through clinics and hospitals. And he had the good sense to understand that real leadership requires recognizing expertise one doesn’t have, hence his fruitful partnership with Jim. He understood that translating our shared dream into reality requires stirring enthusiasm in others. He has brought many into this project, Haitians and Americans and others, who have learned and taught about making a complex institution rise from the mud and work. To his mother and brothers and Heather, to all those who have seen little of David since the quake, now you see why.

My own faith in David’s and Jim’s capacity, and in the good will of all those who gave the staff and stuff and funds to build this hospital, has been richly rewarded. It takes years to turn the nightmare of countless Acephies and Ti Taps and Michelets into a clear vision, not yet realized, but getting ever closer.

I am at once the least surprised and the most joyful man here.

Let me close by citing Jon Sobrino, a Jesuit theologian from El Salvador, in a book subtitled “Earthquake, Terrorism, Barbarity, and Hope.” Not long after two earthquakes in El Salvador, and three decades after suffering the loss there of his closest friends and many he did not know, Father Sobrino has this to say: “Compassion is central to being human. The suffering of victims can de-center human beings and place love at the center. Who fulfills all the commandments? That is, who is truly human? The Samaritan. When he saw the victim, he was moved by pity and bandaged his wounds. Here is the fully realized human being, not because he is ‘religious,’ or ‘democratic,’ or ‘the best,’ but because he is moved to compassion.”

Standing here at University Hospital and in solidarity with Haiti’s public-health authorities, we know we have a lot of work to do to build a national system of health care, including a social safety net able to do a lot more than bandage wounds. This will require thousands of partners, and good leadership, and long years. We have a long way to go just to make this one institution function, as the Boston hospitals functioned after the bombings, and to make University Hospital part of a public system rather than an island of expertise and new equipment surrounded by a deep moat designed to keep people out. Keep accompanying us on this path forward.

Thank you builders, and thank you all who helped them build.

Working in Global Health: Jean Claude Mugunga

Each month we ask a seasoned colleague to share advice for those interested in forging a career in global health. This month we asked Economic Evaluation Analyst Jean Claude Mugunga to discuss his path to PIH.

“I am not going to have another child. This is it,” she said to me as we spoke in the Sovu Health Center, a small clinic in southern Rwanda. She was a 29-year-old woman who had come for a prenatal consultation for her sixth pregnancy. I was a 22-year-old first-year medical student working with a student group called Rwanda Village Concept Project.

The woman went on to tell me that she had never consulted a clinic for a pregnancy before, and that she had delivered all her previous children at home—including her most recent baby boy, who died before he reached 6 months old. She said she came to the clinic this time because one of her neighbors, a newly elected volunteer community health worker (CHW), advised her to seek care. Her husband had passed about two years back from unknown illness; one of the convincing arguments made by the CHW was that HIV may have been responsible for her husband’s death and that by going to a clinic and getting tested, she could possibly protect her unborn baby from infection.

Although my main task of that day was to speak to her about family planning and contraceptive methods, she started asking me question after question—most of which a first-year medical student was not able to answer— about what it meant to her and her baby if she tested positive. She had started to feel comfortable with me. It was obvious how scared she was about the HIV test results.

Having grown up in Rwanda after the genocide—where almost everything had collapsed and families experienced death every day; where diseases like AIDS and malaria were taking lives every day, including my own relatives; where alarming rates of infant and maternal mortality had become an acceptable fate; where everyday life was a harsh struggle—this was obviously not the first time I had engaged with a patient on a personal level in a clinical setting.

It was, however, the first time I had to think hard about how complex and intertwined most health problems are, and what my role in the reconstruction of Rwanda (and my own family) would be. I pondered the role of cultural beliefs in health, and how social and economic hardships perpetuate poor outcomes in any community. Although the picture was not completely clear, I realized that the availability of high-quality, community-based services could lead more people to seek care and improve outcomes.

During my years at the school of medicine, I had opportunities to travel to China, Finland, Sudan, Vietnam, the U.S., and most east African countries to broaden my perspective and education. I would always return home with a captious eye for global health disparities. Before I graduated from medical school, I found out about Partners In Health (PIH) and chose to do my final public health rotation at Rwinkwavu Hospital, where PIH has worked in partnership with the Rwanda Ministry of Health since 2005. I was taking baby steps and opening my eyes and extending my feet into the field of global health.

You have power and you have hands; extend them to the world in need, starting in your community.

To broaden my skills, I moved to Boston to pursue a graduate program in international health policy and management, where I focused on health economics. It felt like forever until I got an opportunity to rejoin PIH in my current role as an economic evaluation analyst within the Monitoring, Evaluation and Quality Improvement team (MEQ).

In a nutshell, the MEQ team helps various PIH programs design practical data collection systems, develop key performance indicators, and assess whether said programs are making a measureable difference. To me, there is no substitute to working with a team that supports the country sites in doing systematic and routine collection and analysis of information from our intervention.

As PIH strives to become more of a learning organization, generating evidence for informed decisions on improvement and on the scale-up of interventions, it is critical to support data use, learn from experiences, and to build the capacity of our partner teams across the sites. More importantly for my role on the team, I am contented by our work in generating evidence on resource utilization and the results obtained.

My exposure to health systems—from HIV and cancer services in Rwanda to high-quality surgical services in rural Haiti, to the cost of care in the U.S.—has enhanced my perspective of global health and my desire to keep pursuing it. I often thought that breaking into the field of global health meant that you have to be coming from somewhere in the “global north” with an Ivy League education to help the “global south.” However, those groundless assumptions did not stop me from stepping into my dream.

Anyone can become a global health champion, regardless of age and regardless of one’s previous career path.

To those who want to contribute to this satisfying work, don’t think of the word “global” as necessarily meaning countries other than your own, or a geographic concept. Rather, think about how illness and poor health have no borders. You have power and you have hands; extend them to the world in need, starting in your community.

Just like me, you will not be satisfied by simply identifying problems, so be driven to pioneer and create effective and sustainable solutions. You will be a more effective agent in the ongoing movement of tackling health inequity and transforming the world.

Finding a Job in Global Health: Advice from Five Experts

Working in Global Health: Advice from PIH’s Kathryn Kempton

Working in Global Health: Advice from PIH’s Ellen Ball

Saving Mothers and Babies in Haiti

The sound of an unborn baby’s heartbeat pulses through the breezy labor ward of University Hospital in Mirebalais, Haiti.

The loud, muffled rhythm is amplified by a machine that monitors fetal heartbeat as the mother’s labor progresses. It’s one of the things that makes Marlene Damas, a nurse-midwife and manager, glad to be working here in the third decade of her career.

“I can hear her vital signs because there’s equipment to identify problems,” Damas said. “It wouldn’t be the same in another place. In some places all you have is a stethoscope, so you can’t hear a change in the patient’s condition.”

“Staff and stuff”—trained, experienced nurses like Damas, equipped with the tools they need to do their jobs—can save lives in a country that still loses too many women in pregnancy and childbirth. In Haiti, just 25 percent of births in rural areas take place in a health facility, many of which lack adequate resources. An estimated 1 in 285 births will result in a woman’s death, a ratio about 16 times higher than in the United States, according to the World Health Organization.

“I like to work with women, because they need help,” Damas said. “There’s a lot of maternal mortality in Haiti, and I’m working to reduce it.”

Damas and the 52 other nursing staff in the University Hospital maternal health ward have participated in extensive trainings since the teaching hospital opened in March 2013. They do hands-on simulations of emergency events, including how to stop post-partum hemorrhage and resuscitate newborns who aren’t breathing. They discuss the latest science on maternal health through journal clubs, where they read and discuss medical articles. And they receive supervision as they learn to conduct procedures such as inserting an intrauterine device to prevent pregnancy.

This year, the women’s health team is also working with community health workers to train them to identify pregnant women in communities and accompany them to prenatal visits and to deliver. One of the main reasons women don’t give birth in hospitals is because of the distance they have to travel, often on foot, Damas says. Community health workers can help overcome that barrier by traveling with patients or helping them stay at the hospital before they’re in labor.

Sometimes Damas receives women on the ward who delivered at home and encountered a problem, and sometimes it’s too late for her team to help. That motivates her to keep working, she says, and she’s excited to see that the quality of care provided at the hospital is encouraging many patients to seek care there.

“This hospital provides great service,” Damas said. “It’s free, so people come from everywhere to receive care from qualified people who are competent and have resources.”

University Hospital delivers more than 200 babies each month, and serves as a referral center for smaller PIH-supported facilities around the Central Plateau. When women are expected to have complications, or do during normal labor, they are transferred to University Hospital for the complex care staff can provide. For that reason, the hospital has a high rate of cesarean deliveries—about 20 to 25 percent of deliveries over the last year. In fact, the hospital has one operating room devoted to C-sections—to make sure the procedure is available around the clock when medically necessary.

Adonis Francoe rests with her daughter, born by cesarean section at University Hospital. Photo: Stephanie Garry/Partners In Health

Next to the labor and delivery ward, Adonis Francoe rested with other women and their babies in the post-partum ward. Francoe, who had her second baby by C-section, also works in the hospital’s community health department and travels to communities to discuss health issues and describe the services available at the hospital. Her first child was born at the small community hospital in Mirebalais, which University Hospital replaced—and it was a much different experience.

“I’m more comfortable here. There’s food and things like a bed for the baby,” she said. Francoe is also glad for the economic opportunities the hospital offers, including her job, which helps her provide for her growing family. “The hospital is great because it gives jobs. Before you had to go far to find work. This is a lot better for the community.”

Meet the New Doctors of PIH Mexico

This spring, a new class of young Mexican doctors begins working in Chiapas, Mexico. Compañeros En Salud, PIH’s sister organization in Mexico, recruits newly graduated doctors to spend their year of required social service in remote community clinics of Chiapas. PIH/CES supports the young physicians with supplies, training, and tools to provide better medical care to some of Mexico’s poorest people.

Dr. Azucena Espinosa: An actress and a doctor

Dr. Azucena Espinosa is from Durango, in north-central Mexico. She studied medicine at the Durango State University in Juarez, and in addition to medicine, she loves theater and works as an actress in a local company.

For Espinosa, working in health is a way to serve the community. She hopes to practice pediatric oncology, and wants to work in Durango because she’s conscious of her roots and the needs of her hometown. She had many options for her social service, but CES appealed to her because of its emphasis on social medicine. She ultimately decided on it because she wanted an opportunity to serve the poorest communities of Mexico.

Entering her year of service, Espinosa feels confident knowing CES provides constant support, supplies, and tools to do her work. During this time, she hopes to reflect on her passion for serving poor communities and find out if social medicine is the path she wants to follow. Espinosa worries about not being adequate to the work of CES, but that feeling urges her to work harder rather than stopping her.

Dr. Kurt Figueroa: Inspired from a young age

Dr. Kurt Figueroa was born in Mexico City and studied medicine at the National Polytechnic Institute. His story is marked by an early relationship with the world of health. His mother is a nurse and took him to small hospitals where she worked. These visits inspired him, and he came to admire the doctors he saw working.

Figueroa plans to specialize in pediatrics and work internationally. His dream is to establish himself in an African country, where the need for good health is critical. He’s taking his first step in global health by practicing rural medicine in Chiapas with PIH/CES.

Figueroa is concerned about the lack of students willing to do their social service in a region such as the Chiapas mountains, where poverty and ill health make conditions more difficult than in large cities. That’s why he wants to devote his time and effort to serving these communities. He hopes not only to hone his clinical skills, but also to grow personally. “This is a time of self-discovery,” he says, smiling.

Dr. Aurea Rodriguez: A better bedside manner

Dr. Aurea Rodriguez is a native of Puebla, not far from Mexico City. She studied medicine there, at the Autonomous University of Puebla. She has wanted to be a doctor since she was little, and considers it to be her calling.

Rodriguez’s dream is to become a pediatrician who alternates between specialist consultations and social projects. She jumped at the opportunity to join CES, especially because of the special training and support it offers. She hopes her time in Chiapas will allow her to improve her bedside manner, through providing quality care and showing warmth in her interactions with the community.

Dr. Eduardo Peters: A step toward greater challenges

Dr. Eduardo Peters is originally from Mexico City but studied at the Monterrey Institute of Technology. His decision to study medicine was the result of a combination of factors: an aptitude for and a love of the sciences, the idea of being able to help people, and, he admits, the social position of being a doctor. His future is still uncertain, though he expects to work internationally and pursue a master’s in health management, administration, and policy in Toronto.

Peters chose to work with CES for his social service year because he believes the project provides everything he needs to be successful: a focus on the most vulnerable communities, coordinated work with an international team, and a bit of adventure that will lead him to take on large challenges. He doesn’t want to start with any expectations, but just see what happens and allow himself to be tested in the toughest situations.

Reflections on the Rwandan Genocide: Antoinette Habinshuti

The Rwandan genocide began 20 years ago this month. More than 1 million people were killed in the course of 100 days. We asked four of our Rwandan colleagues to reflect on the genocide and discuss how their country has evolved in the past two decades. Below, PIH/IMB Deputy Executive Director Antoinette Habinshuti shares her experience. We ask you to stand in solidarity with Rwandans everywhere this month as they commemorate the past and continue to heal. Learn more about PIH/IMB’s work in Rwanda.

In 1994 my immediate family was living outside of Rwanda, in what is now Democratic Republic of Congo, while my extended family—grandparents, aunts, cousins—lived in Rwanda. Like many Rwandans, this family was taken from us during the genocide against Tutsi.

More than 1 million Rwandans were killed, and despair rained over the whole country. Suspicions were rampant. Neighbors no longer shared salt or fire for cooking. People were angry at each other, and the community values we shared were lost.

I had mixed feelings when my family moved back to Rwanda just about a year after the atrocities of the 1994 genocide. I was a teenager. I was happy to know that there was a country we could all call home. But on the other hand, I was very displeased at my parents’ decision to return because this home was bitter, broken, and fragile.

In the years following the genocide, Rwanda implemented massive unity and reconciliation programs. These programs were initially unpopular, but we came to accept them and we started healing. President Kagame implemented a presidential forgiveness program and released from jails detainees presumed to be genocide perpetrators. These individuals were sent back to their communities for reintegration.

During this effort, which was controversial, the president shared some words that are deeply engraved in my memory: “We have an ambitious plan for Rwanda’s development; we don’t have gold or other natural resources—all we have are the hands of Rwandans to accomplish all our goals. I am in no delusion that what the government is asking—unity and reconciliation—is not easy, and it is bitter to live next to anyone who might have been involved in genocide, but we have no other choice. We must commit to working with each other. I am not asking you to love each other, but to live with each other. It’s a bitter medication, but it heals. Justice will be served, but in our own ways—and in our communities, like it was in the old good days.”

His vision for the country’s unity and reconciliation was later supported by Rwanda’s Gacaca Court System, a communal justice system where neighbors shared grievances in an open process that focused on healing.

By 2000, Rwandans were starting to see real progress. There were new academic institutions, including universities offering night classes so people with jobs could still pursue higher education. Old hospitals and health centers were renovated and many new ones were built. We started to hear about development initiatives, including Rwanda’s Vision 2020 (the road map to Rwanda’s development) and Mutuelle de santé (the national health insurance program). Others focused on diversifying crops, creating household incomes for the poorest community members, and organizing community service, to name a few.

No less important, Rwanda is a champion of gender equity.

More than a decade later, Rwanda is known across the globe, not only for its recovery, but for its significant gains in almost every sector. The rate of poverty has dropped, and real GDP growth averaged 8.1% between 2001 and 2012. There have been major improvements in the health sector: average life expectancy has nearly doubled from the year of the genocide, under-5 mortality and maternal mortality rates have plummeted, and the number of people receiving lifesaving antiretroviral therapy has soared.

No less important, Rwanda is a champion of gender equity. Women comprise more than 60 percent of parliament and countless new education opportunities for women and girls have emerged.

Given this transformation, Rwandans who lived for years abroad are returning to their homeland to contribute to their country’s future.

Irrespective of our differences, we have seen the light—the difference in our daily lives between now and then is keenly felt by all.

So what has been the recipe for success and hope in Rwanda? There are many important elements, including leadership that has prioritized equity, health care, and human development for the most vulnerable. In addition, Rwandans have learned that our identity is inextricably linked to what we make of ourselves: We will rise together and we will fall together. If a family’s child is malnourished, it becomes the village’s focus to see that this family can get a kitchen garden and improve the nutrition of the children. Development is driven by true collaboration. In Rwanda, the government, development partners, supporters, and the citizens have embraced this.

When we look at how far we have come in 20 years, we know that we do not want to go back to where we were. Irrespective of our differences, we have seen the light—the difference in our daily lives between now and then is keenly felt by all.

Where we are now requires reflection of who we are as a nation: strong, dedicated, and resilient. Let us always remember this and use our energy and ability to move forward. Our history shares many life lessons and we should always look back at what almost destroyed us and ask why. Let our remembrance of those dark days motivate us to continue rebuilding our country so that we can reach new heights together.

Reflections on the Rwandan Genocide: Peter Niyigena

The Rwandan genocide began 20 years ago this month. More than 1 million people were killed in the course of 100 days. We asked four of our Rwandan colleagues to reflect on the genocide and discuss how their country has evolved in the past two decades. Below, Community Health Department Director Peter Niyigena shares his experience. We ask you to stand in solidarity with Rwandans everywhere this month as they commemorate the past and continue to heal.Learn more about PIH/IMB’s work in Rwanda.

I was 16 years old when the 1994 genocide started. It was a very painful time. I saw many of my neighbors killed, and friends that I used to play with were no more. They too were killed. Those were some of the hardest moments in my life. Schools shut down, so I was out of class for a while.

During and after the genocide, it was almost impossible to access proper health care in Rwanda. Hospitals and health centers had been destroyed, health care providers had lost their lives, and there was no medicine or medical equipment available. Some doctors had escaped to other countries that were peaceful. There wasn’t any health care system due to the destruction. Many people resorted to traditional healing for medical treatment, which was of course not sufficient. Countless additional lives were lost because people didn’t have access to appropriate care or medication.

Seeing the pain and loss of lives ignited a passion to help sick people and to save lives. This is how I ended up as a professional nurse.

In the months after the genocide, I saw many people suffer from unbearable pain and sickness. Seeing lives being lost because individuals couldn’t find medical assistance or medication hit me hard. I wished I could have helped, but I had no means. The level of poverty was so high because almost everything had been destroyed. It didn’t matter that we didn’t have money for basic necessities because they were nowhere to be found. There was no access to simple commodities—food, soap, and clothing. We had no one to turn to for help, apart from the government of Rwanda and humanitarian nongovernmental organizations. These groups helped provide us with some of the basics that we needed, but there were many challenges.

So many died due to the lack of available care. Bearing witness to this tragedy compelled me to study hard and become a health care provider. Seeing the pain and loss of lives ignited a passion to help sick people and to save lives. This is how I ended up as a professional nurse.

I learned about Partners In Health/Inshuti Mu Buzima through a local Rwandan newspaper, The New Times. I read about PIH/IMB, and it seemed like a great place with a good mission and vision, so I applied for a job. I began working with the team in 2005, the year that PIH first came to Rwanda. I am now the director of the PIH/IMB community health department.

Despite the destruction of the genocide, tremendous progress has been made across the entire country. Today, Rwanda’s health sector is a force to be reckoned with. Many hospitals have been built, many care providers have been trained, and the health system is growing stronger every day. I am thankful to the government of Rwanda for the opportunities it has provided me and for inviting and teaming up with PIH.

We are a healthy nation with many success stories to tell. Rwandans now have access to affordable, high-quality health care and are enrolled in our community-based health insurance scheme known as “mutuelle.”
I am proud to say that I have seen so many lives treated and changed through our work.

Reflections on the Rwandan Genocide: Jean Claude Rutayisire

The Rwandan genocide began 20 years ago this month. More than 1 million people were killed in the course of 100 days. We asked four of our Rwandan colleagues to reflect on the genocide and discuss how their country has evolved in the past two decades. Below, Jean Claude Rutayisire, head of community health supervisors in Kayonza District, shares his experience. We ask you to stand in solidarity with Rwandans everywhere this month as they commemorate the past and continue to heal. Learn more about PIH/IMB’s work in Rwanda.

I have only horrifying and frightening memories of the 1994 genocide. I was 16 years old, and I was then a soldier with the Rwanda Patriotic Front (RPF). I remember many women being raped and killed during this period, which spread HIV/AIDS and many other sexually transmitted diseases. There was no access to medications. Hospitals and health centers were destroyed and health providers were killed. People died from different diseases because they had no access to treatment, and many children were orphaned.

Many Rwandans were left homeless and traumatized. As a country and as individuals we had gone backwards. We had to start over from scratch. It wasn’t easy.

I am HIV-positive, and at the time I realized I was infected there was a lot of stigma faced by people living with HIV/AIDS. Many were afraid to come out and say they were infected. They wanted to believe it was witchcraft instead, and people refused to seek out proper medical care.

I was among the first patients treated by PIH and brought back to life.

Then, Partners In Health started working with the Ministry of Health in Rwanda. I was among the first patients treated by PIH and brought back to life. I was very impressed with the work they were doing, especially for people living with HIV/AIDS. Then I started to work with PIH; I was among the very first employees of PIH's Rwandan sister organization, Inshuti Mu Buzima (PIH/IMB). I accompanied other HIV-positive patients and worked very hard to raise awareness of the disease.

We at PIH/IMB work with different stakeholders to fight stigma, and many HIV-positive people no longer live in hiding. Individuals are on treatment, living positively. Most of the people who are HIV-positive in the three districts PIH works with the government have received treatment through PIH-supported health facilities, and they do very well. This is because they have access to medication and they have accompagnateurs who follow up with them daily. This makes it easy for people to adhere to their treatment and to live healthy lives.

Despite what we went through during the genocide, we have triumphed and overcome the sorrows of the past through good governance and great partnerships, like the one with PIH. Rwanda has many accomplishments to celebrate, from the community health insurance program to the expansion of HIV care. For me, it is a blessing to be part of this work.

Read Rwanda Program Officer Emmanuel Kamanzi's Reflection.

Reflections on the Rwandan Genocide: Emmanuel Kamanzi

The Rwandan genocide began 20 years ago this month. More than 1 million people were killed in the course of 100 days. We asked four of our Rwandan colleagues to reflect on the genocide and discuss how their country has evolved in the past two decades. Below, Rwanda Program Officer Emmanuel Kamanzi shares his experience. We ask you to stand in solidarity with Rwandans everywhere this month as they commemorate the past and continue to heal. Learn more about PIH/IMB’s work in Rwanda.

My dad left Rwanda in 1956 after being denied the right to further his studies, even though he had fulfilled all the academic requirements. He wasn’t part of the favored group in the country then, and he moved to Uganda. He was later joined by my grandparents in 1959, when there was massive violence in Rwanda against the Tutsi group. My family stayed in the refugee camp for more than three years in Uganda.

I was born in Uganda in 1981. My family and I returned to Rwanda in 1995, right after the genocide, when I was 14 years old. The beauty of the country my parents narrated to me while in exile in Uganda was not what I found when we returned. The ground was full of human skulls. Most if not all schools, roads, hospitals, and commercial centers were totally destroyed. Thousands of Tutsis tried to escape the slaughter by hiding in churches, hospitals, schools, and government offices. These places, which historically have been places of refuge, were turned into sites of mass murder. Rwinkwavu Hospital in southern Kayonza District—the first Partners In Health-supported site in Rwanda—was among those where many people were killed. Nyarubuye Roman Catholic Church, located in Kirehe District, was one of the churches where people were massacred. Now the church is one of many genocide memorial sites in the country.

The 1994 Rwandan genocide is one of the most tragic and horrible events in history. More than 1 million people were massacred in 100 days. In addition to the killings, the country’s infrastructure was totally destroyed. Many people in Rwanda’s health care work force were either killed or fled the country.

“Tutsi,” “Hutu,” and “Twa” are man-made divisions that were created and imposed by European colonialists in the 1890s. Although the genocide started April 7, 1994, Tutsis had been killed and tortured from the 1950s onward. While the genocide targeted total elimination of the Tutsi group, Hutus who did not believe in the perpetrators’ ideology also lost their lives.

When my family and I returned to Rwanda, I continued focusing on my education.

When my family and I returned to Rwanda, I continued focusing on my education. I attended primary and secondary school, and then later joined the University of Rwanda. Unlike the days before the genocide, I now enjoyed the privilege of equality and could go to school like any other Rwandan citizen. The qualifications to go to university were now based on merit rather than what group one belonged to.

After completing my undergraduate studies, I was looking for a job where I would be in the position to help my country, especially the most poor and vulnerable citizens. I left the University of Rwanda where I was employed as a tutorial assistant right after I completed my studies and took a job in a very rural part of the country. It’s very uncommon in Rwanda for someone to leave a job at a national university and take a job to serve the residents in rural Rwanda. When my friends saw me packing my stuff to go to Kirehe Hospital, they thought something was wrong with me. But I was completely sure in my decision.

Working at PIH for the last five years has been life-changing. I started as the human resource manager while at Kirehe Hospital, which was built by PIH in collaboration with the government of Rwanda. After 10 months, I transitioned to Kayonza District as the district project director, responsible for managing PIH’s district programs. From there I moved to Burera District in the northern part of Rwanda to do similar work. In 2013, I moved to PIH’s Boston office to take on the role of Rwanda program officer, working closely with our Boston-based staff and the Rwanda program staff in the field.

We should all push to be social justice activists, fight inequalities, advocate for the poor, and build partnerships.

In all my roles, I have been thrilled by the lifesaving work of the PIH Rwanda team and our partners at the Rwanda Ministry of Health. The future is bright. Kirehe hospital is now in its third phase of construction and will continue to support a growing number of health centers. Rwinkwavu hospital in Kayonza is a hub for medical education in Rwanda. And last but not least, Burera District is home to Butaro Hospital and the Butaro Cancer Center of Excellence, the first cancer center in rural Rwanda.

It is encouraging and rewarding to be part of this work that touches, changes, and saves the lives of the most poor and vulnerable. We should all push to be social justice activists, fight inequalities, advocate for the poor, and build partnerships to serve vulnerable communities around the world.

It is remarkable to see Rwanda today. It is hard to believe the incredible strides it has made since the genocide. Maternal and under-5 mortality rates have dropped significantly. More than 90 percent of the population is enrolled in the public health care plan. Life expectancy has nearly doubled from 28 in the year of the genocide to 56 in 2012. More than 1 million Rwandans escaped poverty between 2005 and 2010. The formerly disunited Rwandan community is now restored, united, and dedicated to living and working together to build their nation. All of these gains are due to strong and decentralized leadership that treats every Rwandan equally.

As Rwandans commemorate the 20th anniversary of the genocide, there is relief in reflecting on these strides. It is up to us to carry the spirit of hope into the future.

Rwanda 20 Years after the Genocide: 'Investing in Life'

The genocide in Rwanda began 20 years ago this month. Over the course of 100 days, 1 million people were killed, an estimated 250,000 women were raped, and millions fled the small east African country. The international community failed to intervene, and much of the world deemed Rwanda a lost cause in the years immediately after.

Rwanda, however, has shown the world that prioritizing health equity and pursuing a strategic, people-centered approach to development can have a remarkable effect.

This week, more than 60 authors, led by Rwanda Minister of Health Dr. Agnes Binagwaho and Partners In Health co-founder Dr. Paul Farmer, published an article in The Lancet detailing the country’s significant health gains. Between the mid-1990s and 2012, the average life expectancy more than doubled. After having the world's highest rate of child mortality when the genocide ended, Rwanda today has caught up to the global average. And in the last 10 years, the country’s death rate from AIDS fell faster than it did in the U.S. and Western Europe, following the 1996 rollout of antiretroviral therapy.

“In the last decade, death rates from AIDS and tuberculosis have dropped more steeply in Rwanda than just about anywhere, ever.

“In the last decade, death rates from AIDS and tuberculosis have dropped more steeply in Rwanda than just about anywhere, ever. There are important lessons to be learned,” Dr. Farmer said. “In the 30 years that I’ve been involved in the provision of health care services to the poor and marginalized, I can think of no more dramatic example of a turnaround than that achieved in Rwanda.”

Using data from the World Health Organization, the United Nations, and the World Bank, the study’s authors show how an equity-based approach to health fosters broader social and economic development. The authors acknowledge that many challenges persist, including malnutrition and noncommunicable diseases, and note that the government has implemented strategies that ensure high-quality care and social support are available for poor and marginalized patients suffering from these conditions.

PIH and our sister organization Inshuti Mu Buzima (IMB) began working with the Rwanda Ministry of Health in 2005 to improve access to health care in three rural districts and build capacity among local health care workers. In the years since, this partnership has helped open the first comprehensive cancer care center in East Africa, delivered lifesaving care to the hardest-to-reach patients, and transformed medical education.

While there is much to be proud of, we cannot lose sight of Rwanda’s history or take our focus off its future. We stand in solidarity with Rwandans everywhere this month as they commemorate the past and continue to heal.

The Lancet article closes on a seemingly obvious but often overlooked truth. “The lesson of the post-genocide period for Rwanda—and for countries around the world hoping for recovery from social upheavals of many kinds—is that a nation’s most precious resource is its people.”

It’s not just clinical care—it is comprehensive support for disadvantaged people.

You won’t have all the answers, but you can listen and console.

Read more from the Working in Global Health series:

In Mexico, hypertension affects about one in every three adults.

CHWs act as a liaison between the doctor in the clinic and the patient, advocating for his or her care and informing the doctor if problems arise.

A sustained commitment

Celebrating partnership

We help around seven women deliver every day, and sometimes we get over 200 women in a month.

It paid off. Today, Rwabukumba is one year away from finishing his medical training at the National University of Rwanda.

Where are you from?

How did you get involved with Socios En Salud?

The approach was to knock on the doors of these people who—despite all their limitations—wanted to be cured.

How did you feel about all this revolutionary MDR-TB work unfolding?

So we should strengthen our alliances: that’s why we call ourselves 'partners in health.'

What challenges do you face as the executive director?

You’ve been executive director of SES for about a year now. What are your major initiatives at this point?

Besides TB, what other programs are you working on?

I have a lot more gray hairs now than I did a year ago, but that’s part of the job.

A big part of your work also involves research. What’s happening in that arena?

That’s a lot to figure out.

Did you ever imagine you would lead this organization?

Growing up in Cap-Haïtien

Ever since I can remember I wanted to do medicine.

Moving to the capital

A difficult year of service

Life as a resident

My mom is so proud of me doing surgery in one of the biggest hospitals in Haiti.

Improving outcomes by working in the community

Between 2000 and 2010, maternal mortality nearly tripled, from 419 to 1,155 per 100,000 live births.

Addressing maternal mortality is a gate for us to address all aspects of women’s health.

A new level of accompaniment

When health care providers are skilled, knowledgeable, and passionate about their work, our patients have better outcomes.

Teams are not competing against one another, they’re competing together to achieve excellence.

For more about this work, read the recipes Chef Jody Adams created for University Hospital or join her for a live video chat to benefit Partners In Health.

What I’ve learned from Partners In Health is that if we want a sustainable change, we can’t just impose something. We have to see what’s appealing to people.

Cooking for the poor

I work in this restaurant where we feed people who have never, ever worried about their next meal. So in my world, it’s really important to have balance.

In search of the key ingredient

The baking professor

Little by little

Her morning meal, a typical Haitian breakfast of ground corn with fish and vegetables called mais moulin, was reimagined as a baked casserole.

Local foods, international dishes

Asking for seconds

Roasted Potatoes

Ingredients

Directions

Roasted Stuffed Peppers

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Roasted Beet Salad with Orange and Thyme

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Occean's Whole Wheat Bread

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Directions

Romesco—Pepper Nut Sauce

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Directions

Coconut Peanut Sauce

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Parsley Pesto Sauce

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Brandade de Morue

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Oliver’s Chicken Stew

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It makes every Haitian proud to have such a hospital.

Where did you grow up?

Learning about PIH/CES opened my eyes, because it was the first moment I saw I wasn’t alone. There are others thinking the way I think.

What was medical school like?

How did you go from a medical school that exports doctors to work in one of the most under-served areas of your own country?

And how was it?

People often say to me, 'Stop being idealistic, and start being realistic.'

How did the community react to you being there as their doctor?

How did your friends and family respond to you making this choice?

Now you’re working as a supervisor of the new doctors who are now going through this themselves. How is it?